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Cardiovascular Diseases > Congestive Heart Failure > Flashcards

Congestive Heart Failure Flashcards

1
Q

Definition of heart failure

A

An impairment of the heart’s
ability to fill or empty the left ventricle properly = impaired cardiac output

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2
Q

how does the body try to compensate a failing heart?

A

-increase muscle mass (i.e. ventricular hypertrophy)
-activation of RAAS
-activation of SNS

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3
Q

What is afterload?

A

arterial pressure = the resistance against which the heart pumps blood

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4
Q

What is preload?

A

how much blood is being filled in the left ventricles.

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5
Q

What increases afterload?

A

-increased blood volume
-increased vascular tone
-secondary stimulation of SNS and RAAS

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6
Q

Which drugs are used to reduce afterload?

A

drugs that reduce vascular tone in the arteries (Vasodilators)

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7
Q

Which drugs can reduce preload?

A

diuretics (by reducing blood volume)

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8
Q

What is an inotropic drug?

A

drugs that increase heart contractility (ex. digoxin, dobutamine)

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9
Q

Signs of digoxin toxicity?

A

CNS: delirium, hallucinations, visual disturbances
GI: anorexia, nausea, vomiting
heart: bradycardia (PSNS at low dose) which can lead to AV bock, or paroxysmal AV and atrial tachycardiaw

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10
Q

When is dobutamine typically used?

A

in acute therapy (parenteral) to increase contractility and cardiac output, decrease preload

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11
Q

which diuretic is typically used to reduce venous pressure and afterload?

A

thiazide, loop, or potassium sparing diuretics.
(good evidence = spironolactone + ACEi combo)

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12
Q

What are the toxic effects of loop diuretics ?

A
  1. hypokalemia / metabolic alkalosis, can lead to muscle weakness or arrhythmias
  2. ototoxicity esp if given with aminoglycosides
  3. hyperuricemia
  4. hypomagnesemia
  5. dehydration
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13
Q

drug interactions with loop diuretics

A
  1. aminoglycosides
  2. nsaids
  3. probenecid
  4. ACE inhibitors
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14
Q

Side effects of spironolactone

A

-hyperkalemia (incr risk with NSAIDs, ACEi, ARB, or BBs)
-metabolic acidosis
-gynecomastia
-kidney stones

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15
Q

What are the contraindications of potassium-sparing diureticss?

A
  1. oral K+ supplements
  2. chronic renal insufficiency
  3. BB, NSAIDs, ACE/ARBs
  4. dose adjustment with liver disease
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16
Q

Characteristics of HFrEF

A

LVEF < 40%
- decreased pump function (systolic function), dilatation of the left ventricle and decreased
LVEF.

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17
Q

What are the physical symptoms of heart failure?

A
  1. dyspnea
  2. fatigue
  3. fluid retention (edema)
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18
Q

If you want to switch from Ramipril to Entresto, can they be taken together?

A

No. Washout period of 36 hours**

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19
Q

Pt with heart failure and unstable angina is already taking beta blockers and nitrates. What drug can be added to improve symptoms of angina?

A

CCB - amlodipine

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20
Q

Pt with HFrEF and HTN - still has high BP > 140 mmHg despite being on BB and ACEi and spironolactone for HFrEF therapy. What can be added to better control HTN?

A

CCB - amlodipine

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21
Q

What drugs can be used in pregnancy for HFrEF?

A

-beta blockers (Except atenolol)
-hydralazine
-furosemide
-digoxin
-nitrates

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22
Q

Which drugs to avoid in pregnancy?

A

ACE, ARB, ARNI and spironolacton

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23
Q

Which drugs are safe to take in pregnancy?

A

spironolactone
ACEi
beta blockers (metoprolol)

24
Q

The only scenario when ACEi can be combined with ARB in HF?

A

when BB is not tolerated or when there’s resistant CHF.

25
Q

Which CCBs should be avoided in HFrEF?

A

Non-dihydropyridine calcium channel blockers (CCBs) such as verapamil and diltiazem should be avoided in CHF due to their negative inotropic effects, which can worsen heart failure.

26
Q

Drug of choice for african-american population?

A

Avoid ACE/ARB/ARNI. Start hydralazine + isosorbide dinitrate

27
Q

Drug of choice if despite GDMT, pt still has increased HR > 70 and symptoms, no A fib.

A

Ivabradine (avoid in AFib)

28
Q

drug of choice is symptoms persist after optimal GDMT and has persistent A fib?

A

digoxin

29
Q

beta blockers of choice?

A

metoprolol
bisoprolol
carvedilol

30
Q

antidiabetic drugs with CV benefits and reduced HHF?

A

dapagliflozin
empagliflozin

31
Q

common AEs of ARNI?

A

Hypotension, hyperkalemia, and renal impairment

32
Q

why does switching between ACEi and ARNI (and vice versa) require a 36h washout period?

A

The neprilysin inhibition component (sacubitril) has a long half-life, and overlapping with an ACE inhibitor can significantly raise the risk of bradykinin-related side effects.

33
Q

If measuring BNP levels indicated HF, why wont this be effective if patient is already on Entresto?

A

ARNI (sacubitril) blocks neprilysin, which is used to degrade BNP. So by blocking neprilysin, BNP will already be high to increase vasodilation, diuresis and natriuresis, preventing cardiac hypertrophy.

34
Q

1st line tx for HFrEF

A

ARNI or (ACEIs or ARBs) + BB + MRA + SGLT2 inh

35
Q

What is HFpEF

A

LVEF > 50

36
Q

What is HFmEF?

A

LVEF 41-49

37
Q

Risk factors for HFpEF?

A

Older age, female sex, obesity, hypertension, atrial fibrillation, sleep apnea and diabetes.

38
Q

cardiotoxic drugs examples

A

-alcohol
-amphetamines
-cancer therapies
-clozapine
-cocaine

39
Q

drugs that are negative inotropes (reduces heart contraction)

A

-Antiarrythmic drugs
-Beta blockers
-itraconazole
-non-DHP CCBs
-anesthesia meds (propofol)

40
Q

Drugs that cause Na and fluid retention

A

-androgens
-corticosteroids
-drugs with high Na content
-licorice-containing products
-minoxidil
-NSAIDs
-pregabalin
-thiazolidinediones

41
Q

In all patients with HF, Na should be restricted to what amount?

A

< 2-3 grams per day

42
Q

In patients with fluid retention or hyponatremia, fluid intake should be restricted to what amount?

A

< 1.5-2 L /day

43
Q

When should patients alert their physician about weight gain (due to fluid retention)?

A

when they gain 0.5 kg/day on several consecutive days
OR
2 kg in 3 days

-pts should monitor their weight DAILY*

44
Q

NYHA Classes & Descriptions

A

I - no symptoms with ordinary activity
II - symptoms occur with ordinary activity
III - symptoms occur with LESS than ordinary activity
IV - symptoms occur AT REST or with MINIMAL activity

Symptoms = Angina, Dyspnea, Fatigue, Palpitations

45
Q

When are ICDs recommended? (implantable cardioverter defibrillators)

A

Patients with a history of sudden cardiac arrest, V Fib, or hemodynamically unstable sustained V. tach
- NYHA II-III and LVEF < 35%

46
Q

What is the purpose of diuretics used in therapy?

A

-for symptom control
-controls volume overload

47
Q

When is it best to administer diuretics?

A

earlier in the daytime to avoid nighttime diuresis and sleep disturbance

48
Q

Side effects of diuretics

A

-increased uric acid levels (can predispose to gout)
-electrolyte abnormalities: hypoK, hypoMg, hypoNa
-monitor K levels - maintain > 4 mmol. hypoK can cause ventricular arrhythmias and digoxin toxicity.

49
Q

Who is at greatest risk for hyperkalemia before starting RAAS meds?

A

-mod-severe renal dysfunction
-high baseline K+
-diabetes
-those receiving MRAs (K+ sparing diuretics)

50
Q

Who should you avoid MRAs in?

A

-If baseline potassium is > 5 mmol/L
-CrCl < 30 mL/min

51
Q

Difference between eplerenone and spironolactone?

A

Eplerenone doesn’t have anti-androgen effects = no gynecomastia, impotence, or irregular menstruation; however, similar risk of hyperkalemia and renal dysfunction.

52
Q

Role of MRAs in HFrEF?

A

-reduced mortality and morbidity

53
Q

Contraindications of using SGLT2inhibitors?

A

-T1DM
-Allergies
-History of euglycemic ketoacidosis

54
Q

What should be tested in patients prior to starting SGLT2 inhibitors?

A

fluid status
adjust diuretic doses if euvolemic (bc SGLT2i can cause volume depletion by acting as a mild osmotic diuretic)

55
Q

What should the serum concentration of digoxin be?

A

0.6 to 1.2 nmol/L

Cardiovascular Diseases (6 decks)

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