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128 Cards in this Set
- Front
- Back
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inability of the heart to pump enough blood to meet the metabolic demands of the body (dyspnea and fatigue, fluid retention)
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heart failure
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T/F: HF is similar among older blacks, Hispanics, and whites.
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true
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heart fails to pump enough blood to meet meatbolic needs of tissues (aneamia, thyrotoxicosis); demand increase
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high output failure
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heart is unable to pump all of the blood with which it is presented (decreased metabolic contractility)
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low output failure
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caused by dysfunction of the left cardiac chambers
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left heart failure
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symptoms include weakness, shortness or breath induced exertion
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left heart failure
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caused by dysfunction of the right heart chamber
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right heart failure
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symptoms include hepatic congestion, effusion in by body cavities, peripheral edema
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right heart failure
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unfolding in minutes, hours or a few days
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acute heart failure
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evolves over months to years; more common than acute
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chronic heart failure
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reduction in muscle mass; dilated cardiomyopathies; decreased contractility restrictionin Ventricular filling; ventricular hypertrophy; pressure overload, volume overload
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systolic heart failure
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increased ventricular stiffness; infiltrative ischemia and infarct; ventricular hypertrophy; hypertrophic cardiomyopathy; mitral or tricuspid valve stenosis is pericardial disease
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diastolic heart failure
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What are 5 direct causes of heart failure?
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1. mhyocardial abnormalities (CAD)
2. hemodynamic overload 3. ventricular filling abnormalities 4. ventricular dysynergy 5. changes in cardiac rhythm |
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What 6 types of drugs are known to precipitate heart failure?
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antiarrythmics
NSAIDS and COX II inhibitors Ca channel blockers Beta blockers glucocorticoids Androgents and Estrogens |
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What 3 things does neurohormonal activation include?
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adrenergic nervous system
renin-angiotensin system increased production of ADH |
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What are 3 abnormalities that result in heart failure?
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preload
afterload cardiac contractility |
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used to compensate for decreased cardiac output
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hemodynamics
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hypertrophy and dilation in response to mechanical overload
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hemodynamics
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compromised introtropic activity, fall in resting CO
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hemodynamics
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no limitations to physical activity of heart patient
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NYHA Class I
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slight limitations to physical activity of heart patient
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NYHA Class II
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marked limitation of physical activity of heart patient
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NYHA Class III
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symptoms at rest for heart patient
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NYHA Class IV
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What are the 5 stages in the evolution of heart failure?
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1. HF risk factors, no disease or symptoms
2. heart disease, no symptoms 3. asymptomatic, LV dysfunction 4. prior or current HF symptoms 5. refractory HF symptoms |
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What are 4 subjective signs of LV failure?
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SOB
orthopenea cough, weakness confustion (no edema) |
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What are2 subjective signs of RV failure?
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peripheral edema
weakness, fatigue |
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What are 4 objective signs of LV failure?
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EF <40%
rales, S3 gallop rhythm reflex tachycardia increase BUN |
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What are 4 objective signs of RV failure?
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weight gain (fluid retention)
neck vein distention hepatomegaly hepatojugular reflex |
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What are 4 non pharmacologic treatments for HF?
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bed rest
sodium restricted diet smoking cesation alcohol limitation |
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What are the 6 steps in pharmacologic treatment of HF?
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diuretics (edema)
ACE inhibitors (improve symptoms and survival) Beta blockers (use after MI) digitalis (does not prolong life) spironolactone other |
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should not be used as monotherapy
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diuretics
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enhance renal excretion of sodium and water, leading to a decrease in vascular volume
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diuretics
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4 ways to overcome diuretic resistance
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IV administration
increase the dose combinations eliminate drug induced causes |
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3 types of diuretics
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thiazides
loop (high ceiling) potassium sparing |
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4 types of thiazides
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HCTZ
chlorthalidone metolazone indapamide |
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3 types of loop diuretics
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bumetanide
furosemide torsemide |
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can increase does to higher than recommeded to combat resistance, especiatlly with renal disease
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loop diuretics
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3 indications to use loop diuretics
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severe volume overload
severe renal insufficiency persistant edema |
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combination therapy for mild heart failure
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loop
thiazide |
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can be used in combo with thiazide or loop diuretics
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potassium sparing diuretics
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spironolactone "Rales trial"
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aldactone
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eplerenone "Ephesus trial"
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inspira
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indications:
recent or current symptoms despide ACE, diuretics, dig and beta blockers hypokalemia recommended in advanced HF in addition to ACE and diuretics |
spironolactone
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2 potassium sparing diuretics
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spironolactone
eplerenone |
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do not use if hyperkalemia, renal insufficiency
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spironolactone
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What should you start before spironolactone?
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ACE
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monitor serum K at frequent intervals
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spironolactone
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furosemide
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lasix
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bumetanide
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bumex
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torsemide
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demadex
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usual daily dose of Lasix
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20-160 mg/day
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ceiling dose of Lasix
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80-160 mg/day
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half life of Lasix
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0.3-3.4 h
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5 adverse effects of diuretics
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orthostatic hypotension
hyponatremia hypokalemia hyperkalemia hypomagnesium |
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6 causes of diuretic resistance
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patient noncompliance
impaired bioavailability due to gut edema impaired diuretic secretion protein binding in tubule lumen hemodynamic insufficiencies enhanced sodium chloride reabsorption |
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drug of choice for HF
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ACE inhibitors
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improve functional capacity and NYHA class, symptoms, prognosis, quality of life
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ACE inhibitors
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slow disease progression, improve exercise capacity, and dicrease hospitalization
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ACE inhibitors
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may be used in secondary agent in HTN
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ACE inhibitors
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5 ACE inhibitors
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captopril
enalapril lisinopril quinapril ramipril |
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initial dose of Captopril
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6.25mg TID
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target dose of Captopril
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50mg TID
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6 contraindications to ACE inhibitors
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intolerance or adverse reactions
K>5.5 symptomatic hypotension, decrease diuretic dose SCr>3.0 renal artery stenosis pregnancy |
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ACE inhibitors + K supplements
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increase K
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ACE inhibitors + antacids
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decrease bioavailibilty of ACE
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ACE inhibitors + NSAIDS
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decrease hypotensive effects
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ACE inhibitors + allopurinol
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increase risk of hypersensitity
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ACE inhibitors + lithium
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increase lithium conc
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ACE inhibitors + food
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decrease bioavailability of captopril
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6 clinical effects of beta blocker
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improve symptoms (long term only)
reduce remodeling/progression reduce hospitalization reduce sudden death improve survival |
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4 types of beta blockers
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bisoprolol
carvedilol metoprolol tartrate metoprolol succinnate |
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initial dose of carvedilol
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3.125/12 h
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target dose of carvedilol
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25/12 h
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metroprolol XL
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iopressor
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bisprolol
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zebeta
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carvedilol
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coreg
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3 beta blocker contraindications
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asthm
AV block (unless PM) symptomatic HTN/bradycardia |
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digoxin
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lanoxin
digitalis |
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increases contractility
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digoxin
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3 clinical effects of digitalis
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improve symptoms
modest reduction in hospitalization does not improve survival |
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when no adequate response to ACE, diuretics, beta blockers (4th line agent)
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digitalis
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in combo with ACE and diuretics if persisting symptoms
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digitalis
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digitalis dose
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0.125-0.25 mg/day
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digitalis loaded dose
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0.25/6 h
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digoxin toxicity
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0.822 +
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Contraindications to ____:
digoxin toxicity with renal failure advanced AV block w/o PM bradycardia or sick sinus w/o PM PVCs and VT marked hypokalemia WPW with Afib |
digoxin
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lower dosing provides beneficial neurohormonal effects
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digoxin
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monitor serum K, renal function, EKG
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digoxin
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target conc for digoxin
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0.8-2 ng/ml
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6 digoxin toxicity signs
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psychiatry
visual gastrointestinal respiratory cardiac arrhythmias conduction disturbances |
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5 digoxin tox predisposing factors
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hypercalcemia
hypokalemia hypomagniesium hypothyroidism renal insufficiency |
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antidote to severe digoxin tox
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DIGIBIND (Digoxin Immune FAB)
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digibind calc
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# vials = serum level x body weight/100
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only time to use is in patients intolerant to ACE
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angiotensin II receptor blockers (ARB)
vasodialators |
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2 vasodialators
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hydralzaine/isosorbide
dinitrate/nitrate |
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especially good for African Americans
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hydralazine/isosorbide
dinitrate |
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decrease in the effect of a drug when administered in a long-acting form, nitrates especially prone to this
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tolerance
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2 direct acting vasodilators
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hydralazine
isosorbide DN |
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1st combo to demonstrate survival benefit in patients in LVEF<45%
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direct acting vasodialators
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only amlodipine and felodipine are considered to be safe
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calcium channel blockers
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vasodialation but also neg inotropic effects, thus, may worsen HF symptoms (decrease contractility)
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calcium channel blockers
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short-term support for low cardiac output HF
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parenteral inotropic agents
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short-term inotropic-hemodynamic support for major diagnostic/surgical procedures
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parenteral inotropic agents
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pharmacologic bridge to transplantation, LV assist device, coronary artery bypass surgery, etc.
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parenteral inotropic agents
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dobutamine
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dobutrex
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2 positive inotropes
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sympatholmimetics
phosphodiesterase inhibitos |
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2 sympathomimetics
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catecholamines
B-adrenergic agonists |
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3 phosphodiesterase inhibitors
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amrinone
milrinone enoximone |
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management of acute failure only
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dobutamine
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restores renal blood in acute failure
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dopamine
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milrinone
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primacore
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adverse effects of ____:
arrythmias decrease BP thrombocytopenia |
phosphodiesterase inhibitors
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short term support in advanced cardiac failure; long term use not possible
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phosphodiesterase inhibitors
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digitalis glycoside
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digoxin
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digoxin common adverse effect
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anorexia
N/V arrhythmia blurred vision |
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adrenergic receptor agonist
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dobutamine
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dobutamine common adverse effects
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arrythmias
excessive vasoconstriction tachyarrhythmias |
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phosphodiesterase inhibitor
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milrinone
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milrinone common adverse effect
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arrhythmias
hypotension thrombocytopenia |
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normal BNP levels
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100-400
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BNP>400
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heart failure
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nesiritide
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natrecore
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neurohormonal effect of nesiritide
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decreased aldosterone
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hemodynamic effect of nesiritde
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increased diuresis
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symptomatic benefits of nesiritide
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decreased dypsnea
improvement in fatigue |
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used in hospitalized patients with acute decompensated heart failure after tyring Lasix
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nesiritede
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amiodarone
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cortarone
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HF patients with clear indication for antiarrhythmic therapy; not recommended for primary prevention of arrythmic death in HF patients
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amiodarone
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