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27 Cards in this Set

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What are two forms of heart failure and what factors are associated with them?
High Output - CO is normal just isn't enough for body's metabolic needs
Low Output - Primary Heart Fialure (due to mechanical or metabolic disease) or Secondary Heart Failure (attributed to diseases in other organs)
Describe the various stages and associated symptoms of heart failure patients.
Asymptomatic - CO is decreased with no symptoms
Moderate - Fatigue on exertion or exercise with nocturnal dyspnea
Severe - exreme fatigue on exertion, congested lungs, peripheral pitting edema
What type of Cardiomegaly would be present in a condition of CHF?
Eccentric or cardiac dilation
What comprises the vicious cycle of CHF?
Decreased blood mobility due to mechanical dysfunction perpetuating baroreflex response and RAS response yeilding increased TPR, HR, preload, and reabsorption of sodium and in addition a hypervolemic state.
What are the two types of Heart Failure patients that will be treated with pharmacotherapy and through what route will they be treated?
Compensated - oral drugs
Decompensated - parenteral drugs
What are the positive ionotropic agents used to treate heart failure and how do they function?
They are cardiac glycosides (digitalis drugs) that increase force of contraction int he heart and raise CO. Cardiac glycosides include Digoxin, Digitoxin, and Oubain
Dopamine
Dobutamine
Phosphodiesterase Inhibitors
What is the route of elimination for Digoxin and Digitoxin and their half lives?
Digoxin - 1.5 days renal excretion
Digitoxin - 7 days Hepatic Metabolism
How do the cardiac glycosides actually work?
They inhibit Na/K ATP-ase which is used to reestablish the resting membrane potential during diastole by pumping Na out and K in. This is coupled to a Na/Ca exchanger which gets rid of Extra Ca in exchange for one Na. So block ATPase block Ca from leaving (cake!) Increased Ionotropy!
What are some other effects of glycosides besides the ATPase pump effect?
Increased Baroreflex sensitivity (I wonder if this should be decreased)
Decreased Sympathetics
Decreased sensitivity to Catecholamines
Increased parasympathetic tone and increased cardiac sensitivity to Ach
What are the more severe side effect of digitalis?
Incredibly toxic with narrow therapeutic dose
Large effects on serum K levels (hypokalemia)
AV Block!
Ventricular tachycardia
Drug interactions
How does Dopamine work for Heart Failure?
DA1, DA2 (Increase NE), Beta1, and Alpha 1 agonist.
Increases HR, increases ionotropy
DA1 effects are vasodilation of renal and splanchnic arteries, increased GFR, and increased urine
How does Dobutamine work for Heart Failure?
Beta 1 agonist that at low doses can increase ionotropy without increasing HR, essentially increasing CO without increasing demand (I say Bullshit! but whatever)
Side Effect - Long term use tolerance
How do Phosphodiesterase Inhibitors work and what are 2?
Inamrinone and Milrinone
Heart: Selectively blocks Phosphodiesterase III causing increased cAMP --> increased contraction
Peripheral Vasculature: Blocks phossphodiesterase III increasing cGMP --> vasodilation --> decrease preload and afterload (sounds like peripheral backup to me haha)
What are the Heart Failure vasodilator drugs and what do they do?
Na-nitroprusside - NO --> dilation of arteries and veins reducing preload and afterload (CN poisoning in renal failure patients)
Nitroglycerin - Venodilator reducing preload (at higher doses arterial dilator reducing afterload)
Nesiritide - BNP --> Natriuretic, diuretic, and vasodilator (IV, no proarrhythmic potential)
Do you Like Pictures??
Goood!!!
What vasodilators would you use acutely and which would you use chronically for Heart Failure Control?
Acute - Sodium Nitroprusside, Nitroglycerine, Nesiritide
Chronic - Hydralazine, Isosorbide dinitrate
What effect does Hydralazine have and what is a primary side effect?
Causes arterial vasodilation leading to decreased afterload
Side effect - orthostatic hypotension leading to syncope
Low compliance due to Q4hr
What effects does isosorbide dinitrate have?
Decreases preload by venodilation
What are the benefits of captopril and enalapril and what are they?
They are ACE inhibitors.
They can be used to treat heart failure by reducing preload and afterload.
AngII is a powerful vasoconstrictor and potentiates NE release and action - Blockade reverses these effects. AngII also causes Aldosterone release
What is a major heart remodeling effect of Angiotensin II and a secondary heart remodeling effect?
Ang II is a cardiac growth hormone (hypertrophic agent)
It causes release of aldosterone which is also a hypertrophic agent (so not just big but biggie biggie can't you see?)
What are the angiotensin receptors and what do they do?
AT1 - major vasoconstrictor
AT2 - ?? maybe counteracts aldosterone so Vasodilator (possibly)
What are some side effects of ACEi
contraindicated in pregnancy (I don't know why!)
Persistent dry cough due to bradykinin (which is normally broken down by ACE)
escape phenomenon because of alternative production of Ang II
What are the angiotensin Receptor Antagonists and what do they do?
They are Saralasin and Candisartin
They block AT1 but not AT2
They prevent escape phenomenon and maintain breakdown of bradykinin
What are some diuretic drugs that can be used for treatement of Heart Failure?
Loop Diuretics - Furosemide, bumetanide, torsemide
Thiazides
K-Sparing drugs - Spironolactone (causes reverse remodeling in the ventricles)
What are the beta agonists that Dr. Varner wants us to know huh?
Carvedilol and Metoprolol
What does Carvedilol do and how does it work?
It is a beta1, beta2, and alpha1 blocker (ratio of 10:1 beta alpha) Causes blockade of beta plus vasodilation from alpha
How many stages of heart failure is there and what are they treated with (ambulatory patients)?
Four stages I-IV
All treated with Diuretic
All treated with ACEi (replace with ARBs, Hydralazine/Isosorbide dinitrate if intolerant)
Almost all treated with beta blocker
Digoxin is reserved for a-fib or a-flutter b/c it can control reentry circuits, slow AV conduction, and increase ionotropy