Heart Failure Flashcards
an impairment of the contraction of left ventricle such that stoke volume (SV) is reduced for any given end-diastolic volume (EDV) or filling pressure.
Systolic Dysfunction
what is a normal ejection fraction?
Normal: 50 - 70%
Heart failure with preserved left ventricular systolic function (or EF)
Diastolic dysfunction
left ventricular end-diastolic pressure (LVEDP)
Preload
systemic vascular
resistance (SVR)
Afterload
What are 2 toxic responses to NE release?
Arrhythmias
Apoptosis
Patient prevents with SOB, DOE, orthopnea, cough, PND, fatigue and weakness, memory loss and confusion, anorexia
Signs: tachy, rales, diaphoresis, S3 and S4 gallops
LVF
patient presents with : weight gain, transient ankle swelling, abdominal distention, anorexia, nausea
Signs: JVD. Edema, hepatomegaly, ascites, (+) hepatojugular reflux
RVF
HF class with no limitations to physical activity
NYHA class 1
slight limitation of activity, ordinary activity results in symptoms
NYHA class II
marked limitation of activity; less than ordinary activity results in symptoms
NYHA class III
unable to carry on any physical activity without discomfort; symptoms at rest
NYHA class IV
what class if the best for CHF procedure/ therapy?
Class I
CHF guidelines for conditions where there is conflicting evidence and/or divergence of opinions about the usefulness/ efficacy or performing the procedure/ therapy.
Class II
what level is if the data was derived from multiple randomized clinical trial
Level A
what level is when data were derived from a single randomized trial?
Level B
What level is the consensus opinion of experts was primary source of recommendation.
Level C
As GFR decreases, what diuretics don’t work as well?
thiazide only use if GFR >30 ml/lmin
what should you monitor with diuretics.
Monitor K+, Mg2+, BUN, SCr
what class id digitlais?
Class IIa
what is digoxin used for?
patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalization for HF
hemodynamic effects of digoxin
Increased CO
Decreased PCWP
Increased LVEF
what does digoxin help stop?
Neurohomonal effects that the body is trying to do to compensate that actually harm the body
Electrophysiological effects of Digoxin
slowing of sinus rate of SA node
slowed conduction of AV node
when are ionotropic effects of digoxin seen?
low concentrations. Inhibits ATPase pump which incrases intracellular calcium so increased contractility
who does digoxin seem to work better in?
Men
what is a big potential problem with digoxin?
hypokalemia
what drugs decrease digoxin clearance?
Amiodarone and quinidine (so decrease digoxin dose by 1/2)
other drug interaction with digoxin (can decrease digoxin clearnace)
Diltiazem, verapamil, Abx, azole antifungals, propafenone decrease digoxin clearance
furosemide
Symptoms of digoxin toxicity
Ventricular arrhythmias
heart block
anorexia, N/V
Tx of digoxin toxicity
Give digoxin Immune Fab (digibind) binds with digoxin and excreted via kidneys
Everyone with current or prior symptoms of heart failure and reduced LVEF should be taking what?
ACEI
what to monitor w/ ACEI
SrCr
Potassium
BP
cough (bradykinnin)
what drug may interfere w/ the efficacy of an ACEI
aspirin; patients should stick to lowest dose (both are recommended for HF)
signs of intolerance to ACEI
Cough (more common in Chinese)
angioedema (higher AA)
increase in SrCr
Alternative for ACEI
Class I(a) ARBs Class II(c) Combo of isosorbide dinitrate & hydralazine
Beta Blockers used for heart failure
Bisoprolol
Carvedilol
Metoprolol
Contraindications for BB
symptomatic brady
> 1st degree Heart block (unless have pacemaker)
evidence of fluid overload or recent requirement for IV inotropic agents
Monitoring with BBs
HR, BP, weight
when should you consider holding dose or changing reigmen for BB
HPOTN
bradycardia
worsening symptoms
Effects of aldosterone in CHF
NA and H20 retention increased plasma fluid volume elevated BP myocardial and vascular fibrosis excretion of K+ and Mg++ elevated ANP parasympathetic inhibition
In patients with moderate to severe symptoms of heart failure, what should be added to drug regimen?
Aldosterone antagonist (spirolactone, eplerenone)
what do a patient need to have before starting on aldosterone antagonist
SCr <5.0
moderate to severe CHF
what do you need to monitor w/ aldosterone antagonists
K+ and renal function (BUN/ SCr) at 1 week and monthly for first 3 months
When may you combine ACEi and ARB
heart failure (recommended as Class IIb) Use in patients who are persistently symptomatic with reduced LVEF
should you combine ACEI, ARB, and aldosterone antagonist in CHF?
No, should be combining ACEI + aldosterone antagonist
what can you add if a patient has reduced LVEF who is already taking an ACEI and BB for symptomatic HF and who have persistent symptoms.
Nitrates and hydralazine
In africans amercians with NYHA class III or IV HF what can be added along with an ACEI and BB?
isosorbide dinitrate and hydralazine
ASA has been proven to reduce risk of CV events in who?
patients without CHF (not proven in those with CHF)
who are anticoagulants reserved for?
Afib or previous transient ischemic episode
Medications to avoid in CHF
antiarrhythmics (except amiodarone and dofetilide)
CCB (except amlodipine)
NSAIDs (except low dose ASA w/ ischemic patient)
If a patient is asymptomatic, LV dysfunction EF <40%
ACEI or ARBs
BB
What do you add for symptomatic CHF NYHA II
ACEI or ARB BB Diuretics Digoxin Devices
What do you add fro CHF NYHA III
Spironolactone ISDN/HYD ARBs or ACEI (or both) BB Diuretics
Symptomatic CHF NYHA IV
Inotropes LV assist devices transplantation hospice may stop beta blockers
Causes of acute decompensation of HF
Medical- don't take meds nutrition undertreatment progression of dz acute MI
3 compensatory mechanisms of HF
increased sympathetic activation
fluid retention
myocardial dilation and hypertrophy
way to monitor HF and for dx
pulmonary artery catheterization
If the patient is warm and dry and has no signs of CHF what stage are they?
Stage I
If a patient is “warm and wet” and will have S3 and rales, what stage are they?
Stage II
If a patient is “cold and dry”, has low perfusion and can go into hypovolemic shock what stage are they?
Stage III
It a patient is cold and wet what are they probably experiencing?
Cardiogenic shock, stage IV
If adaptive mechanisms fail to maintain cardiac output, what stage is a patient in?
decompensated
3 treatment options for ADHF
Diuretics
vasodilators
inotropes (augment contractility)
what are used to reduce pulmonary and systemic congestion in a decompensated patient
loop diuretic (furosemide) give IV (large doses) and may need continuous infusion
what can happen with over diuresis
reduce CO
must monitor ins and outs
Positive inotropes that help with ADHF
Beta adrenergic agonists (Dobutamine- agonist at beta 1 and 2 and alpha 1)
increases CO and vasodilation (+ inotropy)
what should you monitor with dobutamine
arrhythmias
vitals, urine output
monitor vitals to look for response
How does dopamine in ADHF at medium doses
beta 1 effects which increases CO and some milke alpha 1 which increases SVR
what can too high of doses of dopamine cause
INcrease vasoconstriction which isn’t beneficial in ADHF
Increase intracellular cAMP which increases intracellular calcium which increases contractility and cardiac output
Hosphodiesterase inhibitors
milrinone (need loading dose)
what are some other inotroeps used in ADHF
epinephrine (Beta 1 and 2 and alpha 1 agonist)
norepinephrine(Beta 1 and 2 and alpha 1 agonist)
isoproterenol (beta 1 and beta 2 agonist- increase CO and decrease SVR)
what drugs can lead to arrhythmias (inotropes)
Dobutamine
Milrinone
how are inotropes given
give for a short time period to get patient back to compensation status
what are some venodilators used in ADHF
nitroprusside and nitroglycerin
morphine
nesiritide
what venodilator is preferred when CO is not severely compromised or when other inotropic agents are administered
nitroglycerin
what venodilator is also an arterial vasodilator and is preferred in patients with an increased SVR. also has a thiocyanate toxicity
Nitroprusside
venodilator that reduces preload and heart rate. Typically used in early stage of tx particularly is patient has associated anxiety, restlessness and dyspnea
Morphine
Vasodilator that is a Recombinant B-type natriuretic peptide
Increases intracellular cGMP which leads to smooth muscle relaxation
Promotes vasodilation, natriuresis, and diuresis
Reduces PCWP, SVR, and increase CO
Nesiritide
is there a risk of arrhythmias with nesiritide
No
can you add BB with nesiritide
Yes (can’t add it with inotropes though)
ADR of nesiritide
Worsening in renal function compared to other meds
what should nesiritide be limited to?
patients presenting to hospital w/ ADHF and dyspnea at rest
If a patient is cold and dry what is your therapaeutic goals and tx
Increase CO
give fluids +/- inotropes and mechanical assistance
should you give fluids in “cold and wet” and “warm and wet” patients presentations
No
If a patient is cold and wel with a low BP what do you give?
IV inotropes + IV diuretics + mechanical assistant
If a patient is warm and wet what is your goal and tx
Relieve congestion
Tx- IV diuretics +/- nitrates or nesiritide
Anticoags used for patients in decompensation phase
heparin
LMWH (enoxaparin)
