Note of management acute heart failure
Initially I just read the ESC 2016 guideline and was interested in choosing inotropic agents. I started to reads books and looked for more information.
Hypertension pharmacotherapy part 2 pptPranatiChavan
First-line medications used in the treatment of hypertension include diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), beta-blockers, and calcium channel blockers (CCBs). Some patients will require 2 or more antihypertensive medications to achieve their BP target. As per special consideration, modified treatment is given in the presentation.
Hypertension pharmacotherapy part 2 pptPranatiChavan
First-line medications used in the treatment of hypertension include diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), beta-blockers, and calcium channel blockers (CCBs). Some patients will require 2 or more antihypertensive medications to achieve their BP target. As per special consideration, modified treatment is given in the presentation.
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Perioperative management of patients on corticosteroidsTerry Shaneyfelt
In these annotated PowerPoints I discuss the evaluation and perioperative management of patient taking or who have taken steroids. I discuss how to determine if the adrenal axis is suppressed and how to provide supplemental glucocorticoids if needed. Remember to download these slides to see the annotations for each slide.
hypertension, simplified, jnc 8, treatment and newer modalities to treat. surgical procedures involved for hypertension and jnc 8 versus jnc 7 is compared in this ppt, and also, prevelance and epidemeiology of hypertension is explained. antihypertensives for preffered class and age are explained
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
24. Acute Heart failure medical management | CYC 2016
Diuresis
• clinically evident congestion: 4 to 5 liters of excess volume
• greater than 10 L are not uncommon
Diuresis
Symptom Relief
25. Acute Heart failure medical management | CYC 2016
Diuresis
Initial
• i.v. dose should be at least equal to the pre-existing oral dose
• 2.5 x the outpatient dose:
renal dysfunction/severe volume overload
*transient worsening in renal function
Titration should be rapid with doubling
Consider continuous infusion
• significant volume overload (>5 to 10 liters) or diuretic resistance
26. Acute Heart failure medical management | CYC 2016
Volume Management
Braunwald's heart disease 10th Ed
28. Acute Heart failure medical management | CYC 2016
Cardiorenal Syndrome
Braunwald's heart disease 10th Ed
29. Acute Heart failure medical management | CYC 2016
Cardiorenal Syndrome
Vasodilator can help!
30. Acute Heart failure medical management | CYC 2016
Cardiorenal Syndrome
Use of vasodilators was superior to ultraltration with
regard to preserving renal function and decongestion
Vasodilator Ultrafiltration
35. Acute Heart failure medical management | CYC 2016
Nitrates
Increased coronary blood flow
• Relatively selective for epicardial, (>intramyocardial, coronary arteries)
Goal
• immediate symptom relief
• MAP reduction > 10 mm Hg , SBP > 100 mm Hg
• dose may need to be reduced if SBP is 90 to 100 mm Hg and
often will need to be discontinued with SBP below 90 mm Hg
36. Acute Heart failure medical management | CYC 2016
Nitrates
Recent use of phosphodiesterase-5 inhibitors
(sildenafil, tadalafil, and vardenafil) should be ruled out
38. Acute Heart failure medical management | CYC 2016
Sodium Nitroprusside
a very short half-life (seconds to a few minutes)
SBP 90 to 100 mmHg are typical goals
Tapering the dose of before discontinuation
Cyanide toxicity:
• as low and as short as possible
• no longer than 10 minutes at top dose in the treatment of severe
hypertension
• contraindicated in hepatic or real failure
39. Acute Heart failure medical management | CYC 2016
Sodium Nitroprusside
Being replaced in….
severe acute-on-chronic heart failure by nitrates
hypertensive crises by intravenous nicardipine, fenoldopam, or labetalol
41. Acute Heart failure medical management | CYC 2016
Nesiritide
ASCEND-HF)
• minimal improvement in dyspnea
• as VMAC trial revealed reduced PCWP
• no beneficial effect on hospitalizations for HF or death within 30 days.
• increased incidence of symptomatic hypotension
• no differences in the rates of worsening renal function5
Recombinant human B-type [brain] natriuretic peptide
42. Acute Heart failure medical management | CYC 2016
Vasodilator
Braunwald's heart disease 10th Ed
43. Acute Heart failure medical management | CYC 2016
Sympathomimetic Inotropes and inotropic dilators
Inotropic
Symptom Relief
Maintain end-organ function
Increase Hemodynamic profile
44. Acute Heart failure medical management | CYC 2016
Inotropes
Drugs for the Heart, 8th Edition
46. Acute Heart failure medical management | CYC 2016
Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
+
47. Acute Heart failure medical management | CYC 2016
Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
+/ -
cAMP-mediated inotropy and reduce PCWP through vasodilation
48. Acute Heart failure medical management | CYC 2016
Sympathomimetic Inotropes and inotropic dilators
Inotropic
Vasodilator
+/ -
cAMP-mediated inotropy and reduce PCWP through vasodilation
Limited to
dilated ventricles + reduced EF + SBP <90 mm Hg
or low CO + congestion+organ hypoperfusion
even short-term (hours to few days) :
hypotension, atrial or ventricular arrhythmias, and an increase in in-hospital
and possibly long-term mortality
49. Acute Heart failure medical management | CYC 2016
Dobutamine
• Beta2 Increase CO via afterload reduction in low dose
• decreased aortic impedance and systemic vascular resistance
• Tachyphylaxis : infusions longer than 24 to 48 hrs
• long-term mortality may be increased,as well as increasing cardiac
sympathetic activity in heart failure patients
Drugs for the Heart, 8th Edition
50. Acute Heart failure medical management | CYC 2016
Dobutamine
Side effect:
• tachycardia, increasing ventricular response to Af, atrial and
ventricular arrhythmias, myocardial ischemia
• possibly cardiomyocyte necrosis (direct toxic effects and induction of
apoptosis)
Drugs for the Heart, 8th Edition
51. Acute Heart failure medical management | CYC 2016
Dopamine
• precursor of norepinephrine and releases norepinephrine
• Periphery this effect is overridden by the activity of the prejunctional
dopaminergic-2 receptors, inhibiting norepinephrine release and thereby
helping to vasodilate
Drugs for the Heart, 8th Edition
52. Acute Heart failure medical management | CYC 2016
Dopamine
• Low-dose (≤2 μg/kg/min)
• selective dilation of renal, splanchnic, and cerebral arteries (DA1R)
• Low dose Dopamine + low dose furosemide
• may improved renal function profile and potassium homeostasis
compared with high-dose furosemide (not conclusive!)
Drugs for the Heart, 8th Edition
53. Acute Heart failure medical management | CYC 2016
Dopamine
• Intermediate-dose dopamine (2 to 10 μg/kg/min)
• enhanced NE release, stimulating cardiac receptors with an increase in
inotropy and mild stimulation of peripheral vasoconstricting receptors
• dependent on myocardial catecholamine stores (ineffective in advance
stage )
• Dosing should be gradually decreased from to 3 to 5 μg/kg/min and then
discontinued, avoid potential hypotensive effects of low-dose dopamine
Drugs for the Heart, 8th Edition
54. Acute Heart failure medical management | CYC 2016
Dopamine
• High-dose dopamine (10 to 20 μg/kg/min)
• peripheral and pulmonary artery vasoconstriction (direct agonist
effects on alpha1-adrenergic receptors)
Drugs for the Heart, 8th Edition
55. Acute Heart failure medical management | CYC 2016
Dopamine
Cardiogenic shock or AMI
• 5 mcg/kg/min is enough to give a maximum increase in stroke volume
• Renal flow reaches a peak at 7.5 mcg/kg/min
• Arrhythmias may appear at 10 mcg/kg/min
Drugs for the Heart, 8th Edition
56. Acute Heart failure medical management | CYC 2016
Dopamine
In septic shock
Dopamine has an inotropic effect and increases urine volume
Dopamine is widely used after cardiac surgery
In critically ill hypoxic patients
• may depression of ventilation and increased pulmonary shunting
Drugs for the Heart, 8th Edition
57. Acute Heart failure medical management | CYC 2016
Dopamine
Contraindication in ventricular arrhythmias, and pheochromocytoma
MAO inhibitor 會影響代謝
Drugs for the Heart, 8th Edition
58. Acute Heart failure medical management | CYC 2016
Dopamine or Dobutamine
Dopamine is preferred if the patient requires
pressor effect (high-dose-effect)
+
increase in cardiac output
+
No marked tachycardia or ventricular irritability
Cardiogenic shock: infusion of equal concentrations may afford more
advantages than either drug singly
59. Acute Heart failure medical management | CYC 2016
Epinephrine
Full beta receptor agonist
• inotropy independent of myocardial catecholamine stores
(移植時 denervative好⽤用 )
Potent inotropic agent
• balanced vasodilator and vasoconstrictor effects
Contraindications : late pregnancy
Drugs for the Heart, 8th Edition
60. Acute Heart failure medical management | CYC 2016
Epinephrine
A low physiologic infusion rate ( 0.01 mcg/kg/min)
• decreases BP (vasodilator effect)
Cardiac arrest: combined inotropic-chronotropic stimulation
• High Dose: Alfa stimulation > Beta
Drugs for the Heart, 8th Edition
61. Acute Heart failure medical management | CYC 2016
Phosphodiesterase Inhibitors - Milrinone
Inhibition cAMP degraded
• increases inotropy, chronotropy, and lusitropy in cardiomyocytes
• vasorelaxation in vascular smooth muscle
• Peripheral and pulmonary vasodilation
• ESC: may be considered to reverse the effect of beta-blockade
Decrease Afterload and Preload and is Inotropic
Drugs for the Heart, 8th Edition
62. Acute Heart failure medical management | CYC 2016
Mechanism
World J Cardiol 2016 July 26; 8(7): 401-412
64. Acute Heart failure medical management | CYC 2016
Vasodilation in smooth muscle
Elvebak, R. L., Eisenach, J. H., Joyner, M. J. and Nicholson, W. T.
The Function of Vascular Smooth Muscle Phosphodiesterase III is
Preserved in Healthy Human Aging
65. Acute Heart failure medical management | CYC 2016
Vasodilation in smooth muscle
千萬不要跟Nitrate並⽤用
66. Acute Heart failure medical management | CYC 2016
Mechanism
Subcellular localization
• possibility to stimulate inotropy without increasing heart rate
• Bypasses receptor downregulation
67. Acute Heart failure medical management | CYC 2016
Attention
Extremely long duration
• elimination half-life of 2.5 hours
• pharmacodynamic half-life > 6 hours
Renally excreted
Hypotension and atrial and ventricular arrhythmias
OPTIME-HF (2002) N = 951 Compare with Placebo
• No change in Days with CV-related hospitalization
• excess sustained hypotension (P = .004), new atrial fibrillation/flutter (P
< .001), VT/VF (P = .06)
69. Acute Heart failure medical management | CYC 2016
Levosimendan
Increases myocardial contractility
Cardiac myofilament calcium sensitization by calcium-dependent (systolic)
troponin C binding
Peripheral vasodilation
activation of vascular smooth muscle potassium channels
Some in vitro PDEI activity
70. Acute Heart failure medical management | CYC 2016
Levosimendan
Benefit on mortality?
SURVIVE (2007) N = 1327 Compare with Dobutamine
• No change in dyspnea at 24 hr, days alive out of hospital at 180 days,
all-cause mortality at 31 days, CV mortality at 180 days
REVIVE-2 (2013) N = 600 Compare with Placebo
• More frequent hypotension and cardiac arrhythmias during infusion period;
• numerically higher risk of death, 90 days (REVIVE-1,-2: Levo, 49 deaths/
350 pts. vs. placebo, 40/350, P = .29)
71. Acute Heart failure medical management | CYC 2016
Sympathomimetic Inotropes and inotropic dilators
Inotropic
+
Vasopressor
72. Acute Heart failure medical management | CYC 2016
Vasopressor
Vasopressor (norepinephrine preferably)
considered in cardiogenic shock+ treatment with another inotrope
• to increase blood pressure and vital organ perfusion
• increase in LV afterload
Norepinephrine > Dopamine (fewer side effects and lower mortality)
Epinephrine : restricted to persistent hypotension
despite adequate cardiac filling pressures and the use of other vasoactive agents
73. Acute Heart failure medical management | CYC 2016
Norepinephrine
Logically, should be of most use:
shock-like state + peripheral vasodilation (“warm shock”)
• Combination with PDE inhibitors helps to avoid the hypotensive effects
of the PDE inhibitors
• Contraindications :late pregnancy and preexisting excess
vasoconstriction
Braunwald's heart disease 10th Ed
74. Acute Heart failure medical management | CYC 2016
Recommend Dosing
Braunwald's heart disease 10th Ed