Chronic Heart failure Flashcards
Capoten
captopril
ACE inhibitor
Vasotec*
enalapril
ACE inhibitor
Epaned
enalapril oral solution
Prinivil*
lisinopril
ACE inhibitor
Zestril*
lisinopril
ACE inhibitor
Qbrelis
lisinopril oral solution
Accupril*
quinapril
Altace*
ramipril
Atacand
candesartan
ARB
Cozaar*
losartan
ARB
Diovan*
valsartan
ARB
Toprol XL*
metoprolol succinate
Beta-1 selective Beta-blocker
Kapspargo sprinkle
metoprolol succinate
Beta-1 selective Beta blocker
bisoprolol
Beta-1 selective Beta-blocker
Coreg*
carvedilol IR
Non-selective beta blocker & alpha-1 blocker
Coreg CR*
carvedilol Controlled Release
Non-selective beta blocker & alpha-1 blocker
Lasix*
furosemide
Bumex*
bumetanide
torsemide*
Edecrin
ethacrynic acid
Loop diuretic
What are the Oral equivalent dosing conversions for Loop diuretics?
furosemide 40mg = torsemide 20mg = bumetanide 1mg = ethacrynic acid 50mg
what is the IV:PO dose conversion of furosemide
1:2
furosemide 20mg IV = furosemide 40mg PO
What is the IV:PO dose conversion of bumetanide?
1:1 ratio
what is the IV:PO dose conversion of ethacrynic acid?
1:1 ratio
Aldactone
spironolactone
aldosterone receptor antagonist
CaroSpir
spironolactone
aldosterone receptor antagonist
Inspra
eplerenone
aldosterone receptor antagonist
Farxiga
dapagliflozin
Jardiance
empagliflozin
With Chronic Heart Failure, the heart cannot supply _________________________________________________. This is because there are a number of problems.
There is a problem with ___________________.
or
There is a problem with___________________.
enough oxygen rich blood to the body
filling the left ventricle (relaxation = diastole)
ejection of blood from the left ventricle (contraction = systole)
diastole:
relaxation of ventricles ———————-“di” dilation - relaxation
systole:
contraction of ventricles
Ejection fraction:
blood pumped from the ventricle during each contraction.
Tell patients they have heart failure is scary. heart is failing, which is sorta true but also sorta not.
Heart failure is a syndrome, where the heart is not able to supply enough oxygen rich blood to vital organs of the body.
problem with oxygen demand and oxygen supply
an ejection fraction (EF) < 40% is classified as _____________
HFrEF = Heart Failure with reduced ejection fraction aka “systolic dysfunction”
Heart Failure is typically diagnosed with one main test -
an (ECHO) echocardiogram, which is an ultrasound of the heart. We can see how the heart is performing, and specifically we look to see what is the EF like.
(HFrEF) Heart Failure with reduced Ejection Fraction, also called ____________. The (EF) is ___________
-the left ventricle heart muscle is weakened and not able to squeeze at full potential
systolic heart failure
Less than or equal to 40%
remember heart can’t squeeze as well as it should
Guidelines focus on systolic heart failure.
(HFpEF) Heart Failure with preserved Ejection Fraction also called ____________.
-the left ventricle heart muscle has thickened from working so hard and is stiff, which takes up more space, because it is not able to relax completely, which in turn, allows less blood volume to fit in area.
diastolic heart failure
left ventricle cannot fill up as effectively.
An EF of a normal heart in someone without heart failure ranges from ____________
55 - 70%
Signs and Symptoms of Systolic Heart Failure
What biomarkers are elevated?
Shortness of breath
-orthopnea = shortness of breath that occurs while lying flat and is relieved by sitting or standing up
-dyspnea = difficulty or labored breathing
When the ventricle can’t pump correctly, the problem is that fluid backs up, and patients starts to have fluid overload symptoms. When fluid backs up in the lungs we see shortness of breath, and patients will present with cough. Fluid overload can also be present in other areas of the body, including peripheral edema, lower extremity swelling, ascites. We also can look for (JVD) jugular venous distention, that is when the neck veins are bulging out from fluid overload.
(HJR) Hepatojugular reflux = when we press on patients’ stomach around area of the liver, we can see that neck vein bulge out.
elevated (BNP) B-type natriuretic peptide
elevated (NT-proBNP) N-terminal pro B-type natriuretic peptide
*Both of these are elevated in conditions that cause the ventricles to stretch and work harder.
There are 2 classification systems for systolic heart failure.
(ACC) American college of cardiology/(AHA) American heart association Staging
- A-D A = least sick patient, D = most sick
- addresses patients who do not yet have structural heart disease or symptoms of HF, but who are at high risk
(NYHA) New York Heart Association (FC) Functional Classes
- I-IV I = least sick patient, IV = most sick patient
- based on symptoms
- clinical trials historically enrolled patients based on NYHA FC
NYHA FC Class I
symptoms a patient would have in this class include: _________
No limitations of physical activity.
Ordinary physical activity does not cause symptoms of HF.
NYHA FC Class II
symptoms a patient would have in this class include: _________
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical activity (walking upstairs) causes symptoms of HF.
NYHA FC Class III
symptoms a patient would have in this class include: _________
Maked limitation of physical activity.
Comfortable at rest but minimal exertion (bathing, getting dressed) causes symptoms of HF.
NYHA FC Class IV
symptoms a patient would have in this class include: _________
Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest (SOB while sitting in a chair)
Which ACC/AHA stages do patients have clinical diagnosis of HF?
stages C & D
The ACC/AHA Staging system is used to guide treatment in order to _________________________________.
slow progression of structural heart disease in:
asymptomatic patients (Stages A and B)
- (LVH) left ventricular hypertrophy, low ejection fraction
valvular disease, previous MI
&
symptomatic patients (Stages C & D)
The NYHA FC: categorizes heart failure by _____________
the level of limitation in physical functioning.
Stage A using the ACC/AHA staging system includes patients that
____________________________
Are at risk for development of heart failure, but without symptoms of HF and without structural heart disease or elevated biomarkers.
(patients with hypertension, ASCVD, or diabetes)
Stage B using the ACC/AHA staging system includes patients that
_______________________________
have Pre-HF; structural heart disease, abnormal cardiac function or elevated biomarkers, but without signs or symptoms of HF.
(patients with Left Ventricular Hypertrophy plus SOB, low ejection fraction, valvular disease)
Stage C using the ACC/AHA staging system includes patients that
_________________________________
have a clinical diagnosis of HF
have structural and/or functional cardiac abnormality with prior or current symptoms of HF.
ex. patient with known structural heart disease (LVH) plus SOB, fatigue and reduced exercise tolerance
Stage D using the ACC/AHA staging system includes patients that
________________________________
have a clinical diagnosis of HF
have Advanced HF with severe symptoms, symptoms at rest or recurrent hospitalizations despite maximal treatment. (refractory HF requiring specialized interventions)
Pathophysiology of Heart Failure
As a reminder, the heart is not able to supply the body with enough oxygen rich blood. So, there is this problem of myocardial oxygen supply and myocardial oxygen demand. As a result, the (CO) Cardiac output is decreased (problem).
The body realizes this and then tries to compensate for it using a few different ways:
1)
2)
3)
4)
1) Activation of the Sympathetic Nervous System (SNS)
2) Activation of the Renin Angiotensin Aldosterone System (RAAS)
3) Increasing Vasopressin
4) Increasing Natriuretic Peptides
- which cause us to pee off some of that fluid
all are bad mechanisms to use to compensate, all will cause problems besides #4 enhancing peptides which is really good
(CO) Cardiac Output:
the amount of blood that comes out of left ventricle during systole (contraction)
Cardiac Output equation =
CO = HR x SV
Cardiac output = is the volume of blood that is pumped by the heart in one minute
(HR) Heart Rate = the number of times the heart BPM
(SV) Stroke Volume = the amount of blood volume ejected from the left ventricle during one complete heartbeat
Lifestyle management of HF should include instructing the patient to:
______________
Lots of things the patient can do to avoid being admitted to the hospital
Monitor and Document body weight daily, in the morning after voiding and before eating.
Have patient notify provider if weight increases by 2-4 lbs in one day or 3-5 lbs in one week, or if symptoms worsen.
Restrict sodium intake to <1500mg/day in stages A and B HF
Restrict fluid (1.5 - 2 L/day in stage D HF
Stop smoking, limit alcohol intake, do not use illicit drugs
vaccine recommendations
Reduce weight to BMI < 30kg/m2
Exercise 30min/day for 3-5 days
Avoid stimulants.
Drugs That Cause Or Worsen HF
remember —– Drug Info NATION———- “DI NATION”
these drugs either increase blood pressure or cause retention of fluid.
Dipeptidyl peptidase 4 inhibitors (DPP-4 inhibitors) Alogliptin, Sitagliptin
Immunosuppressants
Non-dihydropyridine calcium channel blockers (verapamil and diltiazem); we don’t use in HF due to negative ionotropic effect, pretty well known for causing a HF decompensation.
Antiarrhythmics- most also have a negative ionotropic effect, particularly.
Class 1 antiarrhythmics. want to avoid in HF at all costs
Thiazolidinediones - cause fluid retention, which can cause an
exacerbation.
Itraconazole
Oncology agents
NSAIDs - these will compete with how loop diuretics are working. Making them a little less effective and can cause or worsen heart failure.
ionotropic effect (negative) =
ionotropic effect (positive) =
Decrease
Increase HR and increase Contractility.
Some of the Class 3 antiarrhythmics like amiodarone and dofetilide, these are considered relatively safe in HF
What drugs work on the compensatory mechanism that inhibits/blocks activation of effects from the (SNS) sympathetic nervous system activation?
Beta-blockers
stop that increase in HR. Also reduce mortality.
What drugs work on the compensatory mechanism that inhibits/blocks activation of effects from the (RAAS) renin angiotensin aldosterone system?
ACE-inhibitors, ARBs, (ARA) aldosterone receptor antagonists
these agents will help combat the fluid retention that we see in heart failure. Also reduce mortality.
What drugs work on the compensatory mechanism that inhibits/blocks activation of effects from the
What drugs work on the compensatory mechanism that inhibits/blocks activation of effects from the
Loop Diuretics target _____________ directly, have no impact on mortality but patients feel a lot better when they are taking one.
fluid retention
Digoxin works on the main issue in heart failure, which is ________________
the decreased CO. Digoxin is a + inotrope, Increasing contractility
Sacubitril works by helping ___________________
keep those Natriuretic Peptides longer. So it helps with this positive compensatory mechanism.
the Loop Diuretics work by acting at the nephron, specifically at the thick portion of the ______________. This is where the diuretics __________________________. These are very potent diuretics that are great at getting rid of fluid but are not very good for hypertension. Although they have no benefit in ___________ they are very good at ___________.
Ascending Limb of the loop of Henle
reabsorb ~25% of sodium & calcium.
mortality
symptomatic improvement
Loop diuretics block ________ and _________ reabsorption in the thick ascending limb of the loop of Henle.
“this keeps the urine concentrated” water follows salts. Having this decrease in fluid volume makes it easier for the heart to pump.
They cause a lot of different electrolytes to be eliminated in the urine including: _______________. So side effects and electrolyte changes are what we are most concerned with.
There are also a few things that can increase with there use, including: ______________
sodium & chloride
sodium(Na), potassium(K), magnesium(Mg), chloride(Cl), calcium(Ca)
(UA) uric acid, (BG) blood glucose, (TG) triglycerides, (TC) total cholesterol, (HCO3) bicarbonate
Oral dose equivalents for Loop diuretics:
Lasix _______ = Demadex______ = Bumex_____ = Edecrin_________
furosemide 40mg = torsemide 20mg = bumetanide 1mg = ethacrynic acid 50mg
what is the IV:PO ration for furosemide??
1:2
ex. furosemide 20mg IV = furosemide 40mg PO
what is the IV:PO ratio for bumetanide?
1:1
what is the IV:PO ratio for ethacrynic acid?
1:1
Loop Diuretics work on getting rid of fluid, decreasing the elevated preload caused by the compensatory mechanism by ____________
increased Vasopressin & increased RAAS from the heart failure
Lasix*
Bumex*
Demadex*
Edecrin
ACE inhibitors work by blocking the ________________. This results in ______________
conversion of angiotensin I to angiotensin II.
decreasing vasoconstriction and decreased aldosterone secretion
Capoten
captopril
starting dose:
Target Dose:
Vasotec*
enalapril
starting dose:
Target Dose:
fosinopril
fosinopril
starting dose:
Target Dose:
Prinivil*
lisinopril
starting dose:
Target Dose:
Zestril*
lisinopril
starting dose:
Target Dose:
perindopril
starting dose:
Target Dose:
Accupril*
quinapril
starting dose:
Target Dose:
Altace*
ramipril
starting dose:
Target Dose:
trandolapril
starting dose:
Target Dose:
Atacand
candesartan
starting dose:
Target Dose:
Cozaar*
losartan
starting dose:
Target Dose:
Diovan*
valsartan
starting dose:
Target Dose:
Entresto*
sacubitril/valsartan
combination of neprilysin inhibitor and ARB
