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Decrease
Reduce
Preload
Fluid
And/or Augment
volume
After load Contractility
1- Toxic metabolites
Nitoprusside 2- Hypotension
3- Reflex tachycardia
4- Coronary steal
1- Hypotension
Nesiritide 2- Not associated with proarrhythmia
3- ??worsening of renal function
3) Inotropic Agents
Indications
1- Peripheral hypoperfusion with :
* hypotension
* decrease renal function.
2- With or without congestion.
3- Refractory HF to diuretics & VDs at
optimal doses.
1- Hypotension:
(milrinone > dobutamine > dopamine)
2- Tachycardia :
Potential
risk with IV (dopamine > dobutamine > milrinone)
Inotropes 3- Proarrhythmia :
(dopamine > dobutamine > milrinone)
4- Mortality.
5- Tachyphylaxis.
4) Beta blocking agents
* Overt AHF is considered a contraindication for BB use.
* Consider IV metoprolol if there is ongoing ischemia or
tachycardia.
(Class IIb Level of evidence C)
* Pts with AMI who stabilize after AHF start early
BB Rx.
(Class IIa Level of evidence B)
* Pts with chronic HF , start BB after AHF stabilization
( usually after 4 days )
(Class I Level of evidence A)
Does It Matter How
Congestion Is Relieved?
- Inotropic Therapy
. Increases mortality
-Diuretic Therapy
. Worsens neurohormonal activation
-Vasodilator Therapy
. Limits renal perfusion pressure.
JAMA 2002;287 :1541
III- Novel strategies for
management of ADHF
A- Neurohormonal aquaretic therapy:
1-Vasopressin RA(tolvaptan) = Samsca (trade name)
used for treatment of hyponatremia.
2-Adenosine type-1 RA .
B- Vasoactive therapy:
1-BNP (Nesiritide)
= Natrecor (trade name).
C- Inotropic therapy:
1-Calcium Sensitizers/PDEI(Levosimendan)
= Simdax (trade name).
D- Mechanical therapy:
1-Ultrafiltration.
2-Aortic Flow Augmentation Device.
Current Cardiology Review 2005;1:1-5.
Nesiritide
VMAC trial
(Vasodilatation in the Management of Acute Congestive heart failure)
PRECEDENT trial
(Prospective Randomized Evaluation of Cardiac Ectopywith
DobutaminE or Nesiritide Therapy)
FUSION-1 study
(Follow Up Serial Infusions Of Nesiritide)
CASINO study
(Calcium Senitizer or Inotropic or None in low
Output heart failere)
* Mortality rate than dobutamine & placebo (15.3% vs 24.7% vs
39.6% at 6 months).
Lancet2002;360:196-202.
Lancet 2002;360:196-202.
Lancet 2002;360:196-202.
J Am Coll Cardiol 2004;43:206.
Treatment of arrhythmias in AHF.
1- VF or pulseless VT :
*Defibrilation (360 J).
* If refractory inject Epinephrine (1mg) or Vasopressin (40 IU )
and/or Amiodarone (150-300 mg ).
2- VT :
* If pt is unstable C.V.
* IF pt is stable inject Amiodarone or Lidocaine ( medical C.V).
3- SVT :
* Use BB when pt is stable ( Metoprolol 5mg as slow IV bolus ).
* Adenosine may be used to slow AV conduction or to cardiovert
re-entry tachycardia.
Treatment of arrhythmias in AHF ( cont )
4- AF or A flutter :
* Pts with AHF& AF should be anticoagulated
* Paroxysmal AF medical or electrical C.V.
* If AF is > 48h pt should be anticoagulated + Optimal rate
control for 3 weeks before C.V ( by Amiodarone and BB ).
* If pt is unstable urgent C.V is mandatory ( LA thrombus
should be excluded by TEE ).
* Verapamil and Diltiazem should be avoided (they may worsen
HF and cause third degree HB).
5- Bradycardia :
* Atropine (o.25- o.5mg) IV to total 1-2mg.
* Theophylline may be used with Atropine resistant bradicardia
( bolus of o.25-o.5mg/kg & then infusion of o.2-o.4mg/kg/h ).
* If bradycardia persists Pacing.
Cardiac disorders and AHF
requiring surgical treatment
1- Cardiogenic shock after AMI in pts with MVD.
2- Post infarction VSD.
3- Free wall rupture.
4- Acute decompensation of pre-existing valve disease.
5- Prosthetic valve failure or thrombosis.
6- Ao aneurysm or dissection rupture into pericardial sac.
7-Acute MR or AR .
8-Rupture aneurysm of sinus of valsalva .
9- Acute decompensation of chronic CM requiring support
by VADs .