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Cardiovascular System > Clinical pharmacology of heart failure > Flashcards

Clinical pharmacology of heart failure Flashcards

1
Q

What is chronic heart failure characterised by (symptoms)?

A
  • By progressive cardiac dysfunction
  • Breathlessness
  • Tiredness
  • Neurohormonal disturbances
  • Sudden death
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2
Q

What are the 2 types of heart failure

A
  • Systolic heart failure (HFrEF)
  • Diastolic (or relaxation) heart failure (HFpEF)

Know systolic, not diastolic!!

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3
Q

Features of Systolic heart failure (HFrEF)

A

Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure

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4
Q

Features of Diastolic heart failure (HFpEF)

A
  • Involves a thickened and stiff heart muscle
  • As a result, the heart does not fill with blood properly
  • This results in fluid backup in the lungs and heart failure
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5
Q

What is the Ejection fraction?

A

Volume of blood ejected from the ventricle with each beat

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6
Q

Chronic heart failure facts

A
  • Affects 2-10% of the population
  • Incidence rises with increasing age
  • Has a poor prognosis with a 5 year mortality of 50% rising to 80% in a year for some patients
  • Patients are often very symptomatic
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7
Q

Risk factors for heart failure

A
  • Coronary artery disease
  • Hyperension (LVH)
  • Valvular heart disease
  • Alcoholism
  • Infection (viral)
  • Congenital heart defects
  • Diabetes
  • Other: obesity, age, smoking, high or low haematocrit level, obstructive sleep apnoea
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8
Q

What is the no.1 risk factor for Heart failure?

A

Hypertension

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9
Q

What is the Frank-Starling Law?

A

If the muscle of a healthy heart is stretched it will contract with greater force and pump out more blood.

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10
Q

Features of Systolic Dysfunction

A
  • Frank-Starling law
  • In the failing or damaged heart this relationship is lost
  • As circulatory volume increases the heart dilates, the force of contraction weakens and cardiac output drops further
  • Cardiac output then activates the RAAS further
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11
Q

What is the result of systolic dysfunction?

A
  • The result is a vicious cycle in which the RAAS is activated, circulatory volume increases and cardiac performance deteriorates further.
  • As the heart starts to dilate the cardiac myocytes undergo hypertrophy and then fibrosis and thus the heart is further weakened.
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12
Q

What is activated fir salt and water retention and vasoconstriction?

A

Renin-Angiotensin-Aldosterone System

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13
Q

What does the activation of the sympathetic system cause the release of?

A

Noradrenaline and Adrenaline

  • Vasoconstriction
  • Stimulate renin release
  • Myocyte hypertrophy
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14
Q

What is used for salt and water excretion and vasodilatation?

A
  • Natriuretic peptide system ANP/BNP

- EDRF

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15
Q

Features of atrial and brain natriuretic peptides

A
  • Potent vasodilators and natriuretic peptides

- Short half-life

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16
Q

What are the 2 main aims of heart failure treatment?

A

To improve symptoms and improve survival

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17
Q

Treatment used to improve symptoms

A
  • Diuretics (loop diuretics)

- Digoxin

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18
Q

Treatment used to improve symptoms and survival

A
  • ACE inhibitors/ARBs
  • Spironolactone
  • Valsartan-sacubitril
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19
Q

Treatment used to improve survival

A
  • Beta-blockers

- Ivabradine

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20
Q

What is used for blocking detrimental hormonal changes?

A

Sympathetic activation

- Carvedilol, Bisoprolol and Metoprolol are beta blockers which are of proven benefit in the treatment of CHF.

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21
Q

RAAS activation: inhibition of Angiotensin II

A
  • Two groups of drugs available to block the effects of angiotensin II
  • ACE inhibitors (Ramipril)
  • Angiotensin antagonists (Valsartan, Losartan_ but these are not as effective (ELITE II)
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22
Q

RAAS activation: Aldosterone inhibition

A
  • Effects blocked by Spironolactone

- Produces a significant reduction in morbidity (RALES)

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23
Q

What treatments are used for enhancing beneficial hormonal changes?

A
  • Natriuretic peptide system
  • ANP/BNP: atrial natriuretic and brain peptides are potent natriuretic agents and vasodilators
  • Metabolised by neutral endopeptidase
  • Neprolysin prevents metabolism and enhances ANP/BNP actions
24
Q

What treatments are used for enhancement of cardiac function?

A
  • Positive Inotropes

- Vasodilators

25
Q

Features of positive inotropes

A
  • These drugs improve the ability of the heart to pump and so improve cardiac status
  • Digoxin is the only drug in common use
26
Q

Features of Vasodilators

A
  • The nitrovasodilators by reducing preload and afterload improve cardiac function (Isosorbide mono or Dinitrate)
  • Hydralazine an arterial dilator has also been shown to improve cardiac function
27
Q

By how much do ACEi and beta blockers reduce mortality and hospitalisation?

A

ACEi - relative risk reduction 35%

Beta Blockers - relative risk reduction 38%

28
Q

Features of Loop Diuretics (Furosemide)

A
  • The main stay of treatment
  • Removes excess salt and water
  • The loop diuretics induce profound diuresis
  • Inhibit the Na-K-Cl transporter in the Loop of Henle
  • Work at very low glomerular filtration rates
  • Prevent the reabsorption of 20% of filtered sodium and water
29
Q

Adverse drug reactions of diuretics

A
  • Dehydration
  • Hypotension
  • Hypokalaemia, Hyponatraemia
  • Gout
  • Impaired glucose tolerance, diabetes
30
Q

Drug-Drugs interactions: Frusemide and aminoglycosides

A

Aural and renal toxicity

31
Q

Drug-Drugs interactions: Frusemide and Lithium

A

Renal toxicity

32
Q

Drug-Drugs interactions: Frusemide and NSAIDs

A

Renal toxicity

33
Q

Drug-Drugs interactions: Frusemide and antihypertensives

A

Profound hypotension

34
Q

Drug-Drugs interactions: Frusemide and Vancomycin

A

Renal toxicity

35
Q

Mechanism to reducing mortality

A
  • Angiotensin blockade
  • Beta receptor blockade
  • Aldosterone blockade
  • ANP/BNP enhancement
36
Q

Does local angiotensin II synthesis require ACE inhibitors?

A

No it is independent of ACE

37
Q

Examples of Angiotensin converting enzyme inhibitors

A
  • Ramipril
  • Enalapril
  • Lisinopril
38
Q

Features of Angiotensin converting enzyme inhibitors

A
  • Completely block angiotensin converting enzyme
  • Prevent the conversion of angiotensin I to angiotensin II
  • Reduce preload and afterload on the heart
39
Q

Features of ACE inhibitors

A
  • In CHF patients significantly reduce: morbidity, mortality
  • Post MI patients to reduce: morbidity, mortality, onset of heart failure
  • Main studies CONSENSUS, SOLVD, SAVE, AIRE, ISSIS-4
40
Q

Adverse drug reactions of ACE inhibitors

A
  • First dose hypotension
  • Cough
  • Angioedema
  • Renal impairment
  • Renal failure
  • Hyperkalaemia
41
Q

ACE inhibitor drug-drug interactions

A

NSAIDs - acute renal failure

Potassium supplements - hyperkalaemia

Potassium sparing diuretics - hyperkalaemia

42
Q

Features of Angiotensin receptor blockers

A
  • ARBs selectively block the angiotensin II, AT1 receptor
  • They are effective, but not as effective as ACEi’s
  • At present recommended for use in ACEi intolerant patients
43
Q

What are the roles of AT1 receptors?

A
  • Vasoconstriction
  • Vascular proliferation
  • Aldosterone secretion
  • Cardiac myocyte proliferation
  • Increased sympathetic tone
44
Q

What are the roles of AT2 receptors?

A
  • Vasodilation
  • Antiproliferation
  • Apoptosis
45
Q

According to studies, is ACEi therapy good?

A

No, greatest benefits in patients not on ACE inhibitor therapy

46
Q

Features of Valsartan-Sacubitril (ARNI)

A
  • Combined valsartan and ARB and Neprilysin
  • ARB blocks AT1 receptor
  • Neprilysin stops break down of ANP and BNP by neutral endopeptidases
47
Q

Features of Aldosterone Antangonists (Spirolactone)

A

Spironolactone

  • Potassium sparing diuretic
  • Inhibits the actions of aldosterone
  • Acts in the distal tubule
  • Used in combination with loop diuretics
  • Particularly useful in resistant oedema

Proven to reduce mortality when used in combinations with ACEi’s

48
Q

Examples of Beta-Blockers in treatment of CHF

A
  • Carvedilol
  • Bisoprolol
  • Metoprolol
49
Q

Features of Beta-blockers in treatment of CHF

A
  • Use of beta-blockers in this treatment of CHF is potentially hazardous and patients must be selected carefully
  • Block the actions of the sympathetic system
  • May precipitate severe deterioration in CHF
  • Have been demonstrated to reduce morbidity and mortality in mild/moderate and severe heart failure by 30%
  • Should be used only when a patient has been stabilised and not during an acute presentation
  • Specialist use only
50
Q

Features of Ivabradine

A
  • Ivabradine is a specific inhibitor of the If current in the sinoatrial node.
  • No action on other channels in the heart or vascular system.
  • Does not modify myocardial contractility and intracardiac conduction, even in patients with impaired systolic function.
51
Q

When is Ivabradine recommended?

A

It can be beneficial to reduce HF hospitalisation for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF <35%) who are receiving standard therapy, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70bpm or greater at rest.

52
Q

Features of Positive Inotropes (Digoxin)

A

Digoxin (the DIG study)

  • Increases availability of calcium in the myocyte
  • Shown to reduce number of hospitalisations
  • No effect on mortality
  • Narrow therapeutic index
  • Arrhythmias
  • Nausea
  • Confusion
53
Q

Features of Anticoagulants (Warfarin)

A

Warfarin

  • Dilated ventricle gives rise to thrombus formation and thrombo-embolic events
  • Warfarin has proven to prevent these events
  • Anticoagulant use if high risk of thromboembolic disease
54
Q

What is the therapeutic regime for heart failure?

A
  • Furosemide +- thiazide, appropriate dose
  • Furosemide + pulsed metolazone
  • ACE inhibitor, appropriate dose
  • Angiotensin receptor blocker
  • ARNI
  • Beta-blocker +- Ivabradine
  • MRA-spironolactone, 25mg
  • Digoxin, TDM
  • Warfarin, TDM
55
Q

Monitoring benefit of treatment

A
  • Symptomatic relief: SOB, tiredness, lethargy
  • Clinical relief: peripheral oedema, ascites, weight
  • Monitor weight regularly: patient performs daily weight assessment, Increase medication according to symptoms or weight
  • Patient education

Cardiovascular System (36 decks)

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