Heart Failure Flashcards
How does Jay Cohn, MD define Heart Failure?
Clinical syndrome in which cardiac dysfunction, be it either systolic or diastolic, is associated with reduced exercise tolerance, ventricular arrhythmias and shortened life span.”
What is Heart Failure?
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
How do you change Heart Failure?
- ) Decrease pathologic sympathetic stimulation
- -> Beta Blocker - ) “Reduce” the load on the failing heart
- -> Diuretics - ) Address issues involving the RAA axis
- -> ACEI
2 types of Heart Failure?
Systolic Heart Failure
Diastolic Heart Failure
What is Systolic Heart Failure?
- Impaired left ventricular contractility.
- Drop in LV ejection fraction
Therapy:
diuretics, ACE inhibitors, digoxin and nonspecific vasodilators
What is Diastolic Heart Failure?
- Problems with ventricular filling or inability of ventricle to relax.
Therapy:
diuretics, vasodilators, inotropic drugs, beta blockers, hydralazine/nitrates
Stages A & B for Heart failure?
At risk for heart failure
Stages C & D for Heart failure?
Heart failure (Overt, symptomatic)
What is the “first” step of the treatment algorithm?
Really “2”
- ) Diuretic + ACEI (or ARB) –> 1st line
2. ) Beta Blocker –> 2nd line
What is the second step of the treatment algorithm when have persisting signs and symptoms?
Add aldosterone antagonist or ARB
What is the second step of the treatment algorithm when have NO persisting signs and symptoms?
1.) Check LVEF
What if LVEF is less than or equal to 35%
Consider ICD
What if LVEF is NOT less than or equal to 35%
No further treatment required
What if after Addition of aldosterone antagonist or ARB and have persisting signs and symptoms?
Check QRS greater than or equal to 120 msec
What if after Addition of aldosterone antagonist or ARB and DO NOT have persisting signs and symptoms?
Check LVEF and go by whether less than or equal to 35% steps
What if QRS is greater than or equal to 120 msec?
Consider CRT-P or CRT-D
CRT = cardiac resynchronization therapy
What if QRS is NOT greater than or equal to 120 msec?
Consider digoxin, LVAD, transplantation
Basics of Stage A heart failure
At high risk for heart failure but without structural heart disease or symptoms of heart failure
What is the patient with Stage A heart failure?
Patients with • hypertension • atherosclerotic disease • diabetes • obesity • metabolic syndrome OR • patients using cardiotoxins • family history of cardiomyopathy
What is the approach to therapy for Stage A heart failure?
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
•
Basics of Stage B heart failure
o Structural heart disease but without symptoms of heart failure (LVEF starting to ↓)
What is the patient with Stage B heart failure?
- previous myocardial infarction
- LV remodeling including left ventricular hypertrophy and low ejection fraction
- Asymptomatic valvular disease
What is the approach to Treatment for Stage B heart failure?
All measures under Stage A
Drugs
• ACEI/ARB in appropriate patients (almost all patients)
• Beta-blockers in appropriate patients
Basics of Stage C heart failure
o Structural heart disease with prior or current symptoms of heart failure
What is the patient with Stage C heart failure?
- known structural heart disease AND
* shortness of breath and fatigue, reduced exercise tolerance
What is the approach to Treatment for Stage C heart failure?
For routine use?
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) •
NYAH Class I?
• Operate well, no symptoms with normal activity
NYAH Class II?
• Give ordinary activity and get dyspnea (Fluid on lungs)
NYAH Class III?
• Work load is less and dyspnea is more obvious
NYAH Class IV?
• Doing nothing (sitting) –> dyspnea and wheezing
What are drugs for selected patients in Stage C heart failure?
- Aldosterone antagonist
- ARB
- Digoxin
- Hydralazine/nitrates
What are devices for selected patients in Stage C heart failure?
Biventricular pacing
• Implantable defibrillators
Basics of Stage D heart failure
o Refractory heart failure requiring specialized interventions
What is the patient with Stage D heart failure?
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
What is the approach to Treatment for Stage D heart failure?
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
What is the Diuretic used in heart failure?
Furosemide
Can use a thiazide like too –> Chlorthalidone
Prescription for Furosemide?
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
What are the diuretics used for?
- Heart failure leading to fluid retention; relieve symptoms but does not stop disease progression
- Should not be used alone to manage heart failure
What is the ACEI used in heart failure?
- **Lisinopril
- Captopril
- Enalapril
Prescription for Lisinopril?
Lisinopril
40 mg
One tablet daily
20-40 mg is optimal dosing; need at least 20 mg to ↓ mortality
What are the ACEI used for?
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
What is the ARB used in heart failure?
Valsartan
Prescription for Valsartan?
80 mg
One tablet twice a day
- 2nd line agent
What are the ARB used for?
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
What is the Beta Blocker used in heart failure?
- *Carvedilol
- Metoprolol ext. rel.
- Bisoprolol
Prescription for Carvedilol?
25 mg
One tablet twice a day
- Initiate at low doses and gradually increase dosing over weeks to target doses
What are the Beta Blocker used for?
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
What LVEF are you aiming for?
greater than 40%
Less than 40% is bad!
What is the Aldosterone Antagonist used in heart failure?
Eplerenone
Prescription for Eplerenone?
50 mg
One tablet daily
- If EF < 30% kick the drug in earlier
- Get rid of hormonal side effects of spironolactone
What are the Aldosterone Antagonistused for?
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!
What is the Vasodilator used in heart failure?
• BiDilTM (Hyrdralazine/nitrate)
Prescription for BiDil (Hyrdralazine/nitrate)?
One tablet three times a day
- Fixed combination, available in multiple strengths
What are the Vasodilators used for?
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
What is the Cardiac Glycoside for heart failure?
Digoxin
Rx for Digoxin?
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)
Digoxin MOA
Negative Chronotroph (↓ HR) = Increased force of contraction and decreased rate of contraction
Digoxin Kinetics
T1/2 of 36 hours so steady state at approximately 2 weeks
Discontinuation possible as drug levels deplete over long period of time
Good candidate for dogoxin
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
Not good candidate for digoxin
- Asymptomatic patients with left ventricular dysfunction and normal sinus rhythm
- Primary therapy for stabilization of patients with acutely decompensated heart failure
ADR of digoxin
Bradycardia (or tachycardia) –> check pulse before give it
Drug interactions of digoxin
Increasing digoxin levels
• antacids
• metoclopramide (Reglan™)
• St. John’s wort
Decreasing digoxin levels • amiodarone • alprazolam (Xanax™) • verapamil • spironolactone (Aldactone™)
Digoxin is what type of drug?
- 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
What are the inotropes?
- Dobutamine Infusion
* Milrinone (Primacor®)
Prescription for Dobutamine?
Dobutamine Infusion
5 mcg/kg/minute
Titrate to effect
MOA of Dobutamine?
Stimulation of the beta 1 receptors of the heart, comparatively mild chronotropic, hypertensive, arrhythmogenic and vasodilative effects
ADR of Dobutamine?
- 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
Prescription for Milrinone (Primacor®)
Loading of 50 mcg/kg IV over 10 minutes then maintenance infusion of 0.5 mcg/kg/min
How Milrinone (Primacor®) works?
o Does not work at adrenergic receptors
- Positive inotrope (↑ HR) and vasodilatory effect (↑ nitric oxide)
o Phosphodiesterase inhibitor
What is the B-Type Natriuretic Peptide (BNP) drug?
Nesiritide (Natrecor™)
Nesiritide (Natrecor™) dosing?
Bolus and then infusion up to 96 hours
MOA of Nesiritide (Natrecor™)
- 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
ADR of Nesiritide (Natrecor™)
Hypotension, Renal function ↓
Theory behind Nesiritide (Natrecor™)?
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
