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Pharmacology (5th year) > Cardiac Failure > Flashcards

Cardiac Failure Flashcards

1
Q

Definition of cardiac failure

A

A clinical syndrome characterised by systemic perfusion inadequate to meet the body’s metabolic demands as a result of impaired cardiac pump function

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2
Q

Causes of cardiac failure

A
  • IHD
  • hypertension
  • valvular heart disease
  • CMO
  • thyrotoxicosis
  • alcohol
  • anaemia
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3
Q

Frank-Starling law

A

The stroke volume of the heart increases in response to an increase in the volume of blood filling the heart, when all other factors remain constant

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4
Q

The chronic heart failure cycle

A
  • LV systolic dysfunction
  • increased end diastolic pressure
  • compensatory responses (vent hypertrophy, RAAS)
  • increased afterload
  • pulmonary oedema
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5
Q

Actions of Ang II

A
  • vasoconstrictor
  • inhibits vagal tone
  • promotes aldosterone production
  • stimulates norepinephrine release from sympathetic nerve terminals
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6
Q

Therapeutic objectives of cardiac failure

A
  • reduce symptoms
  • treat reversible conditions
  • correct aggravating factors
  • modify disease progression
  • reduce hospital admissions
  • reduce sudden death
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7
Q

Drug classes used in heart failure

A
  • Renin-angiotensin system blockers
  • B-blockers
  • diuretics
  • inotropic agents
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8
Q

MOA of furosemide

A
  • inhibits Na-K-Cl co-transporter in ascending loop
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9
Q

MOA of HCTZ

A
  • inhibits NaCl channel in DCT
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10
Q

MOA of spironolactone

A

Aldosterone antagonist (in collecting duct)

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11
Q

Explain concept of low vs high ceiling diuretics

A
  • low ceiling = maximal response achieved at relatively low dose (thiazides and spironolactone)
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12
Q

SEs of furosemide

A
  • electrolyte disturbances
  • ototoxicity
  • dehydration
  • metabolic alkalosis
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13
Q

SEs of Thiazide diuretics

A
  • electrolyte disturbances
  • hyperuricaemia and gout
  • hypercalcaemia
  • high doses (glucose intol and adverse lipid profile)
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14
Q

Chronic management of cardiac failure

A

Step 1 = ACE-inhibitor + diuretics
Step 2 = add Carvedilol (BB)
Step 3 = add spironolactone
Step 4 = add Digoxin

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15
Q

SEs of ACE-inhibitors

A
  • hyperkalaemia
  • hypotension
  • renal failure (GFR falls)
  • chronic dry cough
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16
Q

Contraindications for ACE-I

A
  • renal artery stenosis
  • pregnancy
  • previous angioedema
  • aortic stenosis
17
Q

Management of ACE-I angioedema

A
  • withdraw ACE-I
  • supportive treatment
  • corticosteroids, anti-histamines, adrenalin
  • discuss use of ARB
18
Q

Principles of starting B-blocker

A
  • start with low dose and titrate up
  • add to existing ACE-I + diuretics when stable
  • never stop abruptly (risk ischaemia and infarction)
19
Q

MOA of BB

A
  • lower myocardial energy expenditure
  • prolong diastolic filling
  • increase myocardial blood flow
20
Q

Short-term risks of BB

A
  • worsening heart failure
  • bradyarrhythmias
  • prolonged intraventricular conduction
  • hypotension
  • worsening renal function
21
Q

Relative contra-indications to BB

A
  • HR <60
  • symptomatic hypotension
  • greater than minimal evidence of fluid retention
  • signs of peripheral hypo-perfusion
  • PR interval >0/24 sec
  • 2nd or 3rd degree AV block
  • Hx of asthma or reactive airways
  • PAD with resting limb ischaemia
22
Q

Effects of aldosterone in cardiac failure

A
  • sodium and water retention
  • promote cardiac fibrosis
  • endothelial dysfunction
23
Q

MOA of spironolactone

A
  • aldosterone antagonist

- binds to mineralocorticoid receptor and decreases ENaC

24
Q

When is spironolactone indicated?

A

NYHA III and IV despite treatment with ACE-I and B-blocker

25
Q

SEs of spironolactone

A
  • hyperkalaemia (dont give if K >5 or Cr >120)

- affinity for other steroid receptors (gynaecomastia, hirsuitism, sexual dysfunction)

26
Q

MOA of digoxin

A
  • inhibits Na/K ATPase in myocardium (increases intracellular Ca)
  • increases vagal activity (inhibits SA node and delayed AV nodal conduction)
27
Q

Indications for digoxin

A
  • AF
  • BB fail to control HR <70
  • mod/severe symptoms despite optimal treatment
28
Q

Features of digoxin toxicity

A
  • GI: Nausea, vomiting, dirrhoea
  • Neuro: confusion, facial pain, coloured vision, vertigo
  • CVS: palpitations, arrhythmias, syncope
29
Q

Drugs contraindicated in cardiac failure

A
  • Direct negative inotropic agents
  • TCAs (proarrhythmic)
  • NSAIDs (inhibit diuretics)
  • COX 2 inhibitors
  • corticosteroids (water retention)

Pharmacology (5th year) (15 decks)

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