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Danny's MD3001 Cardiovascular System > 06-10-22 - Pharmacological Treatment of Cardiac Failure > Flashcards

06-10-22 - Pharmacological Treatment of Cardiac Failure Flashcards

1
Q

Learning outcomes

A
  • To understand the strategies for treatment of chronic heart failure
  • To understand the strategies for treatment of acute heart failure
  • Recognise how the apparently paradoxical use of beta blockers is of benefit
  • Understand the mechanism of action and uses of drugs which inhibit the renin-angiotensin-aldosterone system
  • Know the mechanism of action of digoxin and how it increases myocardial contractility
  • Know the mechanism of action and uses of inotropes
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2
Q

What is the New York Heart Association Classification of Heart Failure?

A

1) What is the New York Heart Association Classification of Heart Failure

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3
Q

What is HFrEF?

What is it the same as?

What are the 4 aims of treatment of cardiac failure?

What are the 5 strategies of treatment?

A
  • HFrEF is heart failure with reduced ejection fraction
  • This is another name for Left Ventricular Systolic Dysfunction (LVSD)
  • LVSD = HFrEF
  • 4 aims of treatment of cardiac failure:
    1) Relieve symptoms
    2) Improve exercise tolerance
    3) Reduce incidence of acute exacerbations
    4) Reduce mortality
  • The 5 strategies of treatment:

1) ↑ cardiac contractility

2) ↓ preload and/or afterload in order to ↓ cardiac work demand
* By relaxing vascular smooth muscle
* By reducing blood volume

3) Inhibit the Renin-Angiotensin-Aldosterone-System (RAAS)

4) Prevent inappropriate ↑ in heart rate

5) Mobilise the oedematous fluids

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4
Q

What are the 5 main types of drugs used in chronic heart failure (HFrEF)?

What is an example of each type?

How do these drugs affect heart failure? What is HFpEF?

A
  • 5 main drugs types used in chronic heart failure (HFrEF):

1) Loop diuretics
* e.g furosemide, bumetanide

2) ACE inhibitors
* e.g. ramipril, Lisinopril

3) Angiotensin II receptor blockers
* e.g candesartan, losartan

4) Beta-blockers
* bisoprolol, carvedilol

5) Aldosterone receptor antagonists
* e.g. spironolactone

  • These approaches can prolong life in heart failure and counteract some of the symptoms of heart failure, but they don’t correct the underlying fault
  • HFpEF is heart failure of preserved ejection fraction
  • This heart failure is not that well understood and is a lot rarer
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5
Q

What are the 4 steps in treatment of chronic heart failure?

A
  • 4 steps in treatment of chronic heart failure:

1) DAB
* D = Diuretics (if there is fluid retention)
* A = ACE Inhibitor or ARB
* B = Beta-Blocker
* A and B shown to reduce mortality (i.e. prolong life) and improve quality of life.

2) Adding aldosterone antagonists
* spironolactone, eplerenone
* Add in if on ACEI or ARB + Beta-blocker + diuretic (“DAB”) and symptoms are still present
* In NYHA class II-IV failure (effective in severe heart failure)
* Low doses used
* Reduces symptoms and mortality

3) Step 3 or 4
* Step 1 and 2 is used for most patients with chronic heart failure
* Sacubitril – Valsartan combination
* Sacubitril is a Neprolysin inhibitor
* Valsartan is an ARB

  • Ivabradine
  • Specialist use only
  • Reduces heart rate but not contractility, acts on sinus node.
  • Use only if heart rate > 75 (in SR – sinus rhythm)
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6
Q

What is step 1 of treatment of chronic cardiac failure?

A
  • Step 1 of treatment of chronic cardiac failure:

1) DAB
* D = Diuretics (if there is fluid retention)
* A = ACE Inhibitor or ARB
* B = Beta-Blocker

  • A and B shown to reduce mortality (i.e. prolong life) and improve quality of life.
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7
Q

What are diuretics?

What is step 1 and 2 of diuretics used?

What are 2 examples of each?

When are flexible loop diuretics regimes used to treat cardiac failure?

What is the aim of this treatment?

What is dry weight?

What are 3 self-management techniques patients can use to alter dose of diuretics?

What can the GP do to determine correct dosages?

A
  • Diuretics are substances that help the body get rid of water
  • Step 1 and 2 of diuretics used to treat cardiac failure:

1) Loop diuretics
* Furosemide
* Bumetanide
* Loop diuretics work by inhibiting the NKCC2 ((Na+/K+/2Cl- co-transporter) in TAL (Thick Ascending Limb, loop of Henle), which accounts for about 15-20% of Na+ reabsorption

2) Aldosterone receptor antagonists
* Spironolactone
* K+ sparing diuretic

  • Flexible loop diuretics regimes used to treat cardiac failure if there are clinical signs/symptoms of fluid overload/congestion
  • The aim is to achieve a “dry” weight using the lowest diuretic dose possible.
  • Dry weight is the weight at which there are minimal signs or symptoms of either hypovolemia or hypervolemia
  • 3 self-management techniques patients can use to alter dose of diuretics:
    1) Daily weights – if varies in either direction, alter dose
    2) Symptom review – breathlessness, peripheral oedema
    3) Thirst level, dizziness, “washed out”
  • The GP can conduct blood chemistry checks within a week of any dose change to ensure that it is correct
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8
Q

What are 6 common side effects of loop diuretics?

A
  • Common side effects of loop diuretics (e.g furosemide, bumetanide):
    1) Electrolyte disturbances –low K, Na, Mg, Ca
    2) Hypotension
    3) Renal impairment – measure eGFR
    4) Hypovolaemia!
    5) Nocturia if taken too late in day (urination in the middle of the night)
    6) Acute gout common with high doses
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9
Q

What are the 2 RAAS inhibitors used to treat chronic cardiac failure?

What are 2 examples of each?

In what cases of HF are they used?

How do they affect outcomes?

A
  • 2 RAAS inhibitors used to treat cardiac failure:

1) Angiotensin converting enzyme inhibitors (ACE inhibitors)
* Ramipril
* Lisinopril

2) Angiotensin AT1 receptor antagonists (Angiotensin Receptor Blockers ARBs)
* Candesartan
* Valsartan
* (losartan)

  • RAAS inhibitors are used in HF with reduced EF of all NYHA classes
  • Reduces morbidity/mortality
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10
Q

What 8 systemic effects do ACE inhibitors and ARBs have in HF?

What are 6 symptoms are common to both?

What is a unique symptom of ACE inhibitors?

What is a unique symptom of ARBs?

A
  • Systemic effects do ACE inhibitors and ARBs have in HF:
    1) Reduce salt and water retention
    2) Reduce vasoconstriction
    3) Reduce vascular resistance
    4) Reduce afterload
    5) Improve tissue perfusion
    6) Reduces ventricular remodelling and hypertrophy
    7) Less effective in African or Caribbean ethnicity (try hydralazine + nitrate)
    8) Start low dose, monitoring BP & blood chemistry and symptoms and uptitrating to maximum tolerated or target doses.
  • Symptoms common to both ACE inhibitors and ARBs
    1) Dizziness
    2) Headache
    3) Risk of hyperkalaemia (care with drug which also raise K+)
    4) Renal impairment - can be reno-protective also
    5) Avoid in bilateral renal artery stenosis
    6) Teratogenic - A drug is a teratogen if its administration to the pregnant mother, directly or indirectly, causes a structural or functional change in the foetus or child
  • Unique Angiotensin converting enzyme (ACE) inhibitors symptom - persistent dry cough, tiredness, rare but serious – angioedema
  • Unique Angiotensin AT1 receptor antagonists (ARBs) symptom – back/leg pain
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11
Q

What are CVS effects of B1 receptor blockers?

What is a negative of using Beta-blockers to treat chronic heart failure?

What are 3 positives of using Beta Blockers to treat chronic heart failure?

A
  • CVS effects of B1 receptor blockers:
    1) Decreased HR
    2) Decreased force of contraction
    3) Decreased CO
    4) Decreased BP
  • A negative of using Beta-blockers to treat chronic heart failure is they may slow HR, which could decrease CO
  • 3 positives of using Beta Blockers to treat chronic heart failure:

1) Slowing allows ventricle to fill more completely during diastole
* This will lead to increased EDV, which will lead to increased stroke volume, which will increase cardiac output that way
* This balances out the decrease in cardiac output that Beta-blockers can bring

2) Some Beta-blockers (e.g. carvedilol) cause vasodilation through blockage of alpha-receptors, which ↓ afterload (alpha receptors cause vasoconstriction)

3) Reduce renin release by kidney – will decrease blood pressure

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12
Q

What are 2 examples of beta blockers?

When are Beta-blockers to treat chronic heart failure started?

How are they started?

What 5 cases should we seek specialist advice when using beta blockers?

What 4 CVS drugs might Beta blockers negatively interact with?

What 2 effects can this have? What are 4 side effects of Beat-blockers?

A
  • Examples of beta blockers:
    1) Carvedilol
    2) Bisoprolol
  • Beta blockers are started if there is reduced ejection fraction but stable NYHA class II-IV
  • They are started low, and slowly increased if necessary (star low, go slow) to reduce mortality
  • When using beta blockers, we should seek specialist advice if:
    1) Severe HF
    2) Current exacerbation of HF
    3) Heart block or bradycardia
    4) Persisting signs of fluid overload
    5). low BP (SBP<90mmHg)
  • Beta-blockers may negatively interact with the following CVS drugs:
    1) Digoxin
    2) Amiodarone
    3) Verapamil
    4) Diltiazem
  • These negative interactions can lead to:
    1) Bradycardia
    2) AV block
  • 4 side effects of Beta-blockers:
    1) Bradycardia /Heart Block (contra-indicated)
    2) Fatigue
    3) Shortness of breath (Contra-indicated in Asthma)
    4) Dizziness, cold peripheries, impotence/reduced libido, insomnia (more with older versions)
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13
Q

What 3 ways do we manage the adverse effects of HF drugs?

A
  • How we manage the adverse effects of HF drugs:
    1) Flexible dosing for DABs, may need to up and down titrate.
    2) Review BP – may be low but is patient symptomatic?
    3) Bradycardia – if symptomatic may need to stop beta-blocker or review any other rate controlling drugs patient on.
  • If HR<45 BPM – stop beta-blocker, call specialist
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14
Q

When do we used step 1 and 2 for chronic heart failure?

What are steps 3 and 4 in the treatment of chronic heart failure?

What are other treatments to consider for 3 other concurrent conditions?

A
  • Steps 1 and 2 in the treatment of chronic heart failure is used in most cases
  • Steps 3 and 4:
  • Sacubitril and Valsartan combination used to replace ARB/ACE inhibitor
  • Sacubitril is a Neprolysin inhibitor
  • Valsartan is an ARB
  • Ivabradine
  • Specialist use only
  • Reduces heart rate but not contractility, acts on sinus node.
  • Use only if heart rate > 75 (in SR – sinus rhythm)
  • Other treatment offers to consider for 3 concurrent conditions:

1) Persistent sodium/water retention
* Additional diuretics (e.g. thiazides like metolazone)

2) Co-existing angina
* Oral nitrates
* Amlodipine (care!)

3) Atrial fibrillation
* Digoxin

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15
Q

What is acute heart failure?

What symptoms are worsened?

What are causes of acute heart failure?

What are the aims in treatment of acute heart failure?

A
  • Acute (decompensated) failure is sudden worsening of signs and symptoms of heart failure as a result of severe congestion of multiple organs.
  • This leads to worsened dyspnoea (breathlessness) and oedema
  • Causes of acute heart failure:
    1) MI
    2) Infection
    3) Anaemia
    4) Thyroid dysfunction
    5) arrhythmia
    6) uncontrolled hypertension
    7) Poor concordance
  • Aims in treatment of acute heart failure:
    1) Reduce burden on the heart as rapidly as possible
    2) Normalise ventricular filling pressures
    3) Restore adequate tissue perfusion
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16
Q

What is Digoxin?

When might it be used?

Does it reduce mortality rate?

Why is it a difficult drug to use?

What are digoxin’s mechanisms of action in atrial fibrillation?

What are digoxin’s mechanisms of action in heart failure?

What are the side effects of digoxin/digoxin toxicity?

A
  • Digoxin is a cardiac glycoside
  • It may be used as an option if other treatment strategies are failing
  • It shows no reduction in mortality rate
  • Digoxin is a difficult drug to use as it has a very narrow therapeutic window – difficult to get a therapeutic concentration that isn’t toxic
  • Digoxin’s mechanism of action in:

1) Atrial fibrillation
* ↑ vagal efferent activity to the heart  ↓ SAN firing rate (↓ HR) and ↓ conduction velocity in the AV node

2) Heart failure
* Increases force of myocardial contraction
* Inhibits Na/K ATP-ase pump, thus affecting Na/Ca exchanger, elevating intracellular calcium levels in Sarcoplasmic Reticulum of myocytes, then when Calcium is released, there is strengthened contractility
* i.e. indirectly increases calcium levels and subsequent storage in the SR

  • Side effects of digoxin/digoxin toxicity:
    1) GI upset
    2) Dizziness
    3) Conduction abnormalities
    4) Blurred or yellow vision
17
Q

What are the 5 treatments in the first line treatments of acute heart failure?

A
  • Treatments in the first line treatments of acute heart failure (LMNOP):

1) IV loop diuretics
* Cause venodilation and diuresis (dilation of veins and production of urine)
* Reduces pre-load by reducing blood volume and blood pressure

2) IV opiates (e.g. morphine)
* Reduce anxiety
* Vasodilates, reducing preload
* Reduces sympathetic drive
* Not routinely offered

3) IV, buccal or sublingual nitrates (Glyceryl trinitrate “GTN”)
* Vasodilates
* Reduce preload and afterload

4) Oxygen maintains O2 sats

5) (Positioning – keep patient upright)

18
Q

What is step 2 of treatment of chronic heart failure?

What are aldosterone receptor antagonists?

How do they work?

What are 2 example of aldosterone antagonists?

When are they added to treatment?

What class of heart failure are they used?

What doses are used?

What are they used to reduce?

What are the common side effects of aldosterone receptor antagonists?

A
  • Step 2 of treatment of chronic heart failures adding aldosterone receptor antagonists (aka aldosterone antagonists)
  • Aldosterone receptor antagonists are K+ sparing diuretics
  • Examples of Aldosterone receptor antagonists:
    1) Spironolactone
    2) Eplerenone
  • Aldosterone receptor antagonists are added in if the patient is on ACEI or ARB + Beta-blocker + diuretic (“DAB”) and there are still symptoms
  • They are used in In NYHA class II-IV failure (effective in severe heart failure)
  • Aldosterone receptor antagonists are used in low doses
  • They are used to reduce symptoms and mortality
  • Common side effects of aldosterone receptor antagonists:
    1) Hyperkalaemia
    2) Hyponatraemia (low blood sodium)
    3) Nausea
    4) Hypotension
    5) Gynaecomastia with spironolactone (medication for gyno)
    6) Renal impairment
19
Q

What is the aim of the second line treatment of acute heart failure?

How is this done?

How does all this alter contractility and HR?

Why is this done?

How does Heart failure affect our Frank Starling curve?

How do these treatments help to restore it?

A
  • The aim of second line treatment of acute heart failure is to increase contractility
  • This is through the use of inotropic agents
  • ↑ contractility will ↑ stroke volume, which ↑ Cardiac output (CO) so ↑ clearance of pooled blood in the ventricles
  • As CO increases, baroreceptors sense change in MABP and ↓ sympathetic drive and so ↓ HR and ↓ TPR
  • These effects will lead to an increase in contractility, but will also lower HR, meaning our stroke volume will increase, but we lower the burden on the heart with decreased HR
  • Cardiac failure often leads to a decrease in ability to contract, meaning the Frank Starling mechanisms ability to increase contractility and stroke volume worsens as cardiac failure worsens
  • The use of inotropic effects in the 2nd line defence of acute cardiac failure leads to the Frank Starling mechanism being pushed back up to normal, which allows us to have an increase in contractility and stroke volume with increased stretch
20
Q

When are second line drug treatments for Acute HF used?

What is the first type of medications used?

What are the 4 drugs in this section?

What receptors do they each act on?

What is the 2nd type of drug used to treat acute heart failure?

What drug is in this section?

What receptors do they act on?

A
  • Second line drug treatments for Acute HF are only used in Intensive care units and Coronary Care Units
  • The first type of medications used are Beta-agonists, which are inotropes that increase heart contractility:

1) Dobutamine (beta 1 receptors)
* Used in patients with cardiogenic shock to maintain blood pressure

2) Dopamine (DA > Beta > alpha receptors)
* Increases renal perfusion at low doses – can increase urine produced
* Can increase BP at high doses
* Pushes BP up when it is rapidly dropping to get something around the system

3) Isoprenaline
* Used in bradycardia/heart block emergencies
* Pushes BP up when it is rapidly dropping to get something around the system

4) Adrenaline (beta>alpha receptors)

  • Vasopressors are the second type of medications used to treat acute heart failure:

1) Noradrenaline (alpha > beta receptors
* Vasopressors are a powerful class of drugs that induce vasoconstriction and thereby elevate MABP
* Noradrenaline causes vasoconstriction, raise BP, used in severe septic shock (causes widespread uncontrolled and unregulated dilation of vessel and drops in BP due to sever reaction to infection)
* Pushes the CVS to absolute maximum to retain flow

21
Q

Main points of pharmacological intervention flowchart

A

Main points of pharmacological intervention flowchart

Danny's MD3001 Cardiovascular System (48 decks)

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