CVS - Congestive Heart Failure Flashcards by Richhpal Singh

Heart failure can be divided into

High output HF - increased tissue demand
Low output HF - Heart not adequately pumping

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Which conditions can cause High output HF

Thyrotoxicosis
Severe anaemia

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Left ventricular failure can be characterized by

Pulmonary edema - Dyspnea

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Right ventricular failure can be characterized by

Elevated JVP
Congestive Hepatomegaly

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Aim of treatment in Acute CHF

Congestion - remove the fluid
Heart not pumping - Inotropics (increases contractility)

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Preferred group of diuretics in case of Acute CHF

Loop diuretics - Furosemide

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Common side effects of Loop diuretics and Thiazides

Hypokalemia
Hypomagnesemia
Hyponatremia
Metabolic alkalosis

Hyperglycemia
Hyperlipidemia
Hyperuricemia

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Difference in sire effects of Loop diuretics and Thiazides

Loop diuretics - Hypocalcemia
Thiazides - Hypercalcemia

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Inotropics used in Acute CHF

Beta 1 agonist
PDE-3 Inhibitors

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Beta 1 agonist used in Acute CHF

Dopamine
Dobutamine
Isoprenaline
Nor adrenaline

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PDE-3 inhibitors used in Acute CHF

InAmrinone
Milrinone

Increases cAMP in both heart(Inotropic) and BV(Vasodilation)

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Which drugs are termed as Inodilators and DOC in patient with right sided Heart failure

PDE-3 Inhibitors - InAmrinone, Milrinone

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Aim of treatment in Chronic CHF

Decrease work of heart
Remove the fluid
To reverse LVH or cardiac remodeling

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Drugs used to decrease work of heart in Chronic CHF

Vasodilators

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Vasodilator which only acts on veins

Nitrates

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Vasodilator which only acts on arteries

Hydralazine

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Vasodilators which acts on both Veins and arteries

Sodium Nitroprusside
ACE inhibitors
ARBs

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Drugs used to remove fluid in case of Chronic CHF

Loop diuretics

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Drugs used to reverse Cardiac modeling or to decrease Mortality

Beta blockers
ACE inhibitors
ARBs
Aldosterone Antagonists

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Beta blockers which are commonly used in Chronic CHF

Start with low dose
Carvedilol - MC
Metoprolol
Bisoprolol

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ACE inhibitors

‘PRIL’
Captopril
Lisinopril
Enalapril
Ramipril
Perindopril
Moexipril
Trandolapril

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ACE Inhibitors can increase Bradykinin levels and can cause side effects like

Dry cough
Angioedema

Characteristics of ACE inhibitors

C - Cough
A - Angioedema
P - Prodrugs
T - Taste alternation (Dysgeusia )
O - Orthostatic hypotension
P - Pregnancy avoid
R - Renal artery stenosis avoid
I - increased K(Hyperkalemia) avoid
L - lowers risk of diabetic nephropathy - preferred in diabetics

Which ACE inhibitors are not Prodrugs

Captopril
Lisinopril

Angiotensin receptor Blockers

'Sartan" Valsartan Losartan Telmisartan Irbesartan Eprosartan Candesartan

Difference between ACE inhibitors and ARBs

In ARBs - No cough or Angioedema as side effect Are not Prodrugs

Which ARBs decreases uric acid levels

Losartan

Which ARB can decrease insulin resistance by stimulating PPAR-alpha

Telmisartan

Aldosterone Antagonist used in Acute CHF

Spironolactone - Potassium sparing diuretics Decreases Na+ and H20 Increase K+ and H+

Common side effect of Spironolactone

Gynecomastia

Oral Inotropics that can be used in Chronic CHF

Cardiac glycosides - Digoxin

Cardiac glycosides directly works on

Ventricular muscles

Digoxin works by blocking

Na+-KA ATPase pump - increasing Ca2+ levels - leads to increased contractility

Digoxin have which 2 actions

Increases contractility by acting on ventricular muscles Vagomimetic action - decreases HR and conduction

Due to Vagomimetic action, Digoxin can be given in which condition

Atrial fibrillation

Digoxin is contraindicated in

Renal failure

Side effects of Digoxin

1) Nausea and Vomiting - MC 2)Arrythmia - MC - ventricular bigeminy Most specific - Non paroxysmal Atrial tachycardia with AV block 3) Xanthopsia (Yellow vision) 4) Gynaecomastia

Which drugs can cause Gynecomastia as a side effect

D - Digoxin I S - Spironolactone C - Cimetidine K - Ketoconazole O - oestrogens

Which factors increases chances of Digoxin toxicity

Electrolyte imbalance Drugs Diseases

Which electrolytes imbalances can cause Digoxin toxicity

Hypokalemia Hypomagnesemia Hypercalcemia

Which drugs increases the risk of Digoxin toxicity

Quinidine Verapamil Amiodarone Thiazides

Which disease increases the risk of Digoxin toxicity

Renal failure Liver failure in case of Digitoxin

Treatment of Digoxin toxicity

Correct interactions if any Antiarrhythmic - Lignocaine Digibind

DOC in Digoxin induced ventricular arrythmias

Lignocaine

Bradycardiac agent that can be used in Chronic CHF

Ivabradine

Actions of BNP(Brain natriuretic peptide)

Decreases Sodium (Sodium loss in urine) Powerful vasodilators

BNPs are metabolized by

Neprilysin

Exogenous BNP that can be used in CHF

Nesiritide - not orally effective and Very short acting

Neprilysin inhibitors used in CHF

Sacubitril Ecadotril

Vasopeptidase inhibitors used in CHF

ACE inhibitors + Neprilysin Omapatrilat Sampatrilat

Most commonly used Angiotensin receptor Neprilysin inhibitors (ARNI)

Valsartan+ Sacubitril

Vasopressin receptors antagonist acts on

V1 receptor - Vasoconstriction V2 receptor - decrease urine

Vasopressin receptors antagonist drugs

Conivaptan - iv Tolvaptan - oral - Approved in autosomal dominant adult polycystic kidney disease