hEART fAILURE Flashcards
What is the difference in definition between systolic (HFrEF) and diastolic (HFpEF) heart failure?
HFrEF is systolic heart failure or heart failure with reduced systolic function. Left ventricle ejection fraction is less than 40%. Ventricle cannot pump. Lots of treatment available.
HFpEF is diastolic heart failure or heart failure with preserved systolic function. Ventricle cannot relax. Not a lot of treatment
What are two characteristics of systolic heart failure?
impaired pumping ability of the ventricle leading to a reduced cardiac output
Left ventricle ejection fraction is less than 40%
What are two characteristics of diastolic heart failure?
left ventricle does not fill properly (relax) during diastole leading to reduced CO
ejection fraction is normal but CO is reduced
limited evidence for treatment
What is systolic heart failure also known as?
HFrEF
What tries to maintain cardiac output in heart failure? (3 points)
RAAS, SNS, endothelin, vasopressin, ANP and BNP
Why is it bad to rely on other systems to restore cardiovascular function?
it is associated with disease progression
What happens when you rely on long term SNS activation? (2 points)
myocardial stress and increased oxygen use, cardiac hypertrophy and fibrosis, cardiac muscle cell necrosis and death, arrhythmias
What are five non-pharmacological measures for heart failure?
pt education and counselling
weight loss if obese
regualr exercise
fludi restriction (1-2L per day)
sodium restriction (2-3 grams a day)
no added salt or low salt diets
daily weigths
avoid smoking
alcohol restriction
flu, pneumococcal and covid vax
What are five treatments for HFrEF?
ACEIs
ANG2 receptor antagonists (sartans)\
Neprilysin inhibitors
Diuretics
BBs
Sprionolactone
Ivabradine
Digoxin
SGLT2Is
What are three functions which the RAAS helps regulate?
BP, fluid voluem and electrolyte levels
What is aldosterone?
a hormone released from the adrenal cortex which increases water and sodium absorption and potassium excretion. It acts in the distant convoluted tubule and collecting duct
What does ANG2 do?
Causes vasoconstriction and increased peripheral vascular resistance and causes release of aldosterone which causes increased blood pressure and increased preload/afterload
What is the initial therapy for systolic heart failure?
ACEIs
What are three features of ACEIs? (3 marks)
Reduces preload and afterload, slows progression of heart failure and improves morbidity and mortality
What are three counselling points for people on ACEIs?
start with a low dose, monitor renal function, titrate dose to levels known to improve survival, add a diuretic is symptoms are not adequately controlled.
What can you use if ANG2 receptor antagonists are not effective?
ACEIs
What would you expect to see in renal function and potassium levels if using ANG2RAs in heart failure?
lower renal function and increased potassium
How is renal perfusion controlled in elderly patients with heart failure in regard to renal self-regulation?
prostaglandins vasodilate on afferent renal vessels and ANG2 causes vasoconstriction on efferent renal vessels
what is the effect of aldosterone on sodium and water and potassium levels?
increases sodium and water reabsorption and excretion of potassium
what is the effect of ACEIs and ANG2RAs on sodium and water and potassium levels?
increased sodium and water excretion and reduced potassium excretion
What is ANP, BNP and CNP?
Naturetic peptides which are release on heart distension
List 4 functions of naturetic peptides
vasoialtion, diuresis and natriuresis, inhibition of renin and aldosterone release, reduction of sympathetic activity, reduction on preload and afterload, antihypertrophic and anti-fibrotic effects that reduce cardiovascular modelling
How are naturetic peptides broken down?
by neprilyis, an enzyme
What inhibits the breakdown of natural peptides?
sacubitril
What are 3 effects of sacubitril to treat systolic HF?
vasodialtion, diuresis and naturesis, inhibits renin and aldosterone release, reduces sympathetic activity and reduces preload and afterload
What is one practice point to remember about sacubitril?
never administer with an ACEI as it could cause angioedema- 36 hour washout period
What is a practice point for loop diuretics?
should not be used as monotherapy in HF, does not improve prognosis or mortality
What is a competitive antagonist of aldosterone?
spironolactone
What is the effect of spironolactone on sodium, water and potassium levels?
increases sodium and water excretion and decreases potassium excretion
what are 2 side effect of spironolactone?
it has anti-adrenergic activity which could lead to gynaecomastia
hyperkalaemia due to reduces potassium excretion
What should you not combine with spironolactone?
ACEIs and A2 antagonists- can cause sever hyperkalaemia and death
List 4 beta blockers (including their selectivity) which are useful in systolic HF
Bisoprolol- B1 selective
Metoprolol- B1 selective
Nebivolol- B1 selective (vasodilating properties)
Carvedilol (alpha 1 receptor blocking activity)
What are two possible MOAS of BBs in systolic HF?
reduces sympathetic activity
reduce cardiac ischemia and dysrhythmias
reduced renin release
What are two practice points for BBs in heart failure?
start low and go slow
first four to eight weeks, symptoms may worsen, add to existing ACEIs can cause mortality and morbidity issues
How can you predict adverse outcomes in someone with systolic heart failure?
measure HR
What is the effect of Ivabradine on the heart?
It reduces it by inhibiting the SA node which is responsible for spontaneous depolarisation
What is the drug class of digoxin?
cardiac glycoside
What is the MOA of digoxin?
slows HR and increases contraction force, inhibits the sodium potassium pump causing an increase in intracellular calcium
What are 3 points about Digoxin?
low therapeutic range
long half life
mostly excreted in the urine
hypokalaemia increases toxicity
What are two adverse drug reactions for digoxin?
Nausea, vomiting, diarrhoea, green/yellow vision, bradycardia, ectopic beats and arrhythmias
What is SGLT2?
the predominant transporter for the reabsorption of glucose from the glomerular filtrate back into the circulation
What are two SGLT2 inhibitors?
dapagliflozin and empagliflozin
What should you monitor when using SGLT2Is in HF?
fluid balance
What is the only drug group that shows real benefit in diastolic HF?
SGLT2Is
What is the rationale for drug use in heart failure? (5)
Halt disease progression, improve survival, improve remodelling, prevent complications and relieve symptoms
What are three non-pharmacological treatments for heart failure?
patient education and counselling, fluid and sodium restriction, weight loss if obese, exercise. Flu, pneumococcal and COVID vax
What are three pharmacological options for heart failure?
angiotensin receptor neprilysin inhibitor (ARNI) with a sartan, beta blocker, aldosterone antagonists, SGLT2 inhibitors, loop diuretics, ivabradine and digoxin
What are two drugs used in first line treatment of heart failure?
ARNI (combo of Neprilysin inhibitor and sartan) and SGLT2I
What are 2 adverse effects of an ARNI?
hypokalaemia, renal impairment, hypotension, increased serum creatinine, diarrhoea, cough
What are two things to monitor when using an ARNI?
Monitor serum creatinine, potassium concentration and blood pressure
What are two adverse effects of an SGLT2I?
genital infections, polyuria, dysuria, uti, dyslipidemia, hypoglycaemia
What are 2 things you should monitor when using an SGLT2I?
renal function at least annually, serum creatinine and eGFR.
What are 2 practice points for digoxin?
check renal function and electrolyte concentrations before starting digoxin
regularly assess patients for digoxin toxicity
