Chronic Heart Failure

Question 1

Heart failure

Answer 1

inability to provide enough oxygenated blood to the rest of the body

Question 2

Preload

Answer 2

Amount of blood at end of diastole (end diastolic volume)

Question 3

Afterload

Answer 3

Amount of pressure the heart has to pump up against for systole

Question 4

Ejection fraction (%)

Answer 4

Amount of blood pumped / end diastolic volume

Question 5

what other etiologies cause or increase the risk of developing HF?

Answer 5

HTN
Male
Valve disorders
Pregnancy
Smoking
 Rx Drug induced
Alcohol/Illicit drug use
Pericarditis
Hyperthyroidism
Diabetes
Obesity

Question 6

HF Presentation

Answer 6

SOB
Dyspnea on exertion
Edema- peripheral and/or pulmonary
Need for multiple pillows at night to sleep
Easily fatigued
Ascites
Hepatomegaly
Heart mumurs

Question 7

ACC/AHA Stages of HF
class A

Answer 7

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

Question 8

ACC/AHA Stages of HF
class B

Answer 8

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

Question 9

ACC/AHA Stages of HF
class C

Answer 9

Structural heart disease with prior or current symptoms of HF
Known structural heart disease
AND
Shortness of breath, fatigue, reduced exercise tolerance

Question 10

ACC/AHA Stages of HF
class D

Answer 10

Refractory HF requiring specialized interventions
Marked symptoms at rest despite maximal medical therapy

Question 11

NYHA functional classification

Answer 11

Ordinary activity does not cause symptoms

Question 12

NYHA functional classification

Class II

Answer 12

Ordinary activity causes symptoms

Question 13

NYHA functional classification

Class III

Answer 13

Less than ordinary activity causes symptoms

Question 14

NYHA functional classification

Class IV

Answer 14

Symptoms are present at rest

Question 15

Systolic HF

Answer 15

Most common
Problem with ejection of blood to the lungs or systemic circulation
Result of hypertrophy and dilation of ventricle

Question 16

Diastolic HF

Answer 16

Inability of the heart to fill appropriately
Usually results from stiffness of myocardium
More difficult to treat
Treatment not well defined

Question 17

Mortality reducing agents used in HF

Answer 17

ACE/ARBs
BB
Aldosterone blocking agents
Vasodilators (hydralazine/nitrates) in african americans

Question 18

Which BB can be used for HF

Answer 18

Metoprolol succinate (toporol)
Bisoprolol
Carvedilol

Question 19

BB MOA

Answer 19

blockage of beta receptors leading to decreased heart rate, decreased blood pressure, increased coronary artery blood flow

Question 20

Metoprolol succinate dosing& goal

Answer 20

6.25-12.5 mg/day; goal 200 mg/day

Question 21

Bisoprolol dosing & goal

Answer 21

1.25 mg/day; goal 10 mg/day

Question 22

Carvedilol dosing and goal

Answer 22

3.125 mg twice daily; goal 25 mg twice daily

Question 23

beta blocker ADR

Answer 23

Bradycardia
Worsening of HF if dose is started too high or up titrated too quickly
Respiratory issues

Question 24

ACEi/ARBs MOA

Answer 24

Interference with RAAS ending with disrupting angiotensin II
Produces decreases BP, Na/H2O retention
Afterload reducer

Question 25

Lisinopril staring dose and goal?

Answer 25

start at 5 mg daily, goal dose of 20-40 mg daily

Question 26

ACE/ARB ADR?

Answer 26

Hyperkalemia Cough (ACEi) Hypotension

Question 27

ACE/ARC CI?

Answer 27

Pregnancy Hyperkalemia (K>5.0 meq/L) Bilateral renal artery stenosis Angioedema

Question 28

Aldosterone Blockers MOA

Answer 28

Competes with aldosterone for intracellular mineralcorticoid receptors → Na and H2O excreation (this also increases K in the blood) Decreases preload

Question 29

what drugs belong to the aldosterone blocker class

Answer 29

spironolactone, eplirinone

Question 30

When should you use spironolactone

Answer 30

when you are at goal and still symptomatic

Question 31

Aldosterone Blockers ADR

Answer 31

Hyperkalemia | Gynecomestia

Question 32

what 2 drugs are vasodilatiors

Answer 32

Hydralazine | Isosorbide dinitrate

Question 33

Hydralazine MOA

Answer 33

Predominately vasodilates in coronary, cerebral, and renal arteries

Question 34

Isosorbide dinitrate MOA

Answer 34

Converts into nitric oxide which produces vasodilation

Question 35

When are vasodilators used

Answer 35

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

Question 36

Which drug class is most effective in HF?

Answer 36

loop diuretics

Question 37

Loop Diuretics MOA

Answer 37

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)

Question 38

what are the driving factors in loop diuretic dosing

Answer 38

age and weight

Question 39

When should loop diuretics be used

Answer 39

Initial dosing: Should only be used for symptomatic HF (C or D)

Question 40

what drugs are part of the loop diuretic class

Answer 40

Furosemide Bumetanide Torsemide

Question 41

what is the goal after using loop diuretics

Answer 41

after initial diuresis and reduction of fluid, try to get to the lowest dose possible or even consider discontinuing

Question 42

Loop diuretics ADR

Answer 42

``` Electrolyte imbalances (most common) Hyperglycemia Hyperuricemia Hypokalemia hypomagnesemia ```

Question 43

Digoxin MOA

Answer 43

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

Question 44

what are some key Pharmocokinetics of digoxin

Answer 44

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

Question 45

digoxin dosing regiment

Answer 45

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

Question 46

digoxin ADR

Answer 46

``` High potential for digoxin toxicity Electrolyte disturbances Hypomagnesemia Hypokalemia Bradycardia GI disturbances ```