Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Clinical Pharmacy 2 > Chronic Heart Failure > Flashcards

Chronic Heart Failure Flashcards

1
Q

What is the mortality rate of heart failure?

A
  • up to 40-50% of patients with HF die within 5 years of diagnosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is heart failure?

A

a clinical syndrome with subsets of conditions due to cardiac dysfunction

  • this occurs when the heart is unable to deliver adequate supply of oxygenated blood to meet the metabolic demands of the organs
  • associated with the structural abnormality that develops over time secondary to a sudden or insidious injury
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What kind of heart failure provides a reduced ejection fraction?

A
  • systolic failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Is the ejection fraction compromised in diastolic failure?

A
  • it is
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What conditions will decrease the contractility of the heart?

A
  • rheumatic heart disease
  • cardiomyopathy
  • coronary heart disease/MI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What conditions will increase the after load of the heart?

A
  • hypertension

- aortic stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What conditions will increase the preload of the heart?

A
  • increased sodium and water retention
  • malfunction of the aortic valve
  • drugs (steroids, NSAIDs)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What causes a high output failure?

A

anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Cardiac output is the function of what?

A

CO= SV x HR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What factors influence stroke volume?

A
  • preload
  • contractility
  • after load
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the definition of cardiac output?

A
  • volume of the blood pumped out of the heart per minute
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the definition of heart failure?

A
  • those with an ejection fraction less than 40%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the definition of ejection fraction?

A
  • fraction of blood ejected form the left ventricle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the formula for ejection fraction?

A

EF = (EDV - ESV) / EDV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the definition of the preload?

A
  • degree of filling from the left atrium (venous return, end-diastolic volume)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the definition of the after load?

A
  • arteriolar resistance the heart must pump against to eject stroke volume
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the definition of the end diastolic volume?

A
  • this is the volume that is filling the left ventricle at the end of the diastole
  • this is used as the concrete measure of the preload
  • need to have a normal functioning contractility in order to eject the normal stroke volume from the heart
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What happens in the frank sterling relationship when a person has mild dysfunction?

A
  • when the preload increases, you require a higher amount of pressure or preload to maintain the same stroke volume - you need to increase the preload significantly to have the same output
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What happens in the frank sterling relationship when someone has severe dysfunction?

A

when someone has severe heart failure, you will never be able to achieve the same pressure no matter how much you increase the preload

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the three general patterns of remodelling?

A
  • concentric ventricular remodelling
  • eccentric left ventricular hypertrophy
  • mixed concentric/eccentric hypertrophy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Sarcomeres added in parallel adds to the ___________

A

thickness of the ventricular wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is eccentric hypertrophy?

A
  • the sarcomeres here are being stretched here, the ventricles are being stretched here, ventricles are being enlarged but the wall thickness here is still unchanged
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What does the body do to increase the preload?

A
  • the body starts to retain water and salt, and the body activates the RAAS system
  • angiotensin 2 accomplishes vasoconstriction and leads to water retention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What body attempts to maintain CO and BP by doing what?

A

Increasing preload
- increasing the venous retire in an attempt to increase CO
- sodium and water retention
- activation of the renin angiotensin system
Vasoconstriction
- increase after load
- increase systemic vascular resistance (sympathetic stimulation, activation of renin angiotensin system)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are some of the compensatory mechanisms associated with cardiac heart failure?

A
  1. tachycardia and increased contractility
    - sympathetic stimulation
  2. neurohormonal stimulation
    - compensatory release of hormones in response to hypovolemia - renin, NE, antidiuretic hormones
    - in the long term these contribute to the progression of structural abnormalities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What does angiotensin 2 do?

A
  • increase protein synthesis, cardiac myocytes hypertrophy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What causes a hypertrophied heart?

A
  • diastolic heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What causes a dilated heart?

A
  • systolic heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is heart failure with reduced ejection fraction also known as?

A
  • also known as systolic heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What structural abnormalities are involved in heart failure with reduced ejection fraction?

A
  • low output (congestive) heart failure
  • hypo-functioning left ventricle, decreased contractility
  • ventricles enlarge (dilate as retain blood)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is heart failure with preserved ejection fraction known as?

A
  • diastolic heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are the structural issues involved in heart failure with preserved ejection fraction?

A
  • normal contractility and heart size
  • impaired left ventricular filling during diastole
  • left ventricular stiffness and inability to relax during diastole
    • results in increased resting pressure within the ventricle
    • the increased pressure impedes ventricular filling, therefore reducing stroke volume (EF preserved)
  • can see with thickened left ventricle or stiff ventricle (restrictive cardiomyopathy)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Compensatory mechanisms eventually induce symptoms of heart failure due to what?

A
  1. vasoconstriction: leads to decreased CO
  2. increased HR: leads to increased oxygen utilization
  3. increased preload: leads peripheral and pulmonary edema
  4. decreased exercise tolerance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What are the main signs and symptoms associated with left sided heart failure?

A

PULMONARY CONGESTION

  • dyspnea on exertion
  • orthopnea
  • paroxysmal nocturnal dyspnea
  • pulmonary edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What are the main signs and symptoms associated with right sided heart failure?

A

SYSTEMIC VENOUS CONGESTION

  • organomegaly
  • jugular venous distention
  • hepatojugular reflex
  • lower extremity peripheral edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are other non-specific findings associated with heart failure?

A
  • weakness
  • exercise intolerance
  • fatigue
  • CNS
  • cold, pale, clammy skin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What is class 1 heart failure?

A
  • uncompromised cardiac function

- able to perform ordinary physical activity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is class 2 heart failure?

A
  • slightly compromised

- ordinary physical activity results in symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What is class 3 heart failure?

A
  • moderately compromised

- less than ordinary physical activity results in symptoms

40
Q

What is class 4 heart failure?

A
  • severely compromised function

- symptoms may be present at rest

41
Q

What are the signs on clinical exams of heart failure?

A
  • auscultation of heart and lungs (rales of the lungs)
  • edema
  • jugular vein distention
  • hepatojugular reflux
  • dyspnea
  • chest X ray
42
Q

What are the symptoms of heart failure?

A
  • weakness, fatigue

- exercise tolerance

43
Q

What are the medical management strategies associated with heart failure?

A
  • eliminate exacerbating factors
  • control associated diseases
  • restrict activity when acute
  • sodium restricted diet
  • exercise conditioning when stabilized
  • drug therapy
44
Q

What is the purpose of diuretics in CHF?

A
  • relieve breathlessness and edema in patients with symptoms of signs of congestion
    • reduce intravascular volume, deem, preload and pulmonary congestion
  • achieve diuresis through inhibiting reabsorption of sodium in thick ascending limb and distal convoluted tubule
45
Q

What diuretic works on the thick ascending limb?

A

loop diuretics

46
Q

What diuretic works on the distal convoluted tubule?

A
  • thiazide diuretics
47
Q

In what stage of heart failure are diuretics always used?

A
  • stage 3 and 4 heart failure
48
Q

What is the dose of furosemide that should be used in those with CHF?

A
  • initiate 20-40 mg daily
  • increase the dose accordingly achieve edema free state (dry weight); once symptoms are relieved, use the lowed possible maintenance dose
  • possible diuretic resistance is severe refractory HF - sodium/water reabsorption markedly increased
49
Q

_____ diuretics are unlikely to be effective with significant renal dysfunction (eGFR <30 ml/min)

A

thiazide

50
Q

Why are loop diuretics and thiazide diuretics usually used together?

A

– loop diuretics stop the adoption of Na in the ascending loop- by having both diuretics you are blocking the reabsorption in both the ascending and the distal loop

51
Q

What is the usual dose of HCTZ?

A
  • starting dose is 25 mg, usually dose up to 100 mg/day
52
Q

What is the usual dose of metolazone?

A
  • starting dose is 2.5 mg, usual dose is 2.5-10 mg/day
53
Q

What are the adverse events associated with diuretics?

A
  • volume depletion (leads to dehydration, and reduction in BP and CO)
  • loss of K and Mg (can induce or potentiate digoxin toxicity)
  • renal impairment
54
Q

What is the biggest risk associated with diuresing too aggressively?

A

renal failure- you need to make sure that you are monitoring the creatinine clearance

55
Q

What factors determine the efficacy of the diuretics?

A
  • daily weight
  • input/output
  • jugular venous distention
  • peripheral edema
  • sitting/standing HR and BP
  • organ congestion (pulmonary rales and hepatomegaly)
56
Q

Renal function and electrolytes should be checked ______ after initiation and after dose increase

A

1-2 weeks

57
Q

What is the rationale behind using beta blockers after HF?

A
  • decreases the disease progression and all-cause mortality
  • stops activation of RAAS
  • slows remodelling of cardiac myocytes
58
Q

What is the first line therapy after heart failure?

A
  • beta blockers

- ACE inhibitors

59
Q

What is the purpose of a positive ionotrope after an MI?

A
  • it helps with the contractility of the heart
60
Q

What is the choice of beta blockers by cardiologists?

A
  • bisoprolol

- carvedilol

61
Q

When should beta blockers be initiated those with heart failure?

A
  • initiate when patients are stable and not in acute decompensated heart failure
  • need to start with a very low dose
  • increase dosage approx every 2 weeks
  • aim for the highest dose tolerated
  • avoid large dose reduction or abrupt withdrawal
  • decrease dose if on ionotropes (d/c if patents are in cardiogenic shock)
62
Q

What are the main AE associated with beta blockers?

A
  • postural hypotension
  • headache
  • dizziness
  • bradycardia
  • bronchospasm
  • fatigue
  • decreased exercise tolerance and fluid retention
  • insomnia, vivid dreams
  • sexual dysfunction
  • PAD, cold extremity
  • caution in diabetic
63
Q

What are the hemodynamic effects of ACEI?

A
  • increase CO
  • decrease preload
  • decrease systemic vascular resistance
  • decrease blood pressure
64
Q

What are the hormonal effects of ACEI? (inhibit RAAS)

A
  • decrease angiotensin II
  • decrease aldosterone
  • slow ventricular remodelling
65
Q

What are the main adverse effects associated with ACEI?

A
  • hypotension
  • renal impairment
  • hyperkalemia (concurrent use with K sparing diuretics, MRAs or K supplements, low salt substitutes with high K content)
  • cough
  • rash
  • taste alterations
  • angioedema (swelling of face, lips, tongue and larynx)
66
Q

What ACE inhibitor is the most common to cause a rash as a side effect?

A
  • captopril
67
Q

What are the factors that will determines the efficacy of an ACEI?

A
  • right and left sided symptoms
  • exercise tolerance
  • weight/fluid balance
68
Q

How often should ACEI’s be monitored?

A
  • should be monitored 1-2 weeks after dose initiation and 1-2 weeks after dose titration, then monitor every 3-4 months thereafter
69
Q

What is the rationale for using mineralocorticoid/aldosterone receptor antagonists?

A
  • aldosterone contributes to the sodium/water retention, sympathetic activation, myocardial and vascular fibrosis and other pathophysiologic effects seen in heart failure
70
Q

When are mineralocorticoid/aldosterone receptor antagonists indicated?

A
  • indicated for heart failure state 2-4 in addition to ACEI and BB
71
Q

What are examples of MRAs?

A
  • spironolactone

- eplerenone

72
Q

What are the cautions behind using MRAs?

A
  • hyperkalemia (risk increases with concurrent ACEI, renal impairment)
  • exclude patients with SCr>220 mol/L
  • caution if on digoxin (hyperkalemia will precipitate digoxin toxicity)
  • male patients uncommonly develop breast discomfort or gynecomastia - consider switching to eplorenone
73
Q

____ is the ARB shown to reduce cardiovascular mortality

A

candesartan

74
Q

____ is the ARB shown to improve hospitalization rate due to HF

A

valsartan

75
Q

Hydralazine and nitrate combination has shown to show a significant reduction in ____ and improvement in _____

A

reduction in mortality

improvement in exercise

76
Q

What combination of antihypertensives should african americans be put on?

A
  • ACEIs

- hydralazine/ISN combination

77
Q

What is the rationale for using hydralazine/nitrate combination?

A
  • vasodilation decrease cardiac work by overcoming detrimental effects of compensatory mechanisms
  • achieved through reduction of preload (nitrates) and after load (hydralazine)
78
Q

Hydralazine/nitrate combinations are generally used when a patient is unable to tolerate either _______

A

ACEI or ARB

79
Q

What do angiotensin receptor neprilysin inhibitors (ARNI) act on?

A
  • they act on RAAS and natriuretic peptides
80
Q

What is the rationale for using ARNI?

A
  • increase circulation of a-type natriuretic peptide and BNP by inhibiting neprilysin
  • ANP and BNP enhances diuresis, natriuresis, myocardial relaxation and anti-modeling
  • ANP and BNP also inhibits RAAS
  • AT1 receptor blockage by ARB reduces vasoconstriction, sodium and water retention and myocardial hypertrophy
81
Q

What is neprilysin and what does it do?

A

it is an enzyme that breaks down ANP and BNP- we are inhibiting neprilysin in the body so that we have more ANP and BNP peptides in the body
- these peptides promote diuresis and excretion of sodium- also increase the preload and the after load

82
Q

What is the starting dose of sacubitril/valsartan?

A
  • starting dose of 49/51 mg bid, target dose of 97/103 mg bid
  • – should NOT be used at the same time as an ACEI, or within 36 hours of the last dose of ACEI
83
Q

What are the clinical criteria to use an ARNI?

A
  • NYHA class 2 and 3 HF
  • reduced LVEF <40%
  • patient has at least 4 weeks of treatment with a stable dose of an ACEI or an ARB
  • in combination with a beta blocker and other recommended therapies, including an aldosterone antagonist
  • initiation and up titration should be conducted by a physician experienced with the treatment of heart failure
84
Q

What is the action of If channel inhibitors?

A
  • inhibit f channels within SA node resulting in disruption of If ion current flow, thereby prolonging diastolic depolarization and reducing heart rate
  • no effect on BP, myocardial contractility or AV conduction
85
Q

What is the action of digoxin?

A
  • increase force and velocity pf contraction through inhibition of Na-K-ATPase
  • neurohormonal modulating effects through decreased sympathetic activity with digoxin concentration <1.0 mcg/L
  • decreased AV conduction, used in AF and other atrial arrhythmias
86
Q

Digoxin is a _____ ionotrope

A

positive

87
Q

Digoxin is effective in heart failure associated with what?

A
  • heart failure associated with fast atrial rate, severe HF, S3 gallop, low EF and enlarged heart size
  • no mortality benefit
  • decreases rate of hospitalization
88
Q

What are the benefits of digoxin?

A
  • improves symptoms, exercise performance, decrease hospitalizations
  • improves quality of life
89
Q

What is the role of digoxin in HF therapy?

A
  • use in patients with persistent symptoms despite maximized use of vasodilators and diuretics
90
Q

What are the toxicity symptoms of digoxin?

A
  • noncardiac: N/V, confusion, altered colour vision, weakness, dizziness
  • cardiac: AV conduction disturbances
  • can very easily push a person into a dysarrhythmia
91
Q

What are the factors that affect digoxin activity or toxicity?

A
  • electrolyte disturbances
  • renal function- decreased elimination
  • drug interactions
    (can increase bioavailability: tetracycline, erythromycin
    can decrease bioavailability: antacids, cholestyramine
    can decrease elimination: quinidine, verapamil, amiodarone
    drugs that decrease K or Mg: diuretics)
  • elderly
  • hypothyroidism
92
Q

What is the treatment of digoxin toxicity?

A
  • withdrawal of digoxin
  • correction of electrolyte abnormalities
  • anti-arrhythmic agents
  • pacemaker
  • digoxin specific antibodies
  • oral activated charcoal
93
Q

What are the properties of hawthorn extract?

A
  • inotropic, vasodilating, lipid-lowering, antioxidant, anti-inflammatory
94
Q

What is the evidence behind using hawthorn extract for HF?

A
  • modest increase in exercise tolerance - uncontrolled trials and case series
95
Q

What is the action of coenzyme Q10?

A
  • component of the electron transport chain in the mitochondria
  • micronutrient
  • decreased levels in HF
  • small studies- mixed results
96
Q

What are some common drugs to avoid in HF?

A
  • antiarrhythmic agents (pro arrhythmia, negative ionotropic effects, increased mortality)
  • non-dihydropyridine calcium antagonists (direct negaitve ionotropic effects, contraindicated in patients with systolic chronic heart failure)
  • TCAs (pro arrhythmic potential)
  • NSAIDS (inhibit effects of diuretics and ACEI, cause salt and water retention and can worsen both cardiac and real function)
  • corticosteroids (AE on salt and water retention)
  • doxorubicin, trastuzamab (dose dependent cardiotoxicity)
97
Q

What are some ways to non-pharmacologically manage HF?

A
  • exercise
  • salt and fluid restriction
  • monitor daily morning weight
  • no more than 1 alcoholic drink per day
  • smoking cessation
  • influenza and pneumonococcal vaccination
  • aggressive risk reduction
  • patient education is key (drug adherence, fluid and salt restriction)

Clinical Pharmacy 2 (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions