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Drug’s of the Heart Failure - Cardiology Update FK UNAND · PDF file1 cc = 0,08 mg = 80 mikro Infus ... Tetesan = 60 x 0,25 = 15 tts mikro. Phosphodiesterase inhibitors ... Drug’s

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  • Drugs 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;142:393401.

    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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