Exam 3 - Chronic HF

Question 1

Define Heart Failure. What is #1 cause?

Answer 1

1 cause=CAD

Inability to provide enough oxygenated blood to body.

Question 2

What is the most common form of HF and its result?

Answer 2

Systolic HF. LV can’t get blood to body due to dialation and hypertrophy.

Question 5

Define Cardiac Index. Normal range? What is the CI in HF patients?

Answer 5

Measure of pumping ability from left ventricle to deliver O2. In HF patients their Cardiac Index is low.

Normal range: 2.5-4

Question 6

What is Ejection Fraction? What percent is normal? Systolic and Diastolic HF values?

Answer 6

Amount of blood pumped/end diastolic volume. Below 40% is bad.
Normal=70%
Systolic HF is 3/10 and 30%
Diastolic HF is problem of filling, pumping 3 but can only hold 5, 3/5 for 60%. Looks normal but isn’t.

Question 7

What is mortality of rate in 5 years of heart failure if nothing done? What if everything is done?

Answer 7

Nothing done=50% after 5 years

Everything done=35% after 5 years

Question 8

What are the 4 compensatory mechanisms of HF?

Answer 8

1. RAAS
2. SNS
3. Ventricular Hypertrophy
4. Frank-Starling Law (increase end diastolic pressure)

Question 9

Which four drugs reduce HF mortality?

Answer 9

1. ACEI/ARBs
2. BBs
3. Aldosterone blocking agents
4. Vasodilators (in AAs)

Question 10

Two drugs which reduce HF morbidity?

Answer 10

1. Digoxin

2. Diuretics

Question 11

Treatments for Stages A and B of HF?

Answer 11

A=Treat risk factors. ACEI/ARBs

B=ACEI/ARBs or BBs

Question 12

Routine treatment for Stage C HF? Selected PTs?

Treatment for Stage D HF?

Answer 12

Routine C: ACE/ARBs, BB, diuretics.
Selected C PT: Aldosterone antagonist, digitalis, hydralazine/nitrates

Stage D: End-of-life care. Hospice, transplant, IV Dobutamine

Question 13

ACEI/ARB MOA? Effects on kidneys, H2O/Na, BP, Afterload? Place in therapy?

Answer 13

Interference with RAAS ending by disrupting Angiotensin II.

Decrease BP, decrease Na/H2O retention, decrease Afterload.

Highly excreted with kidneys. Only modify dose if K+ bad.
Used in all stages of HF.

Question 14

ACEI/ARB absolute contraindications?

Answer 14

Preggers, K+ above 5, bilateral renal artery stenosis, angioedema

Question 15

Sacubitril/valsartan (Ernesto) MOA and place in therapy? Time to convert from ACE to Ernesto?

Answer 15

Valsartarn=ARB
Sacubitril=Blocks neprilysin causing vasodilation
Together they add more vasodilation than ARB or ACEi alone.

Used in newly diagnoses with EF less than 40%. Wait 36 hours.

Question 16

Beta-Blocker MOA? Effect on coronary areries? Which three can be used?

Answer 16

Block beta receptors decreasing HR and BP. Increased coronary artery blood flow.

1. Metoprolol Succinate
2. Bisoprolol
3. Carvedilol

Question 17

What stages are Beta Blockers used in? ADR? Why not Metoprolol Tartrate?

Answer 17

A, B, C.

ADRs=Bradycardia, worse HF is BB dose started too high, respiratory issues

Metoprolol Succinate has better outcomes.

Question 18

MOA and place of Ivabradine?

Answer 18

MOA: selectively inhibits “funny channel” in SA and AV nodes and reduces HR

Place: All other meds maxed out and EJ less than 35%. Further enhances Beta-Blockers.

Question 19

Aldosterone MOA and place in which stages? Preload? CI?

Answer 19

MOA: Competes with Aldosterone for intracellular mineralcorticoid receptors. Decrease Na/H2O, increase K. Decreases Preload.

Place: In Stages C and D if on max ACEi/BB and still symptomatic.

CI: Hyperkalemia

Question 20

Hydrazaline and Isosorbide are what class of drugs? Where does each work? Who used in?

Answer 20

Vasodilators.
Hydrazaline=coronary, cerebral, renal arteries
Isosorbide=vasodilation via NO

Used in African Americans.

Question 21

Which diuretics best in HF? Does it improve morbidity or mortality?

Answer 21

Loop Diuretics best. Morbidity.

Question 22

Loop Diuretic MOA? Preload and edema effect? Kidneys?

Answer 22

Increase Na/H2O excretion in Loop of Henle. Reduce preload and edema. Can be used with bad kidneys!

Question 23

What stages get Loop Diuretics? What might you have to do with dose for diuretics and renal failure?

Answer 23

Stages C or D, only if symptomatic.

Increase dose with renal failure.

Question 24

Four most common Loop Diuretics electrolyte abnormalities?

Answer 24

Hyperglycemia, Hyperuricemia

Hypokalemia, Hypomagnesemia

Question 25

Digoxin MOA? Which VD and who gets toxic? How excreted?

Answer 25

MOA: Positive inotropic (+CO), negative chronotropic. Increased Intracellular Na and Ca causes inotrope.

Elderly become toxic due to small VD.
Renally excreted.

Question 26

Signs of Digoxin toxicity? Hyper/hypokalemia and Digoxin?

Answer 26

Bradycardia, heart failure, and hypokalemic.

Hyperkalemia=decrease effects of digoxin
Hypokalemia=increase effects of digoxin

Question 27

How to treat Diastolic HF?

Answer 27

No gold standard. Goal to treat underlying condition.

Question 28

What are 4 the ACC/AHA stages of HF? Which most commonly seen in hospital or clinic?

Answer 28

Class A=at risk, no structural changes
Class B=ventricular hypertrophy and found incidentally
Class C=the typical PT seen in clinicals
Class D=end-of-life

Question 29

Define Preload and Afterload. What happens to LV from afterload?

Answer 29

Preload=amount of blood at end of diastole (end diastolic volume)
Afterload=amount of pressure heart pumps against for systole (measurement of systemic resistance). LV hypertrophy.

Question 30

Define Pulmonary Capillary Wedge Pressure. What will it be in HF patients? Normal range?

Answer 30

Measurement of what’s happening in the capillaries as volume status in the lungs. In acute decom HF PCWP will be high!

Normal range: 8-12

Question 31

Which 4 meds renally excreted

Answer 31

1. ACEi
2. ARB
3. Aldosterone blocker
4. Digoxin

Question 32

When to reduce or d/c loop diuretics?

Answer 32

When excess fluid gone

Question 33

ACEi/ARB decrease which load?

Aldosterone-blocker deceases which load?

Answer 33

ACEi/ARB=Afterload

Aldosterone=Preload

Question 34

Most common ADE of Digoxin?

Answer 34

Stomach funk