Emergency Diagnosis and Treatment of Acute Decompensated
Transcription
Emergency Diagnosis and Treatment of Acute Decompensated
EMERGENCY DIAGNOSIS AND TREATMENT OF ACUTE DECOMPENSATED HEART FAILURE (ADHF) - MARCH 2005 Produced by © 2005 EMCREG-International www.emcreg.org EMERGENCY DIAGNOSIS AND TREATMENT OF ACUTE DECOMPENSATED HEART FAILURE (ADHF) IN THIS ISSUE CME Monograph from the ACEP 2005 Spring Congress Satellite Symposium Orlando, Florida March 4, 2005 EMCREG-International This educational monograph was supported in part by an unrestricted educational grant from Scios. 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THAT DOBUTA MINEDOES)NGENERALGIVENTHEIRINABILITYTOAFFECT OUTCOMEANDINCREASEDINCIDENCEOFADVERSEEFFECTS INOTROPICSUPPORTSHOULDBERESERVEDFORPATIENTSWITH VERYLOWCARDIACOUTPUT4HEYSHOULDONLYBEUSEDIN THE%$SETTINGONPATIENTSWITHSYMPTOMATICHYPOTEN SIONUNTILFURTHERTHERAPYINTRAAORTICBALLOONPUMP CANBEINSTITUTED #ALCIUM SENSITIZERS SUCH AS LEVOSIMENDAN PRODUCE INCREASED INOTROPY IN A CYCLIC !-0INDEPENDENT FASHIONBYINCREASINGTHESENSITIVITYOFTROPONIN#TO INTRACELLULAR IONIZED CALCIUM AS WELL AS PERIPHERAL VASODILATION THROUGH THE VASCULAR +!40ASE CHAN NELS !N EFFECTIVE POSITIVE INOTROPE LEVOSIMENDAN INCREASESINSTROKEVOLUMEANDCARDIACINDEXANDDE CREASES 0#70 RIGHT ATRIAL PRESSURES PULMONARY AR TERIALPRESSURESANDMEANARTERIALPRESSURES)NTHIS STUDYTHEHEMODYNAMICEFFECTSWEREMAINTAINEDDUR INGAHOURINFUSIONANDFORATLEASTHOURSAFTER DISCONTINUATION 7HEN LEVOSIMENDAN WAS ADDED TO DOBUTAMINEIN.EW9ORK(EART!SSOCIATIONCLASS)6 PATIENTS REFRACTORY TO DOBUTAMINE AND FUROSEMIDE OFPATIENTSGETTINGALLTHREEAGENTSCOMPAREDTO NONE 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WITH DECREASEDMYOCARDIALOXYGENCONSUMP TION AND A DECREASE IN VENTRICULAR STRESS A STIMULUS PRESUMED TO DRIVE THE NEU ROHORMONAL ACTIVATION OF!$(& ,ASTLY TOLERANCETOTHESEEFFECTSDOESNOTOCCUR ANDTHESECHANGESINHEMODYNAMICSARE PRESENTANDPERSISTENTTHROUGHOUTTHEAD MINISTRATIONOFNESIRITIDE 4ODATENESIRITIDEISTHEONLYNATRIURETIC PEPTIDEAVAILABLEINTHE53FOR)6THERA PY#OLUCCIETALINTHE%FlCACY4RIAL SHOWED THAT NESIRITIDE CAUSES A DOSERE LATED DECREASE IN 0#70 SYSTEMIC VAS CULARRESISTANCEMEANRIGHTARTERIALPRES SURE DYSPNEA FATIGUE A SIGNIlCANT IN CREASEINCARDIACINDEXANDANIMPROVE MENTINGLOBALSTATUS4HEMOSTCOMMON SIDE EFFECT WAS DOSERELATED HYPOTENSION 4HE #OMPARATIVE 4RIAL EVALUATED NE SIRITIDE VERSUS MANY OTHER CARDIOVASCULAR AGENTS INCLUDING DOBUTAMINE MILRINONE NITROGLYCERIN DOPAMINE AND AMRINONE 'LOBAL CLINICAL STATUS FATIGUE AND DYS PNEAIMPROVEDINALLGROUPSWITHNOSIG NIlCANTDIFFERENCESBETWEENNESIRITIDEAND STANDARDTHERAPY4HEMOSTCOMMONSIDE EFFECTSWEREBRADYCARDIAANDDOSERELATED HYPOTENSION )N "URGER ET AL 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ENCEPROPERADJUSTMENTBASEDONFACTORSINmUENCING TREATMENT DECISION USING ADJUSTMENT FOR COVARIATES ANDPROPENSITYSCORINGWEREMADE2ISKFACTORAND PROPENSITY SCOREADJUSTED ODDS RATIOS /2S FOR IN HOSPITALMORTALITYWERECALCULATED 0ATIENTS WHO RECEIVED INTRAVENOUS NITROGLYCERIN OR NESIRITIDEHADLOWERINHOSPITALMORTALITYTHANTHOSE TREATEDWITHDOBUTAMINEORMILRINONE4HERISKFACTOR ANDPROPENSITYSCOREADJUSTED/2SFORNITROGLYCERIN WERECONlDENCEINTERVAL;#)=n P)ANDnP)COMPARED />LiÊÓ°Ê ÀÌ>ÌÞÊ"``ÃÊ,>ÌÃÊÊ*>À7ÃiÊ/Ài>ÌiÌÊ «>ÀÃÃÊÊÌ iÊ,Ê,i}ÃÌÀÞ°ÊÊ ,i«ÀÌi`ÊÜÌ Ê«iÀÃÃÊvÀÊLÀ> >ÊiÌÊ>]Ê ÊÓääxÊÊ*ÀiÃî° !NALYSIS .4'N VS -),N .4'N VS $/"N .%3N VS -),N .%3N VS $/"N .%3N VS .4'N $/"N VS -),N 5NADJUSTED o o o o o o !DJUSTEDFORCOVARIATES\\ o o o o p e !DJUSTEDFORCOVARIATES ANDPROPENSITYSCOREr o o o o p e XCLUDEFROMAHPI TNSKGBW 0 WISEANLY ATIONDYSPE123MUR 6%& 5.," 3"0 -), .4'VS o P p P e P OR F AR ITE V CO ADJUSTMEN AND OR F AR ITE V CO AND SCORE ADJUSTMEN SODIUM5.CREATN" \ $"0 X3"0ASERITNCLUDGV#O AND YSP E r YTREAMNCOPISLUDHBV# 6%& 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'HALI*+#OOPER2&ORD%4RENDSINHOSPITALIZATIONRATES FORHEARTFAILUREINTHE5NITED3TATESEVIDENCEFOR INCREASINGPOPULATIONPREVALENCE!RCH)NTERN-ED !MERICAN(EART!SSOCIATIONHEARTANDSTROKESTATISTICAL UPDATE$ALLAS4EX!MERICAN(EART!SSOCIATION #UFFE-3#ALIFF2-!DAMS+&ETAL3HORTTERMINTRAVENOUS MILRINONEFORACUTEEXACERBATIONOFCHRONICHEARTFAILUREA RANDOMIZEDCONTROLLEDTRIAL*!-! +RUMHOLZ(-0ARENT%-4U.ETAL2EADMISSIONAFTER HOSPITALIZATIONFORCONGESTIVEHEARTFAILUREAMONG-EDICARE BENElCIARIES!RCH)NTERN-ED /#ONNELL*"4HEECONOMICBURDENOFHEARTFAILURE#LIN#ARDIOL 3UPPL))) 4HE3/,6$)NVESTIGATORS3TUDIESOFLEFTVENTRICULARDYSFUNCTION 3/,6$RATIONALEDESIGNANDMETHODSTWOTRIALSTHATEVALUATE THEEFFECTOFENALAPRILINPATIENTSWITHREDUCEDEJECTIONFRACTION !M*#ARDIOL &RANCIOSA*!!BRAHAM74&OWLER-ETAL2ATIONALEDESIGNAND METHODSFORACOREGCARVEDILOLHEARTFAILUREREGISTRY#/(%2% *#ARD&AIL !DAMS+&/#ONNOR#-/REN2-ETAL$EVELOPMENTOFA MULTICENTERHEARTFAILUREDATABASEINITIALREPORTFROMTHEUNITED INVESTIGATORSTOEVALUATEHEARTFAILURE*#ARD&AIL !CKNOWLEDGMENTS 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