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30 Cards in this Set
- Front
- Back
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as cardiac function decreases....
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...compensatory mechanisms kick in to maintain CO
1. Sympathetic NS is activated- tachycardia and vasoconstriction (use Bblockers) 2. Renin-angiotension aldosterone system: increases in Na and fluid retention--> inc preload; vasoconstriction -->inc afterload 3. Ventricular hypertrophy and remodeling |
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staging of heart failure
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I – cardiac disease without limitations of normal physical activity
II- patients with cardiac disease with slight limitations of physical activity (ordinary physical activity) III- pts with cardiac disease results marked limitation of physical activity IV- inability to carry on any physical activity w/o discomfort (dyspnea at rest) |
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stages of HF 2
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A:pts at high risk of developing HF b/c of the presence of conditions thatare strongly assoc with HF
B: pts who have developed structural heart disease but not sx C: pts who have current or prior sx with underlying structural heart disease D: pts with advanced structural heart dz with marked sx at rest |
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pharmacotherapy goals
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-improve quality of life
- slow progression of disease - prolong surivival - treat: HTN, DM, dyslipidemia, CAD and other underlying causes -standard first line therapies: ACEI, BB, diuretics, digoxin, others |
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most pts with HF are managed with...
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..a combo of 3 drug:
1. Diuretic 2. ACE I 3. Beta blockers -digoxin may be added at any time |
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ACEI and HF
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-reduce preload and afterload and inhibit Ang II effects on myocardium
-improve sx, slow disease proegression and dec mortality in heart failure -5-6 ACE I are approved for HF treatment at target doses -titrate to target dosages |
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ACEI AE
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1. cough**
2. angioedema 3. hypotension 4. K+ retention 5. worsening renal function: check BUN and creatinine!! C/I: angioedema, preg, renal a. stenosis |
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loop diuretics
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-Furosemide (Lasix) (goal to dec wt by 0.4 -1 kg/day)
-dec fluid retention in HF -assessment of volume status (pt should weight themselves on a daily basis, listen to lungs for crackles, palpate extremities for edema) -used in combination regimen -who gets them? - if pt has evidence of fluid retention |
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AE of diuretics
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1. hypotension- can lead to lightheadedness and falls
2. electrolytes imbalances: may used ACEI or K+ supps; digoxin and K+ be careful!! 3. azotemia 4. monitor electrolytes, renal function, volume status |
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Beta blockers and HF
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-role is to reverse sympathetic NS and neurohormonal activations
-Bisoprolol, metoprolol -Alpha/beta blocker --> carvedilo -BB lessens sxs, improves status, and may reduce risk of death and hospitalization |
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as cardiac function decreases....
|
...compensatory mechanisms kick in to maintain CO
1. Sympathetic NS is activated- tachycardia and vasoconstriction (use Bblockers) 2. Renin-angiotension aldosterone system: increases in Na and fluid retention--> inc preload; vasoconstriction -->inc afterload 3. Ventricular hypertrophy and remodeling |
|
|
staging of heart failure
|
I – cardiac disease without limitations of normal physical activity
II- patients with cardiac disease with slight limitations of physical activity (ordinary physical activity) III- pts with cardiac disease results marked limitation of physical activity IV- inability to carry on any physical activity w/o discomfort (dyspnea at rest) |
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stages of HF 2
|
A:pts at high risk of developing HF b/c of the presence of conditions thatare strongly assoc with HF
B: pts who have developed structural heart disease but not sx C: pts who have current or prior sx with underlying structural heart disease D: pts with advanced structural heart dz with marked sx at rest |
|
|
pharmacotherapy goals
|
-improve quality of life
- slow progression of disease - prolong surivival - treat: HTN, DM, dyslipidemia, CAD and other underlying causes -standard first line therapies: ACEI, BB, diuretics, digoxin, others |
|
|
most pts with HF are managed with...
|
..a combo of 3 drug:
1. Diuretic 2. ACE I 3. Beta blockers -digoxin may be added at any time |
|
|
ACEI and HF
|
-reduce preload and afterload and inhibit Ang II effects on myocardium
-improve sx, slow disease proegression and dec mortality in heart failure -5-6 ACE I are approved for HF treatment at target doses -titrate to target dosages |
|
|
ACEI AE
|
1. cough**
2. angioedema 3. hypotension 4. K+ retention 5. worsening renal function: check BUN and creatinine!! C/I: angioedema, preg, renal a. stenosis |
|
|
loop diuretics
|
-Furosemide (Lasix) (goal to dec wt by 0.4 -1 kg/day)
-dec fluid retention in HF -assessment of volume status (pt should weight themselves on a daily basis, listen to lungs for crackles, palpate extremities for edema) -used in combination regimen -who gets them? - if pt has evidence of fluid retention |
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|
AE of diuretics
|
1. hypotension- can lead to lightheadedness and falls
2. electrolytes imbalances: may used ACEI or K+ supps; digoxin and K+ be careful!! 3. azotemia 4. monitor electrolytes, renal function, volume status |
|
|
Beta blockers and HF
|
-role is to reverse sympathetic NS and neurohormonal activations
-Bisoprolol, metoprolol -Alpha/beta blocker --> carvedilo -BB lessens sxs, improves status, and may reduce risk of death and hospitalization |
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B-blockers AE
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1. worsened HF and fluid retention
2. fatigue, depression 3. bradycardia and heart block 4. hypotension 5. impotence -start low and titrate to target! |
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Digitalis
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-MOA: positive inotropic (inc contractility) agent by inhibiting Na/K+ ATPase leading to increased intracellular Ca++ and muscle contraction
-enhances parasympathetic innervation to the heart -reduced combined risk of death and hospitalization -used in conjunction with ACEI and BB to improve sxs and clinical HF status -used in pts who has HF sx despite other therapies |
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therapeutic uses of digitalis compounds
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1. inc ionotropy
2. inc ejection fraction 3. dec preload 4. dec pulmonary congesiton/edema 5. dec AV nodal conduction 6. dec ventricular rate in afib and flutter |
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digoxin AE
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1. cardiac arrhythmias
2. anorexia, N/V/D 3. neuro--> visual (yellow halows, blurred visiom, photophpbia), confusion, disorientation 4. Narrow therapeutic index 5. D/I are NUMEROUS! -monitor K+, Mg2+, renal, EKG -can use DigiBind to block DIG toxicity -start and maintain at 0.125- 0.25mg/day |
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Aldosterone antagonists
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-Sprinolactone
-more selective aldosterone antagonist -->Inspra (eplerenone tablets) -recent or current class IV sx who are taking ACEI and other meds -AE: hyperkalemia, ACEI and ARBs- monitor for hyperkalemia!, gynecomastia in men |
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ARBs (angiotensin receptor blockers)
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-used for HF pts who are intolerant of ACEI
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Hydralazine and isosorbide dinitrate
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-new combo drug
-may be used for pts intolerant of ACEI -has complementary vasodilating effects -AE: poorly tolerated--> chest pain, HA, dizziness, weakness, drug induced lupus-like syndrome |
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Nesiritide (Natrecor) human brain natriuretic peptide (BNP)
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-for acute decompensated HF
-binds to vascular smooth muscle --> inc cGMP cascade of intracellar events lead smooth muscle cell relaxation (dilates veins and arteries) -IV bolus than infusion for pts with severe decompensated heart failure with rest dyspnea -AE: hypotension, HA, tachycardia |
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hospitalized pts with severe decompensated HF may receive...
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-dobutamine infusions or
-Milrinone or shorter acting inamrinon -IV vasodilator/positive inotropic agents as IV infusions -main goal is short term therapy than convert to usualy HF oral meds but some end stage HF pts use outpts infusions -AE: ventricular arrhythmias, thrombocytopenia, and hypersensitivity -DO NOT admin furosemide in IV lines with these 2 drugs |
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drugs that can exacerbate the syndrome of HF and should be avoided in most pts
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1.Antiarrhythmic agents
2. Calcium channel blokers 3. NSAIDS |
