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Cardiac Structure and Consequence of dysfunction > CHF Management: Pharmacology and Treatment > Flashcards

CHF Management: Pharmacology and Treatment Flashcards

1
Q

Relation HF and NYHA

A

-mortality in HF increases with worsening NYHA classification

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2
Q

1 rule for treatment for CHF

A
  • Correct the correctable

- i.e. correct the underlying causes of CHF and the precipitating/exacerbating factors

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3
Q

Causes of CHF (7)

A
  • CAD/MI
  • hypertension
  • diabetes
  • valvular heart disease
  • cardiomyopthy/myocarditis
  • congenital heart disease
  • other diseases (sarcoidosis, amyloidosis, HIV, hemochromatosis, etc)
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4
Q

Precipitating/exacerbating factors - two categories

A

Two categories

  1. Patient related factors
  2. Physician related factors
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5
Q

Patient related factor (precipitating/exacerbating HF) -9

A

1) Arrhythmias
2) Ischemia
3) Anemia
4) Viral illness
5) Fever
6) Thyroid disease
7) Salt and water intake excess
8) Noncompliance with medications
9) Alcohol

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6
Q

Physician related factors (precipitating/exacerbating)

A
  1. Prescription of negatively inotropic agents
  2. Prescription of NSAIDs
  3. Under-dosing of CHF medications
  4. Poor patient communication
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7
Q

Treatment goals CHF (4)

A
  1. Control symptoms
  2. Reduce hospitalization
  3. Prolong life
  4. Prevent disease regression
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8
Q

Acute heart failure -definition

A

Rapid onset of symptoms and signs secondary to abnormalities in cardiac function that may be life threatening and require urgent treatment

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9
Q

Acute heart failure clinical signs (3)

A

1) Respiratory distress
2) Hypertensive/hypotensive
3) Use of accessory muscles

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10
Q

Respiratory distress in acute heart failure signs (4)

A
  • hypoxemia
  • orthopnea
  • tachypnea
  • tachycardia
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11
Q

What does hypotensive in acute HF suggest -what condition

A

-cardiogenic shock (heart not able to pump blood that body needs)

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12
Q

Management general steps of acute CHF (1 + 5)

A
  1. Initial stabilization -ABCs
  2. Correct hemodynamic/intravascular volume abnormalities rapidly (with pharmacologic therapies):
    a) decrease preload
    b) decrease pulmonary edema
    c) decrease ventricular wall stress
    d) increase CO
    e) support BP as necessary
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13
Q

Initial stabilization-specifics (4)

A
  1. Airway (+ oxygenation)
    - supplemental O2 and assisted ventilation as needed (either non invasive ventilation such as CPAP or BIPAP or invasive= intubation)
  2. Vitals, cardiac monitoring
  3. IV access
  4. Seated posture
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14
Q

Acute CHF pharmacological therapy - broad categories (4)

A
  1. Diuretics (loop diuretics)
  2. Vasodilators
  3. Morphine
  4. Inotropes
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15
Q

Diuretics used in acute HF

A

-IV lasix (is first line treatment for acute HF)

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16
Q

Peak diuresis in acute HF

A

-about 30 minutes after dose

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17
Q

How diuretic improve acute HF (2)

A
  • reduction in intravascular volume –> lowered central venous and capillary wedge pressures
  • venodilation effect reduces congestion prior to onset of diuresis
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18
Q

Vasodilators used in acute HF (3)

A
  • nitroglycerine
  • nitroprusside
  • nesirtide
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19
Q

Use of vasodilators- in who

A

-in patients with normal to high BP in addition to diuretic therapy

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20
Q

Effect of vasodilators (2)

A

-rapidly reduces LV filling pressures via venodilation (decreases pre-load)
-also decrease in systemic vascular resistance–> decrease ventricular workload (afterload)
which leads to improved CO

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21
Q

Potentially first presentation of exacerbation of chronic CHF

A

-acute decompensated heart failure

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22
Q

Benefits of inotropes in cardioenic shock (low bp) -2 + indications for use

A

Help maintain systemic perfusion and preserve end organ function
-use in cases of low BP or cardiogenic shock

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23
Q

Overall function of inotropes

A

increase contractility

24
Q

Ex of inotropes (2)

A
  • dobutamine

- milrinone

25
Q

Overall function of vasopressors

A

Increase BP

26
Q

Ex of vasopressors

A
  • dopamine

- norepinephrine

27
Q

Benefits to morphine for patient with acute CHF (2)

A
  • reduces anxiety –> decreases work of breathing
  • decreases central sympathetic outflow leading to arteriolar and venous dilation and decreased cardiac filling pressures
28
Q

What is morphine associated with -disadvantages of administering in cases acute CHF (2)

A
  • increased frequency of mechanical ventilation

- in-hospital mortality

29
Q

When Mechanical intervention for Acute CHF indicated –> when (2)

A

-cardiogenic pulmonary edema or cardiogenic shock despite adequate pharmacologic therapy

30
Q

Mechanical interventions (2)

A

Intra-aortic balloon pump

Left ventricular assist device

31
Q

Why is prompt diagnosis of chronic CHF important (5)

A

1) Slow disease progression
2) Improve LV function
3) Improve quality of life
4) Reduce mortality and hospitalization
5) Generally well tolerated

32
Q

General principles pharmacological therapy of acute CHF (3)

A

1) All patients with CHF and LVEF <40% should be treated with ACE inhibitor and B-blocker
2) Use drugs proven in large -scale clinical trials
3) Titrate to target doses used in clinical trials

33
Q

Examples of ACE inhibitors (5 + ending)

A

“prils”

1) Captopril (capoten)
2) Ensispril (vasotec)
3) Fosinopril (monopril)
4) Lisinopril (prinivil, zesril)
5) Ramipril (altace)

34
Q

Effect of ACE inhibition

A

1) No production of Ang II
- no production of aldosterone
- no production of O free radicals
- no endothelin production
- no TXA2, PGH2 production
- no hypertrophy
* * all these are separate consequences of AngII
2) Does NOT effect bradykinin pathway
- same levels NO, prostacyclin production

35
Q

Which ace is best

A
  • no evidence to suggest a best ACE

- evaluated in CHF trials = captopril, enalapril, ramipril, lisonopril

36
Q

Practical tips ace administration

A

Start with ACE then add B-blocker

37
Q

BP aim for with ACE

A

Ideal BP often < 100mmHg if not symptomatic

38
Q

Changes in electrolytes with ACE

A

accept minor increases in Cr and K

39
Q

What is tolerability of ACE inhibitors improved by (3)

A
  • appropriate volume status
  • start low, go slow approach to titration
  • consider BID dosing
40
Q

Contraindications ACE

A
  • renal impairment
  • hyperkalemia (up to 30% increase in Cr not unexpected, may require close monitoring –> if Cr >30% rise or Cr >250 need to DC)
41
Q

Practical tips use of B-blockers in NYHA I-II patients (3)

A
  • usually well tolerated
  • start low, go slow
  • titrate to target dose
42
Q

Practical tips use B-blockers in NYHA III-IV patients

A
  • initiated by CHF specialists if possible

- CHF clinic if available

43
Q

Contraindicators B blockers

A

1) Symptomatic hypotension
2) Bradycardia
3) Significant AV block
4) Severe asthma (stable COPD usually okay)

44
Q

Angiotensin receptor blockers (ARB’s) - examples (4)

A

“sartans”

  • losartan (cozaar)
  • chandesartan (atacand)
  • irbesartan (avapro)
  • valsartan (diovan)
45
Q

Where in the RAAs system do ARBs act

A

AT1 receptor (receptor that ANG II works on)

46
Q

Physiological effects of AngII 2 at

a) AT1 receptor (5)
b) AT2 receptor (4)

A

AT1 :

  • vasoconstriction
  • sympathetic tone
  • Na+ reabsorption
  • Aldosterone
  • smooth muscle proliferation

AT2:
the opposite of everything AT1 does

47
Q

Current evidence ARBs vs. ace inhibitors

A

neither superior nor equivalent

48
Q

When do use ARBs (3)

A
  • as an alternative if ACE is not tolerated
  • or use with ACE when B-blockers contraindicated/not well tolerated
  • advanced symptoms on maximal therapy - use of triple therapy - B-blockers, ACE, ARBs
49
Q

Example of aldosterone antagonists (2)

A
  • spironolactone

- eplerenone

50
Q

Indication for aldosterone antagonist use

A

1) NYHA II-IV
2) LVEF < 30%
3) Recent hospitalization for CAD/MI

51
Q

What to watch for with aldosterone antagonist use

A

Watch CR/K elevation

52
Q

Principles of using diuretics in CHF (3)

A
  • important with acute congestion
  • once congestion cleared use lowest dose possible
  • combination therapy may be needed for persistent congestion
53
Q

Indications for use of digoxin

A
  • mod -severe symptoms despite max medical therapy

- adjunctive for rate control (ie. if have A-fib and CHF)

54
Q

Categories of vasodilators used

A

1) Nitrates (standard)

2) Nitrates + hydralazine

55
Q

Use of vasodilators -nitrates

A
  • in both acute and chronic CHF

- may improve nocturnal symptoms, exercise tolerance and angina

56
Q

Use of vasodilators -nitrates + hydralazine

A
  • african-americans with systolic CHF in addition to standard therapy
  • other CHF patients unable to tolerate standard therapy
57
Q

Antiplatelet and anticoagulation therapy for chronic CHF

a) treatments
b) indications

A

1) ASA for patients with CAD
2) Anticoagulation
- a-fib

Cardiac Structure and Consequence of dysfunction (7 decks)

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