Clinical Treatment of Heart Failure (complete) Flashcards
What are the general goals of any therapy?
1) ^ QOL by improving survival
2) ^ QOL by reducing symptoms
3) Decrease financial/resource burden of disease
What are the HF-specific goals of therapy?
- Correct underlying cause of HF (sometimes it’s not possible to reverse cause, e.g. infarcted tissue)
- Eliminate precipitating factors (infection, anemia, Na intake)
- Reduction of congestion (fluid optimization is a major dealio!)
- Improve flow
- Modulate neurohormonal activation
What are the major classes of medications for HF?
1) Diuretics
2) Vasodilators
3) Neurohormonal antagonists
4) Inotropes
Describe the use of diuretics
- Reverse Na and fluid retention of HF
- Classes: loop diuretics, thiazide diuretic
- Most common HF therapy
- Can be used chronically and acutely
- Works at far end of F-S curve => decreases in pressure produce ∆s in SV (and CO)
- Congestion symptoms reduced w/o major effects of blood flow
Describe the use of arterial vasodilators
- Decreases LV afterload
- Decreases cardiac work
- Decreases mitral regurgitation
- hydralazine/isosorbide dinitrate in HFrEF (added to ACEI/BB in blacks «— controversial)
Describe the use of venous vasodilators
- Decreases preload
Describe the use of pulmonary arterial vasodilators
- Decreases RV afterload
Describe the use of angiotensin converting enzyme inhibitors (ACEI)
- …prils (lisinopril, enalaprin, benazepril)
- Blocks conversion of AI to AII
Causes:
- Direct vasodilation
- Decreased aldosterone activation
What are the side effects of ACEI?
- Hypotension
- Worsening renal function
- Hyperkalemia
- Cough (kinin potentiation)
- Angioedema
Describe the use of angiotensin receptor blockers
- …sartans (valsartan, candesartan, losartan)
- Blocks AII receptor
- Shown to be equivalent to ACEI
- Controversial whether ACEI + ARB provides added benefit
- Used when pts develop cough to ACEI
What are the side effects of ARBs?
- No cough b/c no kinin production
Similar to ACEI:
- Hypotension
- Worsening renal function
- Hyperkalemia
- Angioedema
Describe the use of aldosterone receptor blockers
- Spironolactone, eplerenone
- Block aldosterone action in kidney (ACEI/ARB block is incomplete)
- Decrease Na => a diuretic
- Antifibrotic
- Side effects: hyperkalemia, gynecomastia (spiro only)
Describe the use of beta-blockers
- …olols
- Antagonizing effect of sympathetic system (NE & epinephrine)
- Beta1 block => negative chronotrope (slows HR, less arrhythmia)
- Alpha1 block: vasodilation
What are the side effects of beta-blockers?
- Negative inotropy: short term loss for long-term gain
- Fluid retention, hypotension, decreased CO (cardiogenic shock)
- Bronchoconstriction
Describe the use of positive inotropic agents
- Used in acute situations via IV => reverse shock
- Chronic use => worsen remodeling & ^ mortality
- 3 types: digoxin, dobutamine, milrinone
Describe implanted cardioverter defibrillators
- For pts with LVEF ≤ 35% or prior dangerous heart rhythms
- Abort sudden cardiac death from ventricular tachy/ fibrillation
Describe cardiac resynchronization therapy/biventricular pacemakers
- LV lead placed from RA through coronary sinus over epicardium of the LV
- For pts w/ QRS >120 msec
- Causes the lateral wall and septal wall to contract together
- Produces more efficient contraction => ^ SV
- May improve mitral valve function => decreased regurgitation
- usually placed with ICD
Describe Stage A therapy goals
Stage A: at high risk for HF but w/o structural heart disease or symptoms of HF
Goals:
- treat HTN
- smoking cessation
- treat lipid disorders
- regular exercise
- discourage alcohol, illicit drug use
- control metabolic syndrome
What are the drugs used in Stage A?
ACEI or ARB
Describe Stage B therapy goals
Stage B: structural heart disease but w/o signs/symptoms of HF
Goals:
- same as Stage A
What are the drugs used in Stage B?
- ACEI or ARB
- Beta-blockers
What are devices used in Stage B?
implantable defibrillators
- in select pts
Describe Stage C therapy goals
Stage C: structural heart disease with prior or current symptoms of HF
Goals:
- same as A & B
- Dietary salt restriction
What are drugs used in Stage C?
Routine:
- Diuretics
- ACEI
- BB
Select pts:
- Aldosterone antagonist
- ARBs
- Digitalis
- Hydralazine/nitrates
What are devices used in Stage C?
- Biventricular pacing
- Implantable defibrillators
in select pts
Describe Stage D therapy goals
Stage D: refractory HF requiring specialized interventions
Goals:
- Same as A, B, & C
What are other options in treating Stage D HF?
- hospice
- Extraordinary measures (e.g. heart transplant, chronic inotropes, permanent mechanical support, experimental surgery/drugs)
What types of txs are used for pts with HF and normal EF?
- Diuretics (volume control)
- Treat underlying condition
- Vasodilators => maintain normal BP
Which treatments have not been successful in improving health outcomes for pts w/ HF and normal EF?
- Neurohormonal agonists (e.g. ACEI, ARB)
- Spironolactone
- ICD/CRT not indicated for pts w/ >35-40%
Describe the importance of prevention of HF. What are specific prevention goals?
Those w/ most conditions below can have HF prevented w/ changes in diet and lifestyle
- HTN
- Diabetes
- Hyperlipidemia
- Physical inactivity
- Excessive alcohol intake
- High dietary Na intake
