Drug’s 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

VasodilatorsNitroprusside, 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

Elkayam, The American Journal of Cardiology

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

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

Felker GM. Am Heart J. 2001;142:393–401.

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

Role of Inotropic Therapy in Acute Heart Failure

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 AgentsDopamine 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

Dobutamine

Clinical action is dose dependent positive inotropic and chronotropic effects.

In low dose induce arterial vasodilatation and in higher induce arterial vasoconstriction

Inotropic Agents

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

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

Inotropic Agents

ESC, Acute Heart Failure, 2012

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