Clinical Treatment of Heart Failure

Question 1

What is the most common HF therapy and what does it do?

Answer 1

Diuretics: Reverses the sodium and fluid retention of HF

- treatment of volume overload

Question 2

What can you augment diuretics with?

Answer 2

thiazide diuretic

Question 3

Do you use diuretics chronically or acutely?

Answer 3

Both:

• Typically PO dose at baseline, adjust to patient need
• Often used IV in the hospital

Question 4

Which part of the Frank-starling curve do diuretics work?

why is this significant?

Answer 4

Typically work at the far end of the Frank-Starling curve,

• such that significant decreases in pressure produce minimal changes in stroke volume (and thus cardiac output).
  → Thus, symptoms of congestion can be reduced without major effects on blood flow

Question 5

How do diuretics treat volume overload?

Answer 5

↑ salt/water excretion
↓ intravascular fluid vol
↓ venous congestion
↓ dyspnea edema

Question 6

describe 2 methods that the body senses ↓ CO and how it resolves it

Answer 6

↓ CO

1. Juxtaglomerular apparatus in kidney senses lower flow → RAAS activation
2. Carotid sinus/aortic baroreceptors sense lower pressure → ANS/ adrenergic activation

Question 7

What does activating the RAAS result in?

Answer 7

1. vasoconstriction
2. ↑ sodium retention → ↑ volume
   - ↓ LV squeez (systolic HF)
   - ↑ stiffness (diastolic HF)

Question 8

ACE inhibitors

• end in?
• block what?

Answer 8

 …prils (lisinopril, enalapril, benazepril)

 Block conversion of ATI to ATII

Question 9

ACE inhibitors effects

Answer 9

 Direct vasodilation

 Decreased aldosterone activation

Question 10

ACE inhibitors side effects

Answer 10

 Hypotension
 Worsening renal function (afferent vasocontraction)
 Hyperkalemia
 Cough (kinin potentiation)
 Angioedema

Question 11

ANGIOTENSIN RECEPTOR BLOCKERS (ARBS)

• end in?
• block what?

Answer 11

 …sartans (e.g. valsartan, candesartan, losartan)
 Effect: Block the receptor of angiotensin II

• In studies have been equivalent to ACEI
• Generally used when patients develop cough to ACEI

Question 12

ARBS side effects

Answer 12

ARBs do not produce kinin potentiation (no cough)

 Otherwise side effects are similar to ACEI

Question 13

ALDOSTERONE RECEPTOR BLOCKERS

Answer 13

Spironolactone and eplerenone

Question 14

ALDOSTERONE RECEPTOR BLOCKERS effects

Answer 14

Block effect of aldosterone on the kidney
• ACEI/ARB aldosterone block is incomplete
• This Produces additional sodium loss (diuretic)
• Antifibrotic

Question 15

ALDOSTERONE RECEPTOR BLOCKERS side effects

Answer 15

Hyperkalemia (requires close monitoring)

Question 16

BETA-BLOCKERS

• end in?
• block what?

Answer 16

…olols (metoprolol, carvedilol, bisoprolol)

Antagonize effect of sympathetic system (epinephrine/norepinephrine)

• β1 blockade:
– Negative chronotrope (slow heart rate, less arrhythmia)
– Negative inotrope (decreased metabolic demand)

*note: [α1 blockade: vasodilation]

Question 17

BETA-BLOCKERS

side effects

Answer 17

Negative inotrope: short-term loss for long-term gain
• Fluid retention
• Hypotension
• Decreased cardiac output, even cardiogenic shock

Bronchoconstriction

Question 18

ACEI + Angiotensin receptor blockers (similar)
Beta Blockers
Aldosterone receptor blockers
- all contribute to do what?

Answer 18

All 3 reduces morbidity and improve survival

- ↓ hypertrophy, fibrosis, apoptosis

Question 19

What class and level are:
ACEI
Beta Blockers
ARBs

Answer 19

Class I level A

Question 20

Class class is digoxin?

Answer 20

Class IIb level B

Question 21

What is the difference between arterial, venous, and pulmonary arterial vasodilation?

Answer 21

 Arterial vasodilation (antihypertensives)
   - Decrease in LV afterload
   - Reduced cardiac work
   -  Less mitral regurgitation
 Venous vasodilation
   - Decrease in preload
 Pulmonary arterial vasodilation
   - Decrease in RV afterload

Question 22

2 types of electrical therapies for HFrEF

Answer 22

Implanted Cardioverter Defibrillators

Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)

*note: CRT/BiV are usually placed with ICD

Question 23

What types of pts receive:

• Implanted Cardioverter Defibrillators
• Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)

Answer 23

Implanted Cardioverter Defibrillators

 Patients with LVEF 120 msec (bundle brank block)

Question 24

Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)

• how is it set up?
• what does it do

Answer 24

Left ventricular lead placed from the RA through the coronary sinus over the epicardium of the LV
- (3 leads: RA, RV, cor sinus/LV)

Cause the LV lateral wall and septal wall to contract together, which produces
 a more efficient contraction / ↑ stroke volume
 may also improve mitral valve function / ↓ regurgitation

Question 25

Effects of Inotropic agents

Answer 25

↑ contractility (SV-VEDP curve increases closer to norm range) ↑ HR Improves symptoms short term Long-term HF is worsened

Question 26

For HFrEF which drugs: - Improve symptoms? - Prolongs survival?

Answer 26

 IMPROVE SYMPTOMS Diuretics (furosemide) Inotropes (for HFrEF - digitalis PO [acute HF w/ shock: dobutamine, milronone)  PROLONG SURVIVAL (for HFrEF) ACE Inhibitors (prils – e.g. lisinopril) Angiotensin Receptor Blockers (sartans – e.g. valsartan) Beta Blockers (olols – e.g. carvedilol, metoprolol) Aldosterone Antagonists (spironolactone, eplerenone) Vasodilators (nitrates, hydralazine, …) Cardiac Resynchronization Therapy (biventricular pacing) Implantable Cardioverter Defibrillator (ICD) [does not improve symptoms] *note: these drugs reduce remodeling, so they help symptoms too