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
what are some reasons that a patient would be on a lower than normal ACEI dose
if CKD (CrCl < 30 mL/min) Hypotension -- if symptomatic! (ok if low BP (to some extent...))
what are the 4 ACEIs used for HF
Lisinopril
Enalapril
Captopril
Ramipril
which ACEI for HF is once a day?
Lisinopril
which ACEI for HF is twice a day?
Ramipril and Enalapril
which ACEI for HF is three times a day?
captopril
For dosing of ACEI in HF:
start low and double the dose how often?
every 2 weeks!!
Q1 - 4 wks…
For dosing of ACEI in HF: lower doses and more monitoring are required with... SCr > \_\_\_\_\_\_ and/or CrCl < \_\_\_\_\_
SCr > 3
ClCr < 30
For dosing of ACEI in HF:
Use with caution if pt…
what 4 things
SBP < 80 mmHg
Volume Depleted
Serum K > 5
SCr > 3
Absolute contraindications for ACEI?
Pregnancy
Hx of Angioedema or Hypersensitivity
Bilateral Renal Artery Stenosis
Hx of well documented intolerance (dat cough)
ADEIs of ACEI
functional renal insufficency hypotension Hyperkalemia skin rash dysguesia (metallic taste in mouth) Cough Angioedema
Monitoring for ACEIs
How to Monitor Renal Function and K+?
1) prior to therapy
2) 1 - 2 weeks after each increase in dose
3) 3- 6 mos intervals
T or F: It is ok to keep a patient on an ACEI even if their SCr has increased?
T and F…. it is ok unless the SCr increases more than 20%
Sacubitril/Valsartan is indicated for who?
HFrEF pts with NYHA Class II-IV
Must have K+ < 5.2
Must have eGFR > 30
ADEs of Sacubitril/Valsartan
just like ACEI/ARB…
Hypotension
Elevations in SCr and K+
(possibly rare) Angioedema
Contraindications for Sacubitril/Valsartan
within 36 hours of ACEI
if had angioedema with ACEI or ARB before
Pregnancy/Lactation
Severe Hepatic Liver impairment
known hypersensitivity to either ARB or ACEI
what are the 3 beta blockers that are ok to use in HF
carvedilol (regular or CR)
Metoprolol
Bisoprolol
Beta blockers are known to have what “special” property…
Reverse Remodeling! (genetic makeup changes)
2 pathways that beta blockers are beneficial for HF pts
Overall blocking cardiac NE.. but the 2 pathways are…
blocking Beta-AR pathway desensitization
AND
decreasing myocyte toxicity from NE
what patients should start a beta blocker
STABEL and EUVOLEMIC
if patient is in hospital for HF exacerbation— when do you start a beta blocker (near beginning or end of stay?)
END!
want them more stable before you start it…)
how do you titrate beta blockers
double the dose every 2 weeks and monitor closely!!
aim for the target dose of beta blockers with in ______ weeks or …..
8 - 12 weeks
OR
high of a dose as tolerated
initial dose for bisoprolol
1.25 mg QD
initial dose for Carvedilol (reg AND CR)
reg: 3.215 mg BID
CR: 10 mg QD
initial dose of Metoprolol XL
12.5 - 25 mg QD
goal HR for beta blockers in HF?
there isn’t one!!
goal dose for bisoprolol
10 mg QD
goal dose for carvedilol (reg and CR)
reg: 25 mg BID
CR: 80 mg QD
goal dose of Metoprolol XL
200 mg QD
if patient is on a beta blocker and the start to experience…
Fluid retention/Worsening HF
What do you do?
don’t stop drug…
intensify diuretic therapy
if patient is on a beta blocker and the start to experience…
Bradycardia/Heart block
What do you do?
reduce beta blocker dose
usually asymptomatic and do not need to treat though
if patient is on a beta blocker and the start to experience…
Hypotension
What do you do?
separate from ACEI to decrease risk
may reduce ACEI or diuretic dose to compensate
if also signs of hypoperfusion (aka low BP) - decrease the dose
benefits for Aldosterone Receptor Antagonists
- decrease K/Mg losses = protect against arrhythmia
decrease Na+ retention
Decrease sympathetic simulation
blocks direct fibrotic action on myocardium
Spironolactone or Eplerenone?
is a substrate of CYP3A4
Eplerenone
Spironolactone or Eplerenone?
has ADEs of gynecomastia, impotence, menstrual irregularities
Sprionolactone
For aldosterone antagonists, the CrCl cut offs are?
> 50
30 - 49
and < 30 - do not use
Spironolactone: if CrCl is > 50
what is initial dose
and maintenance
initial: 12.5 - 25 mg QD
Main: 25 mg QD
Spironolactone: if CrCl is 30 - 49
what is initial dose
and maintenance
initial: 12.5 mg QD or every other day
12. 5 - 25 mg QD
Spironolactone: if CrCl is < 30
what is initial dose
and maintenance
do not use under 30!!!!
Eplerenone: if CrCl is > 50
what is initial dose
and maintenance
initial: 25 mg QD
Main: 50 mg QD
Eplerenone: if CrCl is 30 - 49
what is initial dose
and maintenance
initial: 25 mg q other day
main: 25 mg QD
Eplerenone: if CrCl is < 30
what is initial dose
and maintenance
do not use!!
Avoid Aldosterone antagonists if….?
SCr > 2.5 (men) or > 2 (women) or CrCl < 30 mL/min or K+ > 5 or hx of severe hyperkalemia/recent worsening renal function
Monitoring of Aldosterone Antagonists:
After any change, addition, diseases or acute illness that may affect K+? when to monitor again
3 days - 1 wk
Monitoring of Aldosterone Antagonists: Normal monitoring (when no changes etc)
Q 3 mos
why is ISDN/Hydralazine of benefit?
reduces both preload AND after load because of hella vasodilation
(study to show efficacy in African American patients)
why is ISDN/Hydralazine problematic?
Side effects for dayz!
Reflex tachycardia, hypotension, HA, flushing…
lupus-like syndrome/fluid retention/myocardial ischemia
Hydralazine is a dilator of artieries or veins?
Arteries!
ISDN is a dilator of artieries or veins?
veins!
ISDN:
Initial
Target
Max dose
initial: 20 mg TID/QD
Target: 40 mg TID/QD
Max: 80 mg TID
Hydralazine:
Initial
Target
Max dose
Initial: 25 mg TID/QD
Target: 75 mg TID
Max dose: 100 mg TID
Ivabrandine is indicated for what pts?
- symptomatic HF
- EF < 35%
- in NSR (normal sinus rhythm)
- rHR >/= 70 in MAX TOLERATED beta blocker
Dosing for Ivabradine
start: 2.5 mg BID
adjust q 2 wks
Max: 7.5 mg BID
Adjusting dose for Ivabradine
what are the HR cutoffs
> 60
50 - 60
< 50
Adjusting dose for Ivabradine
pts HR is 60 BPM - what do you do?
increase dose by 2.5 mg (given BID)
Max is 7.5 mg BID tho!
Adjusting dose for Ivabradine
pts HR is in 50 - 60 range - what do you do?
maintain dose
Adjusting dose for Ivabradine
pts HR is < 50 - what do you do?
decrease dose by 2.5 mg (BID)
if already at 2.5, d/c the drug!
ADEs of Ivabradine
Fetal toxicity
A. Fib
Bradycardia/Conduction disturbances
Ivabradine - drug interactions?
it is a CYP3A substrate
Ketoconazole, Diltiazem, Verapamil, grapefruit juice is concern!!
if a HF has persistent HTN (even with ACEI, beta blocker, and diuretic (for Sx) – what do you give them
- ISDN/Hydralazine
OR
Amlodipine/Felodipine
if a HF has Concomitant Angina – what do you give them
amlodipine/felodipine
T or F: Digoxin can reduce mortality
False! only reduces hospitalizations
Target goal of Serum Digoxin Concentrations
< 1
0.5 - 1 is acceptable range
T or F: do not do a loading dose of Digoxin in a pt with HF
True!!! (as long as they are in NSR (normal sinus rhythm) do NOT do a loading dose)
Dosing for Digoxin
- 125 mg - .25 mg QD
0. 125 mg is normal dose to get into appropriate goal range of 0.5 - 0.9
What patients would more than likely get a lower dose of digoxin
> 70 y.o
decreased renal function
low weight
NON-CARDIAC ADEs of Digoxin:
- Anorexia, N/V
- Visual disturbances (halos, photophobia, altered color) (remember Van-Gogh crap)
- Fatigue, weakness, dizziness, confusion, psychosis
Cardiac ADEs of Digoxin
AV block
PVCs, VT, VF!!
Sinus Bradycardia
what is used to treat digoxin toxicity
digibind
what things may predispose someone to digoxin toxicity
Electrolyte disturbances (hypoK+/Mg2+, hyperCa2+) older pt Alkalosis Hypoxia Renal Dysfxn Hypothyroidism Drug interactions! (Verap and Amiod!!)
what electrolyte imbalances increase a pts risk for dig toxicity
hypokalemia
hypomagnesemia
hypercalcemia
T or F: all HF pts need to receive anti-platelet therapy
False!
Should get it only if the have IHD, CAD, or ASCVD along with their HF
T or F: all HF pts need anti-coag therapy
false!!! (only if they have a reason to be on it… like A. Fib.)
Definition of ADHF
Acute Decompensated Heart Failue =
HF exacerbation =
pts with new or worsening HF signs/sx
Definition of Cardiogenic Shock:
Hypotension with Low CO
Definition of Hypotension
SBP < 90 mmHg
MAP (mean arterial pressure) < 70 mmHG
T or F: ADHF includes both HFrEF and HFpEF
true!
ADHF is mainly of worsening HF cases or new cases?
worsening (~70%)
what are the 4 main reasons for why ADHF can happen
CV causes
Metabolic causes
Toxins/Drugs
Drug non-adherence/Dietary indiscretion
What are CV causes that can lead to ADHF
ischemia arrhythmia valvular disease uncontrolled HTN pulmonary embolism progressive HF
what are metabolic causes that lead to ADHF
infection
anemia
thyroid disorders
renal insufficiency
what are some toxins/drugs that can lead to ADHF
negative inotropes, cardiotoxins, Na+/water retention
what is the main way that hospitals distinguish the SOB b/w Pulmonary embolism/pneumonia or heart failure
BNP and Nt-proBNP levels
what are the important “easy” things of a physical examination in ADHF that dictate treatment
warm/cold
and
dry/wet
For ADHF Classifications: What is subset I
warm/dry NORMAL
For ADHF Classifications: What is subset II
warm/wet - pulmonary congestion
For ADHF Classifications: What is subset III
cool/dry - hypoperfusion
For ADHF Classifications: What is subset IV
cool/wet
pulmonary congestion AND hypoperfusion
For ADHF Classifications:
Cardiac Index is a way to measure _______
contractility
For ADHF Classifications:
PCWP is a way to measure
Pre-Load! or LV-End diastolic end pressure
For ADHF Classifications:
Having a LOW PCWP means what?
there is PULMONARY CONGESTION (wet)
For ADHF Classifications:
having a low cardiac index means what?
there is hypoperfusion (Cool)
if pt comes in and has ADHF..
if they are Warm and Wet - what do you do?
IV diuretics!
maybe a venous vasodilator - like morphine..
if pt comes in and has ADHF..
if they are warm and dry - what do you do?
optimize chronic therapy
if pt comes in and has ADHF..
if the pt is cold and dry what do you do?
have to look at PCWP:
if <15 - give IV fluids until PCWP reaches b/w 15 - 18
if < 15 and SBP is < 90 - give IV dopamine
if SBP is > 90 - IV inotrope or arterial vasodilator is good.
if pt comes in and has ADHF..
if pt comes in Cold and wet - what do you do?
if SBP < 90 - IV dopamine
if SBP > 90: inotrope or arterial/venous vasodilator
Dosing Diuretics For Hospitalized Pts:
Initial dose is done by IV…. how to pick a dose?
go with whatever they are taking at home!
*if furosemide 40 mg at home – do 20 mg (b/c bioavailability is wack)
ways to overcome loop diuretic resistance?
Na+/Water restriction increase dose (not just frequency) do a continuous infusion Add thiazide
what are vasodilators are mentioned for ADHF
Nitroprusside* Nitroglycerin Nesiritide Morphine* Enalaprilat Hydralazine
what positive inotropes are mentioned for ADHF
Dobutamine, Milrinone, Dopamine
what is milrinones MOA
PDEI — will increase cardiac indx
(since PDE inhibitor- good to use when pt is on beta blocker…effect wont be blunted by the beta blocker already present)
Dopamine’s dosing leads to different effects… what are the different effects
Low Dose: renal vasculature dilator
Med. Dose: increase myocardial contractility/inotrope
High Dose: Aterial vasoconstriction - increase BP
When dopamine is at a low dose – what is its effect
renal vasculature dilator
When dopamine is at a medium dose – what is its effect
increase myocardial contractility/inotrope
When dopamine is at a high dose – what is its effect
increase arterial vasoconstrition – increase BP
if someone comes in for ADHF — never been on diuretic but they need a diuretic - how do you dose it?
start with 40 mg IV — see how they respond
good to check renal function too!
if they have shitty kidneys — increase the dose!!