Drugs for acute heart failure

chare · Aug 30, 2015

You've had nearly 300 views between this and your other post, and no one has responded. Why do you think this is so?

As I work PICU, I am unable to assist you with these questions. However, if you tell us what you think first, you might find the members here more willing to respond.

zzyzx · Aug 30, 2015

I don't know why. Is there something you know that I don't? I ask the question because i see so many different recomnendations, and i wonder which treatments are obsolete and what is current I am not an ICU nurse, and I have very little experience with these patients. Thanks

chare · Aug 30, 2015

I don't know why. Is there something you know that I don't? I ask the question because i see so many different recomnendations, and i wonder which treatments are obsolete and what is current I am not an ICU nurse, and I have very little experience with these patients. Thanks

When someone comes here and asks several questions, without demonstrating any effort on their part to answer them, it appears that they have not attempted to find an answer on their own or that they are ppsting a bomework assignment. While most members here are more than willing to help, they are more likely to do so if the OP has shown the effort to find the answer themselves.

As I stated previously, show us what you think and chances are you will get a better response.

allnurses Guide · Aug 31, 2015

Are you an RN? I would search a website for peer reviewed articles such as UptoDate or PubMed. Or look at the AHA guidelines.

http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/@gwtg/documents/downloadable/ucm_456868.pdf

Pheebz777, BSN, RN · Aug 31, 2015

Those are pretty vague patient profiles you provided so it is almost impossible to give you a straight answer. But what you need to keep in mind is how to prevent ventricular remodeling, preventing maladaptive compensatory mechanisms (RAAS, SNS stimulation), balancing cardiac output while lowering myocardial oxygen demand, and preventing fluid overload.

It's as simple as that! LOL!

zzyzx · Aug 31, 2015

Thanks for you responses. Yes, I have read UptoDate, as well as an older ICU book that I have. I posted the questions here because I wanted to get responses from nurses who have hands-on experience in these situations. There is only so much you can learn from books.

As an ER nurse and paramedic, I have had lots of pt's that presented with what can be called sympathetic-induced pulmonary edema. The pt presents with flash pulmonary edema and hypertension. These pt's I really liked getting when I worked on the ambulance because we could turn them around quickly with nitro spray and CPAP, to the point where they would go from being in acute distress on scene to calm and stable by the time we arrived at the ER.

However, I have little experience with pt's with cardiogenic shock. The only med on the ambulance that we ever had available to be used was dopamine (and event that was recently it was taken out of our protocols), but I never had occasion to use it in the field. In the ER, I have only seen a couple of patients in cardiogenic shock, and I remember the last one we had the doc ordered an epi drip. I wonder if that is really the right way to treat such a patient, or if dobutamine along with a vasopressor would be better. I know that dopamine has fallen out of favor.

In the ICU (where I have never worked), you probably have pt's who have acute heart failure with pulmonary edema, but you have stable BP's. UptoDate says dobutamine is the best drug for this situation. I understand that it has inotropic effects, which of course is what you would want, but that it also vasodilates. When I have asked co-workers in the ER about dobutamine, I have been told that it has fallen out of favor because of its vasodilatory effect, so I was surprised to see that UptoDate recommends it so strongly. (I was also surprised at how strongly they recommend Lasix, since in my experience with flash pulmonary edema patients it is not useful.)

Basically, I am not looking for book answers since I already know those myself. I am looking to hear from people with a lot more experience than I have to share their hands-on experiences with these issues. Thanks!

allnurses Guide · Aug 31, 2015

OK> posting 1, 2, 3 scenarios asking for "current drug recommendations" will yield just that. If you want opinions or experience, then asking that is more useful.

Dobutamine, dopamine and milrinone are all heavily used in acute decompensated heart failure. You must remember that acute decompensation is a whole different pathophysiologic ballgame and different rules apply. In cardiogenic shock, your primary problem is failure to pump blood. Therefore your primary treatment goal is to improve inotropy and forward flow. Your secondary problem is where the blood that is not being propelled forward ends up - in the lungs primarily (for LV failure). The ways to treat that are diuretics (if you have any blood pressure) and dilatation (eg. pulmonary vasodilation to improve oxygenation and reduce RV afterload and workload).

So its physician preference but we usually choose milrinone or dobutamine as first line. Dobutamine tends to cause more tachycardia and dysrhythmias, milrinone tends to cause more dilation and systemic hypotension. So either may or may not be tolerated. Dopamine gives us some of the benefits of those drugs without the more potent vasodilatory effects (sometimes) so may be used - or is used on the floor when docs don't want to transfer to ICU as the nurses can use dopamine....

Nitro is generally a no-no, at least in my experience, because these people don't have the systemic bp to support it. People with medically-managed ADHF often have BPs running 80-90s systolic.

Basically you want to reduce afterload, optimize preload, and diurese... the best combination of therapies is the one that lets you achieve any of these goals. Otherwise, you're headed to IABP/ECMO/VAD town.