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110 Cards in this Set
- Front
- Back
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How many Americans have heart failure?
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5 million Americans
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How many new cases of heart failure does America have every year?
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550,000 new cases per year
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How many hospital discharges per year?
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1 million hospital discharges per year
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What is the percentage mortality within 5 years of being diagnosed with heart failure?
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50%
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What is the mortality is you have Class IV heart failure?
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1 year mortality which is worse than cancer
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True/False: Heart failure is the most common cause of hospitalization in people over 55.
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False
It is the most common cause of hospitalization in people older than 65 |
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How much does heart failure cost America?
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Over $30 billion annually
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What is the definition of heart failure?
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Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
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What are the clinical symptoms and signs of heart failure secondary to?
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Abnormal ventricular function
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What is the body's response any time cardiac output is decreased?
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Increased heart rate (tachycardia)
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What are the seven signs and symptoms of heart failure?
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1. Tachycardia
2. Ventricular dysfunction 3. Decreased exercise tolerance 4. Shortness of breath 5. Peripheral and pulmonary edema 6. Myocardial infarction 7. Ventricular dilation |
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Describe tachycardia associated with heart failure.
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Because of decreased cardiac output, the body's response is to speed up the heart rate which will cause patients to have tachycardia
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What are three reasons why the baroreflex gets reset?
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1. Decreased sensitivity to arterial pressure
2. Increased sympathetic activity 3. Decreased parasympathetic activity |
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What causes the ventricular dysfunction in heart failure?
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Decreased cardiac output
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What causes the decreased exercise tolerance in heart failure?
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Decreased tissue perfusion and cardiac output
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What causes the shortness of breath in heart failure?
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Decreased cardiac output
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What causes the peripheral and pulmonary edema in heart failure?
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Increased arterial pressure and decreased stroke volume
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What causes the myocardial hypertrophy in heart failure?
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Increased muscle mass due to elevated pressure and increased volume of ventricles
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What causes the ventricular dilation in heart failure?
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Increased ventricular size due to increased ventricular volume
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True or False: Heart failure is more prevalent in males until the age of 65 is reached and then it is fairly equal in prevalence between men and women.
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True
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Describe Class I in heart failure.
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No limitations on physical activity but will see effects with exercise.
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Describe Class II in heart failure.
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Mild symptoms and fatigue with normal activity
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Describe Class III in heart failure.
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Symptoms with minimal activity
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Describe Class IV in heart failure.
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Symptoms even at rest
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What are eight risk factors for heart failure?
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1. Hypertension
2. Diabetes 3. Hyperlipidemia 4. Inactivity 5. Obesity 6. Alcohol 7. Smoking 8. Dietary sodium |
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What is the goal for hypertension to prevent heart failure?
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Generally less than 130/80
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What is the goal for diabetes to prevent heart failure?
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A1C less than 6
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What is the goal for hyperlipidemia to prevent heart failure?
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LDL<100
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What is the goal for inactivity to prevent heart failure?
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20-30 minutes of aerobic activity 3-5 times per week
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What is the goal for obesity to prevent heart failure?
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Weight reduction and a BMI less than 30
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What is the goal for alcohol use to prevent heart failure?
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Men should have less than 2 drinks per day and women should have less than one.
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What is the goal for smoking to prevent heart failure?
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Cessation
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What is the goal for dietary sodium to prevent heart failure?
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Maximum 2-3 grams per day
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What are the seven treatment objectives in heart failure?
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1. Increase survival
2. Decrease Morbidity 3. Increase exercise capacity 4. Increase quality of life 5. Decrease neurohormonal changes 6. Decrease progression of CHF 7. Decrease symptoms |
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Describe Asymptomatic LV Dysfunction.
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No symptoms
Normal exercise Abnormal LV function |
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Describe Compensated CHF.
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No symptoms
Decreased exercise Abnormal LV function |
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Describe Decompensated CHF.
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Symptoms
Larger decrease in exercise Abnormal LV function |
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Describe refractory CHF.
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Symptoms not controlled with treatment
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What happens when the heart becomes less proficient as a pump?
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This leads to a decrease in CO which leads to decreased tissue perfusion which means less blood and oxygen to tissues. This will cause weakness and fatigue.
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Which systems in the body are activated when the CO is decreased?
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SNS
RAAS |
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What does the SNS do when activated by decreased CO?
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SNS elevates heart rate, causes vasoconstriction, the elevated HR will try to get CO up, and elevated BP will try to force blood back to the heart which will increase afterload and cause the heart to work harder.
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What does the RAAS do when activated by decreased CO?
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RAAS has an effect on VSM to constrict and will cause sodium and water retention which can cause congestion and edema.
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What does decreased CO lead to?
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Increased veinous volume causing congestion and edema which leads to breathing problems
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What do ACEIs and ARBs do for heart failure?
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ACEI patients survive longer. ACEIs decrease activity of RAAS decreasing vasoconstriction, so the heart will pump against less pressure. They also have an effect on sodium and water retention, so there is less volume around to pump. ACEIs decrease afterload and preload which gives the heart a chance to pump a little better which can increase CO. ARBs do the same kind of thing.
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What do BB do for heart failure?
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BB decrease HR, decrease forces of contraction, have effects on BP, and will also decrease afterload and preload to slow heart down so the ventricle has more time to fill appropriately.
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What are the three main things that ACEs (and ARBs) and BB do for heart failure?
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1. Allow heart to pump better
2. Higher CO 3. Better tissue perfusion |
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Which family of medications may be added to an ACE or BB in heart failure?
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Loop diuretics will decrease sodium and water retention which will have an effect on congestion of the lungs and edema in the periphery.
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What do vasodilators do when given for heart failure?
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Vasodilators decrease afterload and preload and can decrease veinous pressure
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What do Aldosterone antagonists do for heart failure?
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Tackle the sodium and water retention
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What do inotropic drugs do for heart failure?
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Inotropic agents increase force of contraction.
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What are cardiac glycosides used for in heart failure?
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Cardiac glycosides are inotropic drugs that increase force of contraction of ventricular muscle.
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What is the problem with forcing a stronger contraction to increase the amount of blood that can be pumped?
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Because the heart is working harder, this increases the likelihood of damage due to overwork
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What should anyone with left ventricular dysfunction be taking?
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ACEI or ARB
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Why do BB have to be started at a lower dose?
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Initially there will be problems with ejection fraction going down but over time (three months) will see an increase in left ventricular ejection
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What are six inotropic drugs used in heart failure?
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1. Digoxin
2. Milrinone 3. Inamrinone 4. Cyclic AMP phosphodiesterase (III) inhibitors 5. Dobutamine 6. Dopamine |
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Who first wrote a book on the medicinal uses of Digitalis Glycosides?
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William Withering 1785
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How did William Withering refer to CHF?
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Dropsey
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What did William Withering's book include?
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1. Indications for use
2. Correct doses 3. Signs and symptoms of toxicity 4. Foxglove, Oleander, milkweed, Lilly of the Valley |
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What do Digitalis Glycosides do?
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Enhance contractile activity of the ventricular muscle
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What type of medication is Digoxin?
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Digitalis glycoside
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Which drug, Digoxin or Digitoxin, is no longer available for use in the US?
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Digitoxin
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What is the construction of Digoxin?
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A lactone ring and steroid nucleus essential for activity with three sugar molecules attached to steroid nucleus.
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What do the sugar molecules attached to the nucleus of Digoxin influence?
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1. Absorption
2. Half-life 3. Metabolism |
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Does Digoxin have any effect on overall mortality?
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No
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What did the Digoxin Group Study determine?
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1. Increased sudden death rate
2. Decreased death rate from progressive failure 3. Decreased hospitalizations |
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What did the group study determine about the mortality rates with Digoxin?
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Depends on the dose of drug given.
Decreased mortality rates if <1ng/mL administered Increased mortality rates if >1.5ng/mL |
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What is the older mechanism of action of Digoxin?
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Inotropic agent that increases the force of cardiac muscle contraction (Higher doses - >1.2ng/mL)
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What is the newer mechanism of action of Digoxin?
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Neurohormonal that decreases sympathetic and increase parasympathetic nervous system activity (Lower doses - <1ng/mL), resensitizes baro-reflex, and decreases RAAS
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How does Digoxin cause an increase in force of contraction?
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Inhibits Na/K ATPase which is responsible for maintaining membrane potential.
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What happens is you completely inhibit membrane potential?
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Activity has to be decreased by 30% which gives higher intracellular sodium concentrations. If you completely inhibit membrane potential, it would cause death.
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What is muscle contraction dependent on?
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The amount of calcium available to interact. The more calcium inside the cell means stronger contraction when you get the depolarization.
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What is another transporter in the membrane?
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Na/Ca exchanger increases activity so sodium is exchanged out and calcium is brought into the cell.
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What are seven neurohormonal actions of Digoxin?
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1. Blocking Na+K+ ATPase helps reset baro-reflex, leads to decrease in heart rate
2. Increase in parasympathetic activity in AV node and conduction system 3. Decrease in sympathetic activity - Decreases blood pressure and heart rate 4. Increase in cardiac output - better pumping actions 5. Decreases renin-angiotensin-aldosterone system activity 6. Decreases remodeling and structural changes 7. Increases perfusion of tissues |
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True/False: The actions of digoxin are beneficial short term but detrimental long term.
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True
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What is another use for digoxin besides heart failure?
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Atrial Fibrillation
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What is atrial fibrillation?
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Very rapid atrial heart rate usually driven by SA node which can cause site other than SA node to fire between 400-600 times a minute. (Ectopic pacemaker)
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What does the AV node do when you have the rapid atrial disorganized rate?
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The AV node slows down conduction which is essential to making sure heart pumps appropriately.The AV node can not keep up with all the depolarizations so there is a disconnect.
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What is this problematic?
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When ventricles contract that fast there isn't enough time for them to fill up before contraction.
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Atrial fibrillation makes ventricles less efficient as pumps causing what?
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Decreased cardiac output, fatigue, and other problems
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How does digoxin help with atrial fibrillation?
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Digoxin has the ability to slow down conduction in the AV node. It increases parasympathetic activity.
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What three things are improved if the ventricular rate is controlled in atrial fibrillation?
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1. Symptoms
2. Hemodynamics 3. Cerebral blood flow |
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How is tachycardia prevented in atrial fibrillation?
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1. <100 bpm at rest or >20% decrease from baseline with therapy
2. <155 bpm with exertion and exercise |
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How does Digoxin affect AV node conduction?
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Digoxin has little direct inhibition of AV node conduction.
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What does the enhanced vagal tone do?
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Slows ventricular rate
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When do vagal influences decrease?
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During exertion and exercise
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What may a patient need in high sympathetic state?
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CCB or BB
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What are four areas affected by Digoxin toxicity?
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1. GI
2. Visual disturbances 3. Central symptoms 4. Heart disturbances |
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What are the GI symptoms of digoxin toxicity?
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1. Anorexia
2. Nausea |
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What are the visual disturbances caused by Digoxin toxicity?
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1. Blurred vision
2. Photophobia 3. Xanthopsia (Yellow tinge) 4. Shining lights around objects 5. Yellow-green halos |
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What are the central symptoms caused by digoxin toxicity?
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1. Delirium
2. Fatigue 3. Confusion 4. Dizzyness 5. Abnormal dreams |
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What are the effects on the heart from Digoxin toxicity?
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1. Nodal slowing
2. Increased PR interval 3. Decreased QT interval 4. Depressed ST segment 5. Bradycardia 6. Digoxin induced after depolarization |
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What are the contraindications of Digoxin?
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1. Advanced AV block
2. Severe bradycardia or sick sinus syndrome (SA node fires normal then speeds up then slows down then speeds up...) 3. PVC's and ventricular tachycardia 4. Hyperkalemia 5. Hypomagnesaemia 6. Hypercalcemia 7. Wolf-Parkinson-White |
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How can we treat Digoxin toxicity?
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Digoxin Immune Fab (Digiband)
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How does Digiband work?
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Digiband is an antibody that binds to the antigen-binding site of Ig and rapidly reverses toxicity.
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How is Digiband produced?
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Digiband is produced by immunization of healthy sheep with digoxin coupled to human serum albumin
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Why does Digiband work?
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Digiband has higher affinity for Digoxin than affinity of Digoxin and Na+K+ ATPase
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What are the actions of the other inotropic agents Milrinone, Inamrinone, and Cycli AMP phosphodiesterase (III) inhibitors?
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1. Inotropic as well as vasodilator actions
2. Direct stimulation of myocardial contraction 3. Accelerate myocardial relaxation 4. Balanced arterial and venous dilation (Decreases preload and afterload) 5. Increased cardiac output 6. Approved for short term IV use in acute decompensated heart failure 7. Long term use is associated with higher mortality and morbidity than placebo 8. Thrombocytopenia (Milrinone less) 9. Ventricular arrhythmias |
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What is an inotropic agent that is a selective beta agonist?
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Dobutamine
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What does Dobutamine do?
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IV infusions of Dobutamine stimulates force of contraction more than rate of contraction. Used short term to stabilize patients.
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What is an inotropic agent that works through dopamine and beta receptors?
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Dopamine
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What does dopamine do?
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IV infusions of Dopamine help to maintain renal function
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What is nesiritide?
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Nesiritide is recombinant human B-type natriuretic peptide
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What is the mechanism of action of nesiritide?
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1. Counteracts RAAS
2. Diuresis 3. Relaxes smooth muscle 4. Released from ventricles 5. Vasodilation in both arteries and veins 6. Natriuresis |
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When is nesiritide used?
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Nesiritide is used in acutely decompensated heart failure with dyspnea at rest. Must be given IV, short term use.
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True/False: There is evidence of decreased mortality with Nesiritide.
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False
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What are the adverse effects of Nesiritide?
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1. Hypotension
2. Headache 3. Nausea 4. Bradycardia 5. Ventricular arrhythmias 6. AV node slowing |
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What do you recommend for a patient in Stage A (High Risk with no symptoms) of heart failure?
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1. Risk-factor reduction
2. Patient and family education 3. Treat hypertension 4. Treat diabetes 5. Treat dyslipidemia 6. ACE inhibitors or AT1 blockers in some patients |
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What do you recommend for a patient in Stage B (Structural heart disease with no symptoms) of heart failure?
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1. ACE inhibitors or AT1 blockers in all patients
2. BB in selected patients |
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What do you recommend for a patient in Stage C (Structural disease with previous or current symptoms) of heart failure?
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1. ACE inhibitors and BB in all patients
2. Dietary Na+ restriction 3. Diuretics 4. Digoxin 5. Cardiac resynchronization if bundle-branch block present 6. Revascularization 7. Mitral-valve surgery 8. Consider multidisciplinary team 9. Aldosterone antagonist |
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What do you recommend for a patient in Stage D (Refractory symptoms requiring special intervention) of heart failure?
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1. Inotropes
2. Nesiritide 3. VAD 4. Transplantation 5. Hospice |
