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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
Which CCBs should be avoided in HFrEF?
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
Drug of choice for african-american population?
Avoid ACE/ARB/ARNI. Start hydralazine + isosorbide dinitrate
27
Drug of choice if despite GDMT, pt still has increased HR > 70 and symptoms, no A fib.
Ivabradine (avoid in AFib)
28
drug of choice is symptoms persist after optimal GDMT and has persistent A fib?
digoxin
29
beta blockers of choice?
metoprolol bisoprolol carvedilol
30
antidiabetic drugs with CV benefits and reduced HHF?
dapagliflozin empagliflozin
31
common AEs of ARNI?
Hypotension, hyperkalemia, and renal impairment
32
why does switching between ACEi and ARNI (and vice versa) require a 36h washout period?
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
If measuring BNP levels indicated HF, why wont this be effective if patient is already on Entresto?
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
1st line tx for HFrEF
ARNI or (ACEIs or ARBs) + BB + MRA + SGLT2 inh
35
What is HFpEF
LVEF > 50
36
What is HFmEF?
LVEF 41-49
37
Risk factors for HFpEF?
Older age, female sex, obesity, hypertension, atrial fibrillation, sleep apnea and diabetes.
38
cardiotoxic drugs examples
-alcohol -amphetamines -cancer therapies -clozapine -cocaine
39
drugs that are negative inotropes (reduces heart contraction)
-Antiarrythmic drugs -Beta blockers -itraconazole -non-DHP CCBs -anesthesia meds (propofol)
40
Drugs that cause Na and fluid retention
-androgens -corticosteroids -drugs with high Na content -licorice-containing products -minoxidil -NSAIDs -pregabalin -thiazolidinediones
41
In all patients with HF, Na should be restricted to what amount?
< 2-3 grams per day
42
In patients with fluid retention or hyponatremia, fluid intake should be restricted to what amount?
< 1.5-2 L /day
43
When should patients alert their physician about weight gain (due to fluid retention)?
when they gain 0.5 kg/day on several consecutive days OR 2 kg in 3 days -pts should monitor their weight DAILY*
44
NYHA Classes & Descriptions
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
When are ICDs recommended? (implantable cardioverter defibrillators)
Patients with a history of sudden cardiac arrest, V Fib, or hemodynamically unstable sustained V. tach - NYHA II-III and LVEF < 35%
46
What is the purpose of diuretics used in therapy?
-for symptom control -controls volume overload
47
When is it best to administer diuretics?
earlier in the daytime to avoid nighttime diuresis and sleep disturbance
48
Side effects of diuretics
-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
Who is at greatest risk for hyperkalemia before starting RAAS meds?
-mod-severe renal dysfunction -high baseline K+ -diabetes -those receiving MRAs (K+ sparing diuretics)
50
Who should you avoid MRAs in?
-If baseline potassium is > 5 mmol/L -CrCl < 30 mL/min
51
Difference between eplerenone and spironolactone?
Eplerenone doesn't have anti-androgen effects = no gynecomastia, impotence, or irregular menstruation; however, similar risk of hyperkalemia and renal dysfunction.
52
Role of MRAs in HFrEF?
-reduced mortality and morbidity
53
Contraindications of using SGLT2inhibitors?
-T1DM -Allergies -History of euglycemic ketoacidosis
54
What should be tested in patients prior to starting SGLT2 inhibitors?
fluid status adjust diuretic doses if euvolemic (bc SGLT2i can cause volume depletion by acting as a mild osmotic diuretic)
55
What should the serum concentration of digoxin be?
0.6 to 1.2 nmol/L

Cardiovascular Diseases (6 decks)

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