Acute decompensated heart failure
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| MAP | mean arterial pressure. 80-100 mmHg
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| CO | cardiac output 4-7 L/min
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| CI | Cardiac index 2.8-3.6 L/min/m^2
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| 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.
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| SVR | systemic vascular resistance 800-1200 d/s/cm^3
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| CVP | central venous pressure 2-6 mmHg
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| 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.
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| 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.
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| 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.)
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| 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.
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| 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.
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| 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.
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| 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.
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