CHF Flashcards
1
Q
neurohumoral impact
A
- PTs with HF have elevated levels of NE, Angio II, Aldo, endothelin, vasopressin, cytokines
2
Q
ACE In
A
- 1st line tx
- arteriovenous vasodilation –> increase CO
- no change in HR/contractility
- decrease MVO2
- in contrast to other vasodilators, no neurohumoral activation or reflex tachy
- “-pril”
3
Q
ARBs
A
- can be used in place of ACEI when cough is an issue
- can also be used in tandem with ACEI
- “sartans”
4
Q
Diuretics
A
- decrease volume and preload
- no direct effect on CO (bc PT is operating on flat part of curve) but if you unload too much volume you can decrease CO
- less flow to kidneys –> neurohormonal activation
- mostly furosemide is used (but only use them when you need them)
5
Q
aldosterone antagonists
A
- lower mortality but have to be used at low doses
- only use low doses bc it can cause hyperkalemia –> cardiac probs
- add to class C if creat and K+ ok
6
Q
beta blockers
A
- 2nd line tx
- inhibit adverse effects of sympa NS
- can only use Bisoprolol, metoprolol, carvedilol
- start at very low doses and increase gradually bc then are negative inotropes
7
Q
Digoxin
A
- inhibit Na/K ATPase –> intracellular Na builds up and drives the Na/Ca exchanger –> high intracellular Ca –> increases contractility
- also increases vagal efferent activity to heart –> decreased neurohormonal activation
- 2nd line tx because it improves quality of life but doesn’t prolong life
- narrow therapeutic-toxic window –> cardiac arrhythmias (increased Ca2+ –> DAD)
- kidney metabolism –> careful in kidney failure
- add to class C if frequent rehospitalizations
8
Q
dobutamine
A
- acute decompensated HF
- inotrope (front door approach)
- stimulates b1 receptors –> positive inotrope and chronotrope
- some beta2 and alpha receptor effects too
- continuous IV infusion (quick onset of action and t1/2)
- can develop tolerance after 24-48 hrs of same dose
9
Q
Milrinone
A
- acute decompensated HF
- inotrope (back door approach)
- inhibit phosphodiesterase IIIa: increased levels of cAMP –> increased contractility, HR and relaxation + vasodilation
- continuous IV infusion
- no development of tolerance
- short-term use only
10
Q
Nesiritide
A
- acute decompensated HF
- recombinant form of BNP –> natriuresis and diuresis
- vasodilation
- IV continuous infusion
11
Q
NYHA functional classifications
A
- Class I: disease but no limitations of physical activity
- Class II: slight limitations of physical activity (symptomatic with ordinary physical activity)
- Class III: symptomatic with less than ordinary physical activity
- Clas IV: symptomatic at rest
12
Q
compensatory mechs in HF
A
ANS
- increased HR, contractility, relaxation
- arteriovenous vasoconstriction
Kidney
- activation of RAAS –> arteriovenous vascoconstriction, Na and water retention
Other
- endothelin 1, vasopressin, BNPs, PGEs, FS mechanism, hypertrophy, altered peripheral O2 delivery, anaerobic metabolism
13
Q
JACC HF stages and recommended tx
A
- stage A: at high risk for HF (ie: have HTN atherosclerosis) but w/o structural HD or sx of HF –> ACEI
- Stage B: structural HD disease but w/o symptoms (prior MI, LV remodeling, low EF) –> ACEI and BB
- Stage C: disease and symptomatic –> ACEI, BB and diuretics/hydralazine/aldo antag
- Stage D: refractory HF –> hospice
- **can add digoxin in stage C or D and aldosterone antag
14
Q
hydralazine and nitrates
A
- use in place of ACEI/ARBs if they can’t be tolerated
- add as adjunct in class C if persistently symptomatic
15
Q
Acute decompensated HF hemodynamic profile and tx
A
- wet –> elevated filling pressures –> diuretic/vasodilator
- cold –> poor perfusion –> inotrope
