Emergency Management of Acute Decompensated Heart Failure - PowerPoint PPT Presentation

Loading...

PPT – Emergency Management of Acute Decompensated Heart Failure PowerPoint presentation | free to download - id: 5140bd-ZTMwZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Emergency Management of Acute Decompensated Heart Failure

Description:

Emergency Management of Acute Decompensated Heart Failure Hani Ramadan PharmD Candidate 4/19/2007 Beaumont Hospital Royal Oak, MI * Milrinone VD/Inotrope = inc. CO ... – PowerPoint PPT presentation

Number of Views:628
Avg rating:3.0/5.0
Slides: 52
Provided by: hani156
Learn more at: http://www.royaloasispharmacy.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Emergency Management of Acute Decompensated Heart Failure


1
Emergency Management of Acute Decompensated Heart
Failure
  • Hani Ramadan
  • PharmD Candidate
  • 4/19/2007
  • Beaumont Hospital Royal Oak, MI

2
  • CC Weakness and Shortness of Breath.
  • 4/06/07 (ER)
  • HPI
  • BH is a 95 year-old female with a known history
    of CHF, HTN, anxiety. Patient presents with
    altered mentation along with swelling in the legs
    and arms.
  • PMH
  • HTN, CVA, chronic atrial fibrillation, anxiety.

3
Allergies PCN (rash) SH Lives at home, has a
24 hour caregiver. Medications at Home Atenolol
25 mg qd, pantoprazole 40mg qd, ASA 81 mg qd,
lorazepam 1 mg qhs, clopidogrel 75 mg qd,
acetaminophen 500 mg qid prn, ciprofloxacin 500mg
bid. Physical assessment 3 edema from waist
down. VS H411 W50.0kg T 36oC, P 96,
RR18,BP114/86 HEENT conjunctivae and lids
have no pallor and no jaundice. Pupils equal,
round and reactive to light and accomodation.
Ears, nose and throat normal.
4
  • Lungs bilateral basilar crackles.
  • CV heart rhythm irregular.
  • Abd soft. no n/v/d, no hepatosplenomegaly.
  • Neuro lethargic. GCS14.
  • Labs
  • Na 139 WBC 10.5 Scr 1.8 BNP 1343
  • K 4.1 HGB 9.6 BUN 30 AG 9
  • Cl 108 HCT 48 Plt 296 CK 171 MB 6.4
  • X-Ray small left effusion, atelectasis, no
    pneumothorax.
  • EKG atrial fibrillation w ventricular response,
    with T wave inversions.

5
  • Physicians assessment/plan
  • Congestive Heart Failure Patient will receive IV
    diuretics and monitor for electrolytes.
  • 2. UTI Continue Cipro until the completion of
    the course.
  • Abnormal cardiac enzymes Represent myocardial
    injury. Cardiology consulted.
  • Acute Renal insufficiency Monitor creatinine,
    diuresis and BP.

6
Epidemiology
Mortality is approx. 50 at 5 years
5 million Dx in US
550 000 new cases/yr
1 million hospitalizations/ yr
Economic Costs approx. 29.6 billion (direct and
indirect costs)
Heart disease and stroke statistics- 2006 Update,
American Heart Association
7
Objectives
  • Review the pathophysiology of ADHF.
  • Describe the clinical presentation of ADHF.
  • Apply effective therapeutic strategies using
    consensus guidelines from the (HFSA) and the
    (ESC).
  • Examine the clinical evidence of milrinone and
    niseritide in the treatment of ADHF.
  • Evaluate the appropriateness of treatment.

8
ADHF
  • Rapid onset of signs and symptoms secondary to
    abnormal cardiac function due to systolic,
    diastolic dysfunction, abnormalities in cardiac
    rhythm or to pre-load and after-load mismatch.
  • De novo or acute decompensation of CHF.
  • 50 of patients have a systolic blood pressure
    gt140mmHg.
  • 46 of patients have a preserved (LVEF).
  • Patients often present with multiple
    co-morbidities.
  • Killip Classification.
  • Forrester Classification.
  • Clinical Severity Classification.

9
Pathophysiology
  • LV dysfunction
  • Accumulation of fluid.
  • Decrease in CO Hypoperfusion.
  • Reciprocal Activation of (RAAS)
  • Na, water retention.
  • AGII ET1 Vasopressin.
  • Reflex activation of SNS Epi, NE.

10
Killip Classification
  • Stage I No clinical signs of decompensation.
  • Stage II Heart failure. Rales, S3, PVH.
  • Stage III Severe heart failure. Pulmonary edema
    with rales throughout the lung fields.
  • Stage IV Cardiogenic Shock Hypotension,
    peripheral vasoconstriction, oliguria, cyanosis
    and diaphoresis.

11
Forrester Classification
Cardiac Index (L/min/m2)
18 mmHg
5
Subset I (Normal) Warm and Dry Subset II (Congestion) Warm and Wet
Subset III (Hypoperfusion) Cold and Dry Subset IV (Congestion and hypoperfusion) Cold and Wet
4
3
2.2L/min/m2
2
1
10
20
30
Pulmonary Capillary Wedge Pressure (mmHg)
Nohria A et al. JAMA.2002287 628-40
12
Common Precipitating Factors
  • Medication non-adherence.
  • Dietary indiscretion.
  • Infection (pneumonia, UTI, etc.)
  • Renal failure.
  • Cardiotoxic/nephrotoxic medication.
  • Uncontrolled hypertension
  • Cardiac Arrhythmias
  • Myocardial ishemia
  • Valvular disease
  • Pulmonary embolus
  • COPD
  • Anemia
  • Thyroid disorders
  • Nondihydropyridine CCB
  • Sodium retaining medications

13
Clinical Presentation
Volume Overload Low Cardiac Output
Dyspnea/Fatigue Rales/Wheezing JVD/HJR/AJR Pulmonary/Pitting Edema Reduced oxygen saturation S3 or S4 Electrolyte disturbance Increased serum creatinine Narrow Pulse Pressure Altered Mental Status Pre-renal azotemia Cool extremities Decreased urine output Refractory to IV diuresis
14
Differential Diagnosis
  • Pneumonia
  • Reactive airway disease
  • Pulmonary embolus

15
Diagnosis
  • Diagnosis of ADHF should be primarily based on
    signs and symptoms. (C)

16
Diagnosis
Low-Intermediate clinical suspicion of ADHF
BNP (A)
BNP gt 500pg/ml
BNP lt 50-100pg/ml
BNP 100-500pg/ml
ADHF more likely
Likely, but consider other causes
ADHF less likely
17
Predictors of Mortality
  • BUN gt 43 mg/dl
  • SBP lt 115 mmHg
  • sCr gt2.75 mg/dl


Highest risk of mortality
Fonarow GC et al. JAMA. 2005293572-80
18
Goals of Therapy
  • Improve symptoms and signs of congestion and/or
    hypoperfusion.
  • Reverse hemodynamic abnormalities.
  • Identify the etiology.
  • Minimize side effects.
  • Optimize therapy.
  • Length of stay, mortality, time to hospital
    readmission.
  • Educate patients on medications and self
    assessment of HF.

19
Treatment Strategy
  • Establish a Diagnosis
  • Oxygen and Ventilatory Assistance
  • Symptom Relief
  • Anticoagulation
  • Hemodynamic Support
  • Diuresis/Fluids
  • Vasodilators
  • Inotropes
  • Vasopressors
  • Assess Patient Response
  • Anti-infectives
  • Glucose Control

20
The Principle
Reduce Fluid Overload Reduced Preload (E-DVf),
PCWP
  • Diuretics
  • Inotropes
  • Vasodilators

Increase Contractility Increase CO, EF, Perfusion
Reduce Preload Reduce Afterload
21
Assess Signs/Symptoms/Determine Hemodynamic Status
EC Interventions Cardiac panel (CBC w/diff
platelets, SMA-7 CK-MB, Glucose), TSH, Pox,
ECG, BNP, X-ray
Abnormal
Normal
Consider alternative diagnosis
Evaluate cardiac function by 2DE
Does Patient presents with Distress or pain ?
Characterize type and severity
yes
Is patient hypoxic?
Morphine 3 mg IVPB IIbB
Yes
Does patient present with ischemic chest pain
resistant to opiates or tachycardia?
No but difficult breathing
Oxygen C
CPAP NIPPV
Metoprolol 5 mg IV IIbC
22
Volume Overloaded
(A) Moderate Volume Overload
IV Diuretics Furosmide 20-40 mg Bumetanide
0.5-1.0 mg Torasemide 10-20 mg IB/B
Consider Dopamine lt2-3 ug/kg/min
IIbC Ultrafiltration or Hemodialysis C
Inadequate Response lt 250-500 ml within 2 hours
Consider Severe Volume Overload (B) Or Low
Cardiac Output (C)
Na/fluid restriction Add HCTZ 25-50 mg bid,
or Metolazone 2.5-10 mg qd, or Spironolactone
25-50 mg qd IIbC/C
Refractory to loop thiazides
23
(B) Severe Volume Overload SBPgt90 mmHg
IV Diuretics /- IV Vasodilators Furosmide 40-100
mg IV then 5-40 mg/h inf. Bumetanide 1-4
mg Torasemide 20-100 mg PLUS Nitroglycerin 5-10
ug/min inf. Class IIbC/C
24
(C) Low Cardiac Output
SBP 85-100 mmHg
SBP lt 85 mmHg
SBP gt100 mmHg
Volume repletion Inotrope IIaC/C And/or Dopamine gt
5ug/kg/min
On a B-blocker chronically?
Vasodilator (NTG, Nitroprusside)C
No or D/C
Yes/No
Dobutamine IIaCC 2-3 ug/kg/min
inf. -20ug/kg/min inf.
Consider D/C or reducing dose if sign of
excessive dose are suspected
Hypoperfusion resolving?
Milrinone 25-75ug/kgIVPB over10-20min Then
0.37-0.75ug/kg/min inf. IIbC/IIaCC
yes
No
(D)
Tapper off dobutamine by steps of 2 ug/kg/min
qod optimize tx with hydralazine and/or ACE-I
25
(D) Unresolved hypoperfusion
Transient use of Vasopressor therapy
Use of invasive hemodynamic monitoring C
Epinephrine 0.05-0.5 ug/kg/min inf.
Norepinephrine 0.2-1ug/kg/min /- dobutamine
0.05-0.5 ug/kg/min inf.
26
Monitoring Parameters
  • Oxygen Saturation
  • CBC
  • BP
  • ECG
  • BNP
  • Signs
  • Edema, Rales, Ascites, Hepatomegaly, JVD
  • Symptoms
  • Orthopnea, PND, Dyspnea, Fatigue, Cough
  • Negative/positive balance
  • Electrolytes
  • Urinalysis
  • BUN/Scr
  • ABG

27
(OPTIME-CHF)
  • Outcomes of a Prospective Trial of Intravenous
    Milrinone for Exacerbations of Chronic Heart
    Failure

JAMA, March 27 2002 287(12)1541-1547
Objective To prospectively test whether a
strategy that includes shortterm use of
milrinone in addition to standard therapy can
improve clinical outcomes of patients
hospitalized with an exacerbation of chronic
heart failure.
28
Study Design
  • Prospective randomized double-blind
    placebo-controlled trial.
  • ITTA.
  • Similar baseline characteristics.
  • Randomization to a 48 hour infusion of either
    milrinone (n 477) or placebo ( 472).
  • Milrinone treatment arm Started with an initial
    infusion of 0.5ug/kg/min for 48hrs. (Rate
    adjusted to 0.375 ug/kg/min)

29
Outcome Measures
  • Primary Efficacy Outcome
  • The total number of days hospitalized for
    cardiovascular causes or days decreased within
    the 60 days after randomization.
  • Secondary endpoints
  • Failed therapy because of adverse events.
  • Failed therapy because of worsening heart
    failure.
  • Proportion of patients achieving target doses of
    ACE-I therapy.
  • Time to achieve target ACE-I dose.
  • Symptom improvement in HF score.

30
Patient Selection
Inclusion Criteria Exclusion Criteria
?18 yoa Demonstrated LVEF lt 40 -If physician judged that inotropic therapy was essential. -Active myocardial ischemia within past 3 months. -Atrial fibrillation with poor ventricular rate control. -Sustained VT/Vf.
31
Results
  • Treatment with milrinone did not reduce the
    primary endpoint of days hospitalized for
    cardiovascular causes within 60 days compared
    with placebo.

32
Results (cont)
Placebo (n472)
Milrinone (n 477)
P value
  • Treatment failure cause at 48 hours
  • Adverse event
  • Events during hospitalization
  • MI
  • New atrial fibrillation/flutter
  • Ventricular tachycardia/fibrillation
  • Sustained hypotension

2.1 12.6 lt0.001 0.4 1.5
lt0.18 1.5 4.6 lt0.04 1.5
3.4 lt0.06 3.2 10.7
lt0.001
33
Limitations
  • Study did not directly address patients with
    acutely decompensated chronic heart failure for
    whom inotropic therapy is essential.
  • Non-formal therapeutic protocol.
  • Confounding variables.

34
Conclusions
  • Results do not support the routine use of
    milrinone in patients hospitalized with an
    exacerbation of chronic heart failure.

35
(VMAC)Intravenous Nesiritide vs Nitroglycerin
for Treatment of Decompensated Congestive Heart
Failure
  • Objective To compare the efficacy and safety of
    intravenous nesiritide, intravenous nitroglycerin
    and placebo.

36
Study Design
  • Randomized double-blind, double dummy trial.
  • Patients were stratified to catheterized (n246)
    and non-catheterized (n 243)
  • Patients were then randomized to fixed dose
    nesiritide, adjustable dose niseritide,
    nitroglycerin or placbo for the first 3 hours.
  • After 3 hours patients were in the double dummy
    design of nesiritide and nitroglycerin treatment
    arms.

37
Outcome Measures
  • Primary Endpoint Change in PCWP and patients
    self-evaluation of dyspnea from baseline at
    3hours.
  • Secondary Endpoints
  • Onset of effect on PCWP
  • Effect on PCWP 24 hrs after the start of study
    drug
  • Self-assessed dyspnea and global clinical status
  • Overall safety profile.

38
Inclusion
Inclusion Criteria Exclusion Criteria
Dyspnea at rest Cardiac etiology of dyspnea SBPlt90 Volume depletion CI to IV vasodilators Mechanical ventillation Survival less than 35 days
39
Results
  • Reduction in PCWP was greater in the nesiritide
    group with the first measurement.
  • Beyond 24hr the difference in PCWP between
    nesiritide and nitroglycerin was insignificant.
  • Improvement in dyspnea and global clinical status
    scores in the nesiritide and nitroglycerin were
    not significantly different at any time.
  • HA was more common in the Nitroglycerin group.

40
Limitations
  • Heterogenous patient population
  • Therapeutic protocol.
  • Assessment of mortality/morbidity

41
Conclusion
  • When added to standard care in hospitalized
    patients with ADHF, nesiritied improves
    hemodynamic function and some self-reported
    symptoms more effectively than intravenous
    nitroglycerin.

42
  • CC Weakness and Shortness of Breath.
  • 4/06/07 (ER)
  • HPI
  • BH is a 95 year-old female with a known history
    of CHF, HTN, anxiety. Patient presents with
    altered mentation along with swelling in the legs
    and arms.
  • PMH
  • HTN, CVA, chronic atrial fibrillation, anxiety.

43
Allergies PCN (rash) SH Lives at home, has a
24 hour caregiver. Medications at Home Atenolol
25 mg qd, pantoprazole 40mg qd, ASA 81 mg qd,
lorazepam 1 mg qhs, clopidogrel 75 mg qd,
acetaminophen 500 mg qid prn, ciprofloxacin 500mg
bid. Physical assessment 3 edema from waist
down. VS H411 W50.0kg T 36oC, P 96,
RR18,BP114/86 HEENT conjunctivae and lids
have no pallor and no jaundice. Pupils equal,
round and reactive to light and accomodation.
Ears, nose and throat normal.
44
  • Lungs bilateral basilar crackles.
  • CV heart rhythm irregular.
  • Abd soft. no n/v/d, no hepatosplenomegaly.
  • Neuro lethargic. GCS14.
  • Labs
  • Na 139 WBC 10.5 Scr 1.8 BNP 1343
  • K 4.1 HGB 9.6 BUN 30 AG 9
  • Cl 108 HCT 48 Plt 296 CK 171 MB 6.4
  • X-Ray small left effusion, atelectasis, no
    pneumothorax.
  • EKG atrial fibrillation w ventricular response,
    with T wave inversions.

45
  • Physicians assessment/plan
  • Congestive Heart Failure Patient will receive IV
    diuretics and monitor for electrolytes.
  • 2. UTI Continue Cipro until the completion of
    the course.
  • Abnormal cardiac enzymes Represent myocardial
    injury. Cardiology consulted.
  • Acute Renal insufficiency Monitor creatinine,
    diuresis and BP.

46
Summary
47
References
  • Adams KF et al. J Card Fail. 2006 1210-38.
  • Nieminem MS et al. Eur Heart J 2005 26384-416.
  • Cherney D. et al. Management of Patients with
    Hypertensive Urgencies and Emergencies. JGIM
    200217937-944.
  • Krum H. et al. New and Emerging Drug Therapies
    for the Management of Acute Heart Failure.
    Internal Medicine Journal 200333515-520.
  • Peacock W. F. et al. Acute Emergency Department
    Management of Heart Failure. Heart Failure
    Reviews 20038335-338.
  • Wang T. J. et al. Plasma Natriuretic Peptide
    Levels and the Risk of Cardiovascular Events and
    Death. NEJM 2004350(7)655-663.
  • Alan S. M. et al. Cardiac Natriuretic Peptides A
    Proteomic Window to Cardiac Function and Clinical
    Management. Reviews In Cardiovascular Medicine
    20034(4)S3-S12.
  • Millane T. et al. ABC of Heart Failure Acute and
    Chronic Management Strategies. BMJ
    2000320559-562.
  • DiDomenico RJ.The Annals of Pharmacotherapy 2004
    April38649-660
  • Gregg C. F. et al. The Treatment Targets in Acute
    Decompensated Heart Failure. Reviews In
    Cardiovascular Medicine 20012(2)S7-S12.
  • Diagnosis and Treatment of Acute Heart Failure.
    Retrieved from www.guidelines.gov 2002.
  • Acute Exacerbation of CHF. Australian Heart
    Foundation 200643-49.
  • Rapid Optimization Strategies for Optimal Care
    of Decompensated Congestive Heart-Failure
    Patients in the Emergency Department. Reviews In
    Cardiovascular Medicine 20023(4)S41-S48.
  • Hunt S. A. et al. A Report of the American
    College of Cardiology/American Heart Association
    Task Force on Practice Guidelines (Committee to
    Revise the 1995 Guidelines for the Evaluation and
    Management of Heart Failure). ACC/AHA Practice
    Guidelines 20011-55.
  • VMAC Investigators. JAMA. 20022871531-40.

48
Questions?
49
Level of Evidence
  • Heart Failure Society of America
  • Level A Randomized controlled clinical trials
  • Level B Cohort and case-control studies
  • Level C Expert opinion
  • European Society of Cardiology
  • Class I Evidence and/or general agreement that
    a given diagnostic procedure/treatment is
    beneficial, useful and effective
  •  
  • Class II Conflicting evidence and/or a divergence
    of opinion about the usefulness/efficacy of the
    treatment
  •  
  • Class IIa Weight evidence/opinion is in favour of
    usefulness/efficacy
  •  
  • Class IIb Usefulness/efficacy is less well
    established by evidence/opinion
  •  
  • Class III Evidence or general agreement that the
    treatment is not useful/effective and in some
    cases may be harmful.
  •   
  • Levels of Evidence
  • Level of Evidence A Data derived from multiple
    randomized clinical trials or meta-analysis
  •  

50
Drug Usual Dose ? ß1 ß2 Vasodilation Vasoconstrixn Inotropic Chronotropic HR MAP PAP PWP CVP SVR SV CO
Epinephrine (Adrenaline) 0.01-0.1 µg/kg/min 0.1-0.5 µg/kg/min (1-4 µg/min) - - ? ? ? ? ? ?/? ?/? ?
Norepinephrine (Levophed) 0.03-1.5 µg/kg/min (2-80 µg/min) - - O/ ? ? ? ? ? ? ?/? ?/?
Dopamine (Dobutrex) 1-3 µg/kg/min 3-8 µg/kg/min 8-20 µg/kg/min - - - - a a a O/ ? O/ ? O/ ? O/ ? O/ ? O/ ? ?/? ?
51
Drug Usual Dose ? ß1 ß2 Vasodilation Vasoconstrixn Inotropic Chronotropic HR MAP PAP PWP CVP SVR SV CO
Dobutamine (Dobutrex) 2-30 µg/kg/min - - O/ ? O/ ? O/ ? O/ ? O/ ? O/ ? ? ?
Milrinone (Primacor) LD 50 µg/kg over 10 min., then 0.375-0.75 µg/kg/min - - - - O/ ? ? ? ? O/ ? ? ? ?
Gilman AG, Rall TW., et al. Goodman and Gilmans
The Pharmacological Basis of Therapeutics. 8th
ed. 1993. Marino P. The ICU Book. 2nd ed. 1998.
Young L., Koda-Kimble M. Applied Therapeutics.
6th ed. 1995. Kirby R., Taylor R., et. al.
Handbook of Critical Care. 2nd ed. 1997. Darovic
G., Franklin C. Handbook of Hemodynamic
Monitoring. 1999.
About PowerShow.com