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

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