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57 Cards in this Set

  • Front
  • Back
What causes systolic heart failure?
Any disease process that damages or destroys ventricular muscle.
(myocardial infarction)

*This results in reduced contractility
What is the fundamental problem that results in diastolic heart failure?
The heart loses compliance (becomes more fibrous), thus grows stiffer.

*The heart cannot relax adequately, limiting filling.
What is the effect of early diastolic heart failure on contractile function,cardiac output, ejection fraction, and stroke volume?
EARLY ON:
Contractile function = normal
Ejection fraction = normal
Cardiac output = normal
Stroke volume = LOW

*The ejection fraction is normal because both the stroke volume and EDV are reduced

*Cardiac output iis normal because an increase in heart rate compensates for the lower stroke volume

*OVER TIME, contractile function diminishes
Is pulmonary congestion a result of systolic or diastolic heart failure?
Diastolic heart failure
What is the change in contractility mediated by?
Changes in intracellular concentration of free calcium
Where does fluid accumulation occur with right sided heart failure?
Liver and peripheral edema
Where does fluid accumulation occur with left sided heart failure?
Lungs
In the U.S., what is the primary cause of heart failure?
Ischemic disease (or MI)
In the world, what is the primary cause of heart failure?
Hypertension
What is the New York Heart Association (NYHA) classification of heart failure based on?
Exercise capacity
(functional scheme)
What do the American College of Cardiology (ACC) and American Heart Association (AHA) base their classification of heart failure on?
Staging or progression of heart failure
Describe the 4 classes of the NYHA classification of heart failure
Class I: Asymptomatic cardiac disease
Class II: Dyspnea with heavy exertion
Class III: Dyspnea with light exertion
Class IV: Dyspnea at rest
Describe the 4 stages of the ACC and AHA classification of heart failure.
Stage A: Risk factors for heart failure present
Stage B: Asymptomatic for heart failure
Stage C: Symptomatic for heart failure
Stage D: Refractory to treatment or at the end stage of heart failure
Based on the ACC and AHA classifications, which stage would a patient be at if he/she was experiencing SOB, fatigue, and reduced exercise tolerance?
Stage C
(symptomatic for heart failure)
Based on the ACC and AHA classification for heart failure, which stage would the patient be at if he/she had a previous MI and asymptomatic valvular disease?
Stage B
(asymptomatic for heart failure)
Based on the ACC and AHA classification for heart failure, which stage would the patient be at if he/she was experiencing severe symptoms at rest despite maximal medical therapy?
Stage D
(Refractory to treatment)
Based on the ACC and AHA classification for heart failure, which stage would the patient be at if he/she has hypertention, diabetes mellitus, or coronary artery disease?
Stage A
(risk factors for heart failure)
How does heart failure lead to a reduction in arterial pressure?
Reduced cardiac output
(MAP = CO x TPR)
How does heart failure stimulate the renin-angiotensin-aldosterone system?
Decreased CO --> Decreased arterial pressure --> Decreased renal perfusion --> Increased renin release
How does heart failure result in an increase in sympathetic nervous system activity, and what are the 3 main effects of this?
Decreased CO--> Decrease MAP--> activation of baroreceptor reflex --> increases sympathetic NS.

Effects:
1. Vasoconstriction --> increases TPR to directly restore MAP
2. Increased renin secretion --> increases BV
3. Remodeling of the heart
What are the 2 deleterious effects of vasoconstriction during heart failure?
Due to increased TPR and afterload the following occurs:

1. Reduced CO
2. Increased cardiac filling pressure because SV decreases
What are the 3 effects of angiotensin II during heart failure?
1. Vasoconstriction
2. Remodeling of the heart
3. Increased release of aldosterone--> increased Na+ and water retention --> increased cardiac filling pressure
When are drugs that affect contractility used during heart failure?
At the end-stages of heart failure
List the treatment algorithm for the management of heart failure.
1. Loop diuretic
2. ACE inhibitor
3. B-blocker (one main limitation)
4. Aldosterone inhibitor
5. Angiotensin receptor inhibitor
6. Inotropic agent
Which diuretics are the only ones that can adequately reduce plasma volume?
Loop diuretics
(block Na+ resportion in the thick ascending limb)
How do loop diuretics reduce the work of the heart?
By reducing plasma volume, they reduce EDV and pressure, which reduces the work of the heart.
Why is furosemide a particularly effective loop diuretic?
It also increases venous capacitance, which reduces preload
When are thiazide diuretics used in heart failure?
When the patient doesn't respond to loop diuretics
(however, thiazide diuretics are not as effective)
What is the major influence of K+-sparing/aldosterone antagonists on heart failure?
Reduction in remodeling of the heart
(aldosterone somehow enhances cardiac remodeling)
Which K+-sparing/aldosterone antagonists are used for heart failure?

What is a big advantage of these drugs?
1. Spironolactone
2. Eplerenone

*These drugs have been shows to reduce mortality in heart failure

(Amiloride and triamterone are not used)
List 4 actions of angiotensin II that are inhibited by ACE inhibitors.
ACE inhibitors block the following events:

1. Vasoconstriction --> leads to decreased afterload. Reduced venoconstriction leads to lower filling pressures and EDVs.
2. Secretion of aldosterone --> less Na+/water retension
3. Cardiac remodeling --> reverses remodeling
4. Sympathetic outflow --> reduced
For which people can ACH inhibitors be the first drug of choice for treating heart failure?
1. People who have no overt signs of heart failure and do not need diuretics
2. People who cannot tolerate diuretics
List 2 ACE inhibitors.
1. Captopril
2. Enalopril
What is the MOA of metroprolol succinate?
Selective B1-adrenergic antagonist
What is the MOA of Bisoprolol?
Selective B1-adrenergic antagonist
What is the MOA of Carvedilol?
1. Non-selective B-adrenergic antagonist
2. Selective a1-adrenergic antagonist
What severity of heart failure are beta-blockers recommended to treat?
Mild - moderate heart failure
How should beta blocker be administered?
Very low doses, with the dose gradually increased over a period of two to four months
List 2 adverse effects of beta blockers.
1. Exacerbate heart failure
2. Bronchoconstriction
Which other group of medications is recommended if a patient cannot tolerate ACE inhibitors?
Angiotensin receptor antagonists
Which 2 AT receptor blockers have been tested for use in heart failure?
1. Candesartan
2. Valsartan
What is the only cardiac glycoside used to treat heart failure?
Digoxin
What is the MOA of Digoxin?
Blocks the Na+-K+-ATPase.
(This increases the intracellular concentration of Na+, which increases the intracellular concentration of Ca2+)

*More Ca2+ is stored in the SR, so when the cell becomes depolarized, more Ca2+ will be released --> increased contractility

*The NCX transporter cannot extrude Ca2+ from cell when there is a low extracellular concentration of Na+
If digoxin improves ventricular function, why is it so low on the the recommended therapeutic sequence?
Because it does not reduce mortality, and most of the other medications do.
Digoxin is recommended for which patients?
1. High heart rate
2. Not adequately treated for heart failure with the other recommended drugs
What are the adverse effects of digoxin?
Cardiac arrhythmias, which can lead to sudden death
List two B agonists that may be used to treat heart failure.
1. Dopamine
2. Dobutamine

*Stimulate B1 receptors which increases contractility
When are B agonists used to treat heart failure?
When the patient is in the hospital because of severe heart failure.
(Drugs are given IV for short periods of time).
Chronic use of which drugs is associated with INCREASED mortality from heart failure?
B agonists
What is the major effect of isosorbide dinatrate that makes it an option for treating heart failure?
Increased venous capacitance--> reduces ventricular filling
How is Hydralazine beneficial for treating heart failure?
Reduces afterload by reducing pulmonary and systemic vascular resistance
Which two drugs are combined to form Bidil?
What is the effect of this combination?
Isosorbide dinitrate + hydralazine

Combined, they reduce both venous and arterial resistances

*Shown to decrease mortality in African American males
What is the standard therapy for African Americans for heart failure?
ACE inhibitors + B-blockers + Bidil (isosorbide dinitrate + hydralazine)
Which natriuretic peptide may be used in treating dyspnea associated with heart failure?
Nesiritide
What is Nesiritide approved to treat?
Dyspnea caused by heart failure
Which drug is a recombinant version of brain natriuretic peptide (BNP)?
Nesiritide

*Produces Na+/water excretion; vasodilation
List 4 factors that stimulate cardiac remodeling.
Increases in the following:
1. Sympathetic NS
2. Aldosterone
3. Angiotensin II
4. Filling pressure