CHF Flashcards
What is Stage A in CHF
High risk of HF
What is Stage B in CHF
ASx HF
What is Stage C in CHF
Symptomatic HF
What is Stage D in CHF
Refractory end-stage HF
What do you give in Stage A
ACEI
ARBs
What do you give in Stage B
ACEIs/ARBs or Beta blockers
What do you give in Stage C
AceIs/ARBs AND Beta blockers
What do you give in Stage D
End of life care
Extraordinary measures
Most common cause of HF in USA
CAD and HTN
Sx in HF
Decreased exercise tolerance
Dyspnea
Peripheral/pulm edema
Cardiomegaly
What is seen in Systolic failure
Reduced contractility and EF
What is seen in Diastolic failure
Stiffening (less relaxation)
Reduced CO, but normal EF
What is seen in CHF
Abnormal BV and IF fluid increase
Dyspnea
Peripheral edema
Physiological compensation in CHF
Activation of SNS, RAAS
Tissue remodelling
4 Factors affecting cardiac performance
Preload
Afterload
Contractility
HR
What is preload
Stretching of myocardial muscles to increase contractility
What is afterload
Force against which the ventricles act
What is contractility directly related to
Ca concentration
Drugs for systolic failure
Diuretics Spironolactone ACEIs ARBs Direct vasodilators Beta blocers Inotropic agents
Drugs for diastolic failure
Diuretics
Ca channel blockers
Beta blockers
What do you never give in diastolic failure
+ve Inotropic agents
DOC in heart failure
ACEIs
Teratogenic so contraindicated in pregnancy
ACEIs
ARBs
Reduce HF Sx and Hospital time
DIgoxin
Increase exercise tolerance
Digoxin
Does NOT increase survival
Digoxin
What Thiazides are used in CHF
Chlorthalidon
Hydrochlorothiazide
Metolazone
What Loops are used in CHF
Ethacrynic acid
Furosemide
Torsemide
What Aldosterone antagonists are used in CHF
Spironolactone
Eplerenone
What ACEIs are used in CHF
Captopril
Enalapril
Lisinopril
What ARBs are used in CHF
Candesartan
Valsartan
What direct vasodilators are used in CHF
Hydralazine
NItrates (Isosorbide Dinitrate)
What beta blockers are used in CHF
Carvedilol
Metoprolol
What is the cardiac glycoside used
Digoxin
What are the Inotropic agents used in CHF
Digoxin Milrinone Inamrinone DA Dobutamine Glucagon
Which are more effective, loops or thiazides in CHF
Loops
When do you give thiazide over loop in CHF
Hypertensive heart disease with congestive sx
How do loops and thiazides treat CHF
Relieve pulm congestion and peripheral edema
Decrease orthopnia
Decrease VR and preload and afterload
What do you combine aldosterone antagonists to reduce mortality and morbidity of sever HF
ACEIs
How do aldosterone antagonists treat CHF
Prevent Na retention, K loss and mycardial hypertrophy
When do you give Aldosterone antagonists
Advanced HF
LV dysfunction post MI
When are aldosterone antagonists contraindicated
Pts on K supplements
GI AE of aldosterone antagonists
Gastritis
PUD
Endocrine AE of aldosterone antagonists
Gynecomastia
Decreased libido
Mestrual irregularities
Metabolic AE of aldosterone antagonists
Hyperkalemia
CNS AE of aldosterone antagonists
Lethargy
Confusion
Which ARB is used for HTN vs CHF
HTN - Lorsartan
CHF - Candesartan
How do ARBs act in CHF
Block AT-I receptor
No effect on bradykinin
Effects of ACEIs in CHF
Decrease PVR, BP, afterload, preload, Na/H2O retention, long term remodelling
Increase CO
When do you give ACEIs in CHF
Symptomatic HF
Asymptomatic HF with decreased LV EF or Hx of MI
Which high risk groups can you give ACEIs to
Diabetes
HTN
Atherosclerosis
Obesity
When do you give ARBs
Intolerant to ACEIs
Cough/Angioedema
AE of ACEIs/ARBs
Dry cough (NOT ARBs) Hypotension Renal insufficiency Hyperkalemia Angioedema
What vessels does Hydralazine dilate
Arterioles
What vessels do nitrates dilate
Venules
When do you give direct vasodilators
Intolerant to ACEIs or beta blockers
Adjuvant in Black with advanced HF
AE of Hydralazine
Lupus-like
Tachycardia
Peripheral neuritis
How do beta blockers affect CHF
Reverse remodelling
How do beta blockers act
Decrease HR and RAAS
Protect cardiac muscle from NE
When do you give beta blockers in CHF
Stage B and C with ACEI
What can initial beta blocker tx cause
Fluid retention
Cautious use of beta blockers in whom
Asthma
Severe bradycardia
Has a narrow therapeutic window
Digoxin
Which CHF drug is +ve inotropic and -ve chronotropic
Digoxin
When is Digoxin indicated
HF with A-fib
Give with ACEI and beta blocker
How does Digoxin act
Inhibit Na/K ATPase
Indirect Na/Ca exchange inhibition
Increase Ca
Increase contractility
Effect of Digoxin on HR
Reduces via decreased SNS, RAAS, PVR
How does Digoxin increase refractory period
Decrease conduction through AV node
Where does Digoxin accumulate
Muscle (high Vd)
Does Digoxin need a loading dose?
Yes
What can precipitate Digoxin toxicity
Hypokalemia
How does Digoxin cause Hypokalemia
Competes with K for binding on ATPase
Digoxin toxicity Sx
Atrial arrhythmias
Altered color perception
Halos on dark objects
How do you treat Digoxin toxicity
Withdraw/Reduce
Digitalis Abs
Tx for Digoxin tox with V-tach
Lidocaine and Mg or increase K
Contraindications of Digoxin
Diastolic/Right HF
Uncontrolled HTN
Bradyarrhythmias
What do you NEVER coadmin with Digoxin and why
Quinidine
Verapamil
Amiodarone
Compete with kidney excretion (Increase levels of digoxin in body)
PDE3 inhibitor for short term increase in CO
Milrinone
Inamrinone
Can increase AV conduction
Milrinone
Inamrinone
+ve inotropic, increase CO and decrease preload and afterload
Milrinone
Inamrinone
When do you give DA in CHF
Tx for shock after volume replacement
What is the effect of an intermediate dose of DA
Dopaminergic and beta 1 receptors
Increase force and rate of contraction and renal vasodilation
What is the effect of an lowdose of DA
D1 only
Dilate renal and mesenteric BVs
What is the effect of an high dose of DA
Alpha 1 only
Vasoconstriction (no good)
What is used in short term management of pts with cardiac decompensation
Dobutamine
How does dobutamine work
+ve inotropic, vasodilation
Increase contraction
What does Dobutamine not affect
HR
When do you give Glucagon
Acute cardiac dysfunction from beta blocker OD
How does glucagon work
Increase contractility (not beta) Inotropic and chronotropic
