38. `Heart Failure Treatment (Pharmacology) Flashcards
What is heart failure characterised by? (5)
- progressive cardiac dysfunction
- dyspnoea
- tiredness
- neurohormonal disturbances
- sudden death
Define heart failure.
Heart failure is a state in which the heart is unable to pump blood at the rate commensurate with the requirements of the tissues or can do so only from high pressures. It’s a SYNDROME not a disease.
What are 2 types of heart failure?
- systolic heart failure
1. diastolic (or relaxation) heart failure
What is systolic heart failure?
Decreased pumping function of the heart which results in fluid back up in the lungs and heart failure
What is diastolic (or relaxation) heart failure?
- Involves a thickened and stiff heart muscle and as a result the heart doesn’t fill with blood properly
- This results in fluid backup in the lungs and heart failure
What is the prevalence of chronic heart failure and what is the prognosis like?
- prevalence is 2-10% of population
- poor prognosis, with 5 year mortality of 50% and rising to 80% in a year for some patients
What does chronic heart failure incidence increase with?
Increases with age (and if you’re male)
What are the main risk factors for heart failure? (11)
- coronary artery disease
- hypertension
- valvular heart disease
- alcoholism
- infection (viral)
- diabetes
- congenital heart defects
- Other: obesity, age, smoking, high or low haematocrit level (RBC), obstructive sleep apnoea
- dyslipidaemia (abnormal lipid amount)
- history of MI or angina
- l.ventricular hypertrophy
What do all the cardiac risk factors lead to eventually? What is the pathological progression for chronic heart failure?
- All risk factors lead to myocardial injury which leads to neurohormonal stimulation and myocardial toxicity
- Pathologic remodelling and low ejection fraction leads to symptoms (e.g. fatigue, dyspnoea, oedema)
- Pump failure due to symptoms leads to chronic heart failure and sometimes sudden death
State Frank-Starling Law.
If the muscle of a healthy heart is stretched, it will contract at a greater force and pump out more blood. (i.e. bigger preload means stronger contraction which means more stroke volume)
What happens to Frank-Starling Law in systolic dysfunction?
- this relationship is lost in failing or damaged heart
Describe what happens to the heart in systolic dysfunction in terms of:
- circulatory volume
- force of contraction
- cardiac output
- RAAS system
- as circulatory volume increases, the heart dilates but force of contraction weakens and cardiac output drops
- decrease in cardiac output activates RAAS system (renin angiotensin aldosterone system)
- ongoing cycle of RAAS is activated, circulatory volume increases and cardiac performance (pump) deteriorates
What occurs to the heart over time, as RAAS continues to be dilated when pumping ability decreases?
- the heart starts to dilate as volume of blood increases but pumping weakens
- cardiac myocytes undergo hypertrophy and fibrosis
- heart is further weakened
What causes diastolic dysfunction heart failure or preserved ejection fraction heart failure?
Sustained hypertension
What causes systolic dysfunction heart failure?
myocardial damage i.e. MI
What happens to the body when it detect a fall in cardiac output?
- body registers it as loss in circulatory volume
- vasoconstrictor system activation (sympathetic system)
- slat and water retaining system activation (RAAS)
What is the main mechanism which tries to compensate during heart failure?
Renin angiotensin aldosterone system (RAAS)
What does ACE do?
Converts angiotensin 1 into angiotensin 2 which induces aldosterone secretion
What does aldosterone secretion do in terms of:
- salt and water retention
- plasma volume
- preload
- cardiac workload
- increases salt and water retention
- increases plasma volume
- increases preload
-increases cardiac workload
which all lead to heart failure
What does peripheral venoconstriction as a result of angiotensin 2 do to:
- afterload
- cardiac output
- increases afterload
- decreases cardiac output
which all lead to heart failure
What does the RAAS system cause the release of?
- angiotensin 2
- aldosterone
What is the end results of RAAS? (3)
- salt and water retention
- vasoconstriction
- hypertrophy of fibrosis of cardiac myocytes
Activation of sympathetic system causes the release of noradrenaline and adrenaline, which cause what? (3)
- vasoconstriction
- stimulate renin release
- myocyte hypertrophy
What two chemicals cause salt and water excretion and vasodilation?
- natriuretic peptide system (ANP and BNP) atrial and brain
- EDRF: endothelium derived relaxing factor
What is the final result of chronic heart failure? (3)
- failing heart that can’t pump out sufficient blood to supply needs of the body
- progressive retention of salt and water which results in oedema and pulmonary oedema
- progressive myocyte death and fibrosis
What does heart failure treatment aim to do? (3)
- improve symptoms
- improve survival
- improve symptoms AND survival
What medication aims to improve heart failure symptoms? (2)
- diuretics
2. digoxin
What medication aims to improve heart failure survival? (2)
- beta blockers
2. Ivabradine
What medication aims to improve heart failure symptoms and survival? (3)
- ACEIs and ARBs
- spironolactone
- Valsartan-sacubitril
What does symptomatic treatment aim to do? (3)
- inhibit detrimental neurohormonal adaptations.
- enhance beneficial neurohormonal adaptations
- enhance cardiac function
What are the most common diuretics used for treatment of chronic heart failure symptoms? (2)
- furosemide
- bumetanide
(symptomatic treatment)
What beta blockers are commonly used to block sympathetic system activation/detrimental hormonal changes in chronic heart failure? (3)
- carvedilol
- bisoprolol
- metoprolol
(blocking detrimental hormonal changes)
What 2 groups of drugs are available to block the effects of angiotensin II?
- ACEIs: ramipril
2. Angiotensin antagonists: Valsartan and Losartan (ARBs)
What does spironolactone do which aims to improve symptoms and survival?
- blocks effects of aldosterone
What converts angiotensinogen to angiotensin 1?
renin
What converts angiotensin 1 into angiotensin 2?
ACE
When angiotensin 2 is converted by non-ACE pathways into aldosterone, what effects does this cause? (4)
- sympathetic activation
- vasoconstriction
- cell growth
- Na/H2O retention