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Small Animal Medicine > Cardio - Treatment of HF > Flashcards

Cardio - Treatment of HF Flashcards

1
Q

What pathophysiological parameters can we alter pharmacologically to treat HF?

A

Increase inotropy, decrease preload, decrease afterload, optimize HR, blunt RAAS, blunt SNS

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2
Q

What are the top 3 drugs we can use to decrease preload?

A

Furosemide, Spironolactone, Hydrochlorothiazide

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3
Q

What is the trade name for furosemide?

A

Lasix or Salix

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4
Q

What is the trade name for Spironolactone?

A

Aldactone

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5
Q

What is the trade name for Pimobendan?

A

Vetmedin

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6
Q

What drugs are considered diuretics?

A

Furosemide, Spironolactone, Hydrochlorothiazide

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7
Q

What drug class are weak diuretics and why?

A

Carbonic anhydrase inhibitors - weak due to increased Na resorption distally (PCT)

(Not really used as diuretics)

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8
Q

Where do loop diuretics act?

A

Ascending Loop of Henle

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9
Q

What is the mechanism behind loop diuretics?

A

Act on the Na/K/2Cl co-transporter to block it, therefore allowing electrolytes to remain in the lumen and be excreted in the urine along with water

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10
Q

Where do thiazide diuretics act?

A

DCT

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11
Q

What is the mechanism behind thiazide diuretics?

A

They block resorption of the Na/Cl co-transporter, causing loss of Na and Cl into the lumen - they are excreted out

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12
Q

Where do K+ sparing diuretics act?

A

Distal tubule/Collecting duct

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13
Q

What is the mechanism behind K+ sparing diuretics?

A

They block aldosterone, so you get less of the Na/H antiporter; Na is excreted and K+ is kept (“spared”) in the blood

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14
Q

What type of diuretic is furosemide?

A

It is a loop diuretic

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15
Q

What type of diuretic is hydrochlorothiazide?

A

thiazide diuretic

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16
Q

What type of diuretic is spironolactone?

A

K+ sparing diuretic

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17
Q

In what order would you choose a diuretic in the face of CHF?

A

Furosemide > Spironolactone > Hydrochlorothiazide

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18
Q

What are potential side effects of furosemide?

A

Activates RAAS (need ACEi), azotemia, hypokalemia, metabolic alkalosis, hypochloremia, hypomagnesemia

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19
Q

What are potential side effects of spironolactone?

A

Azotemia, hyperkalemia, facial dermatitis (cats)

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20
Q

What are the side effects of hydrochlorothiazide?

A

Azotemia, hypokalemia, hypercalcemia

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21
Q

What diuretic is the most effective at diuresis?

A

Furosemide

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22
Q

What diuretic activates RAAS and which one blocks RAAS?

A

Furosemide activates RAAS

Spironolactone blocks RAAS

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23
Q

What are the 5 drug options we have to decrease afterload?

A

Enalapril/Benazepril, nitroprusside, amlodipine, hydralazine, sildenafil

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24
Q

What is the general mechanism of drugs that decrease afterload?

A

They are vasodilators

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25
Q

What drug class are enalapril/benazepril in?

A

ACE inhibitors

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26
Q

What drug class is hydralazine in?

A

They increase cGMP

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27
Q

What drug class are nitroprusside and nitroglycerine in?

A

They are nitrates

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28
Q

What drug class is amlopidine in?

A

Ca channel blocker

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29
Q

What drug class is sildenafil in?

A

PDE-V inhibitor

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30
Q

What is the selectivity of vasodilation of enalapril/benazepril?

A

Balanced vasodilator (dilates arteries and veins to some degree)

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31
Q

What is the selectivity of vasodilation of hydralazine?

A

Arteriodilator

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32
Q

What is the selectivity of vasodilation of nitroprusside?

A

balanced vasodilator

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33
Q

What is the selectivity of vasodilation of nitroglycerine?

A

venodilator

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34
Q

What is the selectivity of vasodilation of amlopidine?

A

arteriodilator

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35
Q

What is the selectivity of vasodilation of sildenafil?

A

pulmonary arteriodilator

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36
Q

What is the indication for use of enalapril/benazepril?

A

chronic CHF (always), proteinuria

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37
Q

What is the indication for use of hydralazine?

A

Acute severe CHF

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38
Q

What is the indication for use of nitroprusside?

A

Acute severe CHF (CRI)

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39
Q

What is the indication for use of nitroglycerine?

A

Acute severe CHF (topical paste)

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40
Q

What is the indication for use of amlopidine?

A

Systemic hypertension or severe chronic CHF

41
Q

What is the indication for use of sildenafil?

A

Pulmonary hypertension ONLY

42
Q

What are side effects of enalapril/benazepril?

A

Azotemia/AKI, hypotension

43
Q

What are side effects of hydralazine?

A

Hypotension

44
Q

What are side effects of nitroprusside/nitroglycerine?

A

Nitrate tolerance, cyanide toxicity, hypotension

45
Q

What are side effects of amlopidine?

A

Gingival hyperplasia (dogs), hypotension

46
Q

What are side effects of sildenafil?

A

Hypotension, inguinal/ear tip flushing

47
Q

What 2 vasodilators are given mainly in the hospital setting?

A

nitroprusside and nitroglycerine

48
Q

What 3 drugs are used to increase inotropy?

A

Pimobendan, Dobutamine, Digoxin

49
Q

What mechanism does Dobutamine utilize?

A

It is a ß-adrenergic agonist; binds to ß1 receptor, causing a cascade that results in PKA causing Ca influx into the cell

50
Q

What mechanism does Pimobendan utilize?

A

It is a Ca sensitizer, positive inotrope, and vasodilator;

It inhibits phosphodiesterase III to increase cAMP, and sensitizes actin/myosin to Ca –> increase inotropy

51
Q

What mechanism does Digoxin utilize?

A

It increases IC Ca by acting on 2 different pumps:

  1. Binds Na/K ATPase (normally 3Na out, 2K in) and paralyzes it so that it can no longer send Na out of the cell
  2. Works on the Na/Ca exchanger; Na buildup powers this exchanger, sending excess Na out and bringing Ca in –> extra Ca binds actin/myosin
52
Q

Digoxin is used only in CHF with _____ _____.

A

atrial fibrillation

53
Q

What generally does Digoxin do to the heart, other than increasing inotropy?

A

Decreases HR

54
Q

What inotrope is used in the 1st line for CHF?

A

Pimobendan

55
Q

What effect does Pimobendan have on HR?

A

No change

56
Q

What are the side effects of Pimobendan?

A

Anorexia (rare), pro-arrhythmic (humans)

57
Q

What effect does Dobutamine have on HR?

A

Mild increase

58
Q

What is the indication for using Dobutamine and how is it administered?

A

Cardiogenic shock - IV CRI only

59
Q

What are the side effects of Dobutamine?

A

Vasoconstriction (high doses), ventricular arrhythmias

60
Q

What effect does Digoxin have on HR?

A

decreases it

61
Q

What is the specific indication of use of Digoxin and in what species?

A

atrial fibrillation rate control in dogs only

62
Q

What are the side effects of Digoxin?

A

Vomiting/diarrhea, ventricular arrhythmias, bradycardia

63
Q

The therapeutic index of Digoxin is _____.

A

low

64
Q

What 3 drugs can be used to optimize HR?

A

Digoxin, Diltiazem, Atenolol

65
Q

What HR is used to optimize CO in dogs?

A

~150 - 160 bpm

66
Q

What HR/pattern do most dogs that are in heart failure have?

A

Sinus tachycardia ~160 bpm

67
Q

What eventually happens when the HR in dogs goes above 160?

A

The heart is beating so fast that they are no longer increasing CO

68
Q

What does optimization of HR in HF mean?

A

Treating tachyarrhythmias (or bradyarrhythmias) that compromise CO

69
Q

What drug type would you use to treat rapid atrial fibrillation?

A

negative chronotrope

70
Q

What drug type (and give the names) would you use to treat bradyarrhythmias?

A

Positive chronotrope;

Atropine, theophylline, or artificial pacing

71
Q

What are the negative chronotropes?

A

Diltiazem, Digoxin, Atenolol

72
Q

What is the MOA of Diltiazem?

A

Ca channel blocker (slow conduction at AV node)

73
Q

What effect does Diltiazem have on contractility?

A

Mild decrease

74
Q

What is the specific indicatino for using diltiazem?

A

It is most effective at lowering HR

75
Q

What are the side effects of diltiazem?

A

GI upset, bradycardia, hypotension

76
Q

What is the MOA of Digoxin?

A

Vagomimetic (slow conduction at AV node)

77
Q

What is the MOA of Atenolol?

A

B-adrenergic blocker (slow conduction at AV node)

78
Q

What effect does Digoxin have on contractility?

A

Mild increase

79
Q

What effect does Atenolol have on contractility?

A

Decreases it

80
Q

What is the specific indication for Digoxin?

A

It is a good drug to use in the setting of CHF

81
Q

What is the specific indication for Atenolol?

A

ONLY if started prior to CHF

82
Q

What are side effects of Digoxin?

A

Vomiting/diarrhea, ventricular arrhythmias, bradycardia

83
Q

What are side effects of atenolol?

A

Bradycardia, hypotension, bronchospasm

84
Q

What are the 3 drugs that blunt RAAS/SNS?

A

Enalapril/benazepril, Spironolactone, Atenolol

85
Q

What stimulates renin release?

A

Decreased renal perfusion, increased sympathetic tone, decreased Na to macula densa

86
Q

What 2 aspects of RAAS are we blocking with drugs?

A
  1. Angiotensin II (aldosterone release, SNS stim, hypertrophy of heart/vessels)
  2. ACE
87
Q

Angiotensin II, aldosterone, and SNS stimulation are _____ (AKA bad) because they cause _____ and _____.

A

CARDIOTOXIC, fibrosis, remodeling

88
Q

What is the order of choice for neurohormonal modulators?

A

Enalapril/benazepril = always in chronic CHF

Spironolactone = usually in chronic CHF

Atenolol = ONLY if started prior to CHF

89
Q

What is the acronym for treatment of ACUTE CHF in dogs?

A

FOPS

Furosemide, Oxygen, Pimobendan, Sedation

(+/- dobutamine and nitroprusside if doing very poorly)

90
Q

What is the acronym for ACUTE CHF in cats?

A

FOPS +/- T

Furosemide, Oxygen, Pimobendan, Sedation, +/- Thoracocentesis

(+/- dobutamine)

91
Q

Why would you want to perform a thoracocentesis in a cat with acute CHF?

A

Because it probably has pleural effusion

92
Q

What is the acronym for CHRONIC CHF in dogs?

A

Dogs Are For Special People

Dietary Na restriction, ACEi, Furosemide, Spironolactone, Pimobendan

(+/- Sildenafil if pulmonary hypertension)

(+/- Diltiazem+Digoxin if atrial fibrillation)

93
Q

What is the acronym for CHRONIC CHF in cats?

A

Don’t Forget About Cats, Please

Dietary Na restriction, Furosemide, ACEi, Clopidogrel, Pimobendan

(+/- Atenolol if started before CHF)

94
Q

Why would you consider clopidogrel as part of your treatment of chronic CHF in cats?

A

Because of possible clot formation (HOCM)

95
Q

What is the frequency of tx of HF meds?

A

BID-TID

96
Q

What diet changes should be condiered for patients in HF?

A

Moderate Na restriction (50-80mg per 100kcal), protein/calories to avoid cachexia, supplements such as fish oil, K, mg, taurine, carnitine

97
Q

What exercise/activity modifications should be considered in patients in HF?

A

Allow pets to self-regulate and avoid strenuous activity

98
Q

What are the 2 goals of HF tx?

A

Quantity of life (survival) and Quality of life

Small Animal Medicine (100 decks)

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