heart failure Flashcards

1
Q

Heart failure general info

A

when CO is inadequate to provide the oxygen needed by the body

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2
Q

Heart failure classifications

A
  1. Ejection fraction
  2. Symptoms
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3
Q

Ejection fraction

heart failure classifications

A
  1. Systolic heart failure
    * reduced EF (less than 40)
    * HFrEF- Heart failure reduce ejection fraction
    * impaired cardiac contractility
  2. Diastolic heart failure
    * normal EF
    * HFpEF- heart failure preserved ejection fraction
    * increased myocardial stiffness or an inability of the heart to relax in the absence of reduced contractility
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4
Q

Symptoms

heart failure classifications

A

Acute Heart failure- not stable
Chronic heart failure- stable

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4
Q

Symptoms

heart failure classifications

A

Acute Heart failure- not stable
Chronic heart failure- stable

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5
Q

Goals of tx for heart failure

A
  1. improve patient’s quality of life
  2. reduce symptoms–> (SOB, Nocturia, Fluid retention, Nausea due to edema of the gut)
  3. slow progression during stable periods
  4. prevent or minimize hospitalizaitons
  5. manage acute episodes of decompensated failure
  6. Prolong survival
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6
Q

Goals of tx for heart failure

A
  1. improve patient’s quality of life
  2. reduce symptoms–> (SOB, Nocturia, Fluid retention, Nausea due to edema of the gut)
  3. slow progression during stable periods
  4. prevent or minimize hospitalizaitons
  5. manage acute episodes of decompensated failure
  6. Prolong survival
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7
Q

General therapeutic approach to chronic heart failure

A
  1. determine cause and correct causative factors (tx htn or comorbitities, exercise, weight loss)
  2. sodium and fluid restriction
  3. drugs
  4. devices
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8
Q

pathophys of heart failure factors affecting cardiac function

A
  • cardiac contractility
  • cytokines
  • heart rate and rhythm
  • myocardial relaxation
  • renin-angiotensin sys
  • sympathetic nervous sys
  • ventricular preload and afterload

affect targets

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8
Q

pathophys of heart failure factors affecting cardiac function

A
  • cardiac contractility
  • cytokines
  • heart rate and rhythm
  • myocardial relaxation
  • renin-angiotensin sys
  • sympathetic nervous sys
  • ventricular preload and afterload

affect targets

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9
Q

Chronic systolic heart failure

general therapies BAD CAVA

A
  • diuretics
  • vasodilators, neprilysin inhibitor
  • beta blocker
  • aldosterone receptor antagonists
  • Angiotensin-converting enzyme inhibitors (ACE INHIBITORS)
  • angiotensin receptor blockers (ARBs)
  • Cardiac glycosides (Digoxin)
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10
Q

Acute heart failure

A
  • VID

temporary and trying to stabilize

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11
Q

heart failure stages

A

A: Risk factors- at risk without current or previous symptoms= HTN, CVD, diabetes, obesity, exposure to cardiotoxic agents
B: Structural (Pre heart failure)- evidence of increased filling pressures, RF + high NP or High cardiac troponin
C: Symptoms (symptomatic heart failure)
D: Not responding to drugs- symptoms that interfere with daily life and recurrent hospitalizations (advanced heart failure)

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12
Q

Stage A

at risk

what pts and meds?

A

at high risk for heart failure without structrual heart disease or symptoms

PT w/: HTN, atherosclerotic disease, diabetes, obesity, cardiotoxins, fam hist

TX:
1. Sodium glucose co transporter= TYPE 2 DIABETES AND EITHER CVD OR HIGH RISK CARDIOVASCULAR RISK

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13
Q

Sodium-glucose Cotransporter 2 inhibitor

Stage A

indications, Common SE

A

Dapaglifozin (Faxiga) and Empagliflozin (Jardiance)
Indications:
* pt with heart failure with Reduced ejection fraction
* pt with Type 2 DM with estabilshed cardiovascular disease
* Pt with Type 2 DM to improve glycemic control

SE:
Hypoglycemia, dehydration, vaginal and penile yeast infection (bc pee out glucose)

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14
Q

Farxiga MOA

Dapaglifozin, Sodium glucose cotransporter 2 inhibitor

A

Sodium glucose cotransporter 2= in proximalrenal tubules= responsible for reabsorp of glucose and sodium

excrete glucose= yeast infections

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15
Q

Stage B Pre- Heart failure

structural heart disease without S&S of failure

indications and therapy

A

Indications:
* Pt with previous myocardial infarction
* left ventricular remodeling (including LV hypertrophy and low EF)
* Asymptomatic valvular disease

Tx:
1. Sodium glucose Co-transporter 2 inhibitor (Diab only)
2. Angiotensin converting enzyme inhibitors (ACE inhibitors) or Angiotensin receptor blockers (ARBs)
3. beta blockers
4. statins

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16
Q

Stage B: Pre- heart failure tx

INDICATIONS BASS

A

KNOW THIS

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17
Q

Angiotensin converting enzyme inhibitors

ACE inhibitors

-pril

A
  1. Lisinopril (Zestril)
  2. Enalapril (Vasotec)
  3. Quinapril (Accupril)
  4. Ramipril (Altace)
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18
Q

Indications for ACE inhibitors PPHHD

A
  1. HTN- adult and pediatric
  2. Heart failure- 1st line for pt with Low Ejection Fractions as it has proven to reduce mortality
  3. Post myocardial infarction- 1st line for all pts as proven to reduce mortality
  4. Diabetes mellitus and those at risk for vascular disease- 1st line
  5. Proteinuria- 1st line
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19
Q

ACE benefits in Heart failure SAVVE BAP

A
  1. Improve survival benefit in pt with heart failure and systolic dysfunction= due to inhibit aldosterone and angiotensin 2
  2. improve exercise tolerance
  3. Provide balanced vasodilation (arteries and veins)
  4. Reduce Blood pressure
  5. prevents left ventricular remodeling
  6. reduce aldosterone secretions-> less retention-> reduction of preload
  7. reduced periph res-> reduction in afterload
  8. reduc angiotensin levels-> less symp activity-> by decreasing angiotensin presynaptic effects on norepinephrine release
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20
Q

ACE inhibitors MOA

A

MOA: Inhibit the angiotensin-converting enzymein the vascular endothelium of the lungs

Target: RAAS

MOA starred

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21
Q

ACE inhibitors MOA

A

MOA: Inhibit the angiotensin-converting enzymein the vascular endothelium of the lungs

Target: RAAS

MOA starred

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22
Q

ACE inhibitors AE HACH

A

1. COUGH- secondary to increased bradykinin
2. Angioedema- 2ndary to increased bradykinin
3. Hyperkalemia
4. Hypotension-> dizziness

5. headaches, rash, drug fever

Contraindications: Pregnancy (teratogenic) and bilateral renal artery stenosis

23
ACE inhibitors- drug interactions
1. Potassium sparing diuretics and potassium supplements= increased risk of hyperkalemia= MONITOR POTASSIUM 2. bactrim + ACE= increased hyperkalemia= MONITOR POTASSIUM 3. Nsaids= antagonism 4. lithium= increases levels 5. additive effects with other antihypertensives
24
Angiotensin Receptor Blockers (ARBs) | -artan ## Footnote indications, names
**use of an ARB is recommended if a pt cannot tolerate one of the SE of the ACE inhibitor= cough** Indications: * heart failur * Hypertension * Diabetic Nephrothy Medication: * Candesartan (atacand) * Irbesartan (Avapro) * Losartan (Cozaar) * Valsartan (Diovan)
25
ARBs MOA
MOA: Block the binding of angiotensin 2 to the angiotensin-1 (AT1) receptor (type 1) Target: RAAS
26
ARBs inhibitors AE and drug interactions
Effects similar to ACE inhibitors except **no bradykinin effects** * hypotension * hyperkalemia MONITOR CREATININE AND POTASSIUM LEVELS Drug interactions: * antagonized by NSAIDS * potentiate Calcium channel blockers, Digoxin, Lidocaine * Lithium increase levels
27
Adrenoceptors
1. Adrenal glands synth Catecholamines: Dopamine, Norepinephrine, Epinephrine 2. Catecholamines act as neurotransmitters and hormones-> maintain homeostasis in multiple different ways within the body 3. Receptors that respond to catecholamines are names ADRENOCEPTORS 4. Types of adrenoceptors: alpha 1 type, alpha 2 type, Beta type, Dopamine type 5. Receptors- drugs act as agonists and antagonists
28
Adrenoceptors types and what they cause
29
Catecholamines
Norepinephrine and epinephrine * via Beta 1 receptors: increase the force and rate of contraction of the heart * Myocardial excitability-> extrasystoles-> serious cardiac arrhythmias Norepinephrine * Alpha 1 receptor: Vasoconstriction * Systolic and diastolic bp rise when infused slowly Epinephrine * Beta 2 receptor: dilates the BV in skeletal muscle and liver * widening pulse pressure-> increase of cardiac rate and output
30
Beta type Adrenoceptors | types, what they do, then what Beta blocker does
types of Beta receptors: 1. **Beta 1= heart, lipocytes, brian juxtaglomerular apparatus of renal tubules** 2. B2= bronchial smooth musc and some cardiac muscle 3. B3= muscle of bladder and induces relaxation Effects: 1. Activation 2. Stim **adenylyl cyclase** 3. Increased intracellular levels of **cAMP** 4. cAMP causes cascade * liver: activation of glycogen phosphorylase * heart: increases influx of calcium across the cell membrane * smooth musc: promotes relaxation Beta blocker= **binds to receptor that inhibits Adenylyl cyclase that would increase cAMP which would activate the pump for CAlcium to enter the body and contract muscle** *Beta blocker= decreases Calcium that slows heart to relax and fill effectively to pump to body*
31
Beta blockers overview | objective
32
Beta blockers | common clinical uses, AE, Interactions
Clinical uses: * HTN * Heart failure * Arrythmias * Angina * Post MI AE: * Hypotension * Heart block * bradycardia * Fatigue- sedation * SEXUAL DYSFUNCTION * depression * exercise impairment DEPRESSED COCK BLOCK O BRADY Interactions: * with other cardiac drugs-> hypotension, and iatrogenic heart failure
33
Beta Blockers and Heart failure | meds and why we use them, relative contraindications
Meds: * Carvedilol * Metoprolol (sustained release) * Bisoprolol Why we use? * **Excessive tachy and ae of high catecholamine levels** * **B1 antagonist in kidney= decreases renin release** * **Prevent myocardial remodeling** * ***Mortality benefit in pts with chronic heart failure*** TRRM Relative contraindications: risk vs reward * asthma/COPD * AV Block * Bradycardia * Labile diabetes CAL
34
Advantage of Beta blockers in compensated heart failure
1. improve ventricular function 2. improve exercise tolerance 3. decrease oxidative damage 4. slow progression of heart failure *not used in decomp bc of acute negative inotropic effects= weaken the heart's contractions and slow the heart rate*
35
Stage C symptomatic heart failure | Structural heart disease with prior or current Symptoms of Heart failure ## Footnote Goals, Drugs, drugs for selected pts
Goals: * control symptoms * pt education * prevent hospitalization * prevent mortality Drugs: * Sodium glucose co-transporter 2 inhibitor * Renin angiotensin system blocker * beta blockers * **Diuretics for fluid retention** * **MIneralocorticoid antagonists (MRAs/Aldosterone antagonists)** Drugs for selected pts: **Hydralazine/Isosorbide dinitrate** | Edema, SOB, wheelchair
36
Chronic Systolic Heart failure= reduced Ejection Fraction | 1st line agents
1. Diuretic 2. Sodium glucose cotransporter 2 inhibitor 3. Renin angiotensin system blocker * ARNI * ACE inhibitor * ARB 4. Beta blocker DR BS | MOST DATA FOR PHARM AGENTS
37
Chronic Systolic Heart failure= reduced Ejection Fraction | 1st line agents
1. Diuretic 2. Sodium glucose cotransporter 2 inhibitor 3. Renin angiotensin system blocker * ARNI * ACE inhibitor * ARB 4. Beta blocker | MOST DATA FOR PHARM AGENTS
38
Angiotensin Receptor Neprilysin inhibitor (ARNI) | meds, black box, Indications, SE
Meds: Valsartan/Sacubitril (Entresto) Black box warning: fetal toxicity Indications: * **Reduce risk of cardiovasc death and hospitalization for heart failure in pts with chronic heart failure and reduced ejection fraction STAGE C ONLY** * TX OF SYMPTOMATIC HEART FAILURE WITH SYSTEMIC LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PEDS SE: * hypotension * dizziness * worsening kidney fxn * hyperkalemia SIMILAR TO ACE AND ARB Allows BNP to work bc neprilysin breaks it down 1. sodium and fluid excretion 2. myocardial relaxation 3. inhibit hypertrophy and fibrosis 4. supress sympathetic outflow 5. stim vasodilation | DO NOT GIVE WITH ACE INHIBITORS OR ARBS SINCE VALSARTAN IS AN ARB
39
Angiotensin Receptor Neprilysin inhibitor (ARNI) | meds, black box, Indications, SE
Meds: Valsartan/Sacubitril (Entresto) Black box warning: fetal toxicity Indications: * **Reduce risk of cardiovasc death and hospitalization for heart failure in pts with chronic heart failure and reduced ejection fraction STAGE C ONLY** * TX OF SYMPTOMATIC HEART FAILURE WITH SYSTEMIC LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PEDS SE: * hypotension * dizziness * worsening kidney fxn * hyperkalemia SIMILAR TO ACE AND ARB Allows BNP to work bc neprilysin breaks it down 1. sodium and fluid excretion 2. myocardial relaxation 3. inhibit hypertrophy and fibrosis 4. supress sympathetic outflow 5. stim vasodilation | DO NOT GIVE WITH ACE INHIBITORS OR ARBS SINCE VALSARTAN IS AN ARB
40
Sodium removal
*Maintstay of tx in symptomatic heart failure* 1. **Diuretics- lasix- 1st line to help feel good** 2. **Dietary salt restriction= reasonable to reduce congestive symptoms** *removal of sodium leads to los of potassium* * potassium supplementation * add ACE inhibitor bc hyperkalemia * potassium sparing diuretics
41
Diuretics for heart failure | general principles
**agents/meds that increase urine volume** * **reduce heart failure symptoms-> do not improve survival (star)** * reduce venous pressure and preload * reduce cardiac size-> improved pump efficacy * sodium excretion has slight vasodilating effect
42
Aldosterone antagonists | Potassium sparing diuretics ## Footnote MOA and meds
MOA: Antagonists of the effects of aldosterone in collecting tubules 1. direct antagonism of mineralcorticoid receptors= spironolactone and Eplerenone 2. inhibit sodium entrance via ion channels in luminal mem= Amiloride and triamterene Meds: * Spironolactone (aldactone) * **binds to androgen receptor= abnormal menstraul cycles, gynecomastia (male mammary enlargement), decreased libido**
43
Why target aldosterone?
1. increases resorption of sodium, water, renal excretion of potassium 2. causes myocardial and vascular fibrosis
44
Advantages of Spironolactone in heart failure
**Proven improvement in mortality statistics** * blocks effects of aldosterone-> NA/Fluid secretion, Potassium reabsorption, prevents myocardial fibrosis (reduce likelihood of arrhythmia), reduce vascular fibrosis * prevent myocardial remodeling which improves heart function
45
Summary of diuretics in heart failure
46
Vasodilators for heart failure: categories
1. Selective arteriolar dilators-> reduces afterload= **Hydralazine**- pts with fatigue and low LV output 2. Selective venous dilators-> reduces preload= **Isosorbide dinitrate**- angina 3. Nonselective (mixed) vasodilators= **Isosorbide dinitrate/Hydralazine (Bidil)- Indications= adjunct therapy in African Americans with heart failure= DIDNT RESPOND TO ARB, ARNI, ACE**
47
2ND LINE- positive inotropes | increase strength of contraction, SV, CO
1. increased cytoplasmic calcium concentration 2. increased cardiac contractility 3. increased CO Meds: 1. Cardiac glycosides 2. Beta agonists 3. phosphodiesterase inhibitors
48
Cardiac glycoside (Digitalis): Digoxin | 2nd line- positive inotropic ## Footnote indication, MOA, benefits
Indications: **Heart failure (when diuretics and ACE inhibitors have failed) and Atrial fibrillation** MOA: **Inhibits Na+K+ATPase enzyme (sodium pump) in the myocyte->>>** increases intracellular sodium leading to increased calcium->> increased cardiac contractility * slows conduction velocity through AV node-> Atrial Fibrillation Benefits of digoxin therapy: 1. increased cardiac-> **increased stroke volume and CO** 2. slows the rate and vasodilates 3. decreases preload with improved renal dynamics
49
Digoxin toxicity
Toxicity: Narrow therapeutic index: goal is 1 ng/ml, 2 is toxic High variability High plasma protein binding 70% renal excretion-> must monitor creatinine MUST MONITOR ELECTROLYTES REGULARLY: POTASSIUM, CALCIUM, AND MAGNESIUM- Bc messing with Pump Signs of toxicity: 1. GI symptoms first 2. Visual disturbance- yellow/green haloes, fuzzy Managing: Mild: reduce dose, discontinue potassium depleting drugs, give K+ Severe: **administer Digibind- digoxin specific antibody**, insert temp pacemaker
50
Digoxin drug interacitons
increased levels: * amiodarone * spironolactone Decreased levels: * Rifampin * Metoclopramide | highlighted
51
Sinus node inhibitor | indications, MOA, SE
Ivabradine (Corlanor Indications: 1. **pt with heart failure w/ persistent heart rate of equal to or >70 bpm** with a maximally tolerated beta blocker dose MOA: **slows heart rate by inhibitig cardiac pacemaker current** SE: **transitory bright lights and bradycardia**
52
Diastolic heart failure- Heart failure preserved ejection fraction | goal, tx
Goal: prevent symptoms and decrease hospitalizations TX: 1. **Diuresis to relieve symptoms of congestion** 2. **Follow guideline driven indications for comorbidities** 3. **some therapies that may be useful in reducing risk of hospitalization (but not mortality): *sodium glucose cotransporter 2 inhibitor and a Mineralocorticoid Receptor Antagonist (MRA)***
53
Acute Decompensated heart failure agents
ALL IV IV diuretics IV vasodilators IV inotropes
54
Acute decomp heart failure: Positive Inotropic drugs
Bipyridines-> Milrinone * MOA: inhibits phophodiesterase-> increase in cAMP, increase in contractility and vasodilation * **indicated for acute heart failure** Beta-adrenoceptor agonists * **Dobutamine: increases contractility and decreases afterload** * **Dopamine: activates beta and alpha receptors**
55
Acute decompensated heart failure: Vasodilators
Reduction in afterload-> improve ejection fraction 1. **Nitroprusside = arteriolar and venodilator** 2. **Nitroglycerine**= reduces preload 3. **Nesiritide**= only in acute heart failure
56
Cardiogenic shock | Goal, agents used
Goal: manage hypoperfusion and hypotension Agents: 1. manage fluid status= diuretics vs fluid administration 2. Vasopressors and inotropes= augment both coronary and cerebral blood flow * **Norepinephrine** * **Dopamine** 3. Irreversibly inhibit platelet aggregation (ASA) may improe morbidity | just a reference