Chronic Heart Failure Flashcards
Heart failure
inability to provide enough oxygenated blood to the rest of the body
Preload
Amount of blood at end of diastole (end diastolic volume)
Afterload
Amount of pressure the heart has to pump up against for systole
Ejection fraction (%)
Amount of blood pumped / end diastolic volume
what other etiologies cause or increase the risk of developing HF?
HTN Male Valve disorders Pregnancy Smoking Rx Drug induced Alcohol/Illicit drug use Pericarditis Hyperthyroidism Diabetes Obesity
HF Presentation
SOB Dyspnea on exertion Edema- peripheral and/or pulmonary Need for multiple pillows at night to sleep Easily fatigued Ascites Hepatomegaly Heart mumurs
ACC/AHA Stages of HF class A
At high risk for HF but without structural heart disease or symptoms of HF Hypertension CAD Diabetes mellitus (DM) Obesity Metabolic syndrome OR Using cardiotoxins Family Hx of cardiomyopathy TX: ACE or ARB
ACC/AHA Stages of HF class B
Structural heart disease but without signs or symptoms of HF Previous MI LV remodeling including LVH and EF Asymptomatic valvular disease Tx: ACE or ARB, BB
ACC/AHA Stages of HF class C
Structural heart disease with prior or current symptoms of HF
Known structural heart disease
AND
Shortness of breath, fatigue, reduced exercise tolerance
ACC/AHA Stages of HF class D
Refractory HF requiring specialized interventions
Marked symptoms at rest despite maximal medical therapy
NYHA functional classification
Ordinary activity does not cause symptoms
NYHA functional classification
Class II
Ordinary activity causes symptoms
NYHA functional classification
Class III
Less than ordinary activity causes symptoms
NYHA functional classification
Class IV
Symptoms are present at rest
Systolic HF
Most common
Problem with ejection of blood to the lungs or systemic circulation
Result of hypertrophy and dilation of ventricle
Diastolic HF
Inability of the heart to fill appropriately
Usually results from stiffness of myocardium
More difficult to treat
Treatment not well defined
Mortality reducing agents used in HF
ACE/ARBs
BB
Aldosterone blocking agents
Vasodilators (hydralazine/nitrates) in african americans
Which BB can be used for HF
Metoprolol succinate (toporol)
Bisoprolol
Carvedilol
BB MOA
blockage of beta receptors leading to decreased heart rate, decreased blood pressure, increased coronary artery blood flow
Metoprolol succinate dosing& goal
6.25-12.5 mg/day; goal 200 mg/day
Bisoprolol dosing & goal
1.25 mg/day; goal 10 mg/day
Carvedilol dosing and goal
3.125 mg twice daily; goal 25 mg twice daily
beta blocker ADR
Bradycardia
Worsening of HF if dose is started too high or up titrated too quickly
Respiratory issues
ACEi/ARBs MOA
Interference with RAAS ending with disrupting angiotensin II
Produces decreases BP, Na/H2O retention
Afterload reducer
Lisinopril staring dose and goal?
start at 5 mg daily, goal dose of 20-40 mg daily
ACE/ARB ADR?
Hyperkalemia
Cough (ACEi)
Hypotension
ACE/ARC CI?
Pregnancy
Hyperkalemia (K>5.0 meq/L)
Bilateral renal artery stenosis
Angioedema
Aldosterone Blockers MOA
Competes with aldosterone for intracellular mineralcorticoid receptors → Na and H2O excreation (this also increases K in the blood)
Decreases preload
what drugs belong to the aldosterone blocker class
spironolactone, eplirinone
When should you use spironolactone
when you are at goal and still symptomatic
Aldosterone Blockers ADR
Hyperkalemia
Gynecomestia
what 2 drugs are vasodilatiors
Hydralazine
Isosorbide dinitrate
Hydralazine MOA
Predominately vasodilates in coronary, cerebral, and renal arteries
Isosorbide dinitrate MOA
Converts into nitric oxide which produces vasodilation
When are vasodilators used
in patients who can not tolerate ACE/ARB and also used in African american patients
used in stage C in African Americans and in B/C/D if a contraindication to ACEi exists, race does not matter
Which drug class is most effective in HF?
loop diuretics
Loop Diuretics MOA
exerts their action at the loop of Henle. Increase Na and H2O excretion. Since all diuretics reduce pre-load and edema why are loop diuretics preferred over other agents (such as thiazide diuretics)
what are the driving factors in loop diuretic dosing
age and weight
When should loop diuretics be used
Initial dosing: Should only be used for symptomatic HF (C or D)
what drugs are part of the loop diuretic class
Furosemide
Bumetanide
Torsemide
what is the goal after using loop diuretics
after initial diuresis and reduction of fluid, try to get to the lowest dose possible or even consider discontinuing
Loop diuretics ADR
Electrolyte imbalances (most common) Hyperglycemia Hyperuricemia Hypokalemia hypomagnesemia
Digoxin MOA
positive inotropic activity and negative chronotropic activity
Increase in intracellular Na and Ca→ increase in force of contraction
What is the driving force behind digoxin producing negative chronotropic activity?
Reduced intracellular K and increased intracellular Ca
what are some key Pharmocokinetics of digoxin
Large VD, larger in obese/smaller in elderly
VERY NARROW Therapeutic index!!!!!
Which is more likely to have unintended toxicity?
Elderly-smaller VD leads to increase concentration in the blood
Primarily renally excreted
digoxin dosing regiment
recommend low dose for normal renal function→ 0.125 mg/day (should only be used in symptomatic HF- stage C/D)
Elderly or renal insuficiency → 0.125 mg every other day
Monitor digoxin levels only for toxicity (>2 ng/dl), not efficacy
digoxin ADR
High potential for digoxin toxicity Electrolyte disturbances Hypomagnesemia Hypokalemia Bradycardia GI disturbances
