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Pharmacy > Chapter 2 - Heart Failure > Flashcards

Chapter 2 - Heart Failure Flashcards

1
Q

What is chronic heart failure?

A

Heart failure occurs when the heart in unable to sufficiently pump blood around the body to meet the body’s needs.

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2
Q

What are the symptoms of heart failure?

A
  • SOB
  • Swelling (commonly feet, ankles, stomach, lower back)
  • Fatigue
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3
Q

What measurement is commonly used to describe heart

A

Ejection fraction

EF = stroke volume* / end diastolic volume

*stroke volume = end diastolic volume - end systolic volume

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4
Q

What is the ejection fraction?

A

EF - is the % of blood volume leaving the heart with each beat, and is a measure of left ventricular pumping function.

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5
Q

The smaller the ejection fraction…..

A

…. the more severe the heart failure.

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6
Q

What is the normal EF %?

A

60%

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7
Q

People with an EF

A

<40%

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8
Q

What are the ‘typical’ signs and symptoms of someone with heart failure?

A

SOB, nocturnal paroxysmal dyspnoea (severe SOB and coughing waking someone up at night), orthopnoea (SOB when lying down), ankle swelling,

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9
Q

What are the common risk factors for developing HF?

A

Myocardial infarction, HTN, diabetes, thyroid disease, left ventricular hypertrophy (muscle wall of heart’s left ventricle becomes thickened).

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10
Q

How may thyroid disease contribute to the development of HF?

A

Thyroid hormones have an impact on cardiac myocytes: http://circ.ahajournals.org/content/116/15/1725

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11
Q

What is cardiac output?

A

The amount of blood pumped by the heart in one minute.

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12
Q

What happens to cardiac output in a patient with HF?

A

Cardiac output decreases, consequently leads to a fall in blood pressure.

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13
Q

How does the heart attempt to maintain normal cardiac output in HF?

A

By increasing the heart rate (beats per minute). This may allow less time for filling.

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14
Q

Decreased BP due to decreased cardiac output activates which two systems in the body?

A

RAAS system and sympathetic nervous system - in order to raise blood pressure. (Increasing myocardial contractility, tachycardia and vasoconstriction).

Although this mechanism is trying to increase cardiac output, chronic activation may exhaust the failing heart further.

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15
Q

How does the RAAS system work to raise BP?

A

Renin secreted by kidneys works to convert angiotensinogen (produced in the liver) to angiotensin 1. ACE then works to convert ang 1 to ang 2.

Ang 2 causes vasoconstriction (increase BP) and causes aldosterone to be released (increased water retention).

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16
Q

Which drug/ classes of drugs may precipitate HF?

A 
B-blockers
rate-limiting CCBs (diltiazem and verapamil)
Corticosteroids
Antiarrythmics (class 1) 
NSAIDs
Lithium
17
Q

The severity of heart failure is classified by the New York Heart Association (NYHA) as what?

A

Class I: No limitations. Ordinary physical activity does not cause fatigue, breathlessness or palpitation (asymptomatic LVD included in this category).

Class II: Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina (symptomatically ‘mild’ heart failure)

Class III: Marked limitation of physical activity. Although comfortable at rest, less than ordinary physical activity will lead to symptoms (symptomatically ‘moderate’ heart failure).

Class IV: Inability to carry out any physical activity without discomfort. Symptoms of congestive cardiac failure are present even at rest. With any physical activity, increased discomfort is experienced (symptomatically ‘severe’ heart failure).

18
Q

What is B-type natriuretic peptide (BNP) and what is its significance in HF?

A

BNP is secreted from by the ventricles of the heart in response to excess stretching of myocytes. Plasma concentrations of BNP are elevated in HF.

19
Q

What is the first line treatment for HF?

A

ACE Inhibitor - shown to prolong life and delay progression of the disease. Beneficial use for patients with both symptomatic and asymptomatic HF.

20
Q

When should B-blockers be considered in treatment of HF in addition to an ACE Inhibitor?

A

When patient has symptomatic heart failure and has a LVEF of <40%.

21
Q

Which B-blockers have been studied and therefore licensed to be used for the treatment of HF?

A

Birsoprolol
Carvedilol
Nebivolol

22
Q

If patients are still symptomatic after initial treatment with an ACEI and B-blocker, what is the next step in pharmacological treatment?

A

Adding in an aldosterone antagonist –> Spironolactone or eplerenone. These have been shown to reduce symptoms and hospitilisation in HF, whilst increasing patient survival.

23
Q

What is the role of diuretics in HF?

A

Symptom control of oedema and dyspnoea (shortness of breath)

24
Q

If treatment with an ACEI, B-blocker and aldosterone antagonist is still failing in the treatment of HF, what is the next step in therapy?

A

Consider adding angiotensin receptor neprilysin inhibitor (ARNI) –> sacubitril/valsartan.

Inhibits neprilysin which is an enzyme that breaks down natriuretic peptides which regulate fluid homeostasis, therefore protecting the cardiovascular system from fluid overload.

IMPORTANT: if treatment with an ARNI is being started ACEI or ARB must be stopped.

25
Q

What other drug(s) may be used in the treatment of HF?

A

Ivabridine - purely heart rate regulator. Considered in patients who are in sinus rhythm, have a resting HR of >/= 70bpm and persisting symptoms.

Hydralazine-isosorbide dinitrate - reserved for use in those who can’t tolerate ACEI or ARBs. Should be used in conjunction with B-blocker and aldosterone antagonist. Can also be used in conjunction with digoxin and diuretic therapy.

Digoxin - used in patients in sinus rhythm and with an EF of = 45% who are unable to tolerate B-blocker. Should be used in conjunction with ACEI (or ARB) and aldosterone antagonist.

26
Q

What kind of diuretics are first line in HF with reduced ejection fraction?

A

Loop diuretics e.g furosemide, bumetanide or torasemide

Also effective if patients have a low GFR of 30ml/min or less.

27
Q

Which statin and at what dose does NICE recommend for the primary prevention of cardiovascular disease?

A

Atorvastatin 20mg

28
Q

Which statin and at what dose does NICE recommend for the secondary prevention of cardiovascular disease?

A

Atorvastatin 80mg

29
Q

When should statin therapy be intiated for primary prevention of CVD?

A

Patients with a 10-year risk of CVD of 10% or more

30
Q

Which calculator does NICE recommend to assess cadivascular risk?

A

QRISK2

31
Q

What factors do CVD risk calculators underestimate in patients which may give an inaccurate result?

A
  • serious mental disorder
  • antiretroviral therapy
  • autoimmune disorders such as systemic inflammatory disorders
  • medication causing dislipidaemia e.g antipsychotics, corticosteroids or immunosupressants
  • triglyceride concentration >4.5mmol/l
32
Q

What is the MHRA advice regarding high dose simvastatin (80mg)

A

Increased risk of myopathy

33
Q

What is the max dose of simvastatin if giving with concomitent bezafibrate or ciprofibrate?

A

10mg daily

34
Q

What is the max dose of simvastatin if giving concomitently with amiodarone, amlodipine, verapamik, diltiazem or ranolazine?

A

20mg

Pharmacy (35 decks)

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