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25 Cards in this Set

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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
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
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
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
If you have a diastolic dysfunction, you would give a drug that ... the LV (CCBs, nitroglycerin, BBs)
relaxes
... output heart failure:

Severe chronic anemia
Atrio-ventricular shunt
Thyrotoxicosis – one of the worst
Paget’s disease
“wet” beriberi
High
What is the most important drug for heart failure?
ACE inhibitor (or some type of renin-angiotensin aldosterone inhibitors)
look at slide 10
ok
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
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
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
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
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
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
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
renal artery stenosis
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)
...:

Mostly venodilators

Reduce myocardial ischemia by a decrease in ventricular filling pressure by some direct dilating of coronary arteries. they reduce myocardial ischemia
Nitrates
...:

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
...:

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
... 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
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
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
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
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
...:

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