27 Acute HF

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• treatment very different for acute and chronic

• acute: symptoms of fluid overload, need hospital therapy

• chronic: after treatment at hospital, feels much better, still sick and at risk of dying

Causes

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• fast food, high salt

• acute exacerbation from lack of med compliance

• nl: transient rise in volume triggers RAAS overtime to relieve volume

• HF: transient rise very dangerous, symptoms of HF, hospital

• NSAIDS high yield: taking high dose NSAIDS to treat arthritis classic cause of HF

• Constricted proximal end of hose: NSAIDs cause afferent arteriole vasoconstriction, decreasing GFR

• Bursting from high pressure: NSAIDs can increase blood pressure due to COX inhibition in the kidney, decreasing sodium excretion

• Tall man dousing failing heart balloon: mannitol induced expanded extracellular volume can exacerbate heart failure

• Failing heart balloon locked out of store: CCBs can worsen heart failure (increased sympathetic activity and decreased contractility)

• Darts deflating failing heart balloon: disopyramide can exacerbate heart failure (negative inotropy)

• Trampled failing heart balloon: amiodarone can induce heart failure

Treatment

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• chronic: they already feel better, thus improve mortality more important

3 ways:

• reduce volume (diuretics)

• vasodilate: reduce afterload/preload (vasodilators)

• increase contractility (ionotropes)

Diuretics

• main treatment for both systolic and diastolic

• in acute: gut is often swollen, give IV

• Furious kid: furosemide (a loop diuretic)

• Ethics: ethacrynic acid (a loop diuretic)

• Sulfa-less ethics: ethacrynic acid is not a sulfa drug

• Failing heart balloon: loop diuretics are 1st line for the symptomatic treatment of acute decompensated heart failure with fluid overload

• Wet lungs: loop diuretics treat symptoms of pulmonary edema in an acute heart failure exacerbation

• Yellow inner tube: loop diuretics treat ascites in liver failure

• given together with loop: more Na to DCT from loop. Inhibit more Na absorption at DCT = more excretion

• Failing heart balloon: thiazide diuretics can be useful in the symptomatic treatment of heart failure (loop diuretics are first line)

Vasodilators

• Wet lung spots: nitroglycerine is an acute treatment for pulmonary edema

• acute HF with very high BP, give vasodilators to help

• Failing heart balloon: ACE inhibitors are first line agents in the treatment of chronic heart failure (reduce peripheral resistance, afterload, and blood volume, preload; less Ang II, less sympathetic activity on heart )

• Hydro-boat: hydralazine treats hypertensive emergency

• Dilated red hose: hydralazine is a direct arteriolar vasodilator

• Dynamite: nitrate (e.g. nitroglycerine)

• Failing heart balloon: hydralazine combined with a nitrate (e.g. nitroglycerine) treats heart failure (hydralazine arteriodilation, nitrate venodilation)

Inotropes

• reserved for ICU pts

• One in a million: milrinone

• Don't phoster disinterest: milrinone inhibits phosphodiesterase

• CAMPaign: milrinone decreases breakdown of cAMP

• Flexing arm: milrinone increases cardiac contractility

• Dilated red donkey ears: milrinone causes arteriolar dilation and decreased afterload. Hypotension SE

• milrinone and dobutamine main ones

• "Just DO BUgling" winding up heart flashlight: dobutamine increases heart rate, contractility, and cardiac output (beta-1 effects)

• "Just DO BUgling" friend's dilated sleeves: dobutamine causes vasodilation -> decreases SVR (effects mild due to minimal beta-2 activity)

• Dobutamine increases PULSE PRESSURE, difference between systolic and diastolic (beta-1 increase in contractility)

• Dobutamine increases systolic pressure (beta-1 increase in CO)

• Dobutamine can decrease diastolic pressure (beta-2 arteriolar dilation)

• Others:

• Low kidney tied to single rope: low doses of dopamine act on D1 receptors to increases renal blood flow

• Beta bugler in the middle: medium doses of dopamine activate beta-1 receptors (cardiac activation)

• Alpha scout up high: high doses of dopamine activate alpha-1 receptors (pressor effects)

• Brain helmet on double rope swing: D2 receptors are found in the CNS

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• given usually in hospitals under supervision because dangerous

• stimulate heart in pts with sick heart vulnerable to arrythmias

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• Cr rising: under perfusion of kidneys

• quality of care

• nitrate to feel better

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• Deflated heart balloon: symptomatic treatment of chronic systolic heart failure