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957 Block 3 > 3. Heart Failure > Flashcards

3. Heart Failure Flashcards

1
Q

What is the simple definition of heart failure?

A

The inability of the heart to meet metabolic demands of the body.

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2
Q

What is the function of the heart?

A

Pump oxygenated blood to the body and itself.

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3
Q

What is normal cardiac output?

A

5-7 L/min

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4
Q

What determines cardiac output?

A

CO = HR x SV

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5
Q

What factors influence stroke volume?

A
  • preload
  • contractility
  • afterload
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6
Q

What is preload?

A

The amount of blood in the ventricle at the end of diastole.

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7
Q

How is preload measured?

A

pulmonary capillary wedge pressure (PCWP)

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8
Q

What is contractility?

A

The myocardium’s inherent ability to develop force and/or shorten independent of preload and afterload.

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9
Q

How is contractility measured?

A

ejection fraction (EF)

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10
Q

What is afterload?

A

The force which the ventricle has to work against to eject blood.

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11
Q

How is afterload measured?

A

systemic vascular resistance (SVR)

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12
Q

What does HFpEF stand for?

A

Heart failure with preserved ejection fraction

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13
Q

What is HFpEF?

A

The inability of the heart to fill due to stiff ventricle.

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14
Q

In HFpEF the compliance or relaxation of the ventricle is decreased. (T/F)

A

True

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15
Q

What does HFrEF stand for?

A

Heart failure with reduced ejection fraction

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16
Q

What is HFrEF?

A

The inability of the heart to contract or empty.

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17
Q

What percentage is the threshold for determining reduced ejection fraction?

A

EF < 40%

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18
Q

What is the most common cause of heart failure?

A

Myocardial ischemia and infarction

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19
Q

With the exception of _______ or _______ _______, treatments of HF are targeted at decreasing morbidity and delay mortality.

A
  • transplant

- mechanical support

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20
Q

Early on compensatory mechanisms help increase ___ but ______ underlying disease.

A
  • CO

- worsens

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21
Q

The initial failure in LV performance __ wall stress. (↑/↓)

A

↑ wall stress

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22
Q

What symptoms define functional class I HF?

A

No limitations of physical activity.

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23
Q

What symptoms define functional class II HF?

A

Slight limitations of physical activity (on exertion)

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24
Q

What symptoms define functional class III HF?

A

Marked limitations of physical activity (activities of daily living)

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25
Q

What symptoms define functional class IV HF?

A

Symptoms present at rest.

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26
Q

What are some non-pharmacological therapies?

A
  • reduce salt intake
  • fluid restriction
  • weight loss for obese patients
  • exercise training/ cardiac rehab
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27
Q

What medication decreases preload and/or afterload?

A

vasodilators

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28
Q

What are the vasodilators used in HF?

A
  • ACE-I
  • ARBs
  • ARNI
  • Hydralazine + ISDN
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29
Q

What medications are used to decrease SNS stimulation and/or lower HR?

A

SNS blockade

  • beta blocker
  • Ivabradine
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30
Q

What medications are used to reduce fluid volume?

A

diuretics

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31
Q

What diuretics are used in HF?

A
  • Loop diuretics

- spironolactone

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32
Q

What are contraindications of ACE-I?

A
  • angioedema
  • Anuric renal failure
  • pregnancy
  • bilateral renal artery stenosis
  • K > 5.5
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33
Q

What are some ADRs of ACE-I?

A
  • hypotension
  • angioedema
  • ↑ SCr
  • rash
  • cough
  • neutropenia
  • K retention
  • dysgeusia
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34
Q

Which ACE-I are not prodrugs?

A

captopril or lisinopril

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35
Q

Food __ bioavailability of captopril. (↑/↓)

A

↓ bioavailability

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36
Q

ACE-I should be initiated at a ___ dose. (↑/↓)

A

↓ low dose

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37
Q

What labs should be monitored when starting an ACE-I?

A
  • SCr

- K+

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38
Q

What ACE-Is are good for liver dysfunction?

A

captopril or lisinopril

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39
Q

What are ADRs of ARBs?

A
  • ↓ BP
  • ↑ SCr
  • rash
  • ↑ K+
  • angioedema
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40
Q

Why might a HF patient need an ARB?

A

Alternative to ACE-I in patients who are intolerant. (cough)

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41
Q

What is hydralazine?

A

A direct arterial vasodilator.

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42
Q

Hydralazine is a(n) ______ reducer.

A

afterload

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43
Q

What class(es) of HF is hydralazine commonly used in?

A

NYHA Class II-III

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44
Q

Hydralazine is used in combination with what?

A

nitrates

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45
Q

Why is hydralazine used in combination with nitrates?

A

prevents nitrate tolerance

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46
Q

What are the ADRs of hydralazine?

A
  • ↓ BP
  • NV
  • HA
  • “cardiac steal”
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47
Q

Short acting nitrates are used for HF patients. (T/F)

A

False: long acting

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48
Q

What are the long acting nitrate agents used in HF?

A
  • isosorbide dinitrate

- isosorbide mononitrate

49
Q

Nitrates are a(n) _____ reducer.

A

preload

50
Q

What class of HF are nitrates used in?

A

NYHA Class II-III

51
Q

Nitrates are used in combination with _________.

A

Hydralazine

52
Q

What are ADRs of nitrates?

A
  • HA
  • tachycardia
  • ↓ BP
53
Q

What is an ARNI?

A

Angiotensin Receptor and Neprilysin Inhibition

54
Q

What are the ARNI agents?

A

Sacubitril/ Valsartan

55
Q

How do beta blockers improve HF?

A
  • inhibit SNS
  • improve ventricular filling
  • ↓ afterload and ↑EF
  • ↓ remodeling
  • ↓ hospitalization and mortality
56
Q

What class HF should receive beta blockers?

A

NYHA Class II-III

57
Q

What are the ADRs of beta blockers?

A
  • ↑ SOB, edema, weight gain
  • rales
  • ↓ HR
  • fatigue and depression
  • impotence
58
Q

What are the beta blockers used in HF?

A
  • Carvedilol
  • Metoprolol Succinate
  • Bisoprolol
59
Q

Beta blockers should be started in ___________ stable HF patients.

A

hemodynamically

60
Q

How is beta blocker dose determined in HF?

A
  • titrate up to target dose slowly
  • no more than every 2 weeks as outpatient
  • may need to increase diuretic to increase BB
61
Q

What is Ivabradine?

A

Inhibitor of ion flow through the F-channel, reducing the slow diastolic depolarization of SA node cells, decreasing HR

62
Q

What HF patients are recommended to receive Ivabradine?

A
  • symptomatic CHF
  • LVEF ≤ 35%
  • HR ≥ 70 bpm
  • maxed out on BB or CI for BB
63
Q

What are the beneficial effects of diuretics in HF?

A
  • ↓ preload
  • ↓ congestive symptoms
  • ↑ exercise tolerance
64
Q

Diuretics are a plausible agent for monotherapy in HF. (T/F)

A

False: should not be used as monotherapy

65
Q

What are some drawbacks of diuretic therapy in HF?

A
  • no mortality data
  • electrolyte depletion
  • activate neurohormonal pathways
66
Q

Which loop diuretic is most efficacious when given in equipotent doses?

A

None: they are equal in efficacy

67
Q

Ethacrynic acid has no sulfonamide moiety. (T/F)

A

True

68
Q

Loop diuretics can exacerbate what condition?

A

gout

69
Q

What are ADRs of loop diuretics?

A
  • skin reactions/ light sensitivity
  • interstitial nephritis
  • ototoxicity
  • fluid and electrolyte abnormalities
  • pancreatitis
  • anemia
70
Q

Aldosterone antagonists are also known as what?

A

K sparing diuretics

71
Q

What class of HF should K sparing diuretics be used in?

A

NYHA Class II-IV

72
Q

What are the ADRs of spironolactone?

A
  • gynecomastia
  • hirsutism
  • hyperkalemia
73
Q

Which K sparing diuretic reduces mortality in Class IV HF patients?

A

spironolactone

74
Q

Which K sparing diuretic reduces mortality in Class II/III HF patients?

A

eplerenone

75
Q

What are contraindications for K sparing diuretics?

A
  • Hyperkalemia > 5.0 mmol/L

- Renal insufficiency SCr > 2.5 mg/dL

76
Q

What HF patients should receive loop diuretics?

A

CrCl < 30 mL/min

77
Q

What should be monitored in HF patients on diuretics?

A
  • daily weight
  • fluid intake/ urine output/ CrCl
  • dizziness, lethargy, BP
  • SOB, dyspnea
  • ankle edema
  • muscle cramping, electrolyte imbalance
78
Q

K should be given ____ if possible. (IV/PO)

A

PO

79
Q

More than ___ mEq of K at one time will cause nausea.

A

60

80
Q

Goal of administering K+ should be between __ and ___ mEq/L

A

4-5

81
Q

What are the benefits of Digoxin in HF patients?

A
  • ↑contractility
  • ↑ vagal tone
  • ↑ FC
  • ↑ exercise capacity
82
Q

Digoxin is appropriate for use in what class of HF?

A

NYHA Class II-IV

83
Q

What is the desired therapeutic level of Digoxin in HF?

A

0.5 - 1.0 ng/mL

84
Q

What changes should be monitored in Digoxin use in HF?

A
  • renal failure

- potassium

85
Q

What medications are used to treat arrhythmias in A.fib?

A
  • digoxin
  • beta-blockers
  • amiodarone
  • dofetilde
86
Q

What medications are used to treat ventricular arrhythmias?

A

AMIODARONE

87
Q

Every HF patient ( without CI) should be on what medications?

A
  • Beta-blocker

- ACE-I, ARB, and/or hydralazine+nitrate

88
Q

What medications should be considered for HF patients who are not getting relief with the typical regimen?

A
  • ASA and statin: ischemic CM only
  • spironolactone
  • diuretics for symptoms
  • digoxin
89
Q

What medications should be not used/ used with caution in HF patients?

A
  • corticosteroids
  • NSAIDs
  • non-dihydropyridine CCB
  • Imatinib
  • Metformin
  • TZDs
  • Ampethamines
  • Licorice
90
Q

What are the measurable signs of low-perfusion HF?

A
  • SBP < 90 mmHg
  • MAP < 70 mmHg
  • Cl < 2.2
  • ↑ SCr
  • low serum Na
91
Q

What are some symptoms of low-perfusion HF?

A
  • cool/ clammy extremities
  • AMS
  • decreased urine output
92
Q

What is a main treatment of low-perfusion HF?

A

inotrope therapy

93
Q

What are the measurable signs of pulmonary congestion?

A
  • PCWP > 18 mmHg
  • JVD
  • increased body weight
  • rales
  • hypoxemia
  • respiratory acidosis
94
Q

What are symptoms of pulmonary congestion?

A
  • dyspnea at rest
  • orthopnea
  • cough
95
Q

What are the conventional treatments of ADHF?

A
  • reduce fluid volume
  • decrease afterload/preload
  • augment contractility
96
Q

What medications reduce fluid volume in ADHF?

A

loop or thiazide diuretics

97
Q

What medications decrease afterload/ preload in ADHF?

A

vasodilators: NTG, nesiritide, nitroprusside or milrinone

98
Q

What medications are used to augment contractility in ADHF?

A

inotropes: dopamine, dobutamine, milrinone

99
Q

What are the parameters for Forester Classification Subset I?

A
  • Cardiac index > 2.2

- PCWP < 18 mmHg

100
Q

What are the parameters for Forester Classification Subset II?

A
  • Cardiac index > 2.2

- PCWP > 18 mmHg

101
Q

What are the parameters for Forester Classification Subset III?

A
  • Cardiac index < 2.2

- PCWP < 18 mmHg

102
Q

What are the parameters for Forester Classification Subset IV?

A
  • Cardiac index < 2.2

- PCWP > 18 mmHg

103
Q

Decompensated patients respond very well to large oral doses of loop diuretics. (T/F)

A

False: respond poorly

104
Q

ADHF have ____ oral absorption due to ______.

A
  • poor

- ascites

105
Q

ADHF pharmacodynamic/kinetic issues can be overcome by what?

A

IV administration

106
Q

How can diuretic resistance be overcome in ADHF patients?

A
  • increase oral furosemide
  • change to oral bumetanide or torsemide
  • switch to IVP furosemide
  • increase IV frequency
  • continuous IV infusion
107
Q

What are the advantages of continuous IV infusion in ADHF patients?

A
  • less rebound Na retention
  • decreased braking phenomenon
  • 100% bioavailability
  • easy up titration
  • less tinnitus
108
Q

What are the IV vasodilator agents?

A
  • nitroglycerin
  • nitroprusside
  • nesiritide
109
Q

What are the indications and precautions of IV vasodilators?

A
  • failure to diuresis at high doses of loop diuretics
  • place in therapy: “warm and wet” patients
  • BP must be adequate enough to sustain infusion
110
Q

Why are inotropes used in ADHF?

A

Improvement of hemodynamics and to avoid end organ damage secondary to hypoprofusion/ ischemia in the short term

111
Q

When should you consider an inotrope in ADHF patient?

A

ADHF patients that exhibit signs of low perfusion (shock)

  • SBP < 90 mmHg
  • narrow pulse pressure
  • cool extremities
  • acute mental status change
  • acute renal dysfunction
112
Q

What are inotropes?

A
  • beta AGONISTS

- phosphodiesterase inhibitors (PDI)

113
Q

What is the MOA of inotropes?

A
  • increased contractility

- increased CO

114
Q

What is the MOA of dobutamine?

A

stimulates β1 receptors (some stimulation of β2 and α to lesser extent)

115
Q

What is Milrinone?

A

phosphodiesterase 3 inhibitor

116
Q

What are the ADRs of milrinone?

A
  • low BP
  • increased HR
  • arrhythmias
  • thrombocytopenia
  • increased mortality and hospitalization
117
Q

At dopamine doses above __ mcg/kg/min, vasoconstriction can occur.

A

10

118
Q

What are vasopressors?

A
  • dopamine
  • phenylephrine
  • norepinephrine
  • epinephrine
119
Q

What do vasopressors do?

A

cause vasoconstriction and increase systemic vascular resistance

957 Block 3 (6 decks)

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