Download Heart Failure - Laura J. Langenhop RN, BSN, PCCN, CHFN

Hemodynamics and
common
medications in the
heart failure patient
Laura J Langenhop BSN, RN, PCCN, CHFN
The Wright State University Class of 2015
oBJECTIVEs
• Identify the difference between systolic and diastolic
heart failure.
• Demonstrate understanding for the use of inotropes in
heart failure patients.
• Describe the pathophysiology of heart failure.
• Identify medications used in heart failure.
• Demonstrate understanding of the heart failure core
measures.
HOW DID MY PATIENT GET HEART
FAILURE?
• 1. Poorly Treated HTN
• 5. CAD
• 2. Myocardial Infarction
• 6. Cardiomyopathies (ex.
Alcohol-induced, viral,
drug-induced, restrictive,
hypertrophic)
• 3. Valve Disease
• 4. Atrial Fibrillation
• 7. Congenital Heart Defects
(Yancy et al., 2013; Papadakis,
McPhee, & Rabow, 2014)
SYSTOLIC VS. DIASTOLIC
HEART FAILURE
Systolic Heart
Failure
• The problem is with the ejection or the “pumping
ability”
• EF<40% by definition
• Common Causes: MI, CAD, untreated HTN, dilated
cardiomyopathy
(Yancy et al., 2013)
SYSTOLIC VS. DIASTOLIC
HEART FAILURE
Diastolic heart
failure
• The problem is with a stiff ventricle and not being able
to fill.
• EF >40%
• Common Causes: Age, Women, HTN, AFIB, CAD,
Restrictive Cardiomyopathy, Amyloidosis
(Yancy et al., 2013)
NYHA versus ACC/AHA Stages
of heart failure
What does the
patient look like?
Now We’re going to
the cath lab….
Are they…..
• Wet?
• Dry?
• Have Low cardiac Output?
• Pulmonary HTN?
• Do they have a blockage?
Right Heart
Catheterization
Left Heart
Catheterization
• Venous sheath is placed
• Arterial sheath is placed
• Looking at filling pressures
of the heart to assess volume
status
• Looking at coronary arteries
and need for intervention
(i.e. PCI, balloon)
• DO NOT need IV fluids or
aspirin prior to procedure.
• Need Aspirin 324 mg
ordered and 0.9% NS @
30mL/hr.
CATH LAB REPORT
Normal Pressures
Example of Report
RA
0-8 mm/Hg
10
RV
15-25/0-8 mmHg
42/14/24
PA
15-25/8-10 mmHg
44/17/27
PCWP
6-12 mmHg
15
CO
~4 to 8 L/min
3.8 L/min
CI
2.4 to 4 L/min/m2
2.0 L/m/m2
Common Inotropic
agents
renalfellow.blogspot.com
MILRINONE (Primacor)
• Phosphodiesterase inhibitor
•
•
•
Vasodilation
Inotropic Effects
Little chronotropic effect
• Onset: 5-15 minutes
• Half-life: ~2.5 hours
• Adverse Reactions: Hypotension,
Arrhythmias, Headache, Chest
Pain
• Uses: Volume overload with
decreased CO/CI, Right-sided
heart failure following LVAD
implant
(Marino, 2014)
Dobutamine
(dobutrex)
• Stimulates beta1-adrenergic
receptors causing increased
contractility and heart rate.
• Onset of Action: 1-10 minutes
• Half-Life: ~2 minutes
• Adverse Reactions: Arrhythmias,
Tachycardia, Angina, Palpitations
• Uses: Cardiac Decompensation,
Low CO/CI, Cardiogenic/Septic
Shock
• **Should not be on beta-blockers
if on this medication.
(Marino, 2014)
DOPAMINE
• Stimulates both adrenergic and
dopaminergic receptors. Goal is
to increase cardiac stimulation
and increase renal vasodilation.
• Onset of Action: ~5 minutes
• Half-Life: ~2 minutes
• Adverse Reactions: Low/High
BP, Palpitations, Arrhythmias,
Nausea, Vomiting, Tissue
Necrosis (must go through
central line)
• Uses: Inotropic support and renal
blood flow.
(Marino, 2014)
Qualifications for
inotropic agents
• Cardiac Index <2.2 L/min/m2 prior OR Wedge >20 mmHg prior
to starting.
• Dyspnea at rest
• Maximum dosage of Digoxin, Loop Diuretic, ACE, or vasodilator
(unless reason documented).
• Qualification for Home Inotropic Therapy: Need CI increased by
20%, wedge pressure decrease by 20%, and improved shortness of
breath
pathophysiology OF
heart failure
(Marino, 2014)
DIURETICS
lOOP DIUERTICS
(Furosemide (Lasix), Torsemide (demadex), and
bumetanide (Bumex)
• Given for Acute Decompensated Heart Failure in
Intravenous Form.
• Loop diuretics work by increasing the excretion of
water and sodium excreted by the kidneys.
• Side Effects: Muscle cramps, hypokalemia,
hypomagnesemia, increase in Creatinine, dizziness,
hypotension.
• Consider to Hold: Dramatic increase in Creatinine or
patient is hypotensive.
• On discharge, patient’s will go home with oral Lasix,
Bumex, oral Demadex
Felker et al., 2011
dIURETIC CONVERSION
Bumex
Lasix
Demadex
Equivalent Dose
1 mg
40 mg
20 mg
Bioavailability
~60-80%
50-60%
80%
Usual Dose
0.5 mg-2 mg
(QD or BID)
20 mg-80 mg
(QD-BID)
10 mg-40 mg
(QD-BID)
Duration
4 hours
6 hours
6 hours
(LexiComp, 2015)
Thiazide diuretics
(Metolazone, hydrochlorOthiazIDe,
DIURIL)
• Inhibits sodium reabsorption in the distal tubules
causing increased excretion of sodium and water.
• Diuril will be seen in combination with lasix in the IV
form
• Metolazone may be given as needed, depending on the
patient’s resistance to diuresis.
• Side Effects: Hypotension, Dizziness, fatigue,
headache, N/V/D, hypokalemia, hypomagnesemia
Aldosterone antogonists
(ex. Spirolactone, Eplerenone)
• Competes with aldosterone for receptor sites thereby
increasing sodium and water excretion.
• Uses: NYHA Class III-IV Heart Failure
• Adverse Effects: Hyperkalemia, Hypotension,
Headache, Confusion, Gynecomastia, Renal Failure,
Nausea, Vomiting, Diarrhea.
• Reasons to Hold: If K is >5 or Cr. >2.5
ACCF/AHA 2013 Heart Failure Guidelines
Tolvaptan (samsca)
• Used in patients with hypervolemic or euvolemic
hyponatremia
• Vasopressin antagonist causing excretion of free water
without loss of electrolytes. This results in fluid loss,
increased urine output, and increased serum Na levels.
• Normal dosing: 15 mg-60 mg
• When to hold: If serum Na level increases >10 mEq in
24 hours or if serum Na level is within normal level.
Ace-iNHIBITORS
(i.e. lisinopril, captopril, enalapril)
• Prevents conversion of
Angiotensin 1 to Angiotensin 2
causing vasodilation. Reduce
Afterload and help with
remodeling.
• Indication: High Blood
pressure, <40% EF.
• Adverse Reactions:
Hypotension, Renal
Insufficiency, Hyperkalemia,
Angioedema, Cough, Swelling
of the tongue *EMERGENCY.
• Reasons to Hold: Acute
increase in Creatinine, K >5,
and hypotension
www.medictest.com
Angiotensin II RECEPTOR
BLOCKERS
[Volsartan (Diovan,), losartan (cozaar)]
• Indications: HTN, EF <40%
• Blocks vasoconstriction and
aldosterone-secreting effects of
angiotensin II. Increases urinary flow
rate and increases excretion of
chloride, magnesium, uric acid,
calcium, and phosphate.
• Adverse Reactions: Fatigue,
Hyperkalemia, Hypotension
• Reasons to hold: Acute increase in
Cr., K >5, and hypotension
Vasodilators
Hydralazine
Isosorbide Mononitrate
(Imdur)
• Direct vasodilation of arterioles
with decreased systemic
resistance.
• Vasodilates peripheral veins and
arteries. Decreases cardiac oxygen
demand by decreasing pre-load.
• Adverse Reactions: Headache,
Hypotension, dizziness.
• Improves collateral flow to ischemic
regions.
• Consider holding for
hypotension
• Adverse Reactions: headache,
flushing, dizziness, fatigue, N/V/D,
hypotension.
Taylor et al., 2004
African American Heart Failure Trial
Beta-bLOCKERS
(I.e. mETOPROLOL SUCCINATE, CARVEDILOL)
• Metoprolol Succinate
• Beta-1 adrenergic Selective inhibitor
• Shown to decrease mortality and hospitalizations in patient’s with class IIIV heart failure
• Carvedilol
• Non-selective Beta-1 and Beta-2 adrenergic Selective inhibitor.
• Has shown to decrease PCWP, pulmonary resistance, renal vascular
resistance, decreased SVR
• Helps to decrease heart rate and blood pressure in order for the heart
to “pump” more effectively as well as remodeling the heart.
• Adverse Reactions: Fatigue, bradycardia, dizziness, hypotension
(COMET Trial, MERIT-HF Trial, Yancy et al., 2013)
DIGOXIN
• Heart Failure:
• Increases intracellular sodium promoting calcium influx
in the cell leading to increased contractility.
• Inhibits reabsorption of sodium
• Increases CO and renal blood flow
• +Inotropic effect
• AFIB:
• Used to suppress the AV node conduction in order to
increase refractory period.
• Enhances Vagal Tone
Reasons we stop this: Bradycardia, Renal insufficiency
Heart failure
CORE MEASURES
• Documented Left Ventricular Ejection Fraction
• ACE/ARB (EF <40%)
• Documentation of Beta-Blocker (Carvedilol, Metoprolol
Succinate, or Bisoprolol)
• Post-discharge heart failure appointment within 7 days of
Discharge
(GWTG, CMS, & TJC, 2014)
References
•
American Heart Association (2014). Heart Failure Core Measures.http://www.heart.org/idc/groups/heartpublic/@wcm/@private/@hcm/@gwtg/documents/downloadable/ucm_458657.pdf
•
Centers of Medicare and Medicaid. (2015). Medicare inotropic qualification checklist. http://www.pdfdrive.net/medicare-inotropic-qualification-checklist-e9799412.html
•
Felker, G. M., O’Connor, C. M., & Braunwald, E. (2009). Loop Diuretics in Acute Decompensated Heart failure necessary? evil? A necessary evil? Circulation, 2, 56-62.
doi:10.1161/_CIRCHEARTFAILURE.108.821785
•
Felker, M.G., Lee, K.L., Bull, D.A., Redfield, M.M., Stevenson, L.W.,…& O’Connor C.W. (2011). Diuretic strategies in patients with acute decompensated heart failure. New England
Journal of Medicine, 364, 797-805. doi: 10.1056/NEJMoa10005419.
•
Fuster, V., Asinger, R.W., Cannom, D.S., Crijns, H.J., Frye, R.L., & Torbicki, A. (2001). Guidelines for the management of patients with atrial fibrillation. Circulation, 104: 2118-2150.
http://circ.ahajournals.org/content/104/17/2118.full
•
Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G., ... Yancy, C. W. (2009, March 26). 2009 focused update: ACCF/AHA guidelines for the
diagnosis and management of heart failure in adults. Circulation, 119, 1977-2016. doi:10.1161/CIRCULATIONAHA.109.192064
•
Lexicomp (2014). Retrieved from http://webstore.lexi.comPDA-software-for-nurses
•
Lindenfeld, J., Albert, N.M., Boehmer, J.P., Collins, S.P., Ezekowitz, J.A.,…Walsh, M.A. (2010). Executive summary: HFSA 2010 Comprehensive heart failure practice guideline.
Journal of Cardiac Failure, (16)6. 1-259. http://www.heartfailureguideline.org/_assets/document/Guidelines.pd
•
Marino, P. L. (2014). The ICU book (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
•
Papadakis, S. J. McPhee, S. J. & Rabow, M.W. (2014), Current medical diagnosis & treatment 2014 (49th ed). New York, NY: Appleton & Lange
•
Taylor AL, Ziesche S, Yancy C, et al; (2004). the African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure.
New England Journal of Medicine, 351:2049-2057
•
Yancey, C.W., Jessup, M., Bozkurt, B., Butler, B.,..& Wilkoff, B.L. (2013). 2013 ACCF/AHA guidelines for the management of heart failure. Circulation, 128:1810-1852. doi:
10.1161/CIR.0b013e31829e8776