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1、AcuteHeartFailure/CardiogenicShockApril16,2004DarrenM.Triller,PharmDTheplanStickclosetothetextReviewpharmacologyandpathophysiologyonlytoenhanceunderstandingofthedrugtherapyKnowthefewdrugswellExpectationsforpharmacistsingeneralhospitalorhomecarepracticeTestquestionswilltargettheseg
2、oalsWhyisthisimportant?HFcommondiagnosisHospitalizationsarecommonAssociatedcostsareastronomicalPharmacistswillroutinelybeinvolvedinpreparinganddispensingtoICU/CCUUseofthedrugsisfrequentlyinurgent/emergentsituationsAcuteHF/CardiogenicshockDeathShockIIIHeartFailureIIIIVHTNDrugsMIVal
3、veDzMIRelationships/KeyTermsCardiacoutput=HRxStrokevolumeMAP=COxSVRPreloadContractilityAfterloadFrank-StarlingrelationshipTheBigPictureinFailurePreloadContractilityNeedvolumetoincreasestretch,FrankStarlingNeedcontractilityandratetomaintainoutputNeedconstrictiontomaintainpressureAf
4、terloadVeinsHeartArteriesAutoregulationTheabilitytomaintainbloodflowoverwiderangeofperfusionpressuresCerebralandcoronaryarteriesAbilitydeclinesatMAP<60mmHgMediatedbyvasoconstrictors:epi,NE,AngII,TxA2,vasopressinvasodilators:PGI2,NO,adenosine,natriureticpeptidesNormalreflexmechanis
5、msIncreasepreload:Na/H20retention,RAASIncreasedcontractility:adrenergicoutflow(NE)Increasedafterload:norepi,AngII,endothelin,vasopressinItisimportanttorelax!RememberthatcoronaryarteriesfillduringdiastoleRememberthatfillingduringdiastolecontributestostrokevolume(Starling)Rememberth
6、atincreasingheartratedecreasesventricularandcoronaryfilling,upsetscalciumprocessingbySR,O2demandincreaseChronicHFpatientshavetypicallymaxedoutpreload,anddonothavethereservethatyoudoContractilityIncreasedcontractilitywillprovideincreasedstrokevolume/COforagivenlevelofpreloadandafte
7、rloadChronicHFpatientshavehighcirculatinglevelsofcatecholaminesandarelessresponsivetoadrenergicstimulireceptordownregulationCatecholaminescardiotoxic?Necrosis/apoptosis?Arrhythmias?AfterloadisdoubleedgedswordIncreasedSVRisimportantformaintainingMAPIncreasedafterloadwillreducestrok
8、evolumeslamsthescreendoorbeforeal
