cardio: HF Flashcards
heart failure
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
diastolic dysfunction
HFpEF
systolic dysfunction
HFrEF
common causes of systolic dysfunction
- reduction in muscle mass eg myocardial infarction
- dilated cardiomyopathy
- ventricular hypertrophy: pressure overload, volume overload
common causes of diastolic dysfunction
- increased ventricular stiffness: ventricular hypertrophy, infiltrative myocardial diseases, myocardial ischemia and infarction
- mitral or tricuspid vale stenosis
- pericardal disease eg, pericarditis
comepnsatory responses in HF
- incr preload thru water and sodium retention
- vasconstriction (maintain BP)
- tachycardia and incr contractility
- ventricular hypertrophy and remodelling
RAAS activation
incr ATII -> vasoconstriction and ventricular remodelling
incr aldosterone -> incr blood vol by causing NA and water retention
SNS activation
incr norepinephrine levels -> incr HR, incr contractility, incr peripheral vasconstriction
chronic neurohormonal activation leads to
incr myocardial work, accelerating myocyte cell death, and further decline in cardiac function
heart failure diagnosis
- 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
subjective signs of LV failure
- dyspnea on exertion
- SOB
- orthopnea (2-3 pillows)
- paroxysmal nocturnal dyspnea
- cough
- weakness or fatigue
- confusion
- pallor
objective signs of LV failure
- pleural effusion
- pulmonary congestion, edema
- rales
- S3 gallop rhythm
- reflex tachycardia
- incr urea
subjective signs of RV failure
- peripheral edema
- weakness or fatigue
- pallor
- confusion
objective signs of RV failure
- fluid retention: edema, weight gain
- neck vein distention (JVD)
- hepatomegaly
- hepatojugular reflux
- reflex tachycardia
diff btw NYHA and ACC classification for HF
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
ACC stage: 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
ACC stage: B
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
ACC stage: C
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)
ACC stage: D
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
should non-DHP CCBs be used in patients with LVEF?
no, harmful! decr HR and CO
target dose of captopril
50mg TDS
target dose of enalapril
10-20mg BD
target dose of lisinopril
20-35mg OD
target dose of ramipril
5mg BD
target dose of sacubitril/valsartan
49/51mg BD -> 97/103mg BD
BB used in HF
bisoprolol 10mg OD
carvedilol 25mg or 50mg (for >85kg) BD
metoprolol succinate 200mg OD
nebivolol 10mg OD
MRA
eplerenone, spironolactone
target dose of eplerenone
50mg OD
target dose of spironolactone
50mg OD
target dose of dapagliflozin
10mg OD
target dose of empagliflozin
10mg OD
dose of ivabradine
5mg BD -> 7.5mg BD
dose of digozin
62.5ug OD -> 250ug OD
dose of hydralazine/isosorbide dinitrate
37.5mg/20mg TDS -> 75mg/40mg TDS
dose of vericiguat
2.5mg OD -> 10mg OD
MOA of diuretics
incr urinary NaCl and water losses by decr NaCl reabsorption at different sites in the nephron
diurectics use in therapy
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)
abrupt worsening of renal function or hypoTN may require
temporary discontinuation of diuretics
loop diuretics vs thiazide diuretics
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
loop diuretics eg
frusemide, bumetanide
thiazide diuretics eg
metolazone>HCTZ
usual dose for frusemide
20-80mg OM-BD
usual dose for metolazone
2.5-5mg OM, max 20mg
if pt at dry eight, consider ____ diuretic dose by ___
decr, 50% or be treated intermittently
for pt w weight increases for >0.5-1kg in one day or 2kg/week, incr edema, or returning of SOB:
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
for diuretics refractory,
rule out non-adherance, failure to restrict salt/water intake, or add a diuretic of different MOA
weight loss target with use of diuretics
0.5-1kg/day until ideal dry weight is achieved
signs of vol depletion
- hypoTN, dizziness, weakness
- orthostatic changes in BP (decr SBP by 10-15mmHg or decr DBP by 5-10mgHg)
- decr urine output
incr urea
Na restriction
- mild: <3g/d
- moderate: <2g/d
1 teaspoonful of salt
2g of Na
fluid restriction reco for pt with
hypoNa (<130mmol/L) or with persistent vol retention, despite high diuretic doses and sodium restriction
fluid restriction
<2L/day
does ACEi or ARB contribute to progression of HF?
yes, reduce risk of disease progression!
target dose of lisinopril
20mg OD
target dose of perindopril
8-16mg OD
target dose of ramipril
10mg OD
target dose of candesartan
32mg OD
target dose of losartan
150mg OD
target dose of valsartan
160mg BD or 320mg OD
c/i or warnings for use of ACEi/ARB
- 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
ACEi/ARB cough due to
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
adr of ACEi/ARB
hypoTN, dry cough, functional renal insufficiency, hyperK, angioedema
angioedema due to
accumulation of vasodilating bradykinin
hyperK due to
reduced feedback of AT2 to stimulate aldosterone release
functional renal insufficiency with ACEi/ARB
small and transient incr in SCr, may be 30% above baseline
- risk factors: severe HF, hypoTN, hypoNa, vol depletion, concomitant use of NSAIDs
transient effect of BB in HF
worsen!!!
- but LT, prevents (cardiac remodeling, myocardial hyppertropy, B1 downregulation and a1 upregulation)
BB place in therapy
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
start BB only when
pts are stable
- not requiring incr oxygen supplementation
- no s/sx of vol overload or hypoTN
abrupt withdrawal of BB can lead to
worsening of HF
- use of BB results in upregulation of B-receptors
- withdrawal: incr HR (tachycardia), tachyarrhythmias
c/i or warnings with use of BB
- 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
adr of BB
- bradycardia <60bpm
- hypoTN
- worsening s/sx of HF
- impaired glucose control in diabetics
spironolactone vs eplerenone, which is more selective?
eplerenone
elevated BNP (plasma natriuretic peptide)
hormone release by heart in response to high ventricular filling pressure
- resulting in ventricular wall stress
aldosterone ->
- arrhythmias: K+ and Mg excretion
- edema: water and Na retention
- fibrosis of myocardium and vessels: collagen deposition
avoid ARA initiation if
- SCr > 220umol/L in men and 175umol/L in female or
- CrCl<30
- K >= 5
ARA pregnancy categories
D: spironolactone
B, req monitoring: eplerenone
DDI w eplerenone
CYP3A4 inhibitors: ketoconazole, itraconazole, clarithromycin
spironolactone vs eplerenone: hormone-related effects more common in?
spironolactone
- gynecomastia or breast pain in men (10% vs 1%), impotence, menstrual irregularities, weight gain
avoid concomitant use of ARA with…
NSAIDs, COX-2 inhibitors, high dose ACEi, ARBs: worsen renal function
MOA of digoxin
- parasympathetic activation: central vagal stimulation, slows HR and rhythm (AV node)
- positive inotrope: inhibitio of Na-K ATPase pump
digoxin: place in therapy
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
digoxin dosing
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
in patients with HF without AF
loading dose is not recommended, and dose >250mcg are rarely needed
digoxin c/i
bradycardia, hypo/hyperK, sick sinus syndrome, 2nd and 3rd AV block
common adr of digoxin
loss of appetite, nausea, vomiting, diarrhea (initially)
s/x of digoxin toxicity
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
risk factors for digoxin toxicity
renal insufficiency, hf, dehydration, hypoxia secondary to chronic pulmonary disease, hypoK/Mg, hyperCa
treatment of digoxin toxicity
activated charcoal, digoxin-specific antibody fragments
digoxin target levels
0.5-0.9ng/ml, lower compared to levels recommended for AF
when do we check for digoxin levels?
suspected toxicity, non-compliance, worsening renal function
monitoring parameters for digoxin
serum K>4
serum Mg>2
renal function
heart rate
functional improvement
toxicity
ddi with digoxin: bb may enhance PD effects
digoxin dose may require reduction while optimising BB therapy
nitrates + hydralazine MOA
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
nitrates+hydralazine: place in therapy
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
if SBP < ? and/or patient has sx of orthostasis with vasodilatory therapy, what should you do with nitrates+hydralazine regimen?
80, do not initiate or incr dose
ivabradine MOA
sinus node lf (funny) channel inhibitor -> prolongs diastole -> decr HR, no effect on BP
ivabradine: place in therapy
stable chronic HFrEF (NYHA 2-3), in sinus rhythm, resting HR>=70, despite treatment with max tolerated BB, ACEi/ARB, ARA
ivabradine initial dosing
5mg BD or 2.5mg BD for elderlyi
if pt HR persistently >60bpm, how do you adjust ivabradine dose?
after 2 weeks, incr to max 7.5mg BD
if pt HR 50-60pm, how do you adjust ivabradine dose?
maintain5mg BD
if pt HR <50 or experiencing sx of bradycardia (dizzines, fatigue), how do you adjust ivabradine dose?
decr to 2.5mg BD
if patient HR<50or symptoms of bradycardia persist despite dose titration, how do you adjust ivabradine dose?
discontinue
use of ivabradine in hepatic impairment
no adj req
use of ivabradine in renal impairment
avoid if CrCl<15, due to lack of data
ARNI moa
valsartan, ARB: decr vasoconstriction
sacubitril, neprilysin inhibitor: incr vasodilation
ARNI dosing
start at 50mg/100mg BD
- titrate up every 2-4 weeks until 200mg BD
do not start ARNI until ___ after discontinuing ACEI
36 hours
can you co-adm acei/arb with arni?
no!
c/i for ARNI
- 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
ARNI adr
v common: hyperK, hypoTN, renal impairment
common: dizziness, headache, vertigo, cough, diarrhea, fatigue
adr of SGLT2i
UTI, genital mycotic infections, hypoTN, ketoacidosis
hypoTN with SGLT2i use
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
ketoacidosis with SGLT2-i
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
