Heart Failure Flashcards
Drugs that cause or worsening heart failure
- Chemotherapeutic agents
- amphetamines
- Anti-arrhythmic drugs: particularly class I (procainamide, quinidine, disopyramide, flecainide, and propafenone)
- Itraconazole
- NSAIDs: can cause renal dysfunction, fluid retention and worsen heart failure
- Glucocorticoids can worsen heart failure
- Triptan’s are contraindicated with a history of CV disease or uncontrolled hypertension
- TZD’s particularly Avandia
- Excessive alcohol
- Calcium channel blockers in systolic failure
Causes of systolic heart failure
Nonischemic cardiomyopathy: hypertension, valvular disease, excessive alcohol intake or illicit drug use, congenital heart defects, viral infections, diabetes, and cardio toxic drugs
Ischemic cardiomyopathy: myocardial damage such as that from a myocardial infarction
Signs and symptoms of heart failure
General: dyspnea at rest or on exertion, weakness/fatigue, SOB, reduction exercise capacity, LVH, increased BNP, increase NT – pro-BNP
Left sided heart failure: orthopnea, nocturnal dyspnea, Rales, S3 Gallup, ejection fraction less than 40%
Right sided heart failure: edema, SIGs, jugular venous distention, hepatojugular reflux, hepatomegaly
ACC/AHA staging system
A: at high risk for development of HF but without structural heart disease or symptoms
B: structural heart disease present but w/out signs or symptoms
C: structural heart disease with prior or current symptoms
D: advanced structural heart disease w/ symptoms of HF at rest despite maximal medical therapy
NYHA functional class
I: no limitations of physical activity. Ordinary physical activity does not call symptoms of heart failure
II: slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in symptoms
III: marked limitation of physical activity. Comfortable at rest but minimal exertion causes symptoms
IV: unable to carry out physical activity without symptoms of heart failure and symptoms at rest
Nonpharmacologic therapy
Very very important
- Monitor and document weight daily
- notify physician if symptoms worsen or weight increases
- sodium restriction is reasonable for patients with symptomatic heart failure at less than 1500 mg per day
- consider multivitamin due to dietary restriction and diuretics therapy
- For later stages consider fluid restriction of 1.5 to 2 L per day
- Exercise 30 minutes per day 3 to 5 days a week
OTC or alternative medicine
Avoid the use of ephedrine or pseudoephedrine products
Avoid NSAIDs including Cox two inhibitors
Hawthorne and CoEnzyme Q10 may improve heart failure symptoms based on a small study
Pharmacotherapy
- Cornerstone is diuretic therapy to control fluid volume
- Ace inhibitors and ARBs
- Beta blockers
Loop diuretics
Causes increased excretion of water, sodium, chloride, magnesium, and calcium
Use: only for symptomatic control of congestion no survival benefit
Furosemide (Lasix), bumetanide, torsemide (Demadex), ethacrynic acid (edecrin)
40:1:20:50 mg equivalency
Warning: sulfa allergy
Side effects: hypokalemia, or the static hypotension, decreased electrolytes, increased Yorick acid, increase blood glucose and triglycerides and total cholesterol, photosensitivity, ototoxicity, tinnitus, vertigo, and hearing loss (ear side effects most associated with ethacrynic acid)
Furosemide IV:PO is 1:2
Ace inhibitors and ARBs in heart failure
Titrate the drug to target doses if possible when titrating doses do so to reduce symptoms not blood pressure
Some patients may be on an ace inhibitor and an ARB and some may be on an ace inhibitor and spironolactone but never put a patient on
ace inhibitors: enalapril (Vasotec), lisinopril (prinivil, zestril), quinapril (Accupril), Ramipril (Altace)
ARBs: losartan (Cozaar), valsartan (Diovan), candesartan (Atacand)
Beta blockers
Reduce morbidity and mortality in heart failure
Recommended in all heart failure patients especially those in functional class two through four
Only carvedilol, metoprolol succinate and bisoprolol are recommended in the guidelines
Target doses: bisoprolol 10 mg, metoprolol succinate 200 mg, carvedilol 80 mg
Considerations: do not withdraw abruptly and do not use if sinus bradycardia, second or third degree heart block, sick sinus syndrome, cardiogenic shock and in those with an active asthma exacerbation
Aldosterone receptor antagonist
Reduce morbidity and mortality
Should be added to any patients regimen w/out contraindications in functional class three or four
Drugs: Spironolactone (Aldactone), eplerenone (Inspra)
Blackbox warning: tumor risk with spironolactone
Contraindications: Renal impairment creatinine clearance less than 30, hyperkalemia
Warning: do not initiate therapy in patients with a potassium greater than five or a serum creatinine greater than 2 for females or 2.5 for males
Hydralazine/nitrate
Hydralazine is a direct arterial vasodilator which reduces afterload. Nitrates are venous vasodilators and reduce preload.
Shown to increase survival but not as much as with Ace inhibitors therefore this combination is used as an alternative therapy for patients you cannot tolerate a senators or ARB used you to pour renal function in Jadima or hyperkalemia
This combination may also be beneficial in black patients therefore the product by Dell, is indicated and self identified black patients with functional glass three or four heart failure who are symptomatic despite optimal therapy with Ace inhibitors and beta blockers
Drugs: isosorbide dinitrate/hydralazine (BiDil), hydralazine, isosorbide mononitrate (Monoket)
Isosorbide dinitrate/hydralazine
Contraindication: do not use with a PDE five inhibitor
Side effects: headache, dizziness, hypertension; rarely lupus like syndrome
Monitoring: heart rate, blood pressure, signs and symptoms of heart failure
Hydralazine
Side effects: headache, reflex tachycardia, palpitations, anorexia; rarely lupus like syndrome
Monitoring: heart rate, blood pressure, Sarginson and heart failure
