Recommandé
Recommandé
Contenu connexe
Tendances
Tendances (20)
En vedette
En vedette (20)
Similaire à note of acute heart failure
Similaire à note of acute heart failure (20)
Dernier
Dernier (20)
note of acute heart failure
- 1. Acute Heart Failure Management My Note of 2016 ESC guideline and books Yuan Chieh Chang, 2016
- 2. Acute Heart failure medical management | CYC 2016 Outline •ESC 2016 guideline Tx of acute Heart failure •Prognosis and Identify the high risk •Discharge checklist •Oxygen Therapy •Pharmacology therapy •Diuresis •Vasodilator •Inotropic agents •Inodilator •Inotropic vasopressor
- 3. Acute Heart failure medical management | CYC 2016 ESC 2016 Heart Failure Guideline
- 4. Acute Heart failure medical management | CYC 2016 Definition and Classification Rapid onset or worsening of symptoms and/or signs CONGESTION HYPOPERFUSION Dry & Warm Wet & Warm Dry & Cold Wet & Cold
- 5. Acute Heart failure medical management | CYC 2016 Definition and Classification CONGESTION HYPOPERFUSION Dry & Warm Wet & Warm Dry & Cold Wet & Cold Pulmonary congestion Orthopnea/PND Peripheral oedema Jugular vein distension Hepatomegaly Guts congestion/ascites Hepatojugular reflux 5% of AHF 95% of AHF
- 6. Acute Heart failure medical management | CYC 2016 Definition and Classification CONGESTION HYPOPERFUSION Dry & Warm Wet & Warm Dry & Cold Wet & Cold Cold sweated extremities Oligouria Mental Congusion Dizziness Narraw Pulse pressure
- 7. Acute Heart failure medical management | CYC 2016 Definition of terms
- 8. Acute Heart failure medical management | CYC 2016 Elevated BNP ?
- 9. Acute Heart failure medical management | CYC 2016 Wet Warm Cold Dry Warm Cold Management Vascular Type Fluid distribution Hypertension Predomates Cardiac Type Fluid distribution Congestion Predomates
- 10. Acute Heart failure medical management | CYC 2016 Wet Warm Cold Dry Warm Cold Management Vascular Type Fluid distribution Hypertension Predomates Cardiac Type Fluid distribution Congestion Predomates Diuresis Vasodilator
- 11. Acute Heart failure medical management | CYC 2016 Wet Warm Cold Dry Warm Cold Management Vascular Type Fluid distribution Hypertension Predomates Cardiac Type Fluid distribution Congestion Predomates Diuresis VasodilatorUltrafiltration
- 12. Acute Heart failure medical management | CYC 2016 Management Wet Warm Cold Dry Warm Cold SBP < 90mmHg SBP >= 90mmHg Correct Perfusion Inotropic Mechanical If Medical therapy fail Diuresis in refractory case Vasopressor
- 13. Acute Heart failure medical management | CYC 2016 Management Wet Warm Cold Dry Warm Cold SBP < 90mmHg SBP >= 90mmHg in refractory case Inotropic Diuresis Vasodilator
- 14. Acute Heart failure medical management | CYC 2016 Management Wet Warm Cold Dry Warm Cold Well Compensated ! 調整⼝口服藥就好了了 (Oral Medication)
- 15. Acute Heart failure medical management | CYC 2016 Management Wet Warm Cold Dry Warm Cold Hypoperfused, Hypovolemic Consider Fluid Challenge If still Hypoperfused Inotropic
- 16. Acute Heart failure medical management | CYC 2016 Identify High Risk Patient
- 17. Acute Heart failure medical management | CYC 2016 Risk Braunwald's heart disease 10th Ed
- 18. Acute Heart failure medical management | CYC 2016 Preparing for discharging • persistent clinical congestionassociated • elevations of discharge BNP level High risk for rehospitalization
- 19. Acute Heart failure medical management | CYC 2016 Preparing for discharging Check list Braunwald's heart disease 10th Ed
- 20. Acute Heart failure medical management | CYC 2016 Oxygen Therapy
- 21. Acute Heart failure medical management | CYC 2016 Oxygen therapy Oxygen Therapy in SpO2 <90% or PaO2 <60 mmHg FiO2 ≥0.4 may cause detrimental hemodynamic effects (hyperoxia- induced vasoconstriction)
- 22. 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)
- 23. Acute Heart failure medical management | CYC 2016 Pharmacology Therapy
- 24. 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 Diuresis Symptom Relief
- 25. 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
- 26. Acute Heart failure medical management | CYC 2016 Volume Management Braunwald's heart disease 10th Ed
- 27. Acute Heart failure medical management | CYC 2016 Vasodilator Vasodilator Symptom Relief Reduce Mortality
- 28. Acute Heart failure medical management | CYC 2016 Cardiorenal Syndrome Braunwald's heart disease 10th Ed
- 29. Acute Heart failure medical management | CYC 2016 Cardiorenal Syndrome Vasodilator can help!
- 30. 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
- 31. 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
- 32. Acute Heart failure medical management | CYC 2016 Nitroprusside stealing phenomenon Vasodilator Nesiritide CCB Nitrates High dose Preload Afterload Venous Arterial PCWP/Pulmonary edema Coronary artery Myocardial O2 Consumption
- 33. Acute Heart failure medical management | CYC 2016 Vasodilator effect (Nitrates) ALARM-HF registryBraunwald's heart disease 10th Ed
- 34. Acute Heart failure medical management | CYC 2016 Vasodilator effect (Nitrates) ALARM-HF registry SBP介於100-120mmHg 幫助最⼤大
- 35. 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
- 36. Acute Heart failure medical management | CYC 2016 Nitrates Recent use of phosphodiesterase-5 inhibitors (sildenafil, tadalafil, and vardenafil) should be ruled out
- 37. 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
- 38. 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
- 39. 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
- 40. Acute Heart failure medical management | CYC 2016 Coronary artery CCB Nitrates High dose Nitroprusside stealing phenomenon Vasodilator Nesiritide Preload Afterload Venous Arterial PCWP/Pulmonary edema Myocardial O2 Consumption
- 41. 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
- 42. Acute Heart failure medical management | CYC 2016 Vasodilator Braunwald's heart disease 10th Ed
- 43. Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators Inotropic Symptom Relief Maintain end-organ function Increase Hemodynamic profile
- 44. Acute Heart failure medical management | CYC 2016 Inotropes Drugs for the Heart, 8th Edition
- 45. Acute Heart failure medical management | CYC 2016 Inotropes VasocontrictionVasodilation Inotropic Dobutamine Dopamine Norepinephrine Epinephrine 最⼩小單位：⼀一格(同格間沒差) Chonotropic ++ Arrhythmia risk+++ Arrhythmia risk++ Arrhythmia risk+ (high dose) Arrhythmia risk+ Milrinone Arrhythmia risk+ Hypotension
- 46. Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators Inotropic Vasodilator ＋
- 47. Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators Inotropic Vasodilator ＋/ - cAMP-mediated inotropy and reduce PCWP through vasodilation
- 48. Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators Inotropic Vasodilator ＋/ - cAMP-mediated inotropy and reduce PCWP through vasodilation Limited to dilated ventricles + reduced EF + SBP <90 mm Hg or low CO + congestion+organ hypoperfusion even short-term (hours to few days) : hypotension, atrial or ventricular arrhythmias, and an increase in in-hospital and possibly long-term mortality
- 49. 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
- 50. 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
- 51. 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
- 52. Acute Heart failure medical management | CYC 2016 Dopamine • Low-dose (≤2 μg/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
- 53. Acute Heart failure medical management | CYC 2016 Dopamine • Intermediate-dose dopamine (2 to 10 μg/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 μg/kg/min and then discontinued, avoid potential hypotensive effects of low-dose dopamine Drugs for the Heart, 8th Edition
- 54. Acute Heart failure medical management | CYC 2016 Dopamine • High-dose dopamine (10 to 20 μg/kg/min) • peripheral and pulmonary artery vasoconstriction (direct agonist effects on alpha1-adrenergic receptors) Drugs for the Heart, 8th Edition
- 55. 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
- 56. 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
- 57. Acute Heart failure medical management | CYC 2016 Dopamine Contraindication in ventricular arrhythmias, and pheochromocytoma MAO inhibitor 會影響代謝 Drugs for the Heart, 8th Edition
- 58. 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
- 59. Acute Heart failure medical management | CYC 2016 Epinephrine Full beta receptor agonist • inotropy independent of myocardial catecholamine stores (移植時 denervative好⽤用 ) Potent inotropic agent • balanced vasodilator and vasoconstrictor effects Contraindications : late pregnancy Drugs for the Heart, 8th Edition
- 60. 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
- 61. 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
- 62. Acute Heart failure medical management | CYC 2016 Mechanism World J Cardiol 2016 July 26; 8(7): 401-412
- 63. Acute Heart failure medical management | CYC 2016 Mechanism Ca 藉由SERCA 回到 Sarcoplasmic reticulum • SR內Ca濃度上升可以幫助Systolic phase的釋出⼼心肌收縮 • Cytoplasm內Ca濃度的下降幫助 Diastolic phase的⼼心肌舒張 PDEI 作⽤用在這裡 最終增加Ca回收 cAMP
- 64. 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
- 65. Acute Heart failure medical management | CYC 2016 Vasodilation in smooth muscle 千萬不要跟Nitrate並⽤用
- 66. Acute Heart failure medical management | CYC 2016 Mechanism Subcellular localization • possibility to stimulate inotropy without increasing heart rate • Bypasses receptor downregulation
- 67. 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)
- 68. Acute Heart failure medical management | CYC 2016 Levosimendan Anesthesiology 3 2006, Vol.104, 556-569 Anesthesiology 3 2006, Vol.104, 556-569
- 69. 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
- 70. 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)
- 71. Acute Heart failure medical management | CYC 2016 Sympathomimetic Inotropes and inotropic dilators Inotropic ＋ Vasopressor
- 72. 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
- 73. 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
- 74. Acute Heart failure medical management | CYC 2016 Recommend Dosing Braunwald's heart disease 10th Ed