Heart Failure Flashcards
two ways that someone dies from HF
arrhythmia or pump failure
HFrEF impairment on cardiac function
systolic dysfunction, decreased contractility
HFrEF ejection fraction
EF<40% w symptoms
HFrEF main cause
CAD
HFpEF impairment on cardiac function
diastolic dysfunction, impairment on ventricle filling/relaxing
HFpEF ejection fraction
EF >50% w symptoms
HFmrEF
mildly reduced 41-49%
HFimpEF
improved >40% but previously HFrEF
preload
venous return, LV end diastolic volume
afterload
wall stress
drugs to reduce preload
SGLT2, diuretics
drugs to reduce afterload
ACE, ARB, ARNI, SGLT2, vasodilators
drug classes that induce HF
positive inotropes, cardiotoxins, sodium/water retention
positive inotropes that induce HF
beta blockers, antiarrhythmics, CCB (dilt, verap), itraconzole
direct cardiac toxins that induce HF
doxorubicin, epirubicin, daunomycin, -ibs, ethanol, cocaine, amphetamines, blue cohosh
sodium load/water retention drugs that induce HF
glucocorticoids, androgens, estrogens, NSAIDs, cox2 inhibitors, -glitazone, sodium containing drugs
signs / symptoms pulmonary congestion (wet)
exertional dysopnea (DOE), orthopnea, paroxysymal nocturnal dyspnea (PND), bendopnea, rales, pulmonary edema
NYHA Class I
cardiac disease without limitations of physical activity
NYHA Class II
cardiac disease with slight limitations of physical activity
NYHA Class III
cardiac disease with limitations of physical activity
NYHA Class IV
cardiac disease with inability to cary on physical activity without discomfort
AHA Stage A
High risk developing HF (HTN, CAD, DM)
AHA Stage B
structural heart disease but no HF sx (fibrosis, MI hx)
AHA Stage C
HF symptoms or prior
AHA Stage D
advanced structural heart disease and symptoms at rest despite max therapy
Stage A therapy
ACE/ARB
Stage B therapy
ACE/ARB, beta blocker
Stage C therapy
ARNI/ACE/ARB
beta blocker
SGLT2
MRA
loop diuretic for volume overload
do diuretics reduce mortality?
no
who should receive loop diuretics?
if experiencing volume overload, want lowest dose possible
MOA loop diuretics
increase sodium and water excretion by reducing absorption at ascending limb
loop diuretics release ____ which _____
prostaglandins, increase renal blood flow
loop diuretics are blocked by what
NSAIDS
thiazide diuretics moa
block Na and Cl reabsorption in DCT
used in combo with loop in pts resistant to single drug therapy
hydrochlorothiazide and metolazone
adverse effects diuretics
decrease Mg, K+, Na+, increase uric acid
if fluid overload want to reduce weight:
1-2 lbs/day
when do we need electrolyte replacement?
K < 4
Mg < 2
ACE inhibitors cautions for adding
SBP < 80, K >5, SeCr >3
what SeCr rise is acceptable?
less than or equal to 30%
adverse effects ACE
hypotension, renal issues, hyperkalemia, skin rash, cough, angioedema
sacubitril/valsartan MOA
inhibits degraedation of BNP by inhibiting neprilysin, blocks AT1 receptos
enalapril __ = captopril ___ = lisinopril ___
enalapril 20 = capto 150 = lisinopril 20-40
high dose ACE
high dose ACE equivalent dose of entresto
49/51 BID
max: 97/103 BID
low to medium dose ACE
eGFR <30
age > 75
ACE naive
24/26 BID
how long to wait after ACE use before taking ARB
36 hours
should stage b, no sx get ARNI?
no
beta blockers benefits HF
decrease arrhythmias, cardiac remodeling
dose conversion carvedilol to Coreg CR
3.125 BID = 10 mg daily
6.25 BID = 20 mg daily
12.5 BID = 40 mg daily
25 BID = 80 daily
effects of aldoseterone
sympathetic activation
parasympathetic inhibition
vascular remodeling
MRA effects
decrease K and Mg losses
decrease sympathetic simulation
blocks fibrotic action on myocardium
avoid MRAs with what labs
CrCl<30 or K>5
avoid MRAs with what drugs
NSAIDS
SGLT2s eGFR
dapagliflozin > 30
empagliflozin > 20
BiDil pts to use
african americans needing additional therapy
pts who cant receive ACE/ARB/ARNI
Ivabradine use
pts with HR >70 on max beta blocker dose
ivabradine side effects
fetal toxicity, afib, bradycardia
digoxin effects
increase parasympathetic activity
inhibits Na/K ATPase
goal serum digoxin conc
0.5-0.9 ng/mL
drug interactions with dig
amiodarone (doubles dig)
quinadine
verapamil
itra and ketoconazole (doubles dig)
what to do when taking amiodarone
deecrease dig dose 50%
side effects digoxin
visual disturbances, anorexia, fatigue, N/V, AV block, bradycardia
which drugs should not be used
diltiazem, verapamil, nifedipine
HFpEF drugs
SGLT2 and diuretics mainly
ACE - they don’t reduce mortality
acute decomp HF diagnosis
BNP >400, altered mental status, cold extremeties, worsening renal function,
should you stop beta blockers in decomp hf
no unless recent initation led to the decomp
hold if dobutamine needed
do not add/up titrate
which therapy of decomp HF reduces mortality
none
warm and dry treatment
optimize chronic therapy
warm and wet treatment
IV diuretics / IV vasodilator
cold and dry treatment
SBP > 90 inotrope
SBP < 90 inotrope or arterial vasodilator
cold and wet
IV diuretics
SBP < 90 inotrope
SBP > 90 arterial vasodilator
acute decomp
inital IV diuretic dose should
match or exceed chronic dialy dose
given as bolus
vasodilators used for which
wet, considered over inotropes
who should not get vasodilators
symptomatic hypotension
nitroprusside
balanced vasodilator
HTN crisis
cyanide and thiacynanite toxicity
nitroglycerin
verous preferred vasodilator
ACS and HTN crisis
nesiritide
balanced vasodilation
vasodilator drugs
nitroprusside, nitroglycerin, nesiritide, morphine, enalaprilat, hydralazine
positive inotrope drugs
dobutamine, dopamine, milrinone
dobutamine
stimulates adenylcyclase to increase cAMP
consider if low BP
milrinone
PDE inhibitor
venous > arterial vasodilation
consider if on beta blocker or high SVR
inotropes are for which pts
cold
dopamine
vasopressor
secondary role to dobutamine/milrinone
