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
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- nl: transient rise in volume triggers RAAS overtime to relieve volume
- HF: transient rise very dangerous, symptoms of HF, hospital
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- NSAIDS high yield: taking high dose NSAIDS to treat arthritis classic cause of HF
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- 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
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- Tall man dousing failing heart balloon: mannitol induced expanded extracellular volume can exacerbate heart failure
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- Failing heart balloon locked out of store: CCBs can worsen heart failure (increased sympathetic activity and decreased contractility)
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- Darts deflating failing heart balloon: disopyramide can exacerbate heart failure (negative inotropy)
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- 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
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- main treatment for both systolic and diastolic
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- in acute: gut is often swollen, give IV
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- 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
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- given together with loop: more Na to DCT from loop. Inhibit more Na absorption at DCT = more excretion
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- Failing heart balloon: thiazide diuretics can be useful in the symptomatic treatment of heart failure (loop diuretics are first line)
Vasodilators
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- Wet lung spots: nitroglycerine is an acute treatment for pulmonary edema
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- acute HF with very high BP, give vasodilators to help
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- 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 )
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- 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
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- 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
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- milrinone and dobutamine main ones
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- "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:
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- 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
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- Deflated heart balloon: symptomatic treatment of chronic systolic heart failure
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