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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
Overall function of vasopressors
Increase BP
26
Ex of vasopressors
- dopamine | - norepinephrine
27
Benefits to morphine for patient with acute CHF (2)
- reduces anxiety --> decreases work of breathing - decreases central sympathetic outflow leading to arteriolar and venous dilation and decreased cardiac filling pressures
28
What is morphine associated with -disadvantages of administering in cases acute CHF (2)
- increased frequency of mechanical ventilation | - in-hospital mortality
29
When Mechanical intervention for Acute CHF indicated --> when (2)
-cardiogenic pulmonary edema or cardiogenic shock despite adequate pharmacologic therapy
30
Mechanical interventions (2)
Intra-aortic balloon pump | Left ventricular assist device
31
Why is prompt diagnosis of chronic CHF important (5)
1) Slow disease progression 2) Improve LV function 3) Improve quality of life 4) Reduce mortality and hospitalization 5) Generally well tolerated
32
General principles pharmacological therapy of acute CHF (3)
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
Examples of ACE inhibitors (5 + ending)
"prils" 1) Captopril (capoten) 2) Ensispril (vasotec) 3) Fosinopril (monopril) 4) Lisinopril (prinivil, zesril) 5) Ramipril (altace)
34
Effect of ACE inhibition
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
Which ace is best
- no evidence to suggest a best ACE | - evaluated in CHF trials = captopril, enalapril, ramipril, lisonopril
36
Practical tips ace administration
Start with ACE then add B-blocker
37
BP aim for with ACE
Ideal BP often < 100mmHg if not symptomatic
38
Changes in electrolytes with ACE
accept minor increases in Cr and K
39
What is tolerability of ACE inhibitors improved by (3)
- appropriate volume status - start low, go slow approach to titration - consider BID dosing
40
Contraindications ACE
- 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
Practical tips use of B-blockers in NYHA I-II patients (3)
- usually well tolerated - start low, go slow - titrate to target dose
42
Practical tips use B-blockers in NYHA III-IV patients
- initiated by CHF specialists if possible | - CHF clinic if available
43
Contraindicators B blockers
1) Symptomatic hypotension 2) Bradycardia 3) Significant AV block 4) Severe asthma (stable COPD usually okay)
44
Angiotensin receptor blockers (ARB's) - examples (4)
"sartans" - losartan (cozaar) - chandesartan (atacand) - irbesartan (avapro) - valsartan (diovan)
45
Where in the RAAs system do ARBs act
AT1 receptor (receptor that ANG II works on)
46
Physiological effects of AngII 2 at a) AT1 receptor (5) b) AT2 receptor (4)
AT1 : - vasoconstriction - sympathetic tone - Na+ reabsorption - Aldosterone - smooth muscle proliferation AT2: the opposite of everything AT1 does
47
Current evidence ARBs vs. ace inhibitors
neither superior nor equivalent
48
When do use ARBs (3)
- 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
Example of aldosterone antagonists (2)
- spironolactone | - eplerenone
50
Indication for aldosterone antagonist use
1) NYHA II-IV 2) LVEF < 30% 3) Recent hospitalization for CAD/MI
51
What to watch for with aldosterone antagonist use
Watch CR/K elevation
52
Principles of using diuretics in CHF (3)
- important with acute congestion - once congestion cleared use lowest dose possible - combination therapy may be needed for persistent congestion
53
Indications for use of digoxin
- mod -severe symptoms despite max medical therapy | - adjunctive for rate control (ie. if have A-fib and CHF)
54
Categories of vasodilators used
1) Nitrates (standard) | 2) Nitrates + hydralazine
55
Use of vasodilators -nitrates
- in both acute and chronic CHF | - may improve nocturnal symptoms, exercise tolerance and angina
56
Use of vasodilators -nitrates + hydralazine
- african-americans with systolic CHF in addition to standard therapy - other CHF patients unable to tolerate standard therapy
57
Antiplatelet and anticoagulation therapy for chronic CHF a) treatments b) indications
1) ASA for patients with CAD 2) Anticoagulation - a-fib

Cardiac Structure and Consequence of dysfunction (7 decks)

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