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111 Cards in this Set
- Front
- Back
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What is heart failure?
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Clinical syndrome resulting from structural or functional cardiac disorder that impairs the ability of the heart to fill or eject blood
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What is cardiorenal model of heart failure?
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Na/H20 excess causes fluid overload so diuretics are the primary therapy. This is not very common
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What is the Cardiocirculatory Model of Heart Failure?
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Impaired CO and inadequate contractility so Positive Ionotropes are primary therapy
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What is the Neurohormonal Model of heart failure?
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Initial event promotes systemic disease progression mediated by neurohomones. This is most common
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What are the cardiovascular causes of heart failure?
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Congenital Cardiac Malformations
Primary cardiomyopathy Secondary cardiomyopathy |
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Why does Systolic Dysfunction cause a lower ejection fraction?
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Because there's impaired wall function and a dilated ventricle
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What is systolic dysfunction attributed to?
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Coronary Artery Disease
Nonischemic Cardiomyopathy (HTN, congenital disease, valvular disease, cardiotoxins) Myocarditis Idiopathic |
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What are the etiologies of systolic dysfunction?
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Volume Overload (mitral regurg, aortic regurg and high output states)
Pressure Overload (HTN, pulmonary HTN and outflow obstruction) Loss of Muscle (Myocardial ischemia, MI, Connective tissue disease) Loss of contractility (Alcoholic cardiomyopathy, Chemo agents, Viral/Bacterial) |
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Does diastolic dysfunction cause a change in the ejection fraction?
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Nope
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What happens with diastolic dysfunction?
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There is impaired ventricular relaxation and filling. There is normal wall motion but a decreased volume. There is a loss of elasticity of the CV system
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What is diastolic dysfunction usually caused by?
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Cardiomyopathy: restrictive, infiltrative or hypertrophic
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What are the etiologies of diastolic dysfunction?
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Impaired relaxation (Systemic HTN, LVH, Ischemic heart disease, Constrictive pericarditis, pericardial tamponade, infiltrative myocardial disease)
Impaired filling (mitral stenosis or tricuspid stenosis) |
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What are the signs and symptoms of heart failure?
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Growth failure
Respiratory distress Exercise intolerance Edema Dyspnea Fatigue |
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What is stage A Heart Failure
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High risk of HF without sructural disease or symptoms
Ex. HTN, atheroscelosis, DM |
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What is stage B HF?
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Structural disease without signs/symptoms of HF
Ex. Previous MI |
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What is stage C HF?
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Structural disease with prior/current symptoms of HF
Ex. SOB, fatigue |
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What is stage D HF?
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Refractory HF requiring specialized interventions
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What are the principles of therapy for Systolic HF
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Block the compensatory neurohormonal activation caused by decreased CO
Prevent/minimize Na and H2O retention Eliminate/minimize symptoms Slow progression of hear dysfunction Decrease mortality Increase quality of life |
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Where do you see edema in infants?
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In the face.
In the sacral area |
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What are the short term benefits of Diuretic use in HF?
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Decreased JVD
Decreased pulmonary congestion Decreased peripheral edema |
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What are the intermediated term benefits of Diuretic use in HF?
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Decreased daily symptoms
Improved cardiac function Increased exercise tolerance |
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Will you live longer if you take a Diuretic to treat HF?
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No
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Where to Loop Diuretics work?
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The ascending loop of henle
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What is the MOA of Loop Diuretics?
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Impedes Cl, Na and K reabsorption via the Na/Cl/K pump
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What are the adverse effects of Loop Diuretics?
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Increased K loss because of increased Aldosterone
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Where so Osmotic Diuretics work?
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The proximal tubule, thin descending limb, the distal tubule and the collecting ducts
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What is the MOA of Osmotic diuretics?
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Impedes water reabsorption and indirectly impedes Na reabsorption
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What are the adverse effects of Osmotic diuretics?
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Volume contraction
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Where do Thiazides work?
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The ascending Loop of Henle
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What the is MOA of Thiazide diuretics?
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Impedes Cl reabsorption creating a negative charge which impedes Na reabsorption
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What are the adverse effects of Thiazides?
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Increased K losses
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Where do Aldosterone Blockers work?
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Late distal tubule and early collecting ducts
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What is the MOA of Aldosterone Blockers?
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Impedes Na/K antiports, impeding Na reabsorption and K excretion
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What are the adverse effects of Aldosteron blockers?
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Increased K
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Why are Aldosteron Blockers good? Why bad?
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Good because they don't waste K but they're not very strong so it's best to give with another diuretic
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What do you see a rapid improvement in with a diuretic?
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Edema
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How does resistance to diuretics occur?
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Decreased absorption due to bowel edema and hyperperfusion
Increased exposure leads to changes in kidney structure |
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How do you overcome resistance to diuretics?
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Administer as continuous infusion
Add positive ionotropic agent Increase dose or frequency of drug Add additional diuretic |
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What are the adverse effects of diuretics?
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Electrolyte depletion (Na, K, Mg and Ca)
Hypotension Dizziness Dehydration/Azotemia |
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What do you need to monitor for pts on diuretics?
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BMP
Chem 7 Vitals Body Weight HF symptoms Adverse effects |
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Can a diuretic be used as monotherapy to tx HF?
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No they will die
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Why shouldn't use over use diuretics?
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Because will cause renal impairment
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Which type of diuretic is 1st line tx in HF?
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Loop because have best efficacy
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Which 2 classes of drugs work on the Neurohormonal blockade?
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Ace-I
ARBs |
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What are the benefits of using an ACE-I in HF?
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Decreased mortality
Decreased hospitalizations Symptom improvement Clinical status improvement Better sense of well being Decreased ventricular remodeling |
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What's usually the 1st drug prescribed in HF?
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And ACE-I
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What is the MOA of ACE-I?
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Blocks production of angiotensin 2
Decreases sympathetic stimulation Decreases production of aldostersone and vasopressin Decreases vasoconstriction Increases bradykinins which increases vasodilatory prostaglandins |
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What are the adverse effects of ACE-Is?
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Non productive cough that's super annoying
Increased K Angioedema Renal Insufficiency Hypotension Neutropenia |
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What are the contraindications of giving an ACE-I?
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K greater than 5.5
Hx of angioedema Pregnancy |
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What are the cautions in giving an ACE-I?
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K greater than 5.5
S.Cr greater than 3 Bilateral renal artery stenosis |
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What do you need to monitor for a pt on ACE-I?
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BMP
S.Cr K Vitals CBC HF Symptoms Adverse effects |
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What should everyone HF patient with LV dysfunction get?
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And ACE-I
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What does the class effect of ACE-I's mean?
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If one drug works, they all will
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T of F: You should start with a high dose of ACE-I in a HF patient?
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NO! Start low, titrate slow
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Who doesn't ACE-I's work very well for?
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African Americans, still the best option though
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What is the MOA for ARBs?
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Selectively block binding on angiotensin 2 to the AT1 receptor
Decreases production of aldosterone and vasopressin Decreases vasoconstriction |
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What are the adverse effects of ARBs?
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High K
Angioedema Renal Insufficiency Hypotension Neutropenia |
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What should you monitor with a pt on an ARB?
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BMP
S.Cr. K Vitals CBC HF symptoms |
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Why don't ARBs cause a cough?
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They have no effect on bradykinin
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What should pts who do not tolerate ACE-I's get?
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An ARB - doesn't cause cough but may still cause angioedema
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If a patient is maxed out on ACE-I and Beta Blocker dosing, what should be added to their therapy?
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An ARB
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What are the benefits of Beta Blocker in HF?
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Decreased mortality
Decreased hospitalization Increased ejection fraction Symptom improvement Clinical status improvement |
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What's the MOA for Beta Blockers?
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Blocks the effect of sympathetic neurotransmitters which decreases ventricular arrhythmias, decreases cardiac hypertrophy and decreases HR and vasoconstriction
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What is Carvedilol?
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A mixed beta blocker that has additional alpha 1 blockade
Decreases afterload More decrease in BP than Metoprolol |
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What are the adverse effects of Beta Blockers?
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Hypotension
Decreased HR Fluid retention Depression Weakness/Fatigue Sexual Dysfunction |
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How do you manage the hypotension ass. w/ Beta blocker use?
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Decrease vasodilator therapy.
If hypotension persists: decrease beta blocker |
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How do you manage the fluid retention ass. w/Beta blocker use?
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Increase the diuretic dose.
If fluid retention persists: decrease beta blocker |
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How do you manage the bradycardia ass. w/beta blocker use?
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Decrease the beta blocker.
If bradycardia persists: Discontinue beta blocker |
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What pts need extra caution when giving a beta blocker?
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Severe bronchospastic disease
Asthma Bradycardia Symptomatic hypotension 2nd or 3rd degree heart block |
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What should you monitor in patients taking beta blockers?
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Body weight
Vitals HF symptoms Adverse Effects |
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Patients need to be ____ stable before starting beta blocker therapy
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Fluid
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T or F: Patients may feel more symptomatic for the first few weeks of beta blocker therapy.
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True
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If beta blocker therapy is held for more than ___ hours, consider restarting beta blocker at ____ of previous dose.
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72, 50%
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What are the benefits of Spironolactone?
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Decreased mortality
Decreased hospitalizations Improved symptoms K sparing |
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For what classes of HF can Spironolactone be used?
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3 and 4
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For what classes of HF can Eplerenone be used?
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2
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What are the benefits of using Eplerenone?
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Decreased death and hospitalization
Decreased mortality |
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What are the benefits of using Elperenone with LV dysfunction after an MI?
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Decreased mortality
Decreased composite death |
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What is the MOA of Aldosterone Antagonists?
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Blocks effects of aldosterone in the kidneys and heart
Decreases K and Mg loss which leads to decreased ventricular arrhythmias Decreases Na retention which decreases fluid retention Decreases catecholamine potentiation which decreases BP |
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What are the adverse effects of Aldosterone Antagonists?
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Increased K
Gynecomastia or breast pain Sexual dysfunction Will not reduce edema very well |
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Which pts need caution when given an Aldosterone Antagonist?
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S.Cr greater than 2.5 in men
S.Cr greater than 2 in women K greater than 5.5 |
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What should you monitor with pts on Aldosterone Antagonists?
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BMP, K, S.Cr
HF symptoms Adverse effects |
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Who should you consider giving a Aldosterone Antagonist to?
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Pts with class 3 or 4 HF who are receiving therapy with an ACE-I, Diuretic and beta blocker
Pts after an MI with LV dysfunction |
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Can you give a patient an Aldosterone Antagonist if they're already taking an ACE-I and an ARB?
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No, too high of a risk of hyperkalemia
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What are the benefits of giving Digoxin for HF?
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Improved symptoms
Improved exercise tolerance Decreased hospitalizations NO EFFECT ON MORTALITY |
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What is the MOA of Digoxin?
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Inhibits Na-K adenosine triphosphatase
Decreases central sympathetic outflow by sensitizing cardiac baroreceptors Decreased renal reabsorption of Na Minimal increase in cardiac contractility |
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What are the adverse effects of Digoxin?
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Cardiac toxicities (ventricular arrhythmias, heart blocks, bradycardia)
GI disturbances (NVD) CNS toxicities (confusion, vision changes) |
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What are the risk factors for having an adverse reaction to Digoxin?
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Decreased K and Mg
High Ca Hypothyroidism Interacting meds Renal insufficiency |
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What are the contraindications to giving Digoxin?
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2nd or 3rd degree heart blocks
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What drugs should be given with caution to a pt on Digoxin?
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Amiodarone
Diuretics Cholestyramine Spironolactone Verapamil |
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What should you monitor in a pt on Digoxin?
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BMP: K, S.Cr
Serum Digoxin level (0.8-1.2) Vitals HF symptoms Signs/symptoms of Dig toxicity |
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What you cause you to need increased Digoxin monitoring?
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Change in renal function
Change in EKG Signs/symptoms of Dig toxicity Initiation/discontinuation of interacting meds |
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T or F: You can use Digoxin for acute exacerbation of HF?
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False, long term therapy only
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If a patient is taking Digoxin and Amiodarone at the same time you should decrease the Digoxin dose by ?
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50%
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Start a super low dose of Digoxin in which pts?
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Those with conduction abnormalities, decreased renal function and low lean body mass
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Do you need a loading dose for Digoxin?
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No
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What are the benefits of using Nitrates and Hydralazine in treating HF?
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Decreased heart failure (not as good as ACE-I)
Decreased hospitalizations Improved exercise tolerance |
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What's the MOA of Hydralazine?
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Vasodilator
Enhances the effects of nitrates |
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What is the MOA of nitrates?
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Stimulates nitric acid signaling in the endothelium causing vasodilation
Decreases preload |
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What are the adverse effects of Hydralazine?
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Headache
Hypotension Dizziness Leucopenia/thrombocytopenia Lupus like Syndrome |
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What are the adverse effects of nitrations?
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Headache
Hypotension Dizziness Flushing Flu like symptoms |
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Can you give nitrates or hydralazine alone?
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No they are buddies - always given together
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What should you monitor for pts on Nitrates and Hydralazine?
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CBC: WBC and platelets
Vitals: BP ANA profile: if have Lupus like symptoms HF Symptoms Adverse effects |
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What's the best nitrate to use?
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Isosorbide clinitrate
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What are the benefits of Calcium Channel Blockers in HF?
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No mortality benefit
Tx for HTN |
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Which 2 anti-arrhythmics have been shown to be effective in treating arrhythmias in HF?
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Amiodarone
Dofelide |
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Someone in Stage A of HF will be on what meds?
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ACE-I
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Someone in Stage B of HF will be on what meds?
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ACE-I
Beta Blocker |
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Someone in Stage C of HF will be on what meds?
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ACE-I
Beta Blocker Loop diuretic |
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Someone in Stage D of HF will be on what meds?
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ACLS
Ionotropic therapy Transplantation |
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What meds are red flags for pts in HF?
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Anti-Arrhythmics
Non-DHP CCB Oral hypoglycemics Systemic glucocorticoids Estrogens/Androgens NSAIDS Chemo agents |
