Heart Failure

Question 1

Indications for use of Digoxin in HF

Answer 1

1) Antiarrhythmic for patients with atrial fibrillation

2) Alleviates symptoms and decreases hospitalizations

Question 2

Signs of Digoxin toxicity

Answer 2

Anorexia, N/V/D, fatigue, weakness, decreased HR, yellow/green halo vision, confusion, HA

Question 3

Describe the effect that ACE inhibitors have on ventricular workload.

Answer 3

decrease preload and afterload.

Question 4

Describe the benefits of using ACE inhibitors for heart failure.

Answer 4

reduces morbidity and mortality, reduces hospitilizations in HFrEF, slows disease progression: decreases or prevents ventricular remodeling.

Question 5

When should ACE inhibitors be used in patients with HF?

Answer 5

recommended for all patients with a reduced ejection fraction to prevent HF, all patients with HFrEF unless contraindicated. (pregnancy, angioedema, K > 5.5)

Question 6

How should ACE inhibitors be monitored?

Answer 6

BP, K+, renal function

Question 7

Describe the effect that beta blockers have on ventricular workload.

Answer 7

decreases heart rate and is an antiarrhythmatic

Question 8

Describe the benefits of using beta blockers for heart failure.

Answer 8

reduce morbidity and mortality, reduce hospitalizations, cause revers remodeling of left ventricle: returns heart to more normal size, shape, and function

Question 9

How should beta blockers be monitored?

Answer 9

BP, HR, fluid status

Question 10

Describe the effect that aldosterone antagonists have on ventricular workload.

Answer 10

decreases preload

Question 11

Describe the benefits of using aldosterone antagonists for heart failure.

Answer 11

reduce morbidity and mortality, reduce hospitalizations

Question 12

When should beta blockers be used in the management/treatment of HF?

Answer 12

recommended for all patients with a reduced ejection fraction to prevent HF, all stable patients with HF, unless contraindicated.
Start therapy at low doses, titrate slowly upward to the target dose and monitor closely as initiation tends to produce hypotension, fluid retention and bradycardia

Question 13

When should aldosterone antagonists be used in the management/treatment of HF?

Answer 13

recommended for patients with NYHA class II-IV who have LVEF </= 40% with symptoms of HF or DM

Question 14

How should aldosterone antagonists be monitored?

Answer 14

BP, K+, renal function (check baseline, in 3 days, 1 week, then every month for 3 months for spironolactone.

Question 15

Describe the effect that diuretics have on ventricular workload.

Answer 15

decrease preload

Question 16

Describe the benefits of using diuretics for treatment of heart failure.

Answer 16

relieve congestive symptoms (systemic edema)

Question 17

When should diuretics be used in management/treatment of HF?

Answer 17

recommended in patients with HFrEF with fluid retention.
mild overload: thiazide (especially if pt has HTN)
moderate overload: loop (may need potassium supplement)
severe overload (pulmonary edema): intravenous furosemide.
avoid overdiuresis, espeically if starting an ACEI

Question 18

How should diuretics be monitored?

Answer 18

BP, serum K+ (likely need K+ supplement unless on ACEI, ARB, or K+ sparing diuretic)

Question 19

What are special considerations for beta blockers?

Answer 19

negative ionotropic effect; titrate slowly because of this.

Question 20

When should angiotensin II receptor blockers be used for heart failure?

Answer 20

recommended for patients with HFrEF who are ACE inhibitor intolerant, alternatives to ACE inhibitors as first-line therapy in HFrEF, consider in persistently symptomatic patients with HFrEF on guideline directed medical therapy (in whom an aldosterone antagonist is not indicated or tolerated).

Question 21

How should angiotensin II receptor blockers be monitored?

Answer 21

BP, K+, renal function

Question 22

When should hydralazine/isosorbide be used for heart failure?

Answer 22

recommended for african americans with NYHA class III-IV HFrEF on guideline directed medical therapy or patients with HFrEF who cannot be given ACE inhibitors or ARBs.

Question 23

How should hydralazine/isosorbide be monitored?

Answer 23

watch for headaches, palpitations, nsal congestion

Question 24

When should digoxin be used for treatment of HF?

Answer 24

if no atrial arrhythmia, start BB so decrease HR from digoxin not preclude BB. No significant effect on survival of patients with HF, add digoxin for patients who remain symptomatic despite optimized treatment.

Question 25

How should b-type natriuretic peptide be monitored?

Answer 25

BP-decrease dose if hypotension develops

Question 26

What is the indication for use of b-type natriuretic peptide for HF?

Answer 26

IV treatment with acutely decompensated HF with dyspnea at rest or with minimal activity

Question 27

What are the four main classes of medications used to treat heart failure with left ventricular dysfunction (i.e. reduced LVEF)?

Answer 27

ACE Inhibitors, Beta blockers, Aldosterone Antagonists, and Diuretics