Exam 2 - Sowinski (CHF) Flashcards
2 types of CHF
HFrEF (systolic dysfunction) or HFpEF (diastolic dysfunction)
definition of HFrEF:
HF symptoms with EF < 35 - 40%
definition of HFpEF:
HF symptoms with EF > 50%
main 4 compensatory responses
increased preload
vasoconstriction
tachycardia/increased contractility (SNS activation)
Ventricular hypertrophy/remodeling
why is increased preload bad (aka what is its detrimental effect as part of compensation)
it causes pulmonary/systemic congestion and edema
why is vasoconstriction bad (aka what is its detrimental effect as part of compensation)
increased afterload AND decreased SV AND
further activates compensatory responses
why is tachycardia/increased contractility bad (aka what is its detrimental effect as part of compensation)
shortened diastolic filling time
ventricular arrhythmias
increased risk of myocardial cell death
why is ventricular hypertrophy/remodeling bad (aka what is its detrimental effect as part of compensation)
diastolic/systolic function
Risk of myocardial cell death/ischemia
risk of arrhythmia/fibrosis
3 main categories for drug-induced heart failue
Drugs that cause…
- Decreased contractility
- Direct Cardiac Toxins
- Na+/H2O retention
What are some drugs that will may cause drug induced HF via decreased contractility
Beta blockers
CCBs (verap/diltiazem)
Antiarrhythmics
What are some drugs that will may cause drug induced HF by being a direct cardiac toxin
Amphetamine/Cocaine/Ethanol
- nib drugs (Imatinib, Lapatinib, Sunitinib)
- rubin drugs
- zumab drugs
What are some drugs that will may cause drug induced HF via Na+/H2O Retention
Glucocorticoids Androgens Estrogens NSAIDs/COX-2-Inhibitors Rosiglitazone/Pioglitazone Sodium Containing Drugs
Classic HF Symptoms
- SOB and Chronic lack of Energy!!
- Swelling of feet/legs
- Difficultly sleeping due to breathing problems
- Swollen/tender abdomen w/ loss of appetite
- Cough with FROTHY sputum (??)
- Increased urination at night
- Confusion and/or impaired memory
______ Ventricular failure is more related to signs/symptoms of Systemic venous congestion
RIGHT
______ Ventricular failure is more related to signs/symptoms of pulmonary congestion
LEFT
what are the symptoms of Left Ventricle Failure
since Left..pulmonary congestion happens….therefore.
- DOE
- Tachypnea
- Orthopnea
- Cough
- Hemoptysis
- PND (paroxysmal nocturnal dyspnea)
what are signs of Left Ventricle Failure
Rales S3 gallop pulmonary edema pleural effusion Cheyne-Stokes Respiration
what are the symptoms of right Ventricle Failure
since right..systemic venous congestion...aka lots of fluid overload Abdominal pain Anorexia nausea bloating constipation
what are the signs of right Ventricle Failure
peripheral edema JVD (jugular venous distension) HJR (hepatojugular relfex) Hepatomegaly Ascites
what is rales
when listening to lungs can hear fluid —- sounds like rattling
what is orthopnea
having trouble breathing while laying down
what is PND
Paroxysmal Nocturnal dyspnea
pt wakes up in middle of night and feels like they are drowning
what is cardiomegaly
abnormal heart enlargement
what is JVD
jugular venous distension
can see jugular vein pulsating
what are initial lab assessments done for HF
Hematology/Biochem (CBC, Serum electrolytes, BUN, CR, Thyroid function tests)
ECG (check for arrhythmias!!)
Chest X-Ray
BNP or NT-proBNP
what is a diagnostic value BNP in HF
> 100 pg/mL
what is a diagnostic value NT-proBNP in HF
> 300 pg/mL
How does NYHA classify HF patients
Classes I - IV and based on symptoms
IV - is like hella bad/pt can’t get out of bed without having symptoms
How does AHA classify HF pts
by STAGES A,B,C,D
A is at risk
D - is worst
AHA Classifications:
What is Stage A
pt is at high risk of developing HF (ex: pt has HTN, CAD, DM, Dyslipidemia) NO symptoms
AHA Classifications:
What is Stage B
pt has structural heart disease but NO signs/symptoms of HF
AHA Classifications:
What is Stage C
current or prior HF symptoms with underlying struc. heart disease
AHA Classifications:
What is Stage D
has advanced struc. heart disease and marked Sxs of HF
Definition of Asymptomatic rEF
No HF symptoms with EF < 40%
Definition of HFrEF
HF symptoms with EF < 40%
what classes/stages are known as Asymptomatic rEF
Stage B (AHA)
or
NYHA Funct. Class I
what classes/stages are known as HFrEF
Stage C/D (AHA)
or
NYHA Funct. Class II - IV
HF Pts: Sodium Intake Guidelines
2 - 3 gms/day (aka 4 - 6 gms of NaCl)
may have to do <2 g/day if severe HF
HF pts: Alcohol Intake Guidelines
if have HF due to EtOH – then avoid completely
if not EtOH induced — NMT 2 drinks/day (men) or 1 drink/day (women)
HF Pts: when do you fluid restrict? how how do you fluid restrict?
if hyponatremia (Na < 130 mEq/L); < 2 L/day
Managing HF:
Reduce Intravascular Volume by using ______
diruetics
Managing HF:
Increase myocardial contractility by using ______
positive inotropes
Managing HF:
Decrease ventricular afterload by using _______
ACEIs and Vasodilators
Managing HF:
Block Neurohormones by using what things?
Beta blockers ACEIs ARBs Spironolactone ARNIs
If Pt is Stage A HF — how do you treat it?
Just Control Risk Factors
aka smoking cessation!!
treat any other diseases (DM, HTN, Dyslipidemia, CAD)
if PT has DM or coronary/cerebral, peripheral vascular disease then but them on an ACEI/ARB
If Pt is Stage B HF — how do you treat it?
ACEI/ARB
and Beta-Blockers
(no diuretics because no symptoms)
If Pt is Stage C HF — how do you treat it?
everyone is on ACEI/ARB, Beta blocker, and diuretic
T or F: Diuretics decrease hospitalization AND mortality
FALSE. reduces ONLY hospitalization
T or F: Even if HF pt does not have symptoms they should be on a diuretic
false! no symptoms = no diuretic
long term benefits of diuretics
reduce daily symptoms and improve quality to exercise
short term benefits of diuretics
reduce fluid retention by…
decrease edema/pulmonary congestion/JVD
Diuretics:
They reduce _____load AND reduce _______ pressure
PREload; cardiac filling
if a pt is fluid overloaded, diuretics should be used to reduce weight by ______ (how much?)
1 - 2 pounds/day
Patients need to report any weight gain of _______
3 - 5 lbs/week
____tension and (increase or decrease) SCr or BUN/Cr Ratio is indicative of volume depletion
HYPOtension
INCREASE
What is a loop diuretic’s “additional benefit”
they enhance release of renal prostaglandin
which loop diuretic has erratic bioavailability and which one could replace it
furosemide - erratic
replace w/ torsemide
which thiazide diuretic is erratically absorbed
MTZ (metazolone)
initial dose of torsemide
10 - 20 mg QD
initial dose of furosemide
20 - 40 mg QD or BID
goal dose for furosemide
20 - 160 mg QD or BID
goal dose for torsemide
10 - 80 mg QD
which loop diuretic has the longest duration of action
Torsemide
Main ADEs of diuretics
Hypokalemia
Hypomagnesemia
Volume depletion
Decrease in renal function
Monitoring Parameters for Diuretics
Fluid intake/urinary output Body weight blood pressure Serum Electrolytes (K+/Mg2+) Renal function S/Sx of systemic or pulmonary congestion (JVD etc..)
When using diuretics, K+ and Mg2+ can be low…. you should replace K+ if it is < _____ and replace Mg2+ if it is < ______
K: < 4
Mg: < 2
what drugs are known as neurohormonal blockers
ACEI/ARBs Beta Blockers ARNI MRA (aldosterone antagonists! - mineralcorticoid receptor antag.) ISDN/Hydralazine
what drug combo therapies have been proven to be most effective in HF (the chart about RCTs and the hazard ratio not crossing 1..)
- ARNI + BB + MRA
- ACEI + BB + MRA
ACEI Mechanism:
Bradykinin leads to vaso_____
dilation!
why when ACEI prevents break down of bradykinin thats good….
Angiotensin II leads to vaso______
constriction