Cps Ii Exam 1- Chf

Front 1

NYHA classifications for HF (I-IV)

Back 1

i. Class I—patients with no limitations of activities; they suffer no symptoms from ordinary activities
ii. Class II—patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. ordinary activity results in sx.
iii. Class III—patients with marked limitation of activity; they are comfortable only at rest. less than ordinary activity results in symptoms.

iv. Class IV—patients should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. symptoms of heart failure are present even at rest with increased discomfort with any physical activity.

Front 2

Staging of HF: stage A

Back 2

no structural heart disease but at high risk for developing because of other factors (HTN, CAD, diabetes, treatment with cardiotoxic drugs, rheumatic fever)

Front 3

Stage B

give 3 exapmles

Back 3

ii. Stage B—have structural heart disease that increases their risk of heart failure, but have never had signs or symptoms
1. Post MI patients
2. Evidence of left ventricular dysfunction
3. Asymptomatic valvular disease

Front 4

Stage C

Back 4

iii. Stage C—have past or current heart failure symptoms that are associated with structural heart disease.
1. HF symptoms—SOB, fatigue, reduced exercise tolerance

Front 5

stage D

Back 5

iv. Stage D—have advanced structural heart disease; marked symptoms at rest despite maximal medical therapy; recurrent hospitalization

Front 6

Recognize drugs that may precipitate or exacerbate systolic CHF. (4)

Back 6

a. Thiazolidinediones—may cause sodium and fluid restriction
b. NSAIDs—may cause sodium and fluid restriction
c. Salicylates—may cause sodium and fluid restriction
d. CCB—can worsen heart failure and may increase risk of cardiovascular events (only vasoselective CCBs (amlodipine, felodipine) have been shown not to adversely affect survival)

Front 7

List non-pharmacologic measures appropriate for the patient with CHF (7)

Back 7

a. Sodium restriction—reduce to < 2400 mg/day
b. Reduce amount of saturated fats (red meats, high fat dairy)
c. Increase physical activity—incorporate at least 30 minutes of exercise each day (5 or more days per week)
d. Weight loss
e. Fluid restriction—reduce to <2 L/day especially in hyponatremic patients experiencing fluid retention
f. Reduce alcohol intake to 2 or less drinks per day in men and 1 or less for women
g. Stop smoking
h. Reduce any stress or anxiety

Front 8

initial lisinopril dose and titration (2)

target dose

Back 8

Initial: 2.5-5 mg once daily; then increase by no more than 10 mg increments at intervals no less than 2 weeks to a maximum daily dose of 40 mg

increase q2 weeks
target 20-40 mg

Front 9

Monitoring of lisinopril therapy (6)
when to start

Back 9

(check levels within 7-10 days of initiation)

i. Potassium levels (Hyperkalemia)
ii. Blood pressure (may cause hypotension)
iii. BUN
iv. Serum creatinine
v. Renal function
vi. WBC

Front 10

enalapril initial and target dosing

Back 10

i. Initial dose: 2.5 mg BID
ii. Target dose: 10-20 mg BID

Front 11

lisinopril initial and target dose

Back 11

i. Initial dose: 2.5-5 mg QD
ii. Target dose: 20-40 mg QD

Front 12

diuretics- role in CHF

Back 12

recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload

Front 13

Identify a patient with CHF that would be a candidate for beta-blocker treatment. (2)

Back 13

a. Patients with LVEF <40% (and high heart rate?)
b. Recommended even if patient has diabetes, COPD, or PVD

Front 14

BB: caution in which pt (give values) (2)

not rec'd in whom?

Back 14

Caution in patients with bradycardia (<55 bpm) or hypotension (systolic <80 mmHg)
ii. Not recommended in patients with asthma with active bronchospasm

Front 15

Initiate therapy and recognize target doses for a patient with CHF treated with carvedilol- initial dose, target dose

when to titrate up (and how)

Back 15

Initial dose: 3.125 mg BID
Target dose: 25 mg BID or 50 mg BID if >85 kg

May double dose every 2-4 weeks to the highest dose tolerated by patient

Front 16

before starting BB (e.g. carvedilol...what needs to be done)

Back 16

Before starting…other HF medications should be stabilized and fluid retention minimized

Front 17

patients who should be considered for digoxin (when is it used) (3) not until what stage

Back 17

not until stage C

Patients with systolic heart failure: HF and A. Fib.—should be considered early in therapy to help control ventricular response rate

Patients in normal sinus rhythm with HF

Used in conjunction with other standard HF therapies, including diuretics, ACE inhibitors, and BB in patients with symptomatic HF to reduce hospitalizations

Front 18

digoxin- effect on survival

Back 18

Does not improve survival

Front 19

digoxin used in what degree of CHF (2)

Back 19

mild to severe HF with reduced systolic function

Front 20

special dosing for digoxin- if patient is...(3 characteristics) use this lowre dosing

Back 20

If patient is >70 yo, has impaired renal function, or has a low lean body mass

Low doses (0.125 QD) should be used

Front 21

digoxin dosing

Back 21

0.125-0.25 mg once daily

Front 22

Identify patients with heart failure that may be candidates for the use of spironolactone (3)

Back 22

i. Patients with NYHA class IV or III, symptomatic HF with reduced LVEF (<35%) as addon if maxed out on standard therapy, including diuretics
ii. Should be considered in patients following acute MI, with clinical signs and symptoms or history of diabetes mellitus, and a LVEF <40%.

iii. class II HF , LVEF =< 30%

Front 23

spironolactone starting dose
goal dose

Back 23

i. Initial dose: 12.5-25 mg QD
1. Titrated to 37.5 or 50 mg QD

Front 24

monitoring for spironolactone (2)

Back 24

careful monitoring of refractory HF or persistent hypokalemia (HYPER kalemia???)

Front 25

if serum potassium exceeds ____
what do you do with the dose of spirono

Back 25

If serum potassium exceeds 5.0 mmol/L the dose should be decreased to 25 mg QOD and medications that could be contributing should be adjusted

Front 26

Recognize the diagnostic characteristics of heart failure with normal ejection fraction (4)

Back 26

Unequivocal presence of the symptoms and signs of heart failure

Documentation of preserved left ventricular ejection fraction (or elevated)

Ventricular chamber is not enlarged,

Evidence of left ventricular diastolic dysfunction (by cardiac catheterization)

Front 27

HF with normal EF also known as

Back 27

(DHF—condition which myocardial relaxation and filling are impaired and incomplete; ventricle unable to accept an adequate volume of blood)

Front 28

Recommend appropriate therapeutic agents to manage heart failure with normal ejection fraction and what do you want them to do: avoid what (non pharm)? (4 drugs)

Back 28

Avoidance of excessive sodium intake

Cautious use of diuretics - Relieve pulmonary congestion without excessive reduction in preload

Restoration and maintenance of normal sinus rhythm at a rate that maximizes filling: Beta-adrenergic blockers/calcium channel blockers (both good for ischemia), digoxin (very limited role in management of DHF in normal sinus rhythm)

i. Volume overload—start and titrate diuretic
ii. Treat BP to <130/80
iii. Progression
1. BB if HR >70
2. ACEi
3. CCB

Front 29

goals of treatment for diastolic heart dysfunction (2)

Back 29

control htn
control acute ischemia

Front 30

most effective CCB for DHF (2)

Back 30

a. Verapamil 120-240 mg/day (most effective)
b. Diltiazem 90-120 mg/day (most effective)

Front 31

diuretics to use for CHF (3)

Back 31

LOOPS MORE POTENT for edema

furosemide most common

bumetanide

torsemide

Front 32

thiazides (2) used in CHF and why

Back 32

if loops aren't working (b. Addition of chlorothiazides or matolazone (once or twice daily) to loop diuretics should be considered in patients with persistent fluid retention despite high-dose loop diuretic therapy)

Front 33

furosemide dose starting
max dose

Back 33

20-40 mg qd or bid

can titrate up to 400 mg qd