Drug s of the Heart Failure

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Hartono Setiawan
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1 Drug s of the Heart Failure

2 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

v diuretics 2-3 times daily More effective with

3 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

4 Indication and dosing of diuretics in AHF

5 FUROSEMID Pengenceran : syringe pump : 100 mg (5 amp) /50 cc NaCl 0,9% 1 cc = 2 mg Infus 90 cc NaCl 0,9% 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

6 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

7 Cara pengenceran Morphine 1 = 10 mg Encerkan dengan aqua 10 cc 1 cc = 1 mg

8 Vasodilators Nitroprusside, 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

9 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 Elkayam, The American Journal of Cardiology

10 Intravenous Vasodilator used to treat AHF

11 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

12 Role of Inotropic Therapy in Acute Heart Failure 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 Felker GM. Am Heart J. 2001;142:

13 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

14 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

15 Inotropic Agents Dopamine 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

16 Drugs used to treat AHF that are positive inotropes or vasopressor or both

17 Sediaan 200/5 ml pengenceran 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

18 Inotropic Agents Dobutamine Clinical action is dose dependent positive inotropic and chronotropic effects. In low dose induce arterial vasodilatation and in higher induce arterial vasoconstriction 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 :

19 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% 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

20 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 Nor ephinefrine 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

21 Inotropic Agents 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 ESC, Acute Heart Failure, 2012

22 Terima kasih

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