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BCPS study guide

Acute decompensated heart failure

MAP mean arterial pressure. 80-100 mmHg
CO cardiac output 4-7 L/min
CI Cardiac index 2.8-3.6 L/min/m^2
PCWP pulmonary cardiac wedge pressure. 8-12 mmHg in pts without HF but in HF pts prefer to keep at 12-18 to ensure adequate fill pressures.
SVR systemic vascular resistance 800-1200 d/s/cm^3
CVP central venous pressure 2-6 mmHg
inotropes used in ADHF. what are considered indications for inotropic support in these pts. dobutamine and milrinone. Only when PCWP 15-18, avoid use if not in this range, and CI < 2.2 ("cold" HF). Look at MAP, if greater than or = 50 mmHg, if so then pt should get an inotrope if SBP <90, has symptomatic hypotension or worsening renal failure.
How is PCWP measured and when is this indicated a Schwann Ganz catheter is used to measure PCWP, target 15-18 mmHg in ADHF pts to maintain adequate filling pressures. Use of invasive measurement not recommended however and inotropes not recommended unless can confirm pressures.
MOA of dobutamine and typical dose when used for inotropic support in ADHF increases conversion of ATP to cAMP via adenylyl cyclase. this increases CO. also has some peripheral vasodilation. dose 2.5-5 mcg/kg/min IV (typically 5 mcg/kg/min but max at 20.)
ADEs associated with dobutamine proarrhythmia, tachycardia, hypokalemia, MI, tachyphylaxis after ~48 hours, may increase mortality if used long term. use if pt hypotensive over milrinone which can cause further BP lowering.
ADEs associated with milrinone if pt on a beta blocker consider as opposed to dobutamine. proarrhythmia, hypotension (avoid bolusing), tachycardia, thrombocytopenia (rare), may increase mortality with long term use.
vasodilators used in ADHF. what are considered indications for vasodilator support. nitroprusside, nitroglycerine IV, nesiritide. used when pt has congestion ("wet" HF), reduces PCWP which is elevated >18 in pts with wet HF. can also use nesiritide or nitroprusside as alternatives to inotropes in pts with elevated SVR and low CO.
MOA of milrinone and typical dose for inotropic support in ADHF PDE inhibitor. increases CO by decreasing cAMP breakdown in heart. and in vascular smooth muscle to decrease SVR. typical dose 0.1-0.375 mcg/kg/min but technically can do 50 mcg/kg bolus f/b 0.375 mcg/kg/min up to 0.75.
Created by: mjuhlin



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