Chapter 31: Chronic Heart Failure Flashcards
How does HF occur
when the heart is not able to supply sufficient oxygen-rich blood to the body, because of impaired ability of the ventricle to either fill or eject blood
Symptoms of HF are usually related to _____, which commonly presents as ___ and ___
fluid overload
SOB & edema
What is performed when HF is suspected
An ECHO
An ECHO provides an estimate of
LVEF, which is a measurement of how much blood is pumped out of the left ventricle (the main pumping chamber of the heart) with each contraction
An EF < 40% indicates ___ dysfunction, or HFrEF
systolic
Which ACC/AHA stage is described:
At high risk for development of HF, but without structural heart disease or symptoms of HF (e.g. HTN, CAD, DM, obesity, metabolic syndrome)
Stage A
Which ACC/AHA stage is described:
Structural heart disease present, but without signs or symptoms of HF (e.g. LVH, low EF, valvular disease, previous MI)
Stage B
Which ACC/AHA stage is described:
Structural heart disease with prior or current symptoms of HF (e.g. known structural heart disease, SOB and fatigue, reduced exercise tolerance)
Stage C
Which ACC/AHA stage is described:
Advanced structural heart disease with symptoms of HF at rest despite maximal medical treatment (refractory HF requiring specialized intervention)
Stage D
Which NYHA Functional Class is described:
No limitations of physical activity. Ordinary physical activity does not cause symptoms of HF (e.g. fatigue, palpitations, dyspnea)
NYHA Class I
Which NYHA Functional Class is described:
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity (e.g. walking up a flight of stairs) results in symptoms of HF
NYHA Class II
Which NYHA Functional Class is described:
Marked limitation of physical activity. Comfortable at rest but minimal exertion (e.g. bathing, dressing) causes symptoms of HF
NYHA Class III
Which NYHA Functional Class is described:
Unable to carry any physical activity without symptoms of HF, or symptoms of HF at rest (e.g. SOB while sitting in a chair)
NYHA Class IV
Which labs are increased in HF
Increased BNP, Increased NT-proBNP
What are left-sided signs and symptoms of HF
- Orthopnea: SOB when lying flat
- Paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
- Bibasilar rales: cracking lung sounds heard on lung exam
- S3 gallop: abnormal heart sound
- Hypoperfusion (renal impairment, cool extremities)
General signs and symptoms of HF
- Dyspnea (SOB at rest or upon exertion)
- Cough
- Fatigue, weakness
- Reduced exercise capacity
What are right-sided signs and symptoms of HF
(think of congestion)
- Peripheral edema
- Ascites: abdominal fluid accumulation
- Jugular venous distention (JVD): neck vein distension
- Hepatojugular reflux (HJR): neck vein distension from pressure placed on the abdomen
- Hepatomegaly: enlarged liver d/t fluid congestion
What is cardiac output
volume of blood that is pumped by the heart in 1 minute
How is cardiac output calculated
CO = HR x SV
HFrEF is a low cardiac output state, which the body compensates for by activating neurohormonal pathways to _____ or the _____. This can temporarily increase CO, but chronically leads to myocyte damage and _____
increase blood volume
force or speed of contractions
cardiac remodeling
The main pathways activated in HF are the ___, the ___ and ___
RAAS
SNS
vasopressin
Ang II causes
vasoconstriction
Aldosterone causes
Na and water retention
Vasopressin causes
Vasoconstriction and water retention
NE and EPI release causes ↑ in ___, ___ (positive inotropy) and ____
HR
contractility
vasoconstriction
Patients with HF should be instructed to:
- Monitor and document body weight daily
- Notify provider if weight ↑
- Restrict Na intake to < 1,500 mg/day
Natural products used in HF
Omega-3 FA, hawthorn and Coenzyme Q10
Key drugs that can cause or worsen HF
- Remember: Drug Information NATION*
- DPP4-I; alogliptin, saxagliptin
- Immunosuppressants; TNF-I (e.g., adalimumab, etanercept) and interferons
- Non-DHP CCBs; diltiazem and verapamil (in systolic HF)
- Antiarrhythmics; Class I agents (e.g., procainamide, quinidine, flecainide) in HF, amiodarone and dofetilide have less risk of worsening HF
- TZDs ↑ risk of edema
- Itraconazole
- Onco drugs; anthracyclines (doxorubicin, daunorubicin)
- NSAIDs; all including celecoxib
Which drug classes are used to treat HF
ACEi/ARB/ARNI + BB + loop
Aldosterone receptor antagonist is usually added next
Which drug classes decrease mortality in HF and are recommended for all pts without CI
- ACEi or ARB
- ARNI
- BB
- Aldosterone receptor antagonist
Which 2 drugs decrease mortality in black patients with NYHA Class III-IV when added to an ACEi/ARB and BB or in other patients who cannot tolerate an ACEi or ARB
Hydralazine and nitrates (BiDil)
Which medication classes are also used in HF to improve other aspects, but are not proven to decrease mortality
Loops, Digoxin, Ivabradine (Corlanor)
Where do loop diuretics work
Thick ascending limb of the loop of Henle
Loop diuretics ↑ excretion of which electrolytes/labs
Na, Cl, Mg, Ca and water
note: remember, thiazides increase Ca, while loops decrease Ca levels
Loop diuretic warnings
Sulfa allergy; warning does not apply to ethacrynic acid
Loop diuretics increase which electrolytes/labs
HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol
Ethacrynic acid or rapid IV administration of loops can cause
ototoxicity
Side effects of loops
Orthostatic hypotension and photosensitivity
How should furosemide injection be stored
at room temp
Dose conversions for oral loop diuretics
furosemide 40 mg = torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 50 mg
Furosemide IV:PO ratio
1:2
Which drug class should be avoided with loop diuretics
NSAIDs (can retain water and Na & lower the effect of loops)
ACEi MOA
block conversion of Ang I to Ang II resulting in ↓ vasoconstriction and ↓ aldosterone secretion
ARB MOA
block Ang II from binding to AT1 receptor
Enalapril brand name
Vasotec
Lisinopril brand names
Prinivil, Zestril
Quinapril brand name
Accupril
Ramipril brand name
Altace
ACEi, ARB & ARNI BW
Can cause injury and death to developing fetus when used in 2nd and 3rd trimesters; d/c as soon as pregnancy is detected
ACEi should not be used within __ hrs of sacubitril/valsartan (Entresto)
36
ACEi warnings
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
(same for ARB, but less cough and angioedema)
T/F: ARBs do NOT require a washout period with sacubitril/valsartan (Entresto)
True
Losartan brand name
Cozaar
Valsartan brand name
Diovan
Target dose of enalapril
10-20 mg PO BID
Target dose of lisinopril
20-40 mg PO daily
Target dose of quinapril
20 mg BID
Target dose of ramipril
10 mg daily
Which ACEi is taken TID
captopril
only ACEi with a t in it for TID
Target dose of losartan
50-150 mg daily
Target dose of valsartan
160 mg BID
Which enzyme is responsible for the degradation of several beneficial vasodilatory peptides
Neprilysin
An ARNI is indicated in NYHA Class II-IV patients to reduce ______
HF hospitalizations and CV death
The ARNI, Sacubitril/Valsartan (Entresto) is used in place of
ACEi or ARB
ACEi, ARB and ARNI can decrease clearance of ____ & can increase the risk of toxicity
Lithium
Unlike ACEi or ARBs, the clinical benefits of BB are not a class effect and only the following BB are recommended for HF patients
Bisoprolol, carvedilol (IR, ER), & metoprolol succinate ER
Metoprolol succinate ER target dose in HF
200 mg daily
Carvedilol IR target dose in HF for
- = 85 kg
- > 85 kg
= 85 kg: 25 mg BID
> 85 kg: 50 mg BID
Carvedilol CR target dose in HF
80 mg daily
Metoprolol IV:PO ratio
1:2.5
Which XR BB can be cut in half
Toprol XL
Which BB must be taken with food
Carvedilol
MOA of aldosterone receptor antagonists
DCT and collecting ducts of the nephron
Spironolactone target dose in HF
25 mg daily or BID
ARAs can decrease clearance of which drug, which can increase risk of toxicity
Lithium
MOA of hydralazine
arterial vasodilator which decreases afterload
Nitrates MOA
increase availability of NO, causing venous vasodilation and decreasing preload
Which drugs can be used as an alternative to ACEi or ARBs due to poor renal function, angioedema or hyperkalemia to improve survival in HF
Hydralazine or Isosorbide dinitrate IR/ER
What is the combination of Hydralazine and Isosorbide Dinitrate called
BiDil
When is BiDil indicated
in self-identified black patients with NYHA Class III or IV who are symptomatic despite optimal treatment with ACEi, ARB or ARNI & BB.
Hydralazine warning
DILE
Hydralazine SE
Peripheral edema/HA/flushing/palpitations/reflex tachycardia
Isosorbide dinitrate BW
Do not use with PDE-5 inhibitors
Isosorbide dinitrate SE
Hypotension, HA, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 hr nitrate-free interval), syncope
Digoxin MOA
Inhibits the Na-K-ATPase pump causing a positive inotropic effect (↑ in CO) and exerts a parasympathetic effect, which causes a negative chronotropy (↓ HR)
Digoxin can reduce:
HF related hospitalizations
When should a lower dose of dioxin be used
renal insufficiency (CrCl < 50 mL/min, smaller, older or female)
Typical dose range for digoxin
0.125-0.25 mg PO daily
When switching from IV to PO digoxin, how much should the dose be decreased by
20-25%
What is the therapeutic range of digoxin in HF
0.5-0.9 ng/mL
Initial s/sx of digoxin toxicity
N/V, loss of appetite and bradycardia
Severe s/sx of digoxin toxicity
blurred/double vision, greenish-yellow halos around lights or objects
Digoxin antidote
DigiFab
What electrolyte abnormalities can increase risk of digoxin toxicity
hypokalemia, hypomagnesemia, and hypercalcemia
Reduce digoxin dose by ___% when starting amiodarone
50%
Purpose of ivabradine in HF
reduces the risk of hospitalizations for worsening HF but does not affect mortality
To initiate ivabradine, patients must already be on mortality-reducing agents, including target or max-tolerated doses of BB (or CI to use), and be in ____ with resting HR > ___ BPM
sinus rhythm
70
Ivabradine can cause
bradycardia, which can increase risk of QT prolongation and ventricular arrhythmias (remember, the word is in the name)
Target resting HR for ivabradine
50-60 BPM
Ivabradine SE
Bradycardia, HTN, Afib
What should be checked and corrected prior to correcting K levels
Magnesium
concentration of Oral solution of 10% potassium chloride
20 mEq/15 mL
KCl oral solution should be mixed with __ oz of water
6
T/F: capsule contents of ER Capsules of KCl (Micro-K, Klor-Con Sprinkle) can be sprinkled on a small amount of applesauce or pudding
True
T/F: K-Tab, Klor-Con should be swallowed whole; do not chew, crush, cut, or suck on tablet
True
T/F: Klor-Con M: If difficult to swallow whole, it can be cut in half or dissolved in water (stir for 2 min and drink immediately); do not chew, crush or suck on the tablet
True
