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25 Cards in this Set
- Front
- Back
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What type of dysfunction is it if you have a low left ventricular ejection fraction? (systolic or diastolic?)
CAD, HTN, dilated cardiomyopathy, valvular heart disease (AS, AR, MR), idiopathic hypertrophic subaortic stenosis, post-MI |
systolic
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Early presentation of RS HF will be different than LS HF.
In systolic heart failure: -... sided – crackles, rales, lungs are congested. -... sided – won’t hear anything. Edema, hepatic congestion, elevated liver enzymes, legs will be edematous. |
Left
Right |
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Subtypes of systolic HF:
... output Failure- occurs when the demand for blood exceeds the capacity of an otherwise normal heart to meet the demand (severe anemia, AV malformations, hyperthyroidism) ... cardiac output-fatigue and loss of lean muscle mass as their most prominent symptoms, may also have dsypnea, impaired renal function or altered mental status |
High
Low |
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What type of dysfunction is it if you have a normal or high ejection fraction with abnormal relaxation and left ventricular filling (i.e. “stiff” ventricle)
Hypertensive cardiovascular disease, valvular heart disease, restrictive cardiomyopathy, constrictive pericarditis, atrial fibrillation |
diastolic dysfunction
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If you have a diastolic dysfunction, you would give a drug that ... the LV (CCBs, nitroglycerin, BBs)
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relaxes
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... output heart failure:
Severe chronic anemia Atrio-ventricular shunt Thyrotoxicosis – one of the worst Paget’s disease “wet” beriberi |
High
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What is the most important drug for heart failure?
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ACE inhibitor (or some type of renin-angiotensin aldosterone inhibitors)
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look at slide 10
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ok
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Work up:
... – venous congestion, cardiomegaly, pleural effusions ... – will tell us function of the heart. If it’s dilated vs. diastolic heart failure. Maybe if they have ventricular septal defect. Probably most important test. ... – can show if it’s an acute MI or not, b/c it can show left ventricular hypertrophy which can give us a clue if this patient has had long standing HTN. ... – can show possible ischemia Cardiac catheterization |
CXR
2-D echocardiogram EKG Exercise stress testing |
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Lab findings:
... BUN, creatinine Hyponatremia increased LFT’s ... BNP (brain natriuretic peptide) circulating levels increase in proportion to the severity of CHF -<100pg/mL is normal -Anything greater than 100 is probably abnormal -Anything < 1000 is definitely abnormal -There is a good correlation between BNP and severity of HF. |
increased
increased |
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Non-pharmacologic Tx:
-Determine if CHF is secondary to systolic or diastolic dysfunction -Restrict ... intake <= 3 gm/day -fluid intake to 2L or less if hyponatremia present |
sodium
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Most important drug in CHF is .... If they are allergic, try .... If they’re allergic to that, try ... inhibitors.
Main goal is to decrease ... (decrease in total volume of the body – loop diuretics, fluid restriction, salt restriction) and .... |
ACE inhibitors
ARBs renin preload afterload |
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Pharmacologic therapy:
Vasodilators – nitroglycerin ... preload Arterial and venous vasoconstriction occur due to activation of adrenergic and renin-angiotensin systems. Adrenergic stimulation causes elevated levels of circulating catecholamine. Arterial vasoconstriction increases the impedance (...) against which the left ventricle ejects blood. Reflexive arteriolar vasoconstriction in renal, hepatic, mesenteric, cerebral & myocardial vascular beds results in tissue ... Venous vasoconstriction limits venosus capacitance with resulting venous congestion and elevated diastolic ventricular filling pressures (...). These should be used with caution in patients with fixed cardiac output (ie aortic stenosis, hypertrophic cardiomyopathy or with primarily diastolic dysfunction. |
decreases
afterload hypoperfusion preload |
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Oral vasodilators:
What is the standard of care drug used with CHF? SIDE EFFECTS: Acute renal insufficiency with bilateral renal artery stenosis, rash, angioedema, increased potassium, leukopenia & cough. |
ACE inhibitors
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Creatinine increase is expected when ACE inhibitor is started. If increase is greater than 20%, then think of .... Otherwise, don’t be scared of leaving them on the ACE inhibitor
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renal artery stenosis
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What drug is used in patients with CHF who do not tolerate ACE agents?
-do not have a survival benefit over ACE inhibitors |
Angiotensin II receptor blocker (ARB)
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...:
Mostly venodilators Reduce myocardial ischemia by a decrease in ventricular filling pressure by some direct dilating of coronary arteries. they reduce myocardial ischemia |
Nitrates
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...:
Acts directly on arterial smooth muscle to reduce afterload. Watch for reflex tachycardia, and a drug induced lupus-like syndrome. (10%) one of the 1st drugs that we had to treat HF. It’s a potent vasodilator. SE: peripheral edema, Lupus-like syndrome which is shown by a positive ... on the lab testing. |
Hydralazine
antihistone |
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...:
Block chronic adrenergic stimulation Improve ejection fraction, exercise tolerance and functional class FDA approved drugs -... (best) – beta blocker + alpha blocker. A very potent vasodilator -Bisoprolol -Metoprolol |
beta-blockers
Carvedilol |
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... helps a systolic HF patient (pt. with tachycardia) by increases myocardial contractility. It decreases symptomatology. It has never been shown to decrease mortality.
-narrow therapeutic index, levels must be monitored -frequent drug interactions |
Digitalis glycosides
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Diuretics:
Leads to clinical improvement Frequent assessment of weight, monitor renal function and electrolytes ... diuretics -Hydrochlorothiazide, metolazone -Use in mild CHF, ... can be very useful with a loop due to its effect in the proximal and distal tubule -SE: hyperuricemia, hyperglycemia, hyponatremia, hypokalemia ... diuretics -Acutely reduces preload by venodilator -Most useful class in CHF -Watch for ototoxicity, decreased Calcium and increased uric acid -SE: hypokalemia ... diuretics (aldosterone diuretics) -Not effective diuretics when used alone but have been shown to increase survival and decrease hospital visits -Watch for increased potassium especially in conjunction with ACE agents & NSAID |
Thiazide
metolazone Loop Potassium – sparing |
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Drugs useful in more severe CHF (hospitalized):
Inotropic -... - increased cardiac output with reflex arterial vasodilatation (decreased SVR) (SE: reflex tachycardia possible) Amrinone / Milrinone -... inhibitors - increased cardiac output, decreased SVR, increased intracellular cyclic aderosine monophosate All inotropics can cause hypotension |
Dobutamine
Phosphodiesterase |
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New agent:
... -Recombinant human B-type -Netriureatic peptide (BNP) -FDA approved for hospitalized class IV heart failure -Watch for hypotension -Makes ventricle pump harder. Increases contractility. Never give this drug on the floor or in the middle of the night and go home. Hypotension is common. |
Natrecor – Nesiritide
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Advanced therapy:
Atriobiventricular pacing Intraaortic balloon pump Ventricular assist device – used in HF pts waiting for a transplant ... - Done mostly on young, idiopathic cardiomyopathy patients. They get the most benefit from it. |
Cardiac transplant
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...:
Recommended in pts with EF<30% and mild to moderate symptoms of HF Survival with good functional capacity is anticipated for > 1 year Patient with a ... ventricle is more prone to ventricular fibrillation and sudden death. These patients need to be on cumadin because ventricle is not pumping well --> blood stasis --> clots. Optimization of the treatment (treat HF). Do this first. |
ICD
dilated |
