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

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

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

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

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;142:393401.

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 Agents
Dopamine

Is dose dependent and they involve in three different receptors.

In low dose (< 2 g/kgBW/min),

At doses > 5 g/kgBW/min dopamine

vasodilatation occurs predominantly in renal, coronary, and cerebral vascular

beds.

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

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 : 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

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

Terima kasih