Font size
WorksheetsAcute Heart Failure
Total questions: 30
Worksheet time: 14mins
What is your most trusted source of reference ? Multiple
ESC Guidelines
ACC/AHA Guidelines
Uptodate - Online
Medscape
Sign of Congestion of Left Sided Failure ?
Jugular Venous Distention
Hepatojugular Reflux
Bilateral Leg Edema
Ascites
In Relation to PCWP > 18 mmHg, which is most sensitive ?
DOE
Orthopnea
S3
Rales
In Relation to PCWP > 18 mmHg which is most spesific
DOE
Orthopnea
S3
Rales
Which is not true about dose response curve of loop diuretic ?
A progressively increasing diuresis is achieved at higher doses
Diuretics do not produce natriuresis until a threshold rate of drug excretion is attained
Dose may not exceed maximum effective dose
No diuresis is seen with very low doses
If given higher than ceiling dose, loop diuretic will
No additional natriuresis
Diuresis Efficiency will stay the same
Increase total natriuresis
Longer time to exceed natriuretics threshold
Reasons why IV Loop Diuretics are better than oral in Acute Heart Failure ? Except!
Decrease intestinal perfusion
Reduced Intestinal Motility
Reduce Absorption
IV is as twice potent in CKD
Highest Effective IV diuretic dose needed found in ?
Cirrhosis
Nephrotic Syndrome
AKI
CKD
Recommended Initial Loop Diuretic Dose in AHF by 2017 ESC AHF & CHF Guideline
20 mg IV in deNovo Patients
1 mg/kg IV
40 mg IV in ADHF
at least 2x daily dose
2.5x daily dose in ADHF are related to ? ( DOSE Trial )
Greater Global Assessment of Symptoms
Significant mean change of creatinine level
Greater diuresis and more favourable outcomes
better outcome
what is max effective dose of furosemide in heart failure
40 mg IV
80 mg IV
120 mg IV
100 mg IV
What is the max effective loop diureticdose for those with eGFR < 30 ?
80 mg IV
100 mg IV
200 mg IV
250 mg IV
Bolus and Intermittent Bolus ? Which is True
Bolus more Tinitus
Continuous should be preceded with bolus
Bolus more permanent hearing loss
Significant higher rates of tachycardia in IV Bolus
Consider as adequate diuresis in decongestion
1cc/kg/hour
200 cc/hour
100 cc/hour
50 cc/hour
how fast IV Bolus loop diuretic Should be given ?
< 4 mg/mnt
20-40 mg within 2 minutes
160-200 mg within 30 minutes
60-120 mg within 10 minutes
what is daily diuresis goal for rapid decongestion ?
2400 cc/day
2000 deficit/day
3-5 liters/day
> 5 liters/day
"Breaking Phenomenon" what do you have in mind ?
Inadequate diuresis respond due low diuretic dose
tolerance to loop diuretics
pathological response to excessive diuresis
appropriate hemostatic response
Summarize the term breaking phenomenon
enhanced activity of Ang II & NE
decrease diuretic response due to sodium reabsorption
Hypertrophy of distal tubule
increased mineralcorticoid activity
What is diuretic Resistance ?
Failure of diuretics to achieve decongestion
Persistent signs and symptoms despite increasing doses of diuretic drug
complex interplay between cardiac and renal dysfunction
specific renal adaptation and escape mechanisms
Any threshold for using Diuretic Resistance term ? Except
Persistent congestion despite adequate and escalating
doses of diuretic with >80mg furosemide per day
Amount of sodium excreted as a percentage of filtered
load <0.2%
Failure to excrete at least 90mmol of sodium
within 72h of a 160mg oral furosemide dose given
twice daily
Urinary sodium to urinary furosemide
measured in spot urine > 2 mmol/mg
Pathognomonic features in CKD for diureis resistant ?
RAAS and SNS activation
Elevated levels of circulating organic acids
increased sodium and water resorption in the proximal tubule
Diminished distal flow and increased reabsorption
Do I need to restrict Fluid intake in HF ?
Restrict intake to all patients
Provide fluid requirements 30 cc/kg
Restriction in hyponatremia 125 meq/L
1.5-2L in refractory HF
Any Recommendation for salt intake ?
< 2500 mg/day
2000 - 2500 mg/day
< 3000 mg/day
2000-3000 mg/day
Within Disparities, what is your 2nd Line Decongestion agent ?
Spironolactone
Thiazide
Renal Dose Dopamine
Tolvaptan
how Hct Should be given to acute HF ?
25 mg once daily
Initially 25 - 50 mg/daily
100 mg daily
simultaneous with loop diuretic
how spironolactone should be given
25 mg/day
50 mg/day
100 mg/day
2x50 mg
Renal Dose Dopamine in Acute Heart Failure
ROSE Trial - No Benefit with Potential harm
2,5 ug/kg/mnt is beneficial within 72 hours
Increase the number of arrhythmia
Improve decongestion
what relates most ototoxicity in loop diuretcis ?
Bolus rather than Continuous
IV rather than oral
Speed > 4mg/min
High dose IV
Based on 2012 ESC AHF & CHF Guideline what should we do in urine output < 100 cc within 2 hours w/ loop diuretic
Switch to Continuous loop Diuretci
Consider 2.5x oral dose IV Bolus
Doubling the initial dose
Consider Dobutamine
Based on ESC Position Paper diuresis in HF 2019, Double IV dose is recommended when ?
2 hours urine spot sodium > 50 -70 meq/L
6 hours urine > 100 cc/hours on average
urine within 24 hours > 4 L
Persistent HF
