Cardiopulmonary: HF Flashcards
examples of neurohormonal activation in HF
RAA stimulation
sympathetic stimulation
severity of HF disease is evaluated by
NY Heart Association functional classifications
NYHA classification of heart failure focuses on
activity
ACC/AHA heart failure stages focus on
structural changed
List the classes, I - IV, of NYHA Heart Failure
I-No symptoms c ordinary activity
II-Symptoms c ordinary activity
III-Symptoms c less than ordinary activity
IV-Symptoms at rest
Higher number of letter of class/stage of HF usually means
more drugs used concurrently
Treatment choice for HF is usually based on
Stages/Classes of HF according to NYHA and sometimes ACC/AHA
Compensation derangement: ventricles
ventricular hypertrophy
compensation derangement: neurohormal mechanisms
- adrenergic system
- RAAS
- secretion of ADH and BNP
They go on overdrive and need to be quieted down.
Natriuretic peptides derangements
Normally, these cause you to urinate out sodium. When deranged like in the setting of HF, this may not happen.
Remodeling -> fluid retention -> increased demand
LV becomes floppy, weak, and less effective. Therefore you will have major fluid overload and then derangement of compensation.
Left sided heart failure vs Right sided
Left - lung driven
Right - systemic driven
What is the major cause for symptoms of left sided HF?
Pulmonary congestion
What is the major cause for symptoms of R sided HF?
Systemic venous congestion
High output vs low output HF
less frequent, seen in thyroid disease
demand vs pump function
HFrEF
HF with reduced EF ( <40%)
Systolic
HFpEF
HF with preserved EF (~50%)
Which would you treat more aggressively? Systolic or Diastolic?
Diastolic - in systolic a lot of damage is already done and EF is reduced.
Non pharm tx of HF
lifestyle modification to prevent initial and recurrent injury, progression.
Purpose of pharm intervention for HF
to prevent progression in symptomatic and asymptomatic patients c HF
Digoxin is a
cardiac glycoside
Digoxin is used for its
decreased activation of neurohormonal systems
Digoxin is used more for its _____ properties rather than its ______ property
neurohormonal; positive ionotropic action
Digoxin and mortality
Will increase QoL and reduce symptoms, will not decrease mortality
digoxin:antacids
digoxin needs an acidic environment to work properly
digoxin:St. John’s Wort
SJW is an enzyme inducer
Dig levels for CHF
0.5 - 0.8
Dig levels for A-Fib
0.8 - 1.2
K should be kept at __ when on digoxin
4.0
Mag should be kept at __ while on digoxin
2.0
Downside of using digoxin
Need frequent labwork
Dr. Carey says to keep digoxin level between
0.5 - 1
Why are aldosterone antagonists used in HF
Helps with RAA action, not necessarily used for its diuretic properties.
CCBs in HF - NDHPs or DHPs ?
DHP
Why aren’t NDHP CCBs used in HF?
because of risk for heart block
Vasodilator combo drug used for African American patients in HF
BiDil - hydralazine+ISO DN
Hydralazine/Iso DN use is limited to
patients who cannot take ACE/ARB bc of ineffectiveness or adverse reactions
Why do we limit the use of hydralazine/ISODN?
Compliance issues due to very high pill burden and significant adverse effects
BiDil (hydralazine/ISODN) theorized MoA?
- ISDN exerts dilatory effects by releasing nitric oxide at BV wall
- Hydralazine may also lessen tolerance to nitrates, so nitric oxide remains active longer.
ISODN’s dilatory effects by releasing nitric oxide at the BV wall wears off after about
12 hours
natriuresis
urinating of sodium
adding hydralazine to ISO DN
extends ISODN’s 12 hour dilatory effect
Sacubitril/Valsartan (Entresto) is a combo of
ARB and neprilysin inhibitor
ACC/AHA HF guideline: in NYHA Stage II-III HFrEF patients NOT tolerating ACE or ARB….
replacement with ARB/NI is recommended to decrease morb/mort
When do you use an ARB in HF?
when you can’t tolerate or when you fail an ACE
BNP responds to
stretch of the heart
normal BNP
hundreds
abnormal BNP
thousands
high BNP initial treatment
diurese
dig levels can start to be dangerous after
1
ISDN function
vasodilator
decreases preload
hydralazine function
arteriodilator, decreases afterload
why are hydral and ISODN given together?
competing qualities - one vasodilator (hydralazine), the other then keeps the vessels open (ISO DN via nitric oxide)
hydralazine plus iso dn does what
keeps the vessels open longer.
nitrate holiday
12 hours on 12 hours off. give vessels a chance to respond.
Hydral/iso dn should be given at what freq?
TID or BID. Not Q8
digoxin level for CHF vs for A fib
CHF: .5-.8
Afib: .8-1.2
ISO DN vs MN
dinatrate needs more frequent dosing. MN has longer half life, better for decreasing pill burden.
Summary of tx for HF (6)
ACE diuretic B blockers Digoxin Vasodilators/ISDN (if no ACEs) CCBs
DHP CCB in HF
only if every other agent is maxed out and we need more after load reduction to decrease the bp (and if not in decompensated)
