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Pharm Quiz #2 > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

How does Jay Cohn, MD define Heart Failure?

A

Clinical syndrome in which cardiac dysfunction, be it either systolic or diastolic, is associated with reduced exercise tolerance, ventricular arrhythmias and shortened life span.”

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2
Q

What is Heart Failure?

A

A structural or functional cardiac disorder that impairs the ventricle to fill with or eject blood to meet the needs of the body:

  • Pathologic sympathetic activation
  • Increased load on the failing ventricle
  • -Issues with renin-angiotensin-aldosterone axis
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3
Q

How do you change Heart Failure?

A
  1. ) Decrease pathologic sympathetic stimulation
    - -> Beta Blocker
  2. ) “Reduce” the load on the failing heart
    - -> Diuretics
  3. ) Address issues involving the RAA axis
    - -> ACEI
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4
Q

2 types of Heart Failure?

A

Systolic Heart Failure

Diastolic Heart Failure

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5
Q

What is Systolic Heart Failure?

A
  • Impaired left ventricular contractility.
  • Drop in LV ejection fraction

Therapy:
diuretics, ACE inhibitors, digoxin and nonspecific vasodilators

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6
Q

What is Diastolic Heart Failure?

A
  • Problems with ventricular filling or inability of ventricle to relax.

Therapy:
diuretics, vasodilators, inotropic drugs, beta blockers, hydralazine/nitrates

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7
Q

Stages A & B for Heart failure?

A

At risk for heart failure

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8
Q

Stages C & D for Heart failure?

A

Heart failure (Overt, symptomatic)

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9
Q

What is the “first” step of the treatment algorithm?

Really “2”

A
  1. ) Diuretic + ACEI (or ARB) –> 1st line

2. ) Beta Blocker –> 2nd line

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10
Q

What is the second step of the treatment algorithm when have persisting signs and symptoms?

A

Add aldosterone antagonist or ARB

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11
Q

What is the second step of the treatment algorithm when have NO persisting signs and symptoms?

A

1.) Check LVEF

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12
Q

What if LVEF is less than or equal to 35%

A

Consider ICD

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13
Q

What if LVEF is NOT less than or equal to 35%

A

No further treatment required

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14
Q

What if after Addition of aldosterone antagonist or ARB and have persisting signs and symptoms?

A

Check QRS greater than or equal to 120 msec

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15
Q

What if after Addition of aldosterone antagonist or ARB and DO NOT have persisting signs and symptoms?

A

Check LVEF and go by whether less than or equal to 35% steps

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16
Q

What if QRS is greater than or equal to 120 msec?

A

Consider CRT-P or CRT-D

CRT = cardiac resynchronization therapy

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17
Q

What if QRS is NOT greater than or equal to 120 msec?

A

Consider digoxin, LVAD, transplantation

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18
Q

Basics of Stage A heart failure

A

At high risk for heart failure but without structural heart disease or symptoms of heart failure

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19
Q

What is the patient with Stage A heart failure?

A 
	Patients with
•	hypertension
•	atherosclerotic disease
•	diabetes
•	obesity
•	metabolic syndrome
	OR
•	patients using cardiotoxins
•	family history of cardiomyopathy
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20
Q

What is the approach to therapy for Stage A heart failure?

A

Risk-factor Reduction; Patient Family education
• Treat hypertension
• Encourage smoking cessation
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake, illicit drug use
• Control metabolic syndrome
 Drugs
• ACE inhibitor or ARB in appropriate patients for vascular disease or diabetes  renally protective and good for HTN
•

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21
Q

Basics of Stage B heart failure

A

o Structural heart disease but without symptoms of heart failure (LVEF starting to ↓)

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22
Q

What is the patient with Stage B heart failure?

A
  • previous myocardial infarction
  • LV remodeling including left ventricular hypertrophy and low ejection fraction
  • Asymptomatic valvular disease
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23
Q

What is the approach to Treatment for Stage B heart failure?

A

 All measures under Stage A
 Drugs
• ACEI/ARB in appropriate patients (almost all patients)
• Beta-blockers in appropriate patients

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24
Q

Basics of Stage C heart failure

A

o Structural heart disease with prior or current symptoms of heart failure

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25
Q

What is the patient with Stage C heart failure?

A
  • known structural heart disease AND

* shortness of breath and fatigue, reduced exercise tolerance

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26
Q

What is the approach to Treatment for Stage C heart failure?

For routine use?

A 
	All measures under Stages A and B
	Dietary salt reduction
	Drugs for Routine Use
•	**Diuretics for fluid retention
•	ACEI (built up)
•	Beta blockers (for sure) 
•
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27
Q

NYAH Class I?

A

• Operate well, no symptoms with normal activity

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28
Q

NYAH Class II?

A

• Give ordinary activity and get dyspnea (Fluid on lungs)

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29
Q

NYAH Class III?

A

• Work load is less and dyspnea is more obvious

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30
Q

NYAH Class IV?

A

• Doing nothing (sitting) –> dyspnea and wheezing

31
Q

What are drugs for selected patients in Stage C heart failure?

A
  • Aldosterone antagonist
  • ARB
  • Digoxin
  • Hydralazine/nitrates
32
Q

What are devices for selected patients in Stage C heart failure?

A

Biventricular pacing

• Implantable defibrillators

33
Q

Basics of Stage D heart failure

A

o Refractory heart failure requiring specialized interventions

34
Q

What is the patient with Stage D heart failure?

A

Patients who have marked symptoms at rest despite maximal medical therapy, e.g., those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions

35
Q

What is the approach to Treatment for Stage D heart failure?

A 
	Appropriate measures under Stages A, B and C
	Decision regarding appropriate level of care
	Options
•	Compassionate end-of-life care/hospice
•	Extraordinary Measures
o	heart transplant
o	chronic inotropes
o	permanent mechanical support
o	experimental surgery or drugs
36
Q

What is the Diuretic used in heart failure?

A

Furosemide

Can use a thiazide like too –> Chlorthalidone

37
Q

Prescription for Furosemide?

A

40 mg
One tablet twice a day

 IV dose is only 40 mg due to bioavailability of the oral dose
 IV for decompensated heart failure patients
 PO = maintenance dose for discharge

38
Q

What are the diuretics used for?

A
  • Heart failure leading to fluid retention; relieve symptoms but does not stop disease progression
  • Should not be used alone to manage heart failure
39
Q

What is the ACEI used in heart failure?

A
  • **Lisinopril
  • Captopril
  • Enalapril
40
Q

Prescription for Lisinopril?

A

 Lisinopril
40 mg
One tablet daily
 20-40 mg is optimal dosing; need at least 20 mg to ↓ mortality

41
Q

What are the ACEI used for?

A

o RAAS activated in heart failure and degree of activation corresponds to prognosis
o Benefits seen in all subgroups but greater in severe heart failure
o Improve symptoms within days but more commonly with delay of 4 to 12 weeks
o Titrate dose upward to those used in clinical trials
 Captopril 50 mg 3 times a day
 Enalapril 10-20 mg twice daily
o 1st line therapy

42
Q

What is the ARB used in heart failure?

A

Valsartan

43
Q

Prescription for Valsartan?

A

80 mg
One tablet twice a day

  • 2nd line agent
44
Q

What are the ARB used for?

A

o Difficult to find equivocal evidence of superiority over ACEIs
o Based on more extensive clinical experience with ACEIs and lower cost of ACEIs, ARB role is as:
 Safe and effective alternative
 Patients who cannot tolerate an ACEI

45
Q

What is the Beta Blocker used in heart failure?

A
  • *Carvedilol
  • Metoprolol ext. rel.
  • Bisoprolol
46
Q

Prescription for Carvedilol?

A

25 mg
One tablet twice a day

  • Initiate at low doses and gradually increase dosing over weeks to target doses
47
Q

What are the Beta Blocker used for?

A

o Negative inotropic activity
o Slows progression of disease, decreases post MI mortality
 Because sustained activation of sympathetic system increases myocardial oxygen demand, renal retention of sodium, increased preload and afterload
o Treatment can result in reverse cardiac remodeling
o Significant decrease in systolic/diastolic volumes and increase in left ventricular ejection fraction

48
Q

What LVEF are you aiming for?

A

greater than 40%

Less than 40% is bad!

49
Q

What is the Aldosterone Antagonist used in heart failure?

A

Eplerenone

50
Q

Prescription for Eplerenone?

A

50 mg
One tablet daily

  • If EF < 30% kick the drug in earlier
  • Get rid of hormonal side effects of spironolactone
51
Q

What are the Aldosterone Antagonistused for?

A

o Aldosterone levels may increase 20-fold in heart failure
o Addition to standard treatment (25 mg/day of either agent) may significantly reduce mortality
o Check electrolytes/creatinine within 1 week of start, then monthly/bimonthly until patient potassium levels stable
 Watch renal function too!

52
Q

What is the Vasodilator used in heart failure?

A

• BiDilTM (Hyrdralazine/nitrate)

53
Q

Prescription for BiDil (Hyrdralazine/nitrate)?

A

One tablet three times a day

  • Fixed combination, available in multiple strengths
54
Q

What are the Vasodilators used for?

A

o Can produce sustained improvement in LV ejection fraction
 Addition of hydralazine/nitrate may be best applied to patients with persistent low cardiac output and volume overload
 May be helpful in patients who cannot tolerate ACEIs or ARBs due to renal impairment
 Good for blacks

55
Q

What is the Cardiac Glycoside for heart failure?

A

Digoxin

56
Q

Rx for Digoxin?

A

125 mcg
One tablet daily

  • To reduce dose, make it every other day (long half-life (36 hours)
  • 250 mcg dose can ↑ mortality in HF patients, but A-fib patients need this dose
  • Watch > 70 y/o (bad kidneys  dose every other day)
57
Q

Digoxin MOA

A

Negative Chronotroph (↓ HR) = Increased force of contraction and decreased rate of contraction

58
Q

Digoxin Kinetics

A

 T1/2 of 36 hours so steady state at approximately 2 weeks

 Discontinuation possible as drug levels deplete over long period of time

59
Q

Good candidate for dogoxin

A

Patients with an LVEF less than 40% who continue to have NYHA class II, III and IV symptoms despite optimal therapy may be candidates for digoxin

60
Q

Not good candidate for digoxin

A
  • Asymptomatic patients with left ventricular dysfunction and normal sinus rhythm
  • Primary therapy for stabilization of patients with acutely decompensated heart failure
61
Q

ADR of digoxin

A

Bradycardia (or tachycardia) –> check pulse before give it

62
Q

Drug interactions of digoxin

A

 Increasing digoxin levels
• antacids
• metoclopramide (Reglan™)
• St. John’s wort

	Decreasing digoxin levels
•	amiodarone
•	alprazolam (Xanax™)
•	verapamil
•	spironolactone (Aldactone™)
63
Q

Digoxin is what type of drug?

A
  • Narrow therapeutic range drug, watch for early signs of toxicity
  • Serum levels do not correlate with clinical efficacy; higher levels were associated with increased mortality
64
Q

What are the inotropes?

A
  • Dobutamine Infusion

* Milrinone (Primacor®)

65
Q

Prescription for Dobutamine?

A

Dobutamine Infusion
5 mcg/kg/minute
Titrate to effect

66
Q

MOA of Dobutamine?

A

Stimulation of the beta 1 receptors of the heart, comparatively mild chronotropic, hypertensive, arrhythmogenic and vasodilative effects

67
Q

ADR of Dobutamine?

A
  • Increased heart rate, blood pressure, ventricular ectopic activity, hypotension; premature ventricular beats (≈ 5%; dose-related)
  • Beta-blockers can antagonize the cardiac effects of dobutamine resulting in unopposed increased vascular resistance
68
Q

Prescription for Milrinone (Primacor®)

A

Loading of 50 mcg/kg IV over 10 minutes then maintenance infusion of 0.5 mcg/kg/min

69
Q

How Milrinone (Primacor®) works?

A

o Does not work at adrenergic receptors
- Positive inotrope (↑ HR) and vasodilatory effect (↑ nitric oxide)
o Phosphodiesterase inhibitor

70
Q

What is the B-Type Natriuretic Peptide (BNP) drug?

A

Nesiritide (Natrecor™)

71
Q

Nesiritide (Natrecor™) dosing?

A

Bolus and then infusion up to 96 hours

72
Q

MOA of Nesiritide (Natrecor™)

A
  • Increases intracellular levels of cGMP resulting in smooth muscle relaxation and arterial and venous dilation
  • Reduction of pulmonary capillary wedge pressure and systemic arterial pressure
73
Q

ADR of Nesiritide (Natrecor™)

A

Hypotension, Renal function ↓

74
Q

Theory behind Nesiritide (Natrecor™)?

A

 When LV stretch –> BNP levels rise
 BNP activates atrial natriuretic factor receptors –> decrease in systemic vascular resistance and central venous pressure as well as an increase in natriuresis
• Decrease in blood volume, which lowers systemic blood pressure and afterload, yielding an increase in cardiac output

Pharm Quiz #2 (6 decks)

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