Cardio 10 Deck 6 Flashcards
Pathophysiology of Heart Failure
Complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricles to fill or eject blood (cardiac output [CO])
Determinants of ventricular function
Preload, afterload
Contractility, stroke volume, CO
Heart rate
Left ventricular dysfunction
Increase in end systolic volume
Increase in end diastolic volume
Pulmonary congestion
Decreased CO, hypoperfusion
Compensatory systems
Sympathetic activation
Renin–angiotensin–aldosterone system
American College of Cardiology Heart Failure grages
A through D
D is the most severe
New York heart failure grades
Progresses from 1 to 4
4 is the most severe
Stage A treatment
Lifestyle modification: dyslipidemia, diabetes, hypertension (diuretics or angiotensin-converting enzyme inhibitors [ACEIs])
ACEIs are drug of choice in patients with diabetes.
Angiotensin II receptor blockers (ARBs) are considered in ACEI-intolerant patients, but more expensive.
ACE drug of choice in
patients with diabetes
Angiotensin II receptor blockers (ARBs) are considered
in ACEI-intolerant patients, but more expensive.
Stage B treatement
ACEIs in all patients, ARBs for those who cannot tolerate an ACEI
Beta blockers in most
Stage C treatment
ACEIs and beta blockers in all patients
Diuretics, digoxin
Spironolactone
Stage D treatment
Entresto
Inotropes: dobutamine
Ventricular assist device, transplantation, hospice care
Coronary artery disease
medications used
Nitrites
Aspirin
Chronic atrial fibrillation
medications used
Warfarin or other new anticoagulants that reduce risk of stroke
Diabetes medications used
ACEIs
Thiazides: may increase glucose levels
Beta blockers avoided
Hypertension
Medication used
Use of diuretics early to decrease preload
ACEIs
Hyperlipidemia medication used
statins
Infants and children
medication used
Digoxin, thiazide, and loop diuretics all used
Pregnancy Medications used
ACEIs contraindicated in pregnancy
Diuretics may decrease placental perfusion
Treatment Considerations for heart failure
Early therapy works best.
As heart failure progresses, non-selective beta blocker with both alpha and beta impact work better than cardioselective types.
The advent of neprilysyn inhibitors (i.e. Entresto) has dramatically decreased risk of death and hospitalizations.
Monitoring Heart Failure
Functional capacity Fluid status Weight changes Jugular venous distension Cardiac rhythm Laboratory tests Electrolytes Creatinine Thyroid and liver function
Patient Education for heart failure
Treatment plan
Pathophysiology and chronicity of heart failure
Home monitoring
Drug therapy
Patients should take exactly as directed.
Patients should not miss or double doses.
Digoxin MOA
inhibits sodium/potassium ATPS pump in myocardial cells. Promotes influx of calcium. Increases contractility.
Digoxin Pharmacokiniteics
Readily abosrobed from teh GI tract. Widly distributed protein binding. Half life is 36-48 hours
PO 0.5 - 2 hours peak 2-8 hours durtation 3-4 days
Digoxin drug interactions
amiodarone may increase toxicity
beta blockers, calcium chalen blockers
potassium depleting diuretics my increase toxicity due to hyopcoemia
digoxin loading dose
not recomended for heart failure
digoxin therapeutic serum level
0.8 - 2 ml
digoxin toxic serum level
greater than 2mg
digoxin monitoring
apical pulse rate
<60 hold drug
Antidoe for digoxin
Digoxin immune FAB
Digoxin toxicity S/S
GI distrbances, neurologic abnomralites, fatigue, weakness, headake, depression, facial pain, personality changes, halows, bradicardia
Enteresto class
combination of sacubitril, a neprilysin inhibitor and valsrtan, an angiotensin II receptor blocker
Entresto MOA
Sacubitril inhibits neprilysin increasing peptide levels that are degraded by neprilysin. Valsartan directly antagonizes angiotensin II receptors, blocks vasocnstrictor aldosering secreing effects of angiotensin II
Decreases risk of mortality in pts with HF. prodcues vasodilation, decreases periphearl resistance, decreases b/p
Enteresto avoid in
pregnancy may cause fetal harm. Unknoinw if distributed in breast milk
Enteresto interactions
ACE inhibitors, may cause angioedema, potassium sapring diuretics, may increase risk of hyperkalemia. NSAID may wrosen reanl function.
Ginger, ginseng, licorice may worsen hypertension
HF Dose Enteresto
initially 49 to 51 mg twice daily. May double dose after 2 to 4 weeks
Enteresto ADR
cough, dizinees
angioeima, hypotension, imparied renal function, elevated serum creatinine. renal imparient.
Enteresto evaluation
monitor BMP. Serum BUN, Potassium. Montor for hyperkalema and hypotension.
Enteresto if hypotension occurs
place patietn in trandelmeberg position. alter dose or inerupt treatment. Screan for dug interactions.
