Hemodynamics and common medications in the heart failure patient

Laura J Langenhop BSN, RN, PCCN, CHFN

The Wright State University Class of 2015

oBJECTIVEs

• Identify the difference between systolic and diastolic heart failure.

• Demonstrate understanding for the use of inotropes in heart failure patients.

• Describe the pathophysiology of heart failure.

• Identify medications used in heart failure.

• Demonstrate understanding of the heart failure core measures.

HOW DID MY PATIENT GET HEART FAILURE?

• 1. Poorly Treated HTN

• 2. Myocardial Infarction

• 3. Valve Disease

• 4. Atrial Fibrillation

• 5. CAD

• 6. Cardiomyopathies (ex. Alcohol-induced, viral, drug-induced, restrictive, hypertrophic)

• 7. Congenital Heart Defects

(Yancy et al., 2013; Papadakis, McPhee, & Rabow,

2014)

SYSTOLIC VS. DIASTOLIC

HEART FAILURE

Systolic Heart Failure

• The problem is with the ejection or the “pumping ability”

• EF<40% by definition

• Common Causes: MI, CAD, untreated HTN, dilated cardiomyopathy

(Yancy et al., 2013)

SYSTOLIC VS. DIASTOLIC

HEART FAILURE

Diastolic heart failure

• The problem is with a stiff ventricle and not being able to fill.

• EF >40%

• Common Causes: Age, Women, HTN, AFIB, CAD, Restrictive Cardiomyopathy, Amyloidosis

(Yancy et al., 2013)

NYHA versus ACC/AHA Stages of heart failure

What does the patient look like?

Now We’re going to the cath lab….

Are they…..• Wet?• Dry?• Have Low cardiac Output?• Pulmonary HTN?• Do they have a blockage?

Right Heart Catheterization

• Venous sheath is placed

• Looking at filling pressures of the heart to assess volume status

• DO NOT need IV fluids or aspirin prior to procedure.

Left Heart Catheterization

• Arterial sheath is placed

• Looking at coronary arteries and need for intervention (i.e. PCI, balloon)

• Need Aspirin 324 mg ordered and 0.9% NS @ 30mL/hr.

CATH LAB REPORT

Normal Pressures Example of Report

RA 0-8 mm/Hg 10

RV 15-25/0-8 mmHg 42/14/24

PA 15-25/8-10 mmHg 44/17/27

PCWP 6-12 mmHg 15

CO ~4 to 8 L/min 3.8 L/min

CI 2.4 to 4 L/min/m2 2.0 L/m/m2

Common Inotropic agents

renalfellow.blogspot.com

MILRINONE (Primacor)

• Phosphodiesterase inhibitor• Vasodilation

• Inotropic Effects

• Little chronotropic effect

• Onset: 5-15 minutes

• Half-life: ~2.5 hours

• Adverse Reactions: Hypotension, Arrhythmias, Headache, Chest Pain

• Uses: Volume overload with decreased CO/CI, Right-sided heart failure following LVAD implant

(Marino, 2014)

Dobutamine (dobutrex)• Stimulates beta1-adrenergic

receptors causing increased contractility and heart rate.

• Onset of Action: 1-10 minutes

• Half-Life: ~2 minutes

• Adverse Reactions: Arrhythmias, Tachycardia, Angina, Palpitations

• Uses: Cardiac Decompensation, Low CO/CI, Cardiogenic/Septic Shock

• **Should not be on beta-blockers if on this medication.

(Marino, 2014)

DOPAMINE

• Stimulates both adrenergic and dopaminergic receptors. Goal is to increase cardiac stimulation and increase renal vasodilation.

• Onset of Action: ~5 minutes

• Half-Life: ~2 minutes

• Adverse Reactions: Low/High BP, Palpitations, Arrhythmias, Nausea, Vomiting, Tissue Necrosis (must go through central line)

• Uses: Inotropic support and renal blood flow.

(Marino, 2014)

Qualifications for inotropic agents

• Cardiac Index <2.2 L/min/m2 prior OR Wedge >20 mmHg prior to starting.

• Dyspnea at rest

• Maximum dosage of Digoxin, Loop Diuretic, ACE, or vasodilator (unless reason documented).

• Qualification for Home Inotropic Therapy: Need CI increased by 20%, wedge pressure decrease by 20%, and improved shortness of breath

pathophysiology OF heart failure

(Marino, 2014)

DIURETICS

lOOP DIUERTICS (Furosemide (Lasix), Torsemide (demadex), and

bumetanide (Bumex) • Given for Acute Decompensated Heart Failure

in Intravenous Form.

• Loop diuretics work by increasing the excretion of water and sodium excreted by the kidneys.

• Side Effects: Muscle cramps, hypokalemia, hypomagnesemia, increase in Creatinine, dizziness, hypotension.

• Consider to Hold: Dramatic increase in Creatinine or patient is hypotensive.

• On discharge, patient’s will go home with oral Lasix, Bumex, oral Demadex

Felker et al., 2011

dIURETIC CONVERSION

Bumex Lasix Demadex

Equivalent Dose

1 mg 40 mg 20 mg

Bioavailability ~60-80% 50-60% 80%

Usual Dose 0.5 mg-2 mg(QD or BID)

20 mg-80 mg(QD-BID)

10 mg-40 mg(QD-BID)

Duration 4 hours 6 hours 6 hours

(LexiComp, 2015)

Thiazide diuretics(Metolazone, hydrochlorOthiazIDe,

DIURIL)

• Inhibits sodium reabsorption in the distal tubules causing increased excretion of sodium and water.

• Diuril will be seen in combination with lasix in the IV form

• Metolazone may be given as needed, depending on the patient’s resistance to diuresis.

• Side Effects: Hypotension, Dizziness, fatigue, headache, N/V/D, hypokalemia, hypomagnesemia

Aldosterone antogonists (ex. Spirolactone, Eplerenone)

• Competes with aldosterone for receptor sites thereby increasing sodium and water excretion.

• Uses: NYHA Class III-IV Heart Failure

• Adverse Effects: Hyperkalemia, Hypotension, Headache, Confusion, Gynecomastia, Renal Failure, Nausea, Vomiting, Diarrhea.

• Reasons to Hold: If K is >5 or Cr. >2.5

ACCF/AHA 2013 Heart Failure Guidelines

Tolvaptan (samsca)

• Used in patients with hypervolemic or euvolemic hyponatremia

• Vasopressin antagonist causing excretion of free water without loss of electrolytes. This results in fluid loss, increased urine output, and increased serum Na levels.

• Normal dosing: 15 mg-60 mg

• When to hold: If serum Na level increases >10 mEq in 24 hours or if serum Na level is within normal level.

Ace-iNHIBITORS(i.e. lisinopril, captopril, enalapril)

• Prevents conversion of Angiotensin 1 to Angiotensin 2 causing vasodilation. Reduce Afterload and help with remodeling.

• Indication: High Blood pressure, <40% EF.

• Adverse Reactions: Hypotension, Renal Insufficiency, Hyperkalemia, Angioedema, Cough, Swelling of the tongue *EMERGENCY.

• Reasons to Hold: Acute increase in Creatinine, K >5, and hypotension

www.medictest.com

Angiotensin II RECEPTOR BLOCKERS

[Volsartan (Diovan,), losartan (cozaar)]

• Indications: HTN, EF <40%

• Blocks vasoconstriction and aldosterone-secreting effects of angiotensin II. Increases urinary flow rate and increases excretion of chloride, magnesium, uric acid, calcium, and phosphate.

• Adverse Reactions: Fatigue, Hyperkalemia, Hypotension

• Reasons to hold: Acute increase in Cr., K >5, and hypotension

Vasodilators

Hydralazine

• Direct vasodilation of arterioles with decreased systemic resistance.

• Adverse Reactions: Headache, Hypotension, dizziness.

• Consider holding for hypotension

Isosorbide Mononitrate(Imdur)

• Vasodilates peripheral veins and arteries. Decreases cardiac oxygen demand by decreasing pre-load.

• Improves collateral flow to ischemic regions.

• Adverse Reactions: headache, flushing, dizziness, fatigue, N/V/D, hypotension.

Taylor et al., 2004African American Heart Failure Trial

Beta-bLOCKERS(I.e. mETOPROLOL SUCCINATE, CARVEDILOL)

• Metoprolol Succinate• Beta-1 adrenergic Selective inhibitor • Shown to decrease mortality and hospitalizations in patient’s

with class II-IV heart failure

• Carvedilol• Non-selective Beta-1 and Beta-2 adrenergic Selective inhibitor.• Has shown to decrease PCWP, pulmonary resistance, renal

vascular resistance, decreased SVR

• Helps to decrease heart rate and blood pressure in order for the heart to “pump” more effectively as well as remodeling the heart.

• Adverse Reactions: Fatigue, bradycardia, dizziness, hypotension

(COMET Trial, MERIT-HF Trial, Yancy et al., 2013)

DIGOXIN

• Heart Failure: • Increases intracellular sodium promoting calcium

influx in the cell leading to increased contractility.• Inhibits reabsorption of sodium• Increases CO and renal blood flow• +Inotropic effect

• AFIB:• Used to suppress the AV node conduction in order

to increase refractory period. • Enhances Vagal Tone

Reasons we stop this: Bradycardia, Renal insufficiency

Heart failureCORE MEASURES

• Documented Left Ventricular Ejection Fraction

• ACE/ARB (EF <40%)

• Documentation of Beta-Blocker (Carvedilol, Metoprolol Succinate, or Bisoprolol)

• Post-discharge heart failure appointment within 7 days of Discharge

(GWTG, CMS, & TJC, 2014)

References• American Heart Association (2014). Heart Failure Core Measures.http

://www.heart.org/idc/groups/heart-public/@wcm/@private/@hcm/@gwtg/documents/downloadable/ucm_458657.pdf

• Centers of Medicare and Medicaid. (2015). Medicare inotropic qualification checklist. http://www.pdfdrive.net/medicare-inotropic-qualification-checklist-e9799412.html

• Felker, G. M., O’Connor, C. M., & Braunwald, E. (2009). Loop Diuretics in Acute Decompensated Heart failure necessary? evil? A necessary evil? Circulation, 2, 56-62. doi:10.1161/_CIRCHEARTFAILURE.108.821785

• Felker, M.G., Lee, K.L., Bull, D.A., Redfield, M.M., Stevenson, L.W.,…& O’Connor C.W. (2011). Diuretic strategies in patients with acute decompensated heart failure. New England Journal of Medicine, 364, 797-805. doi: 10.1056/NEJMoa10005419.

• Fuster, V., Asinger, R.W., Cannom, D.S., Crijns, H.J., Frye, R.L., & Torbicki, A. (2001). Guidelines for the management of patients with atrial fibrillation. Circulation, 104: 2118-2150. http://circ.ahajournals.org/content/104/17/2118.full

• Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G., ... Yancy, C. W. (2009, March 26). 2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults. Circulation, 119, 1977-2016. doi:10.1161/CIRCULATIONAHA.109.192064

• Lexicomp (2014). Retrieved from http://webstore.lexi.comPDA-software-for-nurses

• Lindenfeld, J., Albert, N.M., Boehmer, J.P., Collins, S.P., Ezekowitz, J.A.,…Walsh, M.A. (2010). Executive summary: HFSA 2010 Comprehensive heart failure practice guideline. Journal of Cardiac Failure, (16)6. 1-259. http://www.heartfailureguideline.org/_assets/document/Guidelines.pd

• Marino, P. L. (2014). The ICU book (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

• Papadakis, S. J. McPhee, S. J. & Rabow, M.W. (2014), Current medical diagnosis & treatment 2014 (49th ed). New York, NY: Appleton & Lange

• Taylor AL, Ziesche S, Yancy C, et al; (2004). the African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. New England Journal of Medicine, 351:2049-2057

• Yancey, C.W., Jessup, M., Bozkurt, B., Butler, B.,..& Wilkoff, B.L. (2013). 2013 ACCF/AHA guidelines for the management of heart failure. Circulation, 128:1810-1852. doi: 10.1161/CIR.0b013e31829e8776