Download - note of acute heart failure
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Acute Heart Failure ManagementMy Note of 2016 ESC guideline and books Yuan Chieh Chang, 2016
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Acute Heart failure medical management | CYC 2016 Outline
ESC 2016 guideline Tx of acute Heart failurePrognosis and Identify the high riskDischarge checklistOxygen TherapyPharmacology therapy
DiuresisVasodilator Inotropic agents Inodilator Inotropic vasopressor
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Acute Heart failure medical management | CYC 2016
ESC 2016 Heart Failure Guideline
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Acute Heart failure medical management | CYC 2016 Definition and Classification
Rapid onset or worsening of symptoms and/or signs
CONGESTION
HYP
OPE
RFU
SIO
N
Dry & Warm Wet & Warm
Dry & Cold Wet & Cold
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Acute Heart failure medical management | CYC 2016 Definition and Classification
CONGESTION
HYP
OPE
RFU
SIO
N
Dry & Warm Wet & Warm
Dry & Cold Wet & Cold Pulmonary congestionOrthopnea/PNDPeripheral oedemaJugular vein distensionHepatomegalyGuts congestion/ascitesHepatojugular reflux
5% of AHF 95% of AHF
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Acute Heart failure medical management | CYC 2016 Definition and Classification
CONGESTION
HYP
OPE
RFU
SIO
N
Dry & Warm Wet & Warm
Dry & Cold Wet & Cold
Cold sweated extremitiesOligouriaMental CongusionDizzinessNarraw Pulse pressure
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Acute Heart failure medical management | CYC 2016 Definition of terms
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Acute Heart failure medical management | CYC 2016 Elevated BNP ?
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Acute Heart failure medical management | CYC 2016
Wet
Warm
Cold
Dry
Warm
Cold
Management
Vascular Type Fluid distributionHypertension Predomates
Cardiac Type Fluid distributionCongestion Predomates
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Acute Heart failure medical management | CYC 2016
Wet
Warm
Cold
Dry
Warm
Cold
Management
Vascular Type Fluid distributionHypertension Predomates
Cardiac Type Fluid distributionCongestion Predomates
Diuresis Vasodilator
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Acute Heart failure medical management | CYC 2016
Wet
Warm
Cold
Dry
Warm
Cold
Management
Vascular Type Fluid distributionHypertension Predomates
Cardiac Type Fluid distributionCongestion Predomates
Diuresis
VasodilatorUltrafiltration
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Acute Heart failure medical management | CYC 2016 Management
Wet
Warm
Cold
Dry
Warm
Cold
SBP < 90mmHg SBP >= 90mmHg
Correct Perfusion
Inotropic
MechanicalIf Medical therapy fail
Diuresis
in refractory caseVasopressor
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Acute Heart failure medical management | CYC 2016 Management
Wet
Warm
Cold
Dry
Warm
Cold
SBP < 90mmHg SBP >= 90mmHg
in refractory caseInotropic
Diuresis
Vasodilator
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Acute Heart failure medical management | CYC 2016 Management
Wet
Warm
Cold
Dry
Warm
Cold
Well Compensated ! (Oral Medication)
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Acute Heart failure medical management | CYC 2016 Management
Wet
Warm
Cold
Dry
Warm
Cold Hypoperfused, HypovolemicConsider Fluid Challenge
If still HypoperfusedInotropic
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Acute Heart failure medical management | CYC 2016
Identify High Risk Patient
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Acute Heart failure medical management | CYC 2016 Risk
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Preparing for discharging
persistent clinical congestionassociated elevations of discharge BNP level
High risk for rehospitalization
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Acute Heart failure medical management | CYC 2016 Preparing for discharging
Check list
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016
Oxygen Therapy
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Acute Heart failure medical management | CYC 2016 Oxygen therapy
Oxygen Therapyin SpO2
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Acute Heart failure medical management | CYC 2016 Before Intubation
improvement in dyspnea, heart rate, acidosis, and hypercapnea after 1 hour of therapy
may decrease intubation and mortality rates (Not conclusive)
continuous positive airway pressure (CPAP) noninvasive intermittent positive-pressure ventilation (NIPPV)
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Acute Heart failure medical management | CYC 2016
Pharmacology Therapy
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Acute Heart failure medical management | CYC 2016 Diuresis
clinically evident congestion: 4 to 5 liters of excess volume
greater than 10 L are not uncommon
DiuresisSymptom Relief
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Acute Heart failure medical management | CYC 2016 Diuresis
Initial
i.v. dose should be at least equal to the pre-existing oral dose
2.5 x the outpatient dose:
renal dysfunction/severe volume overload
*transient worsening in renal function
Titration should be rapid with doubling
Consider continuous infusion
significant volume overload (>5 to 10 liters) or diuretic resistance
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Acute Heart failure medical management | CYC 2016 Volume Management
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Vasodilator
VasodilatorSymptom ReliefReduce Mortality
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Acute Heart failure medical management | CYC 2016 Cardiorenal Syndrome
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Cardiorenal Syndrome
Vasodilator can help!
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Acute Heart failure medical management | CYC 2016 Cardiorenal Syndrome
Use of vasodilators was superior to ultraltration with regard to preserving renal function and decongestion
Vasodilator Ultrafiltration
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Acute Heart failure medical management | CYC 2016 Vasodilator
Preload Afterload
Venous Arterial
PCWP/Pulmonary edema
Nitrates
Coronary artery
Nitroprusside
High dose
stealing phenomenon
Nesiritide
Myocardial O2 Consumption
CCB
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Acute Heart failure medical management | CYC 2016
Nitroprusside
stealing phenomenon
Vasodilator
Nesiritide
CCBNitrates
High dose
Preload Afterload
Venous Arterial
PCWP/Pulmonary edema
Coronary artery
Myocardial O2 Consumption
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Acute Heart failure medical management | CYC 2016 Vasodilator effect (Nitrates)
ALARM-HF registry Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Vasodilator effect (Nitrates)
ALARM-HF registry
SBP100-120mmHg
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Acute Heart failure medical management | CYC 2016 Nitrates
Increased coronary blood flow
Relatively selective for epicardial, (>intramyocardial, coronary arteries)
Goal
immediate symptom relief
MAP reduction > 10 mm Hg , SBP > 100 mm Hg
dose may need to be reduced if SBP is 90 to 100 mm Hg and often will need to be discontinued with SBP below 90 mm Hg
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Acute Heart failure medical management | CYC 2016 Nitrates
Recent use of phosphodiesterase-5 inhibitors (sildenafil, tadalafil, and vardenafil) should be ruled out
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Acute Heart failure medical management | CYC 2016
Nitrates
High dose
Vasodilator
Nesiritide
CCB
Preload Afterload
Venous Arterial
PCWP/Pulmonary edema
Coronary artery
Myocardial O2 Consumption
Nitroprusside
stealing phenomenon
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Acute Heart failure medical management | CYC 2016 Sodium Nitroprusside
a very short half-life (seconds to a few minutes)
SBP 90 to 100 mmHg are typical goals
Tapering the dose of before discontinuation
Cyanide toxicity:
as low and as short as possible
no longer than 10 minutes at top dose in the treatment of severe hypertension
contraindicated in hepatic or real failure
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Acute Heart failure medical management | CYC 2016 Sodium Nitroprusside
Being replaced in.
severe acute-on-chronic heart failure by nitrates
hypertensive crises by intravenous nicardipine, fenoldopam, or labetalol
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Acute Heart failure medical management | CYC 2016
Coronary artery
CCBNitrates
High dose
Nitroprusside
stealing phenomenon
Vasodilator
Nesiritide
Preload Afterload
Venous Arterial
PCWP/Pulmonary edema
Myocardial O2 Consumption
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Acute Heart failure medical management | CYC 2016 Nesiritide
ASCEND-HF)
minimal improvement in dyspnea
as VMAC trial revealed reduced PCWP
no beneficial effect on hospitalizations for HF or death within 30 days.
increased incidence of symptomatic hypotension
no differences in the rates of worsening renal function5
Recombinant human B-type [brain] natriuretic peptide
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Acute Heart failure medical management | CYC 2016 Vasodilator
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators
InotropicSymptom Relief
Maintain end-organ functionIncrease Hemodynamic profile
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Acute Heart failure medical management | CYC 2016 Inotropes
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Inotropes
VasocontrictionVasodilation
Inotropic
DobutamineDopamine
Norepinephrine
Epinephrine
()
Chonotropic ++ Arrhythmia risk+++
Arrhythmia risk++ Arrhythmia risk+ (high dose)
Arrhythmia risk+ Milrinone
Arrhythmia risk+ Hypotension
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Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
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Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
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cAMP-mediated inotropy and reduce PCWP through vasodilation
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Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
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cAMP-mediated inotropy and reduce PCWP through vasodilation
Limited to dilated ventricles + reduced EF + SBP
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Acute Heart failure medical management | CYC 2016 Dobutamine
Beta2 Increase CO via afterload reduction in low dose
decreased aortic impedance and systemic vascular resistance
Tachyphylaxis : infusions longer than 24 to 48 hrs
long-term mortality may be increased,as well as increasing cardiac sympathetic activity in heart failure patients
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dobutamine
Side effect:
tachycardia, increasing ventricular response to Af, atrial and ventricular arrhythmias, myocardial ischemia
possibly cardiomyocyte necrosis (direct toxic effects and induction of apoptosis)
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
precursor of norepinephrine and releases norepinephrine
Periphery this effect is overridden by the activity of the prejunctional dopaminergic-2 receptors, inhibiting norepinephrine release and thereby helping to vasodilate
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
Low-dose (2 g/kg/min)
selective dilation of renal, splanchnic, and cerebral arteries (DA1R)
Low dose Dopamine + low dose furosemide
may improved renal function profile and potassium homeostasis compared with high-dose furosemide (not conclusive!)
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
Intermediate-dose dopamine (2 to 10 g/kg/min)
enhanced NE release, stimulating cardiac receptors with an increase in inotropy and mild stimulation of peripheral vasoconstricting receptors
dependent on myocardial catecholamine stores (ineffective in advance stage )
Dosing should be gradually decreased from to 3 to 5 g/kg/min and then discontinued, avoid potential hypotensive effects of low-dose dopamine
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
High-dose dopamine (10 to 20 g/kg/min)
peripheral and pulmonary artery vasoconstriction (direct agonist effects on alpha1-adrenergic receptors)
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
Cardiogenic shock or AMI
5 mcg/kg/min is enough to give a maximum increase in stroke volume
Renal flow reaches a peak at 7.5 mcg/kg/min
Arrhythmias may appear at 10 mcg/kg/min
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
In septic shock
Dopamine has an inotropic effect and increases urine volume
Dopamine is widely used after cardiac surgery
In critically ill hypoxic patients
may depression of ventilation and increased pulmonary shunting
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine
Contraindication in ventricular arrhythmias, and pheochromocytoma
MAO inhibitor
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Dopamine or Dobutamine
Dopamine is preferred if the patient requires
pressor effect (high-dose-effect) +
increase in cardiac output+
No marked tachycardia or ventricular irritability
Cardiogenic shock infusion of equal concentrations may afford more advantages than either drug singly
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Acute Heart failure medical management | CYC 2016 Epinephrine
Full beta receptor agonist
inotropy independent of myocardial catecholamine stores ( denervative )
Potent inotropic agent
balanced vasodilator and vasoconstrictor effects
Contraindications : late pregnancy
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Epinephrine
A low physiologic infusion rate ( 0.01 mcg/kg/min)
decreases BP (vasodilator effect)
Cardiac arrest: combined inotropic-chronotropic stimulation
High Dose: Alfa stimulation > Beta
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Phosphodiesterase Inhibitors - Milrinone
Inhibition cAMP degraded
increases inotropy, chronotropy, and lusitropy in cardiomyocytes
vasorelaxation in vascular smooth muscle
Peripheral and pulmonary vasodilation
ESC: may be considered to reverse the effect of beta-blockade
Decrease Afterload and Preload and is Inotropic
Drugs for the Heart, 8th Edition
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Acute Heart failure medical management | CYC 2016 Mechanism
World J Cardiol 2016 July 26; 8(7): 401-412
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Acute Heart failure medical management | CYC 2016 Mechanism
Ca SERCA Sarcoplasmic reticulum SRCaSystolic phase CytoplasmCa Diastolic phase
PDEI Ca
cAMP
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Acute Heart failure medical management | CYC 2016 Vasodilation in smooth muscle
Elvebak, R. L., Eisenach, J. H., Joyner, M. J. and Nicholson, W. T. The Function of Vascular Smooth Muscle Phosphodiesterase III is Preserved in Healthy Human Aging
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Acute Heart failure medical management | CYC 2016 Vasodilation in smooth muscle
Nitrate
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Acute Heart failure medical management | CYC 2016 Mechanism
Subcellular localization
possibility to stimulate inotropy without increasing heart rate
Bypasses receptor downregulation
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Acute Heart failure medical management | CYC 2016 Attention
Extremely long duration
elimination half-life of 2.5 hours pharmacodynamic half-life > 6 hours
Renally excreted
Hypotension and atrial and ventricular arrhythmias
OPTIME-HF (2002) N = 951 Compare with Placebo No change in Days with CV-related hospitalization excess sustained hypotension (P = .004), new atrial fibrillation/flutter (P
< .001), VT/VF (P = .06)
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Acute Heart failure medical management | CYC 2016 Levosimendan
Anesthesiology 3 2006, Vol.104, 556-569
Anesthesiology 3 2006, Vol.104, 556-569
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Acute Heart failure medical management | CYC 2016 Levosimendan
Increases myocardial contractility
Cardiac myofilament calcium sensitization by calcium-dependent (systolic) troponin C binding
Peripheral vasodilation
activation of vascular smooth muscle potassium channels
Some in vitro PDEI activity
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Acute Heart failure medical management | CYC 2016 Levosimendan
Benefit on mortality?
SURVIVE (2007) N = 1327 Compare with Dobutamine
No change in dyspnea at 24 hr, days alive out of hospital at 180 days, all-cause mortality at 31 days, CV mortality at 180 days
REVIVE-2 (2013) N = 600 Compare with Placebo
More frequent hypotension and cardiac arrhythmias during infusion period;
numerically higher risk of death, 90 days (REVIVE-1,-2: Levo, 49 deaths/350 pts. vs. placebo, 40/350, P = .29)
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Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasopressor
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Acute Heart failure medical management | CYC 2016 Vasopressor
Vasopressor (norepinephrine preferably)
considered in cardiogenic shock+ treatment with another inotrope
to increase blood pressure and vital organ perfusion
increase in LV afterload
Norepinephrine > Dopamine (fewer side effects and lower mortality)
Epinephrine : restricted to persistent hypotension
despite adequate cardiac filling pressures and the use of other vasoactive agents
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Acute Heart failure medical management | CYC 2016 Norepinephrine
Logically, should be of most use:shock-like state + peripheral vasodilation (warm shock)
Combination with PDE inhibitors helps to avoid the hypotensive effects of the PDE inhibitors
Contraindications :late pregnancy and preexisting excess vasoconstriction
Braunwald's heart disease 10th Ed
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Acute Heart failure medical management | CYC 2016 Recommend Dosing
Braunwald's heart disease 10th Ed