SRT

Patient Assessment in Heart Failure

• Breathing

• Sleep

• Diet

• Medications

• Activity

• Confusion

• Physical Exam

Breathing

• Do you feel more short of breath? Do you wake up short of breath at night?

• Can you speak as much as you want?

• What makes breathing easier?

• Do you cough? Is it worse than usual?

• Do you cough up secretions?

• Have you increased your oxygen?

Sleep

• Have heart failure symptoms kept you from sleeping.

• Do you sleep in bed or in a chair?

• Can you lay flat in bed?

• How many pillows do you use?

• Have you recently slept more or less than usual?

Diet

• Have you eaten more salty foods or drank more water than usual?

• Have you gained or lost weight recently?

• Have you experienced any swelling?

• How far up your legs does the swelling go?

• Do your clothes and shoes fit more tightly than usual?

Medications

• Have you taken your medications?

• Have you run out of any medications?

• Have you had diarrhea or vomiting?

• Have you taken any extra diuretics?

• Have you changed the dose of any medications?

• Have you taken any OTC medications or herbal supplements?

CAM Product Possibly Harmful Cardiovascular Effects

Aconite

Decreased heart rate (central brainstem effect)Ventricular tachycardia (direct myocardium effect)

Ginseng

Hypotension (increased nitric oxide synthesis)Hypertension (chronic use)Decreased diuretic responsiveness (damaged loop of Henle)

Gossypol Increased effects of diuretics

Gynura Hypotension (inhibits ACE)

LicoriceHypertension, fluid retention (pseudohyperaldosteronism)

Lily of the valley Bradycardia (digitalis glycoside)

TetrandrineHypotension (inhibits L-type calcium channels)

YohimbineHypertension (increased norepinephrine via α2-adrenergic receptor antagonism)

.

American Heart Association 2016

Activity

• How far can you walk?

• Have you recently had to decrease your activity level?

• What activities could you do recently but not now due to your worsened symptoms.

Confusion

• Do you have difficulty remembering information or having feelings of confusion.

• Do you have any other health problems that might make your heart failure worse?

Physical Exam

Inotropes

• MilrinoneTerminal half life 2.3hrs.

• DobutaminePlasma half life is 2 minutes.

Inotropes Aide Memoire

• Client needs a central catheter. ie. PICC, Hickman, implanted port.1. Double lumen is preferred.2. Wash your hands before any contact with the

client or their catheter and you must wear gloves.3. Do not flush inotrope medications down the catheter.4. FDA guidelines indicate that precipitates occur when Furosemide (Lasix)

and Milrinone/Dobutamine are injected at the same time. Do not inject Furosemide in intravenous lines containing Milrinone/ Dobutamine.

5. The client will be discharged on a stable dose of intravenous inotropes.Do not titrate the dose.

Milrinone

• Milrinone, commonly known and marketed under the brand name Primacor, is a medication used in patients who have heart failure. It is a phosphodiesterase 3 inhibitor that works to increase the heart's contractility and decrease pulmonary vascular resistance. Milrinone also works to vasodilate which helps alleviate increased pressures (afterload) on the heart, thus improving its pumping action.

Dobutamine

• Dobutamine is a direct-acting agent whose primary activity results from stimulation of the β1-adrenoceptors of the heart, increasing contractility and cardiac output. Since it does not act on dopamine receptors to induce the release ofnorepinephrine (another α1 agonist), dobutamine is less prone to induce hypertension than is dopamine.

Milrinone

• Indications and Clinical Use• Health Canada-approved Indication• Short-term management of severe heart failure including low

output states following cardiac surgery. • Uses Without Health Canada Approval• To improve cardiac output in advanced cardiovascular life support

of patients with cardiogenic or other forms of shock. Use of milrinone is recommended in conjunction with catecholamines, when catecholamine therapy alone is ineffective [Circulation2005;112(24 Suppl):IV1-203].

• For palliative therapy in patients with end-stage heart failure [Circulation 2009;119(14):e391-479], or those patients awaiting heart transplant surgery.

• © Canadian Pharmacists Association, 2017. All rights reserved.

Milrinone

• Contraindications• Patients who are hypersensitive to milrinone or to any ingredient in

the formulation or component of the container.• Warnings and Precautions• Warning: Serious Warnings and Precautions• Supraventricular and ventricular arrhythmias have been observed in

patients with heart failure (HF) being treated with milrinone. This agent has also been associated with an increase in ventricular ectopy including ventricular tachycardia. Because HF patients are at risk of developing arrhythmias, and milrinone therapy may increase this risk, monitor patients closely for arrhythmias.

• Use milrinone with caution in patients with renal impairment. Dosage adjustment is recommended and reduction in the infusion rate may be necessary in patients with renal impairment.

• © Canadian Pharmacists Association, 2017. All rights reserved.

Milrinone

• Adverse Reactions

• The adverse effects of milrinone mainly involve the cardiovascular system. Ventricular arrythmias are the most common and significant adverse effect. Effects in other body systems, e.g., headache, hypokalemia, thrombocytopenia, are less common.

• © Canadian Pharmacists Association, 2017. All rights reserved.

Milrinone

• More Common Adverse Drug Reactions (≥1%)Cardiovascular• Ventricular arrhythmias (12.6%)• Supraventricular arrhythmias (3.6%)• Hypotension (3.1%)• Angina pectoris/chest pain (1.4%)Neurologic• Headache (2.4%)• © Canadian Pharmacists Association, 2017. All

rights reserved.

Milrinone

• Drug Interactions

• There are no known significant interactions involving milrinone. This agent has been administered with the following drugs with no unusual adverse effects: captopril, chlorthalidone, diazepam, digitalis glycosides, furosemide, heparin, hydralazine, hydrochlorothiazide, insulin, isosorbide dinitrate, lidocaine, nitroglycerin, potassium supplements, prazosin, quinidine, spironolactone and warfarin.

• © Canadian Pharmacists Association, 2017. All rights reserved.

Milrinone

• Dosage

• Concentration: 40mg in 100mls D5W

• Maximum Dose: .5mcg/kg/min

Dobutamine

• Indications and Clinical Use• Health Canada–approved Indications• Short-term inotropic support for adult patients with cardiac

decompensation caused by depressed contractility from heart disease or cardiac surgical procedures.

• Current guidelines recommend dobutamine as temporary therapy to prevent hemodynamic collapse, or as a life-sustaining bridge to more definitive therapy for those patients awaiting mechanical circulatory support, ventricular assist devices, or cardiac transplantation. Long-term use (e.g., exceeding 48 hours) of intravenous inotropic therapy without a specific indication or for reasons other than palliation is potentially harmful [Circulation 2013;128(16):e240-327]. Dobutamine is also recommended as a component of cardiopulmonary resuscitation if an inotrope is indicated following return of circulation [Circulation2010;122(18 Suppl 3):S768-86].

© Canadian Pharmacists Association, 2017. All rights reserved.

Dobutamine

• Contraindications

• Patients with known hypersensitivity to dobutamine or any ingredient in the formulation or component of the container.

• Patients with uncontrolled hypovolemia, pheochromocytoma, idiopathic hypertrophic subaortic stenosis (IHSS), aortic dissection, and systolic blood pressure (SBP) >200 mmHg at rest.

• © Canadian Pharmacists Association, 2017. All rights reserved.

Dobutamine

• Adverse ReactionsAdverse Drug Reactions Overview• The major adverse reactions of dobutamine are increased blood pressure,

tachycardia, ectopic beats and supraventricular or ventricular arrhythmias.Cardiovascular• Increased heart rate, increased blood pressure, premature ventricular beats (5%),

anginal pain (1–3%), dyspnea (1–3%), nonspecific chest pain (1–3%), palpitation (1–3%)

• Dose-related. May require dose reduction or discontinuation of dobutamine. Neurologic • Fever (1–3%), headache (1–3%), nausea (1–3%)• Assess benefits versus risks of continued use. Provide supportive care as needed.

© Canadian Pharmacists Association, 2017. All rights reserved.

Dobutamine

• Drug-Drug InteractionsCOMT Inhibitors • e.g., entacapone• May decrease the metabolism of dobutamine increasing and prolonging its effect.• Avoid concomitant use, if possible; monitor closelyMethyldopa• Blood pressure may increase more than expected in patients taking methyldopa.• Monitor for increased response to dobutamine. May need to discontinue dobutamine. Monoamine Oxidase Inhibitors (MAOIs) • e.g., linezolid, phenelzine, selegiline• MAO inhibition leads to the accumulation of norepinephrine. There may be an increased pressor

response to dobutamine.• Monitor for increased response to dobutamine and adjust dose accordingly. Tricyclic Antidepressants • e.g., amitriptyline, imipramine• Increase in blood pressure may be enhanced in patients taking tricyclic antidepressants.• Monitor for increased response to dobutamine and adjust dose accordingly. © Canadian Pharmacists Association, 2017. All rights reserved.

Dobutamine

• Dosage

• Concentration: 1,000mg in 250mls D5W.

• Maximum Dose: 5mcg/kg/min.

Inotropes Aide Memoire

• Client must have a central catheter. ie. PICC, Hickman, implanted port.1. Double lumen is preferred.2. Wash your hands before any contact with the

client or their catheter and you must wear gloves.3. Do not flush inotrope medications down the catheter.4. FDA guidelines indicate that precipitates occur when Furosemide (Lasix)

and Milrinone/Dobutamine are injected at the same time. Do not inject Furosemide in intravenous lines containing Milrinone/ Dobutamine.

5. The client will be discharged on a stable dose of intravenous inotropes.Do not titrate the dose.

SRT

REJ 2017