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Cardio > Congestive Heart Failure-2 - Exam 2 > Flashcards

Congestive Heart Failure-2 - Exam 2 Flashcards

1
Q

What is the diagnostic evaluation flow for a pt with HF?

A

EKG
CXR
labs (including BNP)
Echo

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2
Q

What does a class I recommendation tell you about the strength?

A

Class I is a STRONG recommendation the benefit greatly outweighs the risk

aka DO IT!!!

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3
Q

What does a class 2a recommendation tell you about the strength?

A

Class 2a: moderate strength

aka you should still probably do it! but Class 1 is a stronger arguement

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4
Q

What is the management for a HFpEF pt? What is another name? What cormorbid specifically needs to be managed appropriately? Diastolic or systolic? What is the EF?

A

lifestyle modifications

pharm (diuretics prn and SGLT2)

f/u q 1-6 months depending on comorbid conditions

appropriate management of chronic dz (especially HTN!!)**

diastolic HF

preserved LVEF ≥50%

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5
Q

What medications are part of the Goal Directed Medical Therapy (GDMT) for HFrEF?

A

HFrEF LVEF less than or equal to 40%

Entresto in class II-III and ACE/ARB in class IV
BB
Mineral Receptor antagonist (MRA)
SGLT2
Diuretics

so 5 meds!! yay meds!!

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6
Q

**A black pt in class III or IV still has LVEF less than 40% after starting all GDMT medications after 30 days, what do you do next?

A

add hydralazine or nitrates

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7
Q

______ are most effective means of providing symptomatic relief to patients with heart failure. Helps with _____ and ______ symptoms

A

Diuretics

dyspnea and fluid overload symptoms

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8
Q

_____ is used in MILD fluid retention. Give 3 examples of meds in this class. **What do you need to monitor? **What do you need to order?

A

thiazides

Hydrochlorothiazide
Metolazone
Chlorthalidone

**Monitor renal function and potassium

** BMP within one week of diuretic therapy initiation or dosage change

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9
Q

______ are used in SEVERE fluid retention. What are the 3 in this class? ** What do you need to monitor? **What do you need to order?

A

loop diuretics

Furosemide
Torsemide
Bumetanide

**MUST monitor renal function and potassium

**BMP within one week of diuretic therapy initiation or dosage change

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10
Q

**What is the BBW for loop diuretics?

A

severe electrolyte abnormalities

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11
Q

When you need to combine thiazides and loops for continued fluid overload symptoms, what medications are preferred?

A

Metolazone and furosemide are most common combination

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12
Q

**What do you need to give concurrently with loop diuretics? **What is the rule of thumb?

A

need to give Potassium chloride at the same time

Rule of thumb is for every 20mg furosemide, you need 10mEq potassium

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13
Q

What is the daily monitoring needed for diuretic therapy use for CHF?

A

need to weigh themselves every day!

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14
Q

What is the generic name for Entresto?

A

sacubitril/valsartan

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15
Q

What drug class is Sacubitril? What is the MOA?

A

neprilysin inhibitor

which limits the breakdown of natriuretic peptides (ANP, BNP)

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16
Q

**If your pt is currently taking lisinopril but you want to change them to Entresto, what is the very important pt education? What is the pt education associated with Losartan (ARBs)?

A

Will need a 36 hr washout period of ACEI prior to starting Entresto

this does NOT apply to ARBs

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17
Q

What is the CI to Entresto? What is the monitoring? What are the SEs?

A

CI if h/o angioedema with ACEI

BMP at baseline and then again 1-2 weeks after starting medication

hypotension and hyperkalemia

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18
Q

What is the monitoring associated with ACE? What are the common SEs?

A

BMP at baseline to evaluate potassium level and renal function, then again in 1-2 weeks

Cough, dizziness, hypotension, hyperkalemia

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19
Q

_____ is the Class I indication for patients who do not tolerate ACE inhibitors. What if they were already on said medication?

A

ARBs

Class IIA indication to continue if pt already on an ARB at time of dx of HF

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20
Q

What 3 BB are recommended in HF? What is important to note? When are they used cautiously?

A

Carvedilol (Coreg), Metoprolol SUCCINATE(Toprol XL), and Bisoprolol (Zebeta)

Use cautiously with bradycardia, first degree AVB, hx of asthma or symptomatic hypotension

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21
Q

What is the monitoring associated with aldosterone antagonists? **When are they CI? What are the SE?

A

Electrolyte and kidney function

**Contraindicated in patients with potassium > 5 and eGFR < 30

SE: Dizziness, HA, hyperkalemia, impaired renal function

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22
Q

What are the SE of SGLT2? Are they used in all pts or just pts with DM?

A

dehydration, hypoglycemia

ALL pts regardless of DM status

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23
Q

**SGLT2 medications are ____ recommendation for HFrEF and ______ recommendation for HFpEF

A

**class 1 for reserved

**class 2a for preserved

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24
Q

______ Class I indication as addition to ACE inhibitor and beta blocker therapy for black patients. What about in non-black patients? What are the SE?

A

Hydralazine/Nitrates (Isosorbide dinitrate)

non-black: hydralazine/nitrates are Class IIA indication as replacement for ACE inhibitor or ARB due to drug intolerance, renal failure

SE: HA, dizzy, hypotension

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25
Q

________ Inhibits the If (cardiac pacemaker current) channel in the sinus node → specifically slows ______. When is it indicated?

A

Ivabradine (Corlanor)

sinus rate

Class IIA indication Approved by the FDA for use in STABLE patients w/ HF

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26
Q

What are the 3 must haves for ivabradine (Corlanor)?

A

Heart rate of ≥70 beats per minute

Be in sinus rhythm

Are taking the maximally tolerated dose of beta-blockers or in patients in whom beta-blockers are contraindicated

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27
Q

_______ has aClass IIB indication – can be beneficial to ADD ON therapy after ACE inhibitor, beta blocker, and aldosterone antagonist

A

Digoxin

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28
Q

digoxin has a greater negative ______ effect than _______. Is titration recommended?

A

Greater negative chronotropic effects than ionotropic

Titration is NOT recommended

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29
Q

What are the monitoring requirements for digoxin?

A

Not commonly used first as it can be toxic!! Levels should be checked 1 week after initiation and occasionally in the setting of new symptoms of renal dysfunction

30
Q

**What drug class that also treats HTN should be avoided in pts with HF? _____ and ______ are harmful to CHF pts and should be avoided!!

A

CCB

**avoid Verapamil and Diltiazem

31
Q

Name 3 additional drug classes that should be avoided in CHF?

A

Certain Antiarrhythmics: avoid: Flecainide, Propafenone, Sotalol

NSAIDs

Thiazolidinediones – Actos (pioglitazone), Avandia (rosiglitazone)

32
Q

Which two antiarrhythmic drugs are preferred in HF?

A

Amiodarone and dofetilide (Tikosyn) are the preferred agents for treating arrhythmias

33
Q

What is the only true class 1 indication for HFpEF?

A

diuretics as needed

34
Q

What are the rules of 2 in non-pharm management of HF?

A
35
Q

When is cardiac rehab recommended in HF?

A

Cardiac rehab is recommended in patients with stable NYHA class II to III HF

36
Q

What is Cardiac Resynchronization Therapy? When is it effective?

A

A type of pacemaker that sends electrical impulses to the heart’s lower chambers to help them beat together. Can also help coordinate timing between left and right sides

An effective therapy in patients with HF and ventricular dyssynchrony identified as a prolonged QRS

37
Q

When is Cardiac Resynchronization Therapy recommended?

A

LVEF < or = 35%

QRS > 120ms

NYHA class III or IV symptoms

38
Q

**When is an ICD indicated for pt who have not yet suffered SCD with ischemic cardiomyopathy?

A

after optimal medical therapy!!

Ischemic CM
ICD is recommended for LVEF < 35% with class II or III HF symptoms and > 40 days post-MI or revascularization

aka already had MI or stent

39
Q

**When is an ICD indicated for pt who have not yet suffered SCD with non ischemic cardiomyopathy?

A

after optimal therapy

Nonischemic CM
LVEF < 35% with NYHA class II or III HF symptoms, > 90 days post dx, and reasonable likelihood of > 1 yr survival

aka no MI or stent, clean cardiac cath

40
Q

What is a the way to prevent SCA? When is it used? What is the monitoring?

A

LifeVest/Assure– a wearable defibrillator

used a bridge to ICD during the waiting period

Repeat echo after 45 or 90 days depending on guideline, If EF improves before then, no further intervention is needed

41
Q

What is the difference between primary and secondary prevention with regards to SCA?

A

primary: for those who have not yet suffered SCD

secondary: pts have survived an episode of SCD

42
Q

**When would you use an ICD as secondary prevention?

A

Secondary Prevention
Patients with HF and cardiomyopathy who have survived an episode of SCD or have sustained VT without obvious reversible causes are recommended for ICD

43
Q

**When would you use ICD in the case of unexplained syncope?

A

Unexplained syncope
Patients with LVEF < 30% and unexplained syncope, recommend ICD

44
Q

______ is a common and potentially fatal cause of acute respiratory distress

A

Acute Decompensated Heart Failure

45
Q

What are some potential causes of Acute Decompensated Heart Failure? What is it characterized by?

A

Causes of acute decompensations include medication noncompliance, myocardial ischemia/infarction, tachyarrhythmias, excessive salt intake

Characterized by acute dyspnea with rapid accumulation of fluid

46
Q

**What does acute pulmonary edema present like? What will the lung exam reveal?

A

**Severe dyspnea, production of pink, frothy sputum, diaphoresis and cyanosis are also likely

inspiratory rales, wheezes and rhonchi are also common

47
Q

What is the flow of diagnostics associated with Acute Decompensated Heart Failure?

A

EKG
CXR
BNP
Echo
Cardiac enzymes
CBC/CMP

in that order!`

48
Q

What are the 2 mainstays of treatment for ADHF?

A

diuretic and vasodilator therapy

49
Q

_____ are first line diuretics in ADHF. What is the dose in already on diuretic therapy? When does peak diuresis occur?

A

Loop diuretics!!!

If already on chronic oral therapy,** IV **should be at least equal if not greater

Peak diuresis occurs 30 min after administration

IV route is preferred!!

50
Q

What is cardioreneal syndrome due to?

A

Due to elevated venous pressure and reduced cardiac output → renal hypoperfusion
Renal function may actually improve with diuresis

51
Q

What do you need to monitor with regards to diuresis for a ADHF pt?

A

Vital signs

Fluid status via Daily weights and I’s/O’s

Renal function, electrolytes

52
Q

What do you do in ADHF if the diuretics are not working?

A

sodium restrict

water restrict in patients with hyponatremia

consider adding a second diuretic

check albumin levels

53
Q

_____ is the only IV thiazide diuretic

_____ is the thiazide diuretics of choice for renal failure

_______ minimizes potassium wasting

A

Chlorothiazide is the only IV diuretic

Metolazone oral diuretic of choice for renal impairment

Aldosterone antagonist minimizes potassium wasting

54
Q

Why do you need to check albumin levels in ADHF?

A

If albumin is low, diuretics don’t work as well!

55
Q

When is vasodilator therapy indicated in ADHF? What medication is used MC?

A

Recommended for patients without hypotension and severe symptomatic fluid overload

Nitroglycerin

56
Q

______ is a potent vasodilator that has both venous and arteriolar effects. When is it commonly used? What is important to note about it? What is the limitation?

A

nitroprusside

Used when pronounced afterload reduction

metabolizes to cyanide so can be fatal in large doses due to accumulation

limit use to 24-48 hours especially in renal failure

57
Q

How does morphine act as a vasodilator? What may it lead to?

A

Morphine increases venous & arterial dilation, lowering LA pressure, and relieves anxiety, which can reduce the efficiency of ventilationa

Morphine may lead to CO2 retention by reducing the ventilatory drive.

58
Q

Need to hold ______ in ADHF especially if severely decompensated or hypotensive. When do you want to restart it?

A

Beta Blockers

Wait until discharge and patient is stable to initiate therapy!

59
Q

What are the 2 inotrophic agents? When are they indicate?

A

Milrinone and Dobutamine

Indicated for patients with severe LV systolic dysfunction to

60
Q

_______ MOA phosphodiesterase inhibitor (PDE3) with mostly inotropic properties, but also causes vasodilation. Has inotrophic and lusitropic effects. What is the SE?

A

Milrinone

hypotension

61
Q

_____ MOA stimulates B1 receptors to increase BP, HR, but also has vasodilation effects. Has both inotropic AND chronotropic effects. What is the SE?

A

Dobutamine

HTN

62
Q

________is given in ADHF as Venous Thromboembolism Prophylaxis. Can also try ______ if previous tx is CI

A

Heparin, LMWH (Lovenox) or Fondaparinux (Arixtra)

Sequential compression devices (SCDs)

63
Q

_______ is another name for Continuous Renal Replacement Therapy (CRRT). What is it good for?

A

Ultrafiltration

Effective method to remove excess fluid without major hemodynamic compromise and no effect on serum electrolytes

64
Q

How does ultrafiltration compare to hemodialysis?

A

Uses peripheral venous access and small blood volume, compared to hemodialysis

65
Q

When is Durable Mechanical Circulatory Support (MCS) recommended? What are the 2 major options?

A

pts in cardiogenic shock!

Recommended in patients with:

Cardiac index (CI) less than 2.0 L/min per m2

Systolic arterial pressure less than 90 mmhg

Pulmonary capillary wedge pressure above 18 mmhg

Intraaortic balloon counterpulsation

Internally implanted left ventricular assist device

66
Q

How does the intra-aortic balloon pump work?

A

Balloon is placed in the aorta and deflates during systole, creating suction, allowing heart to pump more effectively with each beat
In contrast, it will inflate during diastole allowing blood to be pushed back into the heart and helping with full relaxation/filling

67
Q

How does the Left ventricular and biventricular assist devices work? **When is it most commonly used?

A

Blood is pumped mechanically from the ventricles back through the circulatory system (helps give a little push to blood flow when the ventricles aren’t working well)

Most commonly seen in end stage heart failure - especially as a bridge to transplant

68
Q

_______ is Left ventricular and biventricular assist device that is completely inside the body

A

Impella

69
Q

______ Takes blood out of the circulatory system, oxygenates the blood through a pump, and replaces it into the circulatory system.

A

ECMO (Extracorporeal membrane oxygenation)

70
Q

What are the normal ranges for cardiac index? What info does it provide?

A

Normal CI ranges from 2.6 to 4.2 L/min/m²x

Provides info on left ventricular function

71
Q
A

Cardio (20 decks)

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