CVS Pharmacology 3: Heart Failure. Flashcards
Definition: a state which the heart is unable to pump blood at a rate sufficient to meet the body’s requirement or can do so only at elevated filling pressure?
Heart failure.
List 4 causes of HF?
1- MI.
2- cardiomyopathies.
3- viral infections.
4- excessive alcohol.
List the symptoms of left-sided heart failure?
1- low cardiac output.
2- elevated pulmonary venous pressure.
3- dyspnea.
List the symptoms of right-sided heart failure?
Symptoms of fluid retention; usually RV failure is secondary to LV failure.
List the 4 symptoms of low output (forward failure)?
1- fatigue.
2- dizziness.
3- SOB.
4- aggravated by physical exercise.
Increased filling pressure leads to what?
Congestions of the organs upstream of the heart (backward failure).
Backward failure leads to what?
Edema, maldigestion, and ascites.
Definition: an emergency condition in which the patient was asymptomatic before the onset of heart failure?
Acute HF.
Acute HF is seen in which conditions?
Acute injury such as MI.
Definition: long term syndrome in which the patient exhibits symptoms over a long period of time?
Chronic HF.
Chronic Hf is usually as a result of what?
A result of pre-existing cardiac condition.
List the 9 factors precipitating HF?
1- myocardial ischemia or infract.
2- dietary sodium excess.
3- excess fluid intake.
4- medication noncompliance.
5- arrhythmias.
6- intercurrent illness (e.g. infection).
7- conditions associated with increased metabolic demand (e.g. pregnancy, thyrotoxicosis).
8- administration of drug with negative inotropic property of fluid retaining properties (e.g. NSAIDs, corticosteroids).
9- alcohol.
Patients with HF are often categorized by the ____ classification.
NYHA.
List the 4 HF classes of NYHA? And what do they mean?
1- class I: asymptomatic.
2- class II: symptomatic with moderate activity.
3- class III: symptomatic with mild activity.
4- class IV: symptomatic at rest.
HF is often preventable by what?
By early detection of patients at risk and by early intervention.
List the 3 stages of HF?
1- stage A.
2- stage B.
3- stage C&D.
What is stage A HF?
Risk of developing HF (eg. HTN) aggressive t/t of HTN, modification of coronary risk factors, reduction of alcohol intake.
What is stage B HF?
Structural heart disease but no symptoms of HF (eg. Previous MI, LVH, valvular ds), ACE-I and BB, more aggressive t/t of HTN, surgical intervention.
What is stage C&D HF?
- Clinical HF.
- Patients refractory to therapy.
Which NYHA class is stage C HF?
NYHA II/III.
Stage D HF may need which type of management?
May need heart transplantation.
List the 4 compensatory physiological responses in HF?
1- increased sympathetic activity.
2- activation of the RAAS.
3- activation of natriuretic peptides.
4- myocardial dysfunction.
The pathophysiology of HF is complex and involves which four major interrelated systems?
1- the heart itself.
2- the vasculature.
3- the kidney.
4- neurohumoral regulatory circuits.
List the 7 drugs used in HF?
1- ACE-I.
2- ARBs.
3- aldosterone antagonist.
4- diuretics.
5- beta blockers.
6- direct vaso- and venodilators.
7- inotropic agents.
List the 3 new drugs used in HF?
1- HCN channel blocker.
2- B-type natriuretic peptide.
3- ARNI.
Give an example of HCN channel blocker?
Ivabradine.
Give an example of B-type natriuretic peptide?
Nesirtide.
List the 5 treatment principles of HF?
1- neurohumoral modulation.
2- preload reduction.
3- afterload reduction.
4- increased cardiac contractility.
5- heart rate reduction.
List the 3 goals of HF treatment?
1- decrease symptoms.
2- slow disease progression.
3- improve survival.
Which drugs improve mortality, morbidity, exercise tolerance, and left ventricular ejaction fraction?
ACE-I.
List 4 examples of ACE-I?
1- capropril.
2- lisinopril.
3- enalapril.
4- ramipril.
List 3 examples of ARBs?
1- losartan.
2- valsartan.
3- candesartan.
Beta blockers protect the heart from which adverse long-term consequences of sympathetic overstimulation?
1- increased energy consumption.
2- arrhythmias.
3- cell death.
4- improve perfusion of the myocardium by prolonging diastole.
List 4 BBs in HF?
1- bisoprolol.
2- carvedilol.
3- metoprolol.
4- nebivolol.
Which patients should be treated with a beta blocker?
All patients with symptomatic HF (stage C, NYHA II-IV) and all patients with left ventricular dysfunction (stage B, NYHA I) after MI.
Beta blockers should be initiated only in which patients and at what doses?
Only in clinically stable patients at very low doses.
Beta blockers should not be used in which type of HF?
New-onset or acutely decompensated heart failure.
Diuretics are useful in reducing the symptoms of volume overload by what?
1- decreasing the extracellular volume.
2- decreasing the venous return.
Which type of diuretics are the most effective in severe HF?
Loop diuretics like furosemide and bumetanide.
List the 2 AE of diuretics?
1- loop diuretics and thiazides cause hypokalemia.
2- potassium sparing diuretics help in reducing the hypokalemia due to these diuretics.
List 2 examples of potassium sparing diuretics?
Spironolactone or eplerenone.
Which effects does aldosterone inhibition has?
Minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.
What is the AE of spironolactone?
Gynecomastia.
Combination of potassium supplements of ACE-I can increase the risk of what?
Hyperkalemia.
Which drugs can be used specially in patients who cannot tolerate ACE-I?
Isosorbide dinitrate and hydralazine.
Nitrates and hydralazine improve outcomes in which race of patients?
African-Americans.
List the MOA of digoxin?
1- inhibition of Na/K ATPase pump increase intracellular sodium concentration - eventually increase cytosolic calcium.
2- increases force of cardiac contraction.
3- restores the vagal tone (HR and oxygen demand decreases).
4- abolishes the sympathetic over activity.
Digoxin comes from which plant?
Obtained from digitalis plant (foxglove).
Which AE does digoxin has?
1- initial indicators of toxicity: anorexia, nausea, vomiting.
2- blurred vision, yellowish vision (xanthopsia).
3- cardiac arrhythmias: almost every type of arrhythmia can be produced.
What is the treatment of digoxin toxicity?
1- stop digoxin.
2- digoxin antibody (digibind).
What is the treatment for digoxin induced tachyarrhythmias?
When caused by chronic use of digitalis and diuretics - infuse KCI.
What is the treatment for digoxin induced ventricular arrhythmias?
Lidocaine i.v.
What is the treatment for digoxin induced supraventricular arrhythmias?
Propranolol.
What is the treatment for digoxin induced AV block and bradycardia?
Atropine.
What is the treatment of dyspnoea and other symptoms in refractory CHF?
Nesiritide.
Which actions does nesiritide has?
1- enhances salt and water retention.
2- potent vasodilator.
3– reduces ventricular filling pressure.
The latest addition to standard combination therapy of HF is what?
Angiotensin receptor-neprilysin inhibitor (ARNI).
Sacubitril and valsartan.
Sacubitril has which type of effect?
Inhibits neprilysin.
Valsartan has which type of effect?
ARB.
ARNI combines which effects?
Inhibition of the RAAS with activation of a beneficial axis of neurohumoral activation, the natriuretic peptides.
What is the ACC/AHA recommends for HF patients who remain symptomatic on an ACE-I, BB, aldosterone inhibitor?
Use of sacubitril/valsartan as a replacement for ACE-I.
HCN channel blocker: ivabradine has which action?
Hyperpolarization-activated cyclic nucleotide-gated channel blocker.
HCN channel blocker: ivabradine is responsible for which current?
I(f) current
Inhibition of the HCN channel with ivabradine use results with which action on HR?
Results in a lower heart rate.
List a use of HCN channel blocker: ivabradine?
Used in HFrEF to improve in patients with sinus rhythm above 70 bpm.
Treatment of HF with reduced LVEF is aimed at what?
Relieving symptoms, improving functional status and preventing death and hospitalizations.
Management of heart failure with reduced LVEF is based on correcting what?
Correction of reversible causes (eg. Valvular lesions, uncontrolled HTN, drugs with negative inotropy such as CCBs).
What is the pharmacological treatment of HF with reduced LVEF?
A combination of a diuretic and an ACE-I should be the initial treatment in most symptomatic patients with early addition of BB.
List the non-pharmacological management of HF with reduced LVEF?
Implantable cardioefibillators, diet and exercise training, coronary revascularaization, cardiac transplantation.
Half of the patients with HF have which type of LVEF?
Normal LVEF, often with diastolic dysfunction.
Which therapy has been shown to improve HF with normal LVEF?
No therapies have been shown to improve survival in this population.
What is the management of acute HF and pulmonary edema?
1- oxygen (to maintain arterial PO2 greater than 60 mmHg).
2- morphine (increases vascular capacitance, lowering LA pressure, relieves anxiety).
3- iv diuretic therapy (furosemide is indicated even if the patient has not exhibited fluid retention).
4- nitrate therapy (reduces BP and LV filling pressure).
5- iv nesiritide (a recombinant form of human BNP, is a potent vasodilator that reduces ventricular filling pressures and improves cardiac output).
List the 6 symptoms of acute HF and pulmonary edema?
1- acute onset or worsening of dyspnea at rest.
2- tachycardia, diaphoresis, cyanosis.
3- pulmonary rales, rhonchi; expiratory wheezing.
4- radiograph shows interstitial and alveolar oedema with or without cardiomegaly.
5- arterial hypoxemia.
List the 6 causes of acute HF and pulmonary edema?
1- acute MI.
2- exacerbation of chronic HF.
3- acute severe HTN.
4- AKI.
5- acute volume overload.
6- high altitude.
