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Pharm II > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

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.

A

Systolic Dysfunction

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2
Q

what is a normal ejection fraction?

A

Normal: 50 - 70%

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3
Q

Heart failure with preserved left ventricular systolic function (or EF)

A

Diastolic dysfunction

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4
Q

left ventricular end-diastolic pressure (LVEDP)

A

Preload

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5
Q

systemic vascular

resistance (SVR)

A

Afterload

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6
Q

What are 2 toxic responses to NE release?

A

Arrhythmias

Apoptosis

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7
Q

Patient prevents with SOB, DOE, orthopnea, cough, PND, fatigue and weakness, memory loss and confusion, anorexia
Signs: tachy, rales, diaphoresis, S3 and S4 gallops

A

LVF

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8
Q

patient presents with : weight gain, transient ankle swelling, abdominal distention, anorexia, nausea
Signs: JVD. Edema, hepatomegaly, ascites, (+) hepatojugular reflux

A

RVF

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9
Q

HF class with no limitations to physical activity

A

NYHA class 1

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10
Q

slight limitation of activity, ordinary activity results in symptoms

A

NYHA class II

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11
Q

marked limitation of activity; less than ordinary activity results in symptoms

A

NYHA class III

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12
Q

unable to carry on any physical activity without discomfort; symptoms at rest

A

NYHA class IV

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13
Q

what class if the best for CHF procedure/ therapy?

A

Class I

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14
Q

CHF guidelines for conditions where there is conflicting evidence and/or divergence of opinions about the usefulness/ efficacy or performing the procedure/ therapy.

A

Class II

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15
Q

what level is if the data was derived from multiple randomized clinical trial

A

Level A

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16
Q

what level is when data were derived from a single randomized trial?

A

Level B

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17
Q

What level is the consensus opinion of experts was primary source of recommendation.

A

Level C

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18
Q

As GFR decreases, what diuretics don’t work as well?

A

thiazide only use if GFR >30 ml/lmin

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19
Q

what should you monitor with diuretics.

A

Monitor K+, Mg2+, BUN, SCr

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20
Q

what class id digitlais?

A

Class IIa

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21
Q

what is digoxin used for?

A

patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalization for HF

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22
Q

hemodynamic effects of digoxin

A

Increased CO
Decreased PCWP
Increased LVEF

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23
Q

what does digoxin help stop?

A

Neurohomonal effects that the body is trying to do to compensate that actually harm the body

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24
Q

Electrophysiological effects of Digoxin

A

slowing of sinus rate of SA node

slowed conduction of AV node

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25
Q

when are ionotropic effects of digoxin seen?

A

low concentrations. Inhibits ATPase pump which incrases intracellular calcium so increased contractility

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26
Q

who does digoxin seem to work better in?

A

Men

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27
Q

what is a big potential problem with digoxin?

A

hypokalemia

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28
Q

what drugs decrease digoxin clearance?

A

Amiodarone and quinidine (so decrease digoxin dose by 1/2)

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29
Q

other drug interaction with digoxin (can decrease digoxin clearnace)

A

Diltiazem, verapamil, Abx, azole antifungals, propafenone decrease digoxin clearance
furosemide

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30
Q

Symptoms of digoxin toxicity

A

Ventricular arrhythmias
heart block
anorexia, N/V

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31
Q

Tx of digoxin toxicity

A

Give digoxin Immune Fab (digibind) binds with digoxin and excreted via kidneys

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32
Q

Everyone with current or prior symptoms of heart failure and reduced LVEF should be taking what?

A

ACEI

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33
Q

what to monitor w/ ACEI

A

SrCr
Potassium
BP
cough (bradykinnin)

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34
Q

what drug may interfere w/ the efficacy of an ACEI

A

aspirin; patients should stick to lowest dose (both are recommended for HF)

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35
Q

signs of intolerance to ACEI

A

Cough (more common in Chinese)
angioedema (higher AA)
increase in SrCr

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36
Q

Alternative for ACEI

A 
Class I(a) ARBs 
 Class II(c) Combo of isosorbide dinitrate & hydralazine
37
Q

Beta Blockers used for heart failure

A

Bisoprolol
Carvedilol
Metoprolol

38
Q

Contraindications for BB

A

symptomatic brady
> 1st degree Heart block (unless have pacemaker)
evidence of fluid overload or recent requirement for IV inotropic agents

39
Q

Monitoring with BBs

A

HR, BP, weight

40
Q

when should you consider holding dose or changing reigmen for BB

A

HPOTN
bradycardia
worsening symptoms

41
Q

Effects of aldosterone in CHF

A 
NA and H20 retention
increased plasma fluid volume
elevated BP 
myocardial and vascular fibrosis
excretion of K+ and Mg++
elevated ANP
parasympathetic inhibition
42
Q

In patients with moderate to severe symptoms of heart failure, what should be added to drug regimen?

A

Aldosterone antagonist (spirolactone, eplerenone)

43
Q

what do a patient need to have before starting on aldosterone antagonist

A

SCr <5.0

moderate to severe CHF

44
Q

what do you need to monitor w/ aldosterone antagonists

A

K+ and renal function (BUN/ SCr) at 1 week and monthly for first 3 months

45
Q

When may you combine ACEi and ARB

A 
heart failure (recommended as Class IIb) 
Use in patients who are persistently symptomatic with reduced LVEF
46
Q

should you combine ACEI, ARB, and aldosterone antagonist in CHF?

A

No, should be combining ACEI + aldosterone antagonist

47
Q

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.

A

Nitrates and hydralazine

48
Q

In africans amercians with NYHA class III or IV HF what can be added along with an ACEI and BB?

A

isosorbide dinitrate and hydralazine

49
Q

ASA has been proven to reduce risk of CV events in who?

A

patients without CHF (not proven in those with CHF)

50
Q

who are anticoagulants reserved for?

A

Afib or previous transient ischemic episode

51
Q

Medications to avoid in CHF

A

antiarrhythmics (except amiodarone and dofetilide)
CCB (except amlodipine)
NSAIDs (except low dose ASA w/ ischemic patient)

52
Q

If a patient is asymptomatic, LV dysfunction EF <40%

A

ACEI or ARBs

BB

53
Q

What do you add for symptomatic CHF NYHA II

A 
ACEI or ARB
BB 
Diuretics 
Digoxin
Devices
54
Q

What do you add fro CHF NYHA III

A 
Spironolactone
ISDN/HYD
ARBs or ACEI (or both) 
BB
Diuretics
55
Q

Symptomatic CHF NYHA IV

A 
Inotropes
LV assist devices
transplantation
hospice 
may stop beta blockers
56
Q

Causes of acute decompensation of HF

A 
Medical- don't take meds
nutrition
undertreatment
progression of dz
acute MI
57
Q

3 compensatory mechanisms of HF

A

increased sympathetic activation
fluid retention
myocardial dilation and hypertrophy

58
Q

way to monitor HF and for dx

A

pulmonary artery catheterization

59
Q

If the patient is warm and dry and has no signs of CHF what stage are they?

A

Stage I

60
Q

If a patient is “warm and wet” and will have S3 and rales, what stage are they?

A

Stage II

61
Q

If a patient is “cold and dry”, has low perfusion and can go into hypovolemic shock what stage are they?

A

Stage III

62
Q

It a patient is cold and wet what are they probably experiencing?

A

Cardiogenic shock, stage IV

63
Q

If adaptive mechanisms fail to maintain cardiac output, what stage is a patient in?

A

decompensated

64
Q

3 treatment options for ADHF

A

Diuretics
vasodilators
inotropes (augment contractility)

65
Q

what are used to reduce pulmonary and systemic congestion in a decompensated patient

A

loop diuretic (furosemide) give IV (large doses) and may need continuous infusion

66
Q

what can happen with over diuresis

A

reduce CO

must monitor ins and outs

67
Q

Positive inotropes that help with ADHF

A

Beta adrenergic agonists (Dobutamine- agonist at beta 1 and 2 and alpha 1)
increases CO and vasodilation (+ inotropy)

68
Q

what should you monitor with dobutamine

A

arrhythmias
vitals, urine output
monitor vitals to look for response

69
Q

How does dopamine in ADHF at medium doses

A

beta 1 effects which increases CO and some milke alpha 1 which increases SVR

70
Q

what can too high of doses of dopamine cause

A

INcrease vasoconstriction which isn’t beneficial in ADHF

71
Q

Increase intracellular cAMP which increases intracellular calcium which increases contractility and cardiac output

A

Hosphodiesterase inhibitors

milrinone (need loading dose)

72
Q

what are some other inotroeps used in ADHF

A

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)

73
Q

what drugs can lead to arrhythmias (inotropes)

A

Dobutamine

Milrinone

74
Q

how are inotropes given

A

give for a short time period to get patient back to compensation status

75
Q

what are some venodilators used in ADHF

A

nitroprusside and nitroglycerin
morphine
nesiritide

76
Q

what venodilator is preferred when CO is not severely compromised or when other inotropic agents are administered

A

nitroglycerin

77
Q

what venodilator is also an arterial vasodilator and is preferred in patients with an increased SVR. also has a thiocyanate toxicity

A

Nitroprusside

78
Q

venodilator that reduces preload and heart rate. Typically used in early stage of tx particularly is patient has associated anxiety, restlessness and dyspnea

A

Morphine

79
Q

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

A

Nesiritide

80
Q

is there a risk of arrhythmias with nesiritide

A

No

81
Q

can you add BB with nesiritide

A

Yes (can’t add it with inotropes though)

82
Q

ADR of nesiritide

A

Worsening in renal function compared to other meds

83
Q

what should nesiritide be limited to?

A

patients presenting to hospital w/ ADHF and dyspnea at rest

84
Q

If a patient is cold and dry what is your therapaeutic goals and tx

A

Increase CO

give fluids +/- inotropes and mechanical assistance

85
Q

should you give fluids in “cold and wet” and “warm and wet” patients presentations

A

No

86
Q

If a patient is cold and wel with a low BP what do you give?

A

IV inotropes + IV diuretics + mechanical assistant

87
Q

If a patient is warm and wet what is your goal and tx

A

Relieve congestion

Tx- IV diuretics +/- nitrates or nesiritide

88
Q

Anticoags used for patients in decompensation phase

A

heparin

LMWH (enoxaparin)

Pharm II (16 decks)

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