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43 Cards in this Set
- Front
- Back
Heart Failure
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The inability of the body to maintain adequate cardiac output to meet the metabolic demands of the body
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Types of Heart Failure
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High Output--normal CO; due to metabolic factors; normal CO is not enough; not very common
Low Output--decreased CO; the heart cannot generate enough output--pumping less blood; most common |
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Primary Causes
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A problem with the heart itself
Coronary Artery Disease (CAD) Infarction Arrhythmia Congenital Valve Dysfunction Drug Toxicity |
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Secondary Causes
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Heart is affected second to some other process
Hypertension Liver Disease Renal Disease COPD |
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Left Side Heart Failure
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Leads to a back-up of blood into the LUNGS (Pulmonary Congestion)
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Early Stage of Heart Failure
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Someone just looks like they are out of shape; have trouble going up stairs
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Moderate Stage of Heart Failure
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Person will have trouble with Pulmonary Congestion at night, so may sleep with lots of pillows or upright in a lay-z-boy
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End Stage of Heart Failure
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Lots of PITTING EDEMA present, no exercise tolerance
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Treatment of CHF
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Often symptomatic
Want to treat the underlying cause Overall Goals: decrease cardiac work (wall stress), increase CO, control Na+ and H2O Drugs Used Include: - diuretics - vasodilators - positive inotropic drugs - beta receptor antagonists |
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Goal of Diuretics
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Excrete Na+ and H2O by...
- decreasing Vascular volume - decreasing Edema - decreasing Preload - decreasing Pulmonary Congestion |
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Diuretics in the Treatment of HF: Classification and Mech. of Action
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Classification: Diuretics are drugs which eliminate Na and water by acting directly on the kidney.
The diuretics are the primary line of therapy for the majority of patients with heart failure and pulmonary congestion. Mech. of Action: Diuretics (loop, thiazides and potassium-sparing) produce a net loss of Na and water acting directly on the kidney, decrease acute symptoms which result from fluid retention (dyspnea, edema). Diuretic drugs are classically divided into three groups: 1) thiazides, 2) loop diuretics and 3) potassium-sparing |
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Thiazide Diuretics
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Inhibit the active transport of Cl-Na in the cortical diluting segment of the Ascending Limb of the Loop of Henle
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Loop Diuretics
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Inhibit the transport of Cl-Na-K in the Thick portion of the Ascending Limb of the Loop of Henle
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Potassium-Sparing Diuretics
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Inhibit the reabsorption of Na in the distal convoluted and collecting tubules
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Loop Diuretics
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FUROSEMIDE
BUMETANIDE TORSEMIDE **BIG USE IN HEART FAILURE** |
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Loop Diuretics: Mech. of Action and Use
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Mech. of Action: inhibit Na+ -K+ - 2Cl- symporter on Ascending Limb of Loop of Henle
Use: monotherapy for heart failure--reduce vascular volume, edema, pulmonary congestion - IV administration for decompensated HF *Improve symptoms but do not increase survival |
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Compensated HF
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Living with it; still functioning
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Decompensated HF
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The people in trouble in the Emergency Room setting
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Thiazide Diuretics
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HYDROCHLOROTHIAZIDE
*Improve symptoms but do not increase survival |
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HYDROCHLOROTHIAZIDE
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Mech. of Action: inhibit Na+ and Cl- co-transporter on the Distal Convoluted Tubule
Use: in resistance to loop, may be combined with loop, to produce synergistic natriuresis *Improve symptoms but do not increase survival |
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Potassium-Sparing Diuretics
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AMILORIDE
TRIAMTERENE SPIRONOLACTONE *Trials shows Spironolactone alone and in combo. with ACE(-) increase survival |
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Potassium- Sparing Diuretics: Mech. of Action and Use
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Mech. of Action:
- Amiloride, Triamterene--block Na+ conductance channel - Spironolactone--aldosterone antagonist Use: limit K+ wasting; block the effects of aldosterone on the heart--attenuate remodeling |
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Vasodilators Treatment Goal
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Decrease Peripheral Resistance by...
- decreasing Preload - decreasing Afterload |
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Angiotensin Converting Enzyme Inhibitors (ACE)
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CAPTOPRIL
ENALAPRIL LISINOPRIL |
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ACE Inhibitors
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Mech. of Action: decrease peripheral resistance--> decrease afterload and preload--> increase CO
- Decrease Aldosterone Release - Decrease Na+ and H2O absorption - Decrease Cardiac hypertrophy and remodeling Side Effects: cough, can increase serum K+, hypotension *Trials show ACE(-) have a significant increase on survival (longevity) and decrease hospital admissions |
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Type 1 Angiotensin II Receptor (AT1) Antagonists
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LOSARTAN
CANDISARTAN * Trials show them to be as effective as ACE(-) in treating CHF |
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Type 1 Angiotensin II Receptor (AT1) Antagonists: Mech. of Action and Advantages
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Mech. of Action: block AT2 receptors, effects similar to ACE(-)
Potential Advantages: decrease side effects--bradykinin metabolism unaffected AT2 receptors not blocked **ACE inhibitors or Angiotensin Receptor Antagonists are drugs of choice for heart failure** |
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Other Vasodilators
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Sodium Nitroprusside
Nitroglycerin Hydralazine Isosorbide Dinitrite Nesiritide |
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SODIUM NITROPRUSSIDE
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IV administration ONLY--very potent and short-acting; used for decompensated pts.
Mech. of Action: converted to NO; preload and afterload reducer Side Effects: hypotension, reflex tachycardia, ischemia |
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NITROGLYCERIN
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Topical, Sublingual, IV
Mech. of Action: converted to NO; decrease preload and some effect on afterload Side Effects: hypotension, reflex tachycardia, ischemia, tolerance Decrease VR and decrease pulmonary congestion |
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HYDRALAZINE
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Oral Administration
Mech. of Action: unknown; decrease afterload **Isosorbide dinitrite and hydralazine often used in combination in pts who cannot take ACE(-). A synergistic vasodilator action |
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ISOSORBIDE DINITRITE
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Oral Administration
Mech. of Action: converted to NO; decrease preload **Isosorbide dinitrite and hydralazine often used in combination in pts who cannot take ACE(-). A synergistic vasodilator action |
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NESIRITIDE
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Recombinant form of human brain natriuretic peptide (BNP)
IV infusion Mech. of Action: increase cyclic GMP; produces natriuretic, diuretic, and vasodilator responses (decrease preload and afterload) Use: acute treatment of dyspnea in CHF * This is an emergency room drug; IV only; very short-acting |
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Positive Inotropic Drugs
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DIGOXIN, Digitoxin (Cardiac Glycosides)
DOPAMINE DOBUTAMINE INAMRINONE and MILRINONE(Phosphodiesterase Inhibitors) |
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Positive Inotropic Drugs: Treatment Goal
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Increase Ventricular Performance--> increase CO by increasing FC (very rarely used)
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DIGOXIN, Digitoxin (aka Digitalis Drugs): Cardiac Glycosides
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Absorption: Oral
Elimination: Renal Mech. of Action: **inhibit (block) Na+/K+ ATPase--> increase intracellular Ca2+ and increase FC** - increase FC--> increase CO --> decrease preload and congestion, increase renal perfusion (decrease renin) **FC is directly proportional to concentration of intracellular Ca2+ Other Effects: Increase parasympathetic tone; decrease automoticity, decrease speed of AV conduction Side Effects: very narrow therapeutic index (S.E. are increased by low K+); GI effects; Cardiac Arrhythmias Treatment of Side Effects: Lidocaine, potassium, beta blockers; Fab fragments (digitalis antibodies) Use: Reserved for pts. in HF with ATRIAL ARRHYTHMIA, or if symptoms persist after ACE(-) and beta antagonists |
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DOPAMINE
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D1, Beta 1, and Alpha 1 agonist
Mech. of Action: low dose, dilate renal artery **Long term use is not recommended |
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DOBUTAMINE
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Beta 1 agonist
Emergency Room drug, can only be given IV Mech. of Action: increase FC without increasing HR Side Effects: tolerance occurs which leads to tachycardia--so usually only used for a couple of weeks **Long term use is not recommended |
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Phosphodiesterase Inhibitors
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INAMRINONE
MILRINONE (given IV) |
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Phosphodiesterase Inhibitors: Mech. of Action and Use
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Mech. of Action: increase intracellular levels of cAMP by inhibiting its breakdown; increase cAMP--> phosphorylation of Ca2+ channels--> increase intracellular Ca2+--> increase FC
- In Vascular Smooth Muscle --> increase cGMP--> vasodilation and decrease preload and afterload Use: short term severe failure |
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Beta Receptor Antagonists
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CARVEDILOL (beta 1, beta 2, and alpha 1)--10x more potent as a beta than an alpha
METOPROLOL (beta 1) BISPROLOL (beta 1) |
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Beta Receptor Antagonists: Mech. of Action
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Decrease SNA to heart, decrease HR + O2 consumption
Decrease deleterious effects of catecholamines (decrease hypertrophy and remodeling) Increase Ventricular Function (increase EF) These hearts do not have to work as hard, the heart will actually work better Beta therapy will decrease symptoms, increase longevity, and decrease hospital admissions in HF and post MI |
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What 3 categories increase life expectancy?
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ACE Inhibitors
Beta Blockers Ca Sparing Diuretics |