3. Heart Failure Flashcards
What is the simple definition of heart failure?
The inability of the heart to meet metabolic demands of the body.
What is the function of the heart?
Pump oxygenated blood to the body and itself.
What is normal cardiac output?
5-7 L/min
What determines cardiac output?
CO = HR x SV
What factors influence stroke volume?
- preload
- contractility
- afterload
What is preload?
The amount of blood in the ventricle at the end of diastole.
How is preload measured?
pulmonary capillary wedge pressure (PCWP)
What is contractility?
The myocardium’s inherent ability to develop force and/or shorten independent of preload and afterload.
How is contractility measured?
ejection fraction (EF)
What is afterload?
The force which the ventricle has to work against to eject blood.
How is afterload measured?
systemic vascular resistance (SVR)
What does HFpEF stand for?
Heart failure with preserved ejection fraction
What is HFpEF?
The inability of the heart to fill due to stiff ventricle.
In HFpEF the compliance or relaxation of the ventricle is decreased. (T/F)
True
What does HFrEF stand for?
Heart failure with reduced ejection fraction
What is HFrEF?
The inability of the heart to contract or empty.
What percentage is the threshold for determining reduced ejection fraction?
EF < 40%
What is the most common cause of heart failure?
Myocardial ischemia and infarction
With the exception of _______ or _______ _______, treatments of HF are targeted at decreasing morbidity and delay mortality.
- transplant
- mechanical support
Early on compensatory mechanisms help increase ___ but ______ underlying disease.
- CO
- worsens
The initial failure in LV performance __ wall stress. (↑/↓)
↑ wall stress
What symptoms define functional class I HF?
No limitations of physical activity.
What symptoms define functional class II HF?
Slight limitations of physical activity (on exertion)
What symptoms define functional class III HF?
Marked limitations of physical activity (activities of daily living)
What symptoms define functional class IV HF?
Symptoms present at rest.
What are some non-pharmacological therapies?
- reduce salt intake
- fluid restriction
- weight loss for obese patients
- exercise training/ cardiac rehab
What medication decreases preload and/or afterload?
vasodilators
What are the vasodilators used in HF?
- ACE-I
- ARBs
- ARNI
- Hydralazine + ISDN
What medications are used to decrease SNS stimulation and/or lower HR?
SNS blockade
- beta blocker
- Ivabradine
What medications are used to reduce fluid volume?
diuretics
What diuretics are used in HF?
- Loop diuretics
- spironolactone
What are contraindications of ACE-I?
- angioedema
- Anuric renal failure
- pregnancy
- bilateral renal artery stenosis
- K > 5.5
What are some ADRs of ACE-I?
- hypotension
- angioedema
- ↑ SCr
- rash
- cough
- neutropenia
- K retention
- dysgeusia
Which ACE-I are not prodrugs?
captopril or lisinopril
Food __ bioavailability of captopril. (↑/↓)
↓ bioavailability
ACE-I should be initiated at a ___ dose. (↑/↓)
↓ low dose
What labs should be monitored when starting an ACE-I?
- SCr
- K+
What ACE-Is are good for liver dysfunction?
captopril or lisinopril
What are ADRs of ARBs?
- ↓ BP
- ↑ SCr
- rash
- ↑ K+
- angioedema
Why might a HF patient need an ARB?
Alternative to ACE-I in patients who are intolerant. (cough)
What is hydralazine?
A direct arterial vasodilator.
Hydralazine is a(n) ______ reducer.
afterload
What class(es) of HF is hydralazine commonly used in?
NYHA Class II-III
Hydralazine is used in combination with what?
nitrates
Why is hydralazine used in combination with nitrates?
prevents nitrate tolerance
What are the ADRs of hydralazine?
- ↓ BP
- NV
- HA
- “cardiac steal”
Short acting nitrates are used for HF patients. (T/F)
False: long acting
What are the long acting nitrate agents used in HF?
- isosorbide dinitrate
- isosorbide mononitrate
Nitrates are a(n) _____ reducer.
preload
What class of HF are nitrates used in?
NYHA Class II-III
Nitrates are used in combination with _________.
Hydralazine
What are ADRs of nitrates?
- HA
- tachycardia
- ↓ BP
What is an ARNI?
Angiotensin Receptor and Neprilysin Inhibition
What are the ARNI agents?
Sacubitril/ Valsartan
How do beta blockers improve HF?
- inhibit SNS
- improve ventricular filling
- ↓ afterload and ↑EF
- ↓ remodeling
- ↓ hospitalization and mortality
What class HF should receive beta blockers?
NYHA Class II-III
What are the ADRs of beta blockers?
- ↑ SOB, edema, weight gain
- rales
- ↓ HR
- fatigue and depression
- impotence
What are the beta blockers used in HF?
- Carvedilol
- Metoprolol Succinate
- Bisoprolol
Beta blockers should be started in ___________ stable HF patients.
hemodynamically
How is beta blocker dose determined in HF?
- titrate up to target dose slowly
- no more than every 2 weeks as outpatient
- may need to increase diuretic to increase BB
What is Ivabradine?
Inhibitor of ion flow through the F-channel, reducing the slow diastolic depolarization of SA node cells, decreasing HR
What HF patients are recommended to receive Ivabradine?
- symptomatic CHF
- LVEF ≤ 35%
- HR ≥ 70 bpm
- maxed out on BB or CI for BB
What are the beneficial effects of diuretics in HF?
- ↓ preload
- ↓ congestive symptoms
- ↑ exercise tolerance
Diuretics are a plausible agent for monotherapy in HF. (T/F)
False: should not be used as monotherapy
What are some drawbacks of diuretic therapy in HF?
- no mortality data
- electrolyte depletion
- activate neurohormonal pathways
Which loop diuretic is most efficacious when given in equipotent doses?
None: they are equal in efficacy
Ethacrynic acid has no sulfonamide moiety. (T/F)
True
Loop diuretics can exacerbate what condition?
gout
What are ADRs of loop diuretics?
- skin reactions/ light sensitivity
- interstitial nephritis
- ototoxicity
- fluid and electrolyte abnormalities
- pancreatitis
- anemia
Aldosterone antagonists are also known as what?
K sparing diuretics
What class of HF should K sparing diuretics be used in?
NYHA Class II-IV
What are the ADRs of spironolactone?
- gynecomastia
- hirsutism
- hyperkalemia
Which K sparing diuretic reduces mortality in Class IV HF patients?
spironolactone
Which K sparing diuretic reduces mortality in Class II/III HF patients?
eplerenone
What are contraindications for K sparing diuretics?
- Hyperkalemia > 5.0 mmol/L
- Renal insufficiency SCr > 2.5 mg/dL
What HF patients should receive loop diuretics?
CrCl < 30 mL/min
What should be monitored in HF patients on diuretics?
- daily weight
- fluid intake/ urine output/ CrCl
- dizziness, lethargy, BP
- SOB, dyspnea
- ankle edema
- muscle cramping, electrolyte imbalance
K should be given ____ if possible. (IV/PO)
PO
More than ___ mEq of K at one time will cause nausea.
60
Goal of administering K+ should be between __ and ___ mEq/L
4-5
What are the benefits of Digoxin in HF patients?
- ↑contractility
- ↑ vagal tone
- ↑ FC
- ↑ exercise capacity
Digoxin is appropriate for use in what class of HF?
NYHA Class II-IV
What is the desired therapeutic level of Digoxin in HF?
0.5 - 1.0 ng/mL
What changes should be monitored in Digoxin use in HF?
- renal failure
- potassium
What medications are used to treat arrhythmias in A.fib?
- digoxin
- beta-blockers
- amiodarone
- dofetilde
What medications are used to treat ventricular arrhythmias?
AMIODARONE
Every HF patient ( without CI) should be on what medications?
- Beta-blocker
- ACE-I, ARB, and/or hydralazine+nitrate
What medications should be considered for HF patients who are not getting relief with the typical regimen?
- ASA and statin: ischemic CM only
- spironolactone
- diuretics for symptoms
- digoxin
What medications should be not used/ used with caution in HF patients?
- corticosteroids
- NSAIDs
- non-dihydropyridine CCB
- Imatinib
- Metformin
- TZDs
- Ampethamines
- Licorice
What are the measurable signs of low-perfusion HF?
- SBP < 90 mmHg
- MAP < 70 mmHg
- Cl < 2.2
- ↑ SCr
- low serum Na
What are some symptoms of low-perfusion HF?
- cool/ clammy extremities
- AMS
- decreased urine output
What is a main treatment of low-perfusion HF?
inotrope therapy
What are the measurable signs of pulmonary congestion?
- PCWP > 18 mmHg
- JVD
- increased body weight
- rales
- hypoxemia
- respiratory acidosis
What are symptoms of pulmonary congestion?
- dyspnea at rest
- orthopnea
- cough
What are the conventional treatments of ADHF?
- reduce fluid volume
- decrease afterload/preload
- augment contractility
What medications reduce fluid volume in ADHF?
loop or thiazide diuretics
What medications decrease afterload/ preload in ADHF?
vasodilators: NTG, nesiritide, nitroprusside or milrinone
What medications are used to augment contractility in ADHF?
inotropes: dopamine, dobutamine, milrinone
What are the parameters for Forester Classification Subset I?
- Cardiac index > 2.2
- PCWP < 18 mmHg
What are the parameters for Forester Classification Subset II?
- Cardiac index > 2.2
- PCWP > 18 mmHg
What are the parameters for Forester Classification Subset III?
- Cardiac index < 2.2
- PCWP < 18 mmHg
What are the parameters for Forester Classification Subset IV?
- Cardiac index < 2.2
- PCWP > 18 mmHg
Decompensated patients respond very well to large oral doses of loop diuretics. (T/F)
False: respond poorly
ADHF have ____ oral absorption due to ______.
- poor
- ascites
ADHF pharmacodynamic/kinetic issues can be overcome by what?
IV administration
How can diuretic resistance be overcome in ADHF patients?
- increase oral furosemide
- change to oral bumetanide or torsemide
- switch to IVP furosemide
- increase IV frequency
- continuous IV infusion
What are the advantages of continuous IV infusion in ADHF patients?
- less rebound Na retention
- decreased braking phenomenon
- 100% bioavailability
- easy up titration
- less tinnitus
What are the IV vasodilator agents?
- nitroglycerin
- nitroprusside
- nesiritide
What are the indications and precautions of IV vasodilators?
- failure to diuresis at high doses of loop diuretics
- place in therapy: “warm and wet” patients
- BP must be adequate enough to sustain infusion
Why are inotropes used in ADHF?
Improvement of hemodynamics and to avoid end organ damage secondary to hypoprofusion/ ischemia in the short term
When should you consider an inotrope in ADHF patient?
ADHF patients that exhibit signs of low perfusion (shock)
- SBP < 90 mmHg
- narrow pulse pressure
- cool extremities
- acute mental status change
- acute renal dysfunction
What are inotropes?
- beta AGONISTS
- phosphodiesterase inhibitors (PDI)
What is the MOA of inotropes?
- increased contractility
- increased CO
What is the MOA of dobutamine?
stimulates β1 receptors (some stimulation of β2 and α to lesser extent)
What is Milrinone?
phosphodiesterase 3 inhibitor
What are the ADRs of milrinone?
- low BP
- increased HR
- arrhythmias
- thrombocytopenia
- increased mortality and hospitalization
At dopamine doses above __ mcg/kg/min, vasoconstriction can occur.
10
What are vasopressors?
- dopamine
- phenylephrine
- norepinephrine
- epinephrine
What do vasopressors do?
cause vasoconstriction and increase systemic vascular resistance
