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competency 10/11 > cardio: HF > Flashcards

cardio: HF Flashcards

1
Q

heart failure

A

clinical syndrome, characterised by a group of symptoms that result from the inability of the heart to pump blood at a rate sufficient to meet the metabolic demands of the body

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2
Q

diastolic dysfunction

A

HFpEF

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3
Q

systolic dysfunction

A

HFrEF

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4
Q

common causes of systolic dysfunction

A
  • reduction in muscle mass eg myocardial infarction
  • dilated cardiomyopathy
  • ventricular hypertrophy: pressure overload, volume overload
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5
Q

common causes of diastolic dysfunction

A
  • increased ventricular stiffness: ventricular hypertrophy, infiltrative myocardial diseases, myocardial ischemia and infarction
  • mitral or tricuspid vale stenosis
  • pericardal disease eg, pericarditis
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6
Q

comepnsatory responses in HF

A
  1. incr preload thru water and sodium retention
  2. vasconstriction (maintain BP)
  3. tachycardia and incr contractility
  4. ventricular hypertrophy and remodelling
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7
Q

RAAS activation

A

incr ATII -> vasoconstriction and ventricular remodelling
incr aldosterone -> incr blood vol by causing NA and water retention

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8
Q

SNS activation

A

incr norepinephrine levels -> incr HR, incr contractility, incr peripheral vasconstriction

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9
Q

chronic neurohormonal activation leads to

A

incr myocardial work, accelerating myocyte cell death, and further decline in cardiac function

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10
Q

heart failure diagnosis

A
  • history and physical :signs of organ hypoperfusion, vol status
  • lab tests: BNP. CBC, serum electrolytes, renal and hepatic function, lipid profile, HbA1c, thyroid function
  • chest xray: cardiomegaly, pleural effusion
  • ECG, EKG: arrhythmias, hypertrophy
  • Echocardiography: EF
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11
Q

subjective signs of LV failure

A
  • dyspnea on exertion
  • SOB
  • orthopnea (2-3 pillows)
  • paroxysmal nocturnal dyspnea
  • cough
  • weakness or fatigue
  • confusion
  • pallor
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12
Q

objective signs of LV failure

A
  • pleural effusion
  • pulmonary congestion, edema
  • rales
  • S3 gallop rhythm
  • reflex tachycardia
  • incr urea
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13
Q

subjective signs of RV failure

A
  • peripheral edema
  • weakness or fatigue
  • pallor
  • confusion
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14
Q

objective signs of RV failure

A
  • fluid retention: edema, weight gain
  • neck vein distention (JVD)
  • hepatomegaly
  • hepatojugular reflux
  • reflex tachycardia
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15
Q

diff btw NYHA and ACC classification for HF

A

NYHA does not include asymptomatic indiv who are at high risk for developing HF and who may benefit from preemptive lifestyle changes and drug therapy vs ACC classification takes into account risk for heart failure and presence of structural heart disease

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16
Q

ACC stage: A

A

at high risk for HF (HTN, CHD, DM, alcoholism or strong FHx), but without structural heart disease or symptoms of HF
- does not correspond to any NYHA classification

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17
Q

ACC stage: B

A

structural heart disease but without signs or symptoms of HF
- NYHA 1: no limitation of physical activity, ordinary physical activity does not cause symptoms of HF

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18
Q

ACC stage: C

A

structural heart disease with prior or current sx of HF
- could be NYHA class 1, 2 (slight limitation of physical activity, comfortable at rest but ordinary physical activity results in sx of HF), 3 (marked limitation of physical activity, comfortable at rest but less than ordinary activity causes sx of HF), 4 (unable to carry on any physical activity without symptoms of HF or sx of HF at rest)

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19
Q

ACC stage: D

A

refractory HF requiring specialised interventions
- correspond to NYHA 4: unable to carry on any physical activity without symptoms of HF or sx of HF at rest

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20
Q

should non-DHP CCBs be used in patients with LVEF?

A

no, harmful! decr HR and CO

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21
Q

target dose of captopril

A

50mg TDS

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22
Q

target dose of enalapril

A

10-20mg BD

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23
Q

target dose of lisinopril

A

20-35mg OD

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24
Q

target dose of ramipril

A

5mg BD

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25
Q

target dose of sacubitril/valsartan

A

49/51mg BD -> 97/103mg BD

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26
Q

BB used in HF

A

bisoprolol 10mg OD
carvedilol 25mg or 50mg (for >85kg) BD
metoprolol succinate 200mg OD
nebivolol 10mg OD

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27
Q

MRA

A

eplerenone, spironolactone

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28
Q

target dose of eplerenone

A

50mg OD

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29
Q

target dose of spironolactone

A

50mg OD

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30
Q

target dose of dapagliflozin

A

10mg OD

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31
Q

target dose of empagliflozin

A

10mg OD

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32
Q

dose of ivabradine

A

5mg BD -> 7.5mg BD

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33
Q

dose of digozin

A

62.5ug OD -> 250ug OD

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34
Q

dose of hydralazine/isosorbide dinitrate

A

37.5mg/20mg TDS -> 75mg/40mg TDS

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35
Q

dose of vericiguat

A

2.5mg OD -> 10mg OD

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36
Q

MOA of diuretics

A

incr urinary NaCl and water losses by decr NaCl reabsorption at different sites in the nephron

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37
Q

diurectics use in therapy

A

indicated to provide sx relief of fluid overload:
- circulatory congestion (pulmonary and peripheral congestion)
- cardiac distension (enlarged heart on chest radiograph)

NOT USED AS MONOTHERAPY in pt w HF: do not affect natural history and progression
^ provide sx relief more quickly than other drugs (hours vs weeks-months)

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38
Q

abrupt worsening of renal function or hypoTN may require

A

temporary discontinuation of diuretics

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39
Q

loop diuretics vs thiazide diuretics

A

loop provide powerful diuretic effect, thus preferred in pt w HF + possess vasodilating properties which reduce renal vascular resistance
- maintain effectiveness until CrCl<5

thiazide used mainly for BP control and rarely for sx of fluid retention, may be added on to a loop to enhance diuretic effect
- lose effectiveness when CrCl<30, unless in combi w loop

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40
Q

loop diuretics eg

A

frusemide, bumetanide

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41
Q

thiazide diuretics eg

A

metolazone>HCTZ

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42
Q

usual dose for frusemide

A

20-80mg OM-BD

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43
Q

usual dose for metolazone

A

2.5-5mg OM, max 20mg

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44
Q

if pt at dry eight, consider ____ diuretic dose by ___

A

decr, 50% or be treated intermittently

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45
Q

for pt w weight increases for >0.5-1kg in one day or 2kg/week, incr edema, or returning of SOB:

A

consider incr diuretic dose temporarily until stable or asymptomatic
- refer to dr if sudden, unexpected weight gain of 2kg in 3 days r >3kg in 1 week

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46
Q

for diuretics refractory,

A

rule out non-adherance, failure to restrict salt/water intake, or add a diuretic of different MOA

47
Q

weight loss target with use of diuretics

A

0.5-1kg/day until ideal dry weight is achieved

48
Q

signs of vol depletion

A
  • hypoTN, dizziness, weakness
  • orthostatic changes in BP (decr SBP by 10-15mmHg or decr DBP by 5-10mgHg)
  • decr urine output
    incr urea
49
Q

Na restriction

A
  • mild: <3g/d
  • moderate: <2g/d
50
Q

1 teaspoonful of salt

A

2g of Na

51
Q

fluid restriction reco for pt with

A

hypoNa (<130mmol/L) or with persistent vol retention, despite high diuretic doses and sodium restriction

52
Q

fluid restriction

A

<2L/day

53
Q

does ACEi or ARB contribute to progression of HF?

A

yes, reduce risk of disease progression!

54
Q

target dose of lisinopril

A

20mg OD

55
Q

target dose of perindopril

A

8-16mg OD

56
Q

target dose of ramipril

A

10mg OD

57
Q

target dose of candesartan

A

32mg OD

58
Q

target dose of losartan

A

150mg OD

59
Q

target dose of valsartan

A

160mg BD or 320mg OD

60
Q

c/i or warnings for use of ACEi/ARB

A
  • significant renal impairment (SCr>250umol/L)
  • hyperK >5.5mmol/L
  • persistent symptomatic hypoTN, SBP<80mmHg
  • known or suspected renal artery stenosis or aortic stenosis
  • angioedema (ACEi>ARB)
  • pregnancy, esp during 2nd and 3rd trimestersc
61
Q

ACEi/ARB cough due to

A

accumulation of bradykinin and incr prostaglandin (ACEi»>ARB)
- first few weeks to months, stops 1-2 weeks after discontinuation and returns within days of rechallenge

62
Q

adr of ACEi/ARB

A

hypoTN, dry cough, functional renal insufficiency, hyperK, angioedema

63
Q

angioedema due to

A

accumulation of vasodilating bradykinin

64
Q

hyperK due to

A

reduced feedback of AT2 to stimulate aldosterone release

65
Q

functional renal insufficiency with ACEi/ARB

A

small and transient incr in SCr, may be 30% above baseline
- risk factors: severe HF, hypoTN, hypoNa, vol depletion, concomitant use of NSAIDs

66
Q

transient effect of BB in HF

A

worsen!!!
- but LT, prevents (cardiac remodeling, myocardial hyppertropy, B1 downregulation and a1 upregulation)

67
Q

BB place in therapy

A

indicated in all stable patients with HFrEF (NYHA classes 2-3), may be initiated and titrated slowly in NYHA class 4 pt, and recommended for asymptomatic pt with HFrEF stage B to decr risk of progression

68
Q

start BB only when

A

pts are stable
- not requiring incr oxygen supplementation
- no s/sx of vol overload or hypoTN

69
Q

abrupt withdrawal of BB can lead to

A

worsening of HF
- use of BB results in upregulation of B-receptors
- withdrawal: incr HR (tachycardia), tachyarrhythmias

70
Q

c/i or warnings with use of BB

A
  • acute decompensated HF
  • uncontrolled bronchospastic disease
  • symptomatic or marked bradycardia (HR<55bpm)
  • 2nd-3rd degree heart block
  • persistent symptomatic hypoTN (SBP<80mmHg)
  • DM with recurrent hypoglycemia
  • ischaemic limb disease, if severely symptomatic
71
Q

adr of BB

A
  • bradycardia <60bpm
  • hypoTN
  • worsening s/sx of HF
  • impaired glucose control in diabetics
72
Q

spironolactone vs eplerenone, which is more selective?

A

eplerenone

73
Q

elevated BNP (plasma natriuretic peptide)

A

hormone release by heart in response to high ventricular filling pressure
- resulting in ventricular wall stress

74
Q

aldosterone ->

A
  • arrhythmias: K+ and Mg excretion
  • edema: water and Na retention
  • fibrosis of myocardium and vessels: collagen deposition
75
Q

avoid ARA initiation if

A
  • SCr > 220umol/L in men and 175umol/L in female or
  • CrCl<30
  • K >= 5
76
Q

ARA pregnancy categories

A

D: spironolactone
B, req monitoring: eplerenone

77
Q

DDI w eplerenone

A

CYP3A4 inhibitors: ketoconazole, itraconazole, clarithromycin

78
Q

spironolactone vs eplerenone: hormone-related effects more common in?

A

spironolactone
- gynecomastia or breast pain in men (10% vs 1%), impotence, menstrual irregularities, weight gain

79
Q

avoid concomitant use of ARA with…

A

NSAIDs, COX-2 inhibitors, high dose ACEi, ARBs: worsen renal function

80
Q

MOA of digoxin

A
  • parasympathetic activation: central vagal stimulation, slows HR and rhythm (AV node)
  • positive inotrope: inhibitio of Na-K ATPase pump
81
Q

digoxin: place in therapy

A

symptomatic (NYHA class 2-4), despite treatment with ACE-i/ARB, BB and MRA
- no mortality benefits

may be considered early in therapy for pt with both HF and AF, to control ventricular response rate

82
Q

digoxin dosing

A

initiate and maintain at a dose of 62.5mcg-125mcg OD
- lower doses may be required in pt > 70yo, impaired renal function, female or low lean body mass

83
Q

in patients with HF without AF

A

loading dose is not recommended, and dose >250mcg are rarely needed

84
Q

digoxin c/i

A

bradycardia, hypo/hyperK, sick sinus syndrome, 2nd and 3rd AV block

85
Q

common adr of digoxin

A

loss of appetite, nausea, vomiting, diarrhea (initially)

86
Q

s/x of digoxin toxicity

A

cardiac: arrhythmias, bradycardia and AV block
non-cardiac: blurred vision, xanthopsia (disturbances in colour vision), incr RR, excitation, headachle, malaise, drowsiness, dizziness, and apathy
^ cardiac sx may occur before noncardiac sx

87
Q

risk factors for digoxin toxicity

A

renal insufficiency, hf, dehydration, hypoxia secondary to chronic pulmonary disease, hypoK/Mg, hyperCa

88
Q

treatment of digoxin toxicity

A

activated charcoal, digoxin-specific antibody fragments

89
Q

digoxin target levels

A

0.5-0.9ng/ml, lower compared to levels recommended for AF

90
Q

when do we check for digoxin levels?

A

suspected toxicity, non-compliance, worsening renal function

91
Q

monitoring parameters for digoxin

A

serum K>4
serum Mg>2
renal function
heart rate
functional improvement
toxicity

92
Q

ddi with digoxin: bb may enhance PD effects

A

digoxin dose may require reduction while optimising BB therapy

93
Q

nitrates + hydralazine MOA

A

nitrates:
- venous dilator
- preload-reducing
- decr left and right atrial pressure
- useful if sx of isolated pulmonary and venous congestion

hydralazine:
- arterial dilator
- afterload-reducing
- decr SV and incr CO
- useful in severely compromised LVF

94
Q

nitrates+hydralazine: place in therapy

A

african americans w symptomatic HF and already receiving optimal therpay of ACEi and BB

current or prior symptomatic HFrEF who cannot receive ACEi/ARB due to drug intolerance, hypoTN, or renal insufficiency

95
Q

if SBP < ? and/or patient has sx of orthostasis with vasodilatory therapy, what should you do with nitrates+hydralazine regimen?

A

80, do not initiate or incr dose

96
Q

ivabradine MOA

A

sinus node lf (funny) channel inhibitor -> prolongs diastole -> decr HR, no effect on BP

97
Q

ivabradine: place in therapy

A

stable chronic HFrEF (NYHA 2-3), in sinus rhythm, resting HR>=70, despite treatment with max tolerated BB, ACEi/ARB, ARA

98
Q

ivabradine initial dosing

A

5mg BD or 2.5mg BD for elderlyi

99
Q

if pt HR persistently >60bpm, how do you adjust ivabradine dose?

A

after 2 weeks, incr to max 7.5mg BD

100
Q

if pt HR 50-60pm, how do you adjust ivabradine dose?

A

maintain5mg BD

101
Q

if pt HR <50 or experiencing sx of bradycardia (dizzines, fatigue), how do you adjust ivabradine dose?

A

decr to 2.5mg BD

102
Q

if patient HR<50or symptoms of bradycardia persist despite dose titration, how do you adjust ivabradine dose?

A

discontinue

103
Q

use of ivabradine in hepatic impairment

A

no adj req

104
Q

use of ivabradine in renal impairment

A

avoid if CrCl<15, due to lack of data

105
Q

ARNI moa

A

valsartan, ARB: decr vasoconstriction

sacubitril, neprilysin inhibitor: incr vasodilation

106
Q

ARNI dosing

A

start at 50mg/100mg BD
- titrate up every 2-4 weeks until 200mg BD

107
Q

do not start ARNI until ___ after discontinuing ACEI

A

36 hours

108
Q

can you co-adm acei/arb with arni?

A

no!

109
Q

c/i for ARNI

A
  • known hx of angioedeme, hereditary angioedema
  • concomitant use or use within 36hr of ACE
  • concomitant use with aliskiren (renin antagonist, not used in mgmt of HF) in pt w DM or eGFR <60
  • pregnancy
110
Q

ARNI adr

A

v common: hyperK, hypoTN, renal impairment

common: dizziness, headache, vertigo, cough, diarrhea, fatigue

111
Q

adr of SGLT2i

A

UTI, genital mycotic infections, hypoTN, ketoacidosis

112
Q

hypoTN with SGLT2i use

A

due to intravascular vol depletion
- incr risk in patients with renal impairment (eGFR<60), elderly, pt on other antihypertensives, and pt w low SBP
- correct hypovol before intiiation

113
Q

ketoacidosis with SGLT2-i

A

decreased insulin secretion after normalisation of BGL
- risk factors: pancreatic insulin deficiency, dose decrease of insulin, caloric restriction, feer and other stress events
- temp discontinue therapy 3 d prior to surgery

competency 10/11 (31 decks)

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