27- Heart Failure Flashcards
1
Q
bisoprolol
A
sustained release beta blocker
- anti-arrhythmic benefit, impair SNS, improved LV structure and function by preventing remodeling
- improvement of abnormal Ca2+ handling in HF- preventing hyperphosphorylation of RyR which causes diastolic leak of Ca2+ from SR
- should be prescribed to all patients with reduced LVEF (stage C) unless contraindicated (bradycardia/reactive airway)
- side effects- fluid retention, fatigue, weakness, bradycardia, heart block, hypotension
- reduce death from HF
2
Q
carvedilol
A
beta 1/2 and alpha 1 blocker
- anti-arrhythmic benefit, impair SNS, improved LV structure and function by preventing remodeling
- improvement of abnormal Ca2+ handling in HF- preventing hyperphosphorylation of RyR which causes diastolic leak of Ca2+ from SR
- should be prescribed to all patients with reduced LVEF (stage C) unless contraindicated (bradycardia/reactive airway)
- alpha 1 block reduces afterload and workload of heart
- side effects- fluid retention, fatigue, weakness, bradycardia, heart block, hypotension
- reduce death from HF
3
Q
metoprolol
A
beta 1 blocker
- anti-arrhythmic benefit, impair SNS, improved LV structure and function by preventing remodeling
- improvement of abnormal Ca2+ handling in HF- preventing hyperphosphorylation of RyR which causes diastolic leak of Ca2+ from SR
- should be prescribed to all patients with reduced LVEF (stage C) unless contraindicated (bradycardia/reactive airway)
- side effects- fluid retention, fatigue, weakness, bradycardia, heart block, hypotension
- reduce death from HF
4
Q
digoxin
A
inhibit Na/K pump- reduced the gradient for Na/Ca exhange pump
- increases force of cardiac contraction by increasing intracellular free Ca2+
- the increased CO decreases reflex SNS activity and increases renal perfusion
- sensitizes cardiac baroreceptors, may increase vagal tone by increasing SA nodal cell sensitivity to ACh which decreases SNS, increase paraSNS activity on heart
- also inhibits Na/K pump in kidney reducing renal tubular reabsorption of Na and reducing renin release
- used for HF with Afib, or severe symptoms of HF despite other therapy
- Toxicity causes arrhythmias and heart block, it is recommended to keep levels below 1 ng/ml
5
Q
digitoxin
A
inhibit Na/K pump- reduced the gradient for Na/Ca exhange pump
- increases force of cardiac contraction by increasing intracellular free Ca2+
- the increased CO decreases reflex SNS activity and increases renal perfusion
- sensitizes cardiac baroreceptors, may increase vagal tone by increasing SA nodal cell sensitivity to ACh which decreases SNS, increase paraSNS activity on heart
- also inhibits Na/K pump in kidney reducing renal tubular reabsorption of Na and reducing renin release
- used for HF with Afib, or severe symptoms of HF despite other therapy
- Toxicity causes arrhythmias and heart block, it is recommended to keep levels below 1 ng/ml
6
Q
eplerenone
A
aldosterone antagonist
- used for moderately severe HF with LV dysfunction after MI
- it is not recommended to give without concomitant diuretic therapy
- side effects- hyperkalemia, NSAIDS decrease efficiency, diarrhea, gastritis, GI bleed, CNS symptoms, rash, cross reaction with other steroid receptors
- clearance rate significantly decreased by CYP3A4 inhibitors
7
Q
spironolactone
A
aldosterone antagonist
- used for moderately severe HF with LV dysfunction after MI
- it is not recommended to give without concomitant diuretic therapy
- side effects- hyperkalemia, NSAIDS decrease efficiency, diarrhea, gastritis, GI bleed, CNS symptoms, rash, cross reaction with other steroid receptors
8
Q
hydralazine (Apresoline)
A
Arterial Vasodilator
- little effect on venous tone and filling pressure
- reduces renal vascular resistance and inc. renal BF so can be used in those intolerant to ACEIs
- used in combo with isosobide dinitrate (BiDil)
- used alone or in combo with nitrates may provide hemodynamic improvement for those in advanced HF and being treated with other agents
- together with isosorbide, inc. survival but not as effectively as ACEIs
9
Q
isosorbide (Isordil)
A
Vasodilator
- inc. venous capacitance thus lowering preload
- inc. coronary artery flow via vasodilation enhances ventricular function
- not effective as arterial dilator thus limiting use as single agent
10
Q
nitroglycerin (Nitrostat)
A
Parenteral Vasodilator
- NO source relatively selective for venous capacitence vessels
- indicated for treatment of L. sided HF due to ischemia or when prompt reduction of filling pressure required
11
Q
dobutamine
A
Beta-Agonist
- first choice for patients with systolic dysfunction and congestion associated with HF (no dopa activation)
- stimulates B1 (inotropy) and B2 (dilation)
- inotropic effect dominates at typical infusion rates (inc. in renal BF proportional to inc. in CO)
- can use continually for several days but tolerance develops
- may cause tachycardia and arrhythmias
12
Q
dopamine
A
Beta/Alpha Agonist (Dopamine as well but not discussed)
- stimulates B1 receptors on heart to stimulate contractility (chronotropy and inotropy) and typical infusion rates
- stimulates a-adrenergic receptors at high infusion rates (may be desirable with circulatory failure but not HF)
- can cause tachycardia that promotes ischemia in those with CAD
13
Q
inamrinone
A
cAMP Phosphodiesterase Inhibitor
- short term support of circulation in advanced HF
- stimulate contraction and accelerate relaxation by preventing degredation of cAMP
- cAMP activates PKA resulting in inc. Ca++ entry, inc. SR Ca++ uptake, and inc. Ca++ release– net effect is inc. cytosolic Ca++ to stimulate contraction
- also stimulate arterial and venodilation
- CO inc. due to inc. contractility and dec. afterload
14
Q
milrinone (Primacor)
A
cAMP Phosphodiesterase Inhibitor
- short term support of circulation in advanced HF
- stimulate contraction and accelerate relaxation by preventing degredation of cAMP
- cAMP activates PKA resulting in inc. Ca++ entry, inc. SR Ca++ uptake, and inc. Ca++ release– net effect is inc. cytosolic Ca++ to stimulate contraction
- also stimulate arterial and venodilation
- CO inc. due to inc. contractility and dec. afterload
- has more favorable s/fx profile, shorter half-life, and more selective for PDE-3 and is best among PDE inhibitors for short term inotropic support
15
Q
Nitroprusside
A
Parenteral Vasodilator
- NO source that reduces both ventricular filling pressure and SVR
- used in ICU settings for management of decompensated HF
