Drugs of the Heart Failure

Diuretics

For achieving optimal volume status

eliminate or minimize congestion
High doses of i.v diuretics 2-3 times
daily
More effective with continous i.v.
Combination diuretics
Resistent diuretics is a common
problem
Diuretics

For achieving optimal volume status

eliminate or minimize congestion
High doses of i.v diuretics 2-3 times daily
More effective with continous i.v.
Combination diuretics
Resistent diuretics is a common problem
Indication and dosing of diuretics in AHF
FUROSEMID

Pengenceran :
syringe pump : 100 mg (5 amp) /50 cc NaCl 0,9%
1 cc = 2 mg

Infus
90 cc NaCl 0,9% + 100 mg (5 amp) 100 cc= 100 mg
1cc = 1 mg
Misal dosis furosemid yang diinginkan 5 mg /jam
mikrodrip (5 cc/jam) = 300/60 menit = 5 tts/menit
Morphine and its analogues

In patient present with restlessness and

dyspnoea

Morphine induces
Venodilatation
Mild arterial dilatation
Reduce heart rate

Dose : 3 mg IV bolus, rate 1 mg/min.

Repeated if required

ESC guidelines Acute Heart Failure, 2012

Cara pengenceran

Morphine 1 ampul @1cc = 10 mg

Encerkan dengan aqua 10 cc
1 cc = 1 mg
Vasodilators
Nitroprusside, Nitroglycerin, Nitrate family

Work by cGMP mediated smooth muscle

relaxation -> vasodilation
Decrease myocardial work by afterload
and preload reduction
May cause hypotension
May cause headache
Nitrate
Not evaluated by large scale studies
Many studies shown their favorable effect
Limitation
Side effect
Nitrate Resistance
Nitrate Tolerance
Prevention
Intermittent dosing : 12 hour nitrate free interval
Escalating dose
Concomitant use of hydralazine

Elkayam, The American Journal of Cardiology

Intravenous Vasodilator used to treat AHF
pengenceran
ISDN
Sediaan ISDN ampul 10 cc = 10 mg
Syringe pump tanpa diencerkan 1 cc = 1 mg

Infus
1 amp (10 mg) dalam 100 cc NaCl 0,9%
100 cc = 10 mg
1 cc = 0,1 mg
Misal : dosis yang diinginkan 2 mg/jam
20 cc/jam
Makrodrip 20 tts x 20 = 400 tts/jam = 7 tts/menit
 Role of Inotropic Therapy in
Acute Heart Failure

The use of inotropes as a treatment of :

cardiogenic shock
diuretic/ACE inhibitor refractory heart failure
decompensations
a short-term bridge to definitive treatment, such
as revascularization or cardiac transplantation,
is potentially appropriate

Felker GM. Am Heart J. 2001;142:393401.

Inotropic Agent
Indication :
Peripheral hypoperfusion (hypotension, decrease
renal function) with or without congestion

Patients with CHF :

Clinical course, symptom and prognosis may depend on
haemodynamics parameter
Improvement of haemodynamics may become a goal of
treatment
Beneficial effect of improvement haemodynamics
potentially counteract by the rise of arrythmia (increase
oxygen demand, Ca++ loading, excessive increase in
energy) may potentially harmful
ESC, Acute Heart Failure, 2012
 Inotropes:
Dopamine, Dobutamine, Milrinone

Improve cardiac output

- by directly increasing cardiac contractility
Significant proarrhythmic effects
May precipitate ischemia
Not recommended for routine use in AHF, but
clearly have a role in specific patients
Inotropic Agents
Dopamine
Is dose dependent and they involve in three different receptors.

In low dose (< 2 g/kgBW/min),

vasodilatation occurs predominantly in renal, coronary, and cerebral vascular
beds.

At doses > 5 g/kgBW/min dopamine

will increase peripheral vascular resistance via adrenergic receptors

However if no response is seen in diuresis the therapy should be

terminated
(Level of evidence C, class IIb)

ESC, Acute Heart Failure, 2005

Drugs used to treat AHF that are positive
inotropes or vasopressor or both
 pengenceran
Sediaan 200/5 ml

Syringe pump 200 mg/50 cc NaCL 0,9%

Dosis sesuai tabel

Infus
200 cc +200 mg dopamin 1 cc = 1 mg = 1000 mikrogram

Misal : pasien dengan BB 50 kg memerlukan drip dopamin 5 mikro/KgBB/menit

Kebutuhan 5 x 50 kg = 250 mikrogram/menit 0,25 cc/menit
Mikrodrip : 0,25 x 60 = 15 tts/menit
 Inotropic Agents

Dobutamine
Clinical action is dose dependent positive
inotropic and chronotropic effects.
In low dose induce arterial vasodilatation
and in higher induce arterial
vasoconstriction

ESC, Acute Heart Failure, 2005

dobutamin
Sediaan 5 cc= 250 mg
syringe pump
50 cc = 250 mg
1 cc = 5 mg
dosis sesuai tabel

Infus
250 cc NaCl 0,9% + 250 mg dobutamin
1 cc = 1 mg
Misal : pasien dengan BB 50 kg memerlukan drip dobutamin 5 mikro/KgBB/menit
Kebutuhan 5 x 50 kg = 250 mikrogram/menit 0,25 cc/menit
Mikrodrip : 0,25 x 60 = 15 tts/menit
 Nor ephinefrine
Sediaan
4 ml = 4 mg
Syringe pump
50 cc = 4 mg
1 cc = 0,08 mg = 80 mikro
Infus
1 ampul dilarutkan dalam 200 cc NaCl 0,9%
200 cc = 4 mg
1cc = 0,02 mg = 20 mikro
Misal pasien dengan BB 50 kg membutuhkan Norephinefrin 0.1 mikro/kgBB/menit
50 x 0.1 = 5 mikro/menit
= 0,25 cc
Tetesan = 60 x 0,25 = 15 tts mikro
 Inotropic Agents

Phosphodiesterase inhibitors
Block the breakdown of cyclic AMP into
AMP (milrinone, enoximone)
In advance HF, associated with inotropic,
lusitropic, vasodilating effects
Intermediate between vasodilator and
predominant inotrope

ESC, Acute Heart Failure, 2012

Terima kasih