Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

*Heart Failure > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Diagnosis of Heart Failure

Symptoms suggestive of HF

A
  • dyspnea at rest or on exertion
  • reduced exercise capacity, unexplained fatique, or weakness
  • orthopnea
  • paroxysmal nocturnal dyspnea or nocturnal cough
  • early satiety, nausea and vomiting, abdominal discomfort, or constipation
  • wheezing or cough
  • confusion, delirium or depression
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Diagnosis of Heart Failure

Physical examination findings

A
  • elevated jugular venous pressure or hepatojugular reflux
  • S3 gallop
  • rales
  • displaced apical pulse, or PMI (“point of maximum impulse”)
  • ascites
  • edema
  • cardiac enlargement
  • cardiac murmurs suggesting valvular dysfunction
  • narrow pulse pressure
  • cool extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Diagnosis of Heart Failure

Other pertinent diagnostic and laboratory findings

A

1) assessment of B-types natriuretic peptide (BNP) or N-terminal po BNP (NT-proBNP) level is recommended by guidelines, especially when diagnosis is uncertain
2) BNP > 100 pg/ml
3) NT-proBNP cut points of more than 450 pg/mL for patients younger than 50 years, more than 900 pg/mL for patients 50-74 years of age, and more than 1800 pg/mL for patients 75 years and older are predictive of HF
4) LVEF less than 40% as determined by echocardiography, radionuclide angiography (MUGA [multiple gated acquisition scan], considered the “gold standard” for LVEF measurement), or it is seldom used because of its higher cost and invasiveness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

HF with reduced LVEF

A
  • historically called systolic HF
  • a clinical syndrome characterized by signs and symptoms of HF and reduced LVEF.
  • usually associated with left ventricular (LV) chamber dilation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

HF with preserved LVEF

A
  • historically called diastolic HF
  • a clinical syndrome characterized by signs and symptoms of HF with preserved LVEF, variably defined as greater than 40%, greater than 45%, or greater than 50%
  • usually associated with a nondilated LV chamber.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

NYHA Class I HF

A
  • no limitation of physial activity

- ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

NYHA Class II HF

A
  • slight limitation of physical activity

- comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

NYHA Class III HF

A
  • marked limitation of physical activity

- comfortable at rest, but ordinary physical activity results in fatigue, palpitations or dyspnia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

NYHA Class IV HF

A
  • unable to carry on any physical activity without discomfort
  • symptoms present at rest
  • if any physical activity is undertaken, discomfort is increased
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ACC/AHA Stage A HF

A
  • at high risk of heart failure
  • no identified structural or functional abnormality
  • no signs or symptoms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

ACC/AHA Stage B HF

A
  • developed structural heart disease that is strongly associated with the development of heart failure but without signs or symptoms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

ACC/AHA Stage C HF

A
  • symptomatic heart failure associated with underlying structural heart disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

ACC/AHA Stage D HF

A
  • advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Common comorbidities with HF

A

1) CAD
2) HTN
3) Diabetes
4) Renal impairment
5) Atrial fibrillation (AF)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Captopril in HF

A

Capoten
Initial dose - 6.25mg tid
Target dose - 50mg tid
Mean dose achieved in trials - 122.7mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Enalapril in HF

A

Vasotec
Initial dose - 2.5mg bid
Target dose - 10mg bid
Mean dose achieved in trials - 16.6mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Fosinopril in HF

A

Monopril
Initial dose - 5 -10mg qd
Target dose - 80mg qd
Mean dose achieved in trials - N/A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Lisinopril in HF

A 
Zestril, Prinivil
Initial dose - 2.5-5mg qd
Target dose - 20mg qd
Mean dose achieved in trials
   - 4.5mg/day (low dose in ATLAS)
   - 33.2mg/day (high dose in ATLAS)
  • no difference in mortality between high and low dose groups
  • 12% lower risk of death or hospitalization in high- versus low-dose group
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Quinapril in HF

A

Accupril
Initial dose - 5mg bid
Target dose - 80mg qd
Mean dose achieved in trials - N/A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Ramipril in HF

A

Altace
Initial dose - 1.25-2.5 mg qd
Target dose - 10mg qd
Mean dose achieved in trials - N/A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Trandolapril in HF

A

Mavik
Initial dose - 1mg qd
Target dose - 4mg qd
Mean dose achieved in trials - N/A

22
Q

Candesartan in HF

A

Atacand
initial Dose - 4-8mg qd
Target Dose - 150mg qd
Mean dose achieved in trials - 24mg/day

23
Q

Losartan in HF

A

Cozaar
Initial Dose - 12.5-25 mg qd
Target Dose - 150mg qd
Mean dose achieved in trials - 129mg/day

24
Q

Valsartan in HF

A

Diovan
Initial Dose - 40mg bid
Target dose - 160 mg bid
Mean dose achieved in trials - 254 mg/day

25
Q

Addition of an ARB to ACE inhibitor therapy

A
  • Adding an ARB may be recommended for patients with HF who remain symptomatic despite optimal treatment with ACE inhibitors and beta-blockers (unless contraindications are present)
  • It is generally preferred to add a mineralocorticoid receptor antagonist (MRA) before an ARB in this setting
  • combination therapy is associated with a higher risk of hyperkalemia and increase in SCr; thus, patients should be carefully selected and closely monitored while receiving combined ARB and ACE inhibitor therapy
26
Q

ARBs for patients with evidence of LV systolic dysfunction post-MI with or without HF symptomsq

A
  • valsartan showed non inferiority to captopril for the end points of mortality alone and fatal and nonfatal cardiovascular events in the Valsartan in Acute Myocardial Infarctions (VALIANT) trial; thus either ARB or ACE inhibitors are appropriate in this setting
  • Combining valsartan with captopril was not associated with improvements in clinical outcomes; however, adverse event rates were higher in this group. Thus, there is no advantage to using combination in these patients
  • Use of ARBs in post-MI patients with reduced EF or HF symptoms who are intolerant of ACE inhibitors is recommended by the ACC/AHA guidelines (class I recommendations)
27
Q

Beta blockers in heart failure

General considerations

A
  • beta blockers in conjuction with ACE inhibitors are the cornerstone of HF pharmacotherapy
  • Use of specific beta-blockers (e.g. bisoprolol, carvedilol, or metoprolol succinate) is recommended for all patients with current or previous HF symptoms and with reduced systolic dysfunction without contraindications because of compelling evidence from randomized control trials
  • Beta blockers inhibit the deleterious effects of the sympathetic nervous system on HF progression, prevent/reverse cardiac remodelling, and reduce the risk of sudden cardiac death
  • Beta blockers are generally well tolerated, but they should only be newly initiated in patients who are currently clinically stable and euvolemic
  • initiate at the lowest possible dose and up-titration a 1- or 2- week intervals is recommended to reduce risk of worsening of HF symptoms
28
Q

Beta-blockers in heart failure
Recommended doses
Bisoprolol

A

Zebeta
Initial daily dose - 1.25mg qd
Target dose - 10mg qd
Mean dose achieved in trials - 8.6mg/day

29
Q

Beta-blockers in heart failure
Recommended doses
Carvedilol

A

Coreg
Initial daily dose - 3.125 mg bid
Target dose - 25 mg bid
Mean dose achieved in trials - 37 mg/day

Coreg CR
Initial daily dose - 10mg qd
Target dose - 80 mg qd
Mean dose achieved in trials - N/A

30
Q

Beta-blockers in heart failure
Recommended doses
Metoprolol succinate

A

Toprol XL
Initial daily dose - 12.5 - 25mg qd
Target dose - 200mg qd
Mean dose achieved in Trials - 159 mg/day

31
Q

Mineralocorticoid Receptor Antagonists (MRA)

A
  • treatment with an MRA has traditionally been recommended for patients with systolic dysfunction and severe HF symptoms (NYHA class III or IV) despite optimal pharmacologial therapy
  • RALES - spironolactone decreased all-cause mortality by 30%
  • EMPHASIS-HF showed epleronone reduced risk of death and hospitalization among patients with systolic HF and mild symptoms
  • Hyperkalemia is a significant complications of MRA therapy
  • incidence of gynecomastia with spironolactone was 10% in RALES trial
  • close monitoring for hyperkalemia - 3 days, 1 week, and monthly thereafter for 3 months then at regular intervals as dictated by patient characteristics
  • both eplerenone and spironoactone are MRAs but eplerenone is a selective MRA that has a lowere incidence of endocrine-related adverse effects (i.e. gynecomastia) because of its reduced affinity for glucocorticoid, androgen, and progesterone receptors
32
Q

Spironolactone in HF

A

Aldactone
Initial dose - 12.5-25 mg/day
Target dose - 25 mg/day
Mean dose achieved in trials - 26mg/day

33
Q

Epleronone in HF

A

Inspra
Initial dose - 25 mg/day
Target dose - 50mg/day
Mean dose achieved in trials - 52.6mg/day

34
Q

Fixed dose hydralazine / isosorbide dinitrate in HF

A

BiDil
Initial dose - 37.5mg hydralazine/20mg ISDN tid
Target dose - 75mg hydrazine/40mg ISDN tid
Mean dose in achieved in trials - 142.5mg/76mg

35
Q

Hydralazine in HF

A

Apresoline
Initial dose - 10-37.5mg qid
Target dose - 75mg qid
Mean dose in achieved in trials - 270mg/day

36
Q

Isosorbide dinitrate in HF

A

Isordil
Initial dose - 10-20mg qid
Target dose - 40mg qid
Mean dose achieved in trials - 136mg/day

37
Q

Furosemide in HF

A

Lasix

Initial dose - 20-40 mg/day or bid

38
Q

Bumetanide in HF

A

Bumex

0.5-1.0 mg/day or bid

39
Q

Torsemide

A

Demadex

10-20 mg/day

40
Q

Guidelines for minimizing risk of hyperkalemia in patients treated with MRAs

A

1) Impaired renal function is a risk factor and increases progressively when creatinine exceeds 1.6 mg/dL. In elderly and those with low muscle mass determine CrCl exceeds 30mL/min
2) Not recommended when baseline K > 5.0
3) Initial dose of spironolactone 12.5mg or epleronone 25mg and then increased to 25mg and 50 mg if appropriate
4) risk is increased when combined with higher doses of ACEIs (captopril >= 75mg daily, enalapril or lisinopril >= 10mg daily
5) NSAIDs and COX2 inhibitors should be avoided
6) K supplements should be d/c’d or reduced
7) Monitor K @ 3 days, 1 week, and then at least monthly for the first 3 months
8) diarrhea or other causes of dehydration should be addressed emergently

41
Q

Combining ACEIs and ARBs in HF

A

1) MRAs are recommended over ARBs in patients who remain symptomatic despite optimal therapy with ACEI and beta blockers
2) Triple therapy with an ACEI, ARB and MRA is not recommended because inc risk of hyperkalemia and/or increased SCr

42
Q

Hydralazine and ISDN in HF

A

1) may be used in pts with symptomatic systolic HF intolerant of ACEIs or ARBs because of renal insufficiency, hyperkalemia, or, in some cases angioedema. Better than placebo but not preferred over ACEIs
2) has a specific niche as add on therapy compared with other evidence-based pharmacotherapies in the the treatment of African American patients with HF
3) in patients who remain symptomatic despite maximally tolerated doses of ACEI and beta-blocker therapy, adding hydrazine and ISDN is reasonable, regardless of race
4) The evidence for this approach is strongest for the African American population

43
Q

Diuretics in HF

A

1) Loop diuretics are preferred in pts with HF and symptoms of hypervolemia
2) Lowest dose and some pts can be taught to self manage - requires education and accessibility to health care provider
3) loop diuretics only provide symptomatic relief but they do not demonstrably affect mortality
3) pharmacodynamic drug interactions with ACEIs… if hypotension or SCr increases it may be reasonable to decrease diuretic first
4) if diuretic resistance occurs the following should be considered:
- emphasize Na and fluid restriction
- increase loop diuretic dose
- if furosemide, try bumetanide or torsemide for improved oral absorption
- switch from oral to parenteral dosing
- consider 2nd diuretic (eg distal tubular diuretics metolazone or HTCZ) 30 minutes before dosing the loop diuretic to augment diuretic effects
5) routine monitoring for renal impairment and electrolyte abnormalities as well as orthostasis with sitting, standing BP and HR

44
Q

Digoxin in HR

A

1) optimal therapeutic range is 0.5-1.0 ng/ml
2) DIG trial lower risk of hospitalization but before beta blocker evidentce based therapy and no mortality benefit in this trial

45
Q

Digoxin in HR

Signs of toxicity

A
  • Arrythmias
    • ventricular ectopy
    • AV conduction block of any type
    • paroxysmal AF with block
    • accelerated junctional rhythm
    • bidirectional ventricular tachycardia (rare)
  • GI disturbances (rare)
  • CNS disturbances
  • Visual changes
46
Q

Digoxin in HR

Significant drug interactions

A
  • amiodarone
  • dronedarone
  • verapamil
  • erythromycin
  • clarithromycin
  • teleprevir
  • quinidine
  • saquinavir
47
Q

phosphodiesterase-5 inhibitors in HF

A
  • in patients with stable systolic HF
  • dose in clinical trial is 50mg po tid
  • associated with improved diastolic relaxation indices as well as reduced LV filling pressure accompanied by reverse remodelling effects compared to placebo
  • well tolerated but ade’s include:
    • common (>10%) - headache, dyspepsia
    • 2-10% - flushing, insomnia, dizziness, rash, ocular changes (color perception, sensitivity to light, or blurred vision), congestion/sinusitis
    • <2% - hypersensitivity, amnesia, anemia
48
Q

HF therapies not recommended in ambulatory setting

A
  • outpatient intermittent nesiritide infusions

- outpatient inotrope infusions

49
Q

Drugs to avoid in HF

A
  • NSAIDs
    • may potentiate fluid retention
    • may potentiate renal dysfunction (esp with ACEI)
    • shown to increase HF hospitalizations
  • select calcium channel blockers
    • with negative inotrope effects (verapamil, diltiazem and nifedipine)
    • amlodipine and nifedipine but increase peripheral edema
  • antiarrhythmic agents
  • thiazolidinediones
  • high dose corticosteroids
50
Q

Standard pharmacological management strategies for HF with preserved ejection fraction

A
  • no therapy was shown to increase morbidity and mortality

- HTN should be monitored and controlled

*Heart Failure (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions