heart failure Flashcards
HF
A mismatch between right and left heart volume
outputs”
left side failure
becomes cecexic. backs up in lungs and coughs
right heart failure
builds up fluid in abdomen (ascites)
systolic hf
decrease contractility. decrease EF. patients tend to be younger. dialated hearts
diastolic HF
decrease ventricular filling decrease CO. cannot fill because its stiff. older patients. hypertrophied heart
main hf causes
ischemia, idiopathic, viral, immune mediated, htn
ischemic HF
Can contribute to both systolic and diastolic
dysfunction
• Most common (~70%?) type of HF in
America.
2) Idiopathic HF
Familial? (~ 1/3?) • Toxins? • Parasitic? • Undiagnosed viral? • Pregnancy-related?
3) Viral HF
Viral” (another term for “idiopathic) • Many, many viruses implicated. Viruses “errantly” take up residence in myocardial cells… • Moderate/severe cardiomyopathy (what’s this?) develops… • …and may or may not fully or completely resolve (eventually) • Might require valvular Sx due to new cardiac “geometry
Immune-Mediated HF
Specific cardiac antibodies attack
cardiomyocytes
• Possible link to other immune-mediated
diseases (like what?) LUPUS RHEUMATOID ARTHRITIS
• Acute myocardial infarctions (AMIs) may
expose novel cardiac antigens affecting
long-term prognosis. inside of heart is supposed to be inside and body will develop immune response to heart
why does the heart remodel
Heart cells die… …they’re replaced with fibrotic tissues… …and remaining cells hypertrophy
What forces contribute to the chronic
downhill HF slide?
chronic sympathetic stim. and renin angiotensin aldosterone system
goals of therapy for HF
1) Improve/alleviate critter’s symptoms • 2) Slow that “downhill slide” towards transplant/VAD/death • 3) Improve survival ***Increase critter’s QALYs*
six classes of QALY improving drugs
1) Positive Inotropes
2) Diuretics
3) Renin/Angiotensin Blockers
4) Primary Vasodilators
5) β-Blockers
6) Aldosterone Antagonists
7) Neprilysin Inhibitor (the future?)
positive inotropes
Cardiac Glycosides
- Catecholamines
- Bipyridines
digitalis
digoxin. cardiac glycoside. Positive Inotrope • Negative Chronotrope • Increased Baroreceptor sensitivity. *Narrow therapeutic window -Arrhythmias, GI symptoms *No evidence these drugs prolong life!
how doe digitalis work
Blocks Na⁺/K⁺-ATPase “The Sodium Pump”
…and you know what THAT causes! increase NA INCREASE CA increase contraction
PREFERRED DRUG FOR CARDIAC
ARREST!!
Epinephrine (Adrenaline). Also handy for anaphylactic (what’s this?)
reactions
-Predictable side effects.
Dopamine
A relatively non-specific catecholamine; acts
on dopaminergic receptors
• Improves cardiac function in heart failure.
• Also used for renal failure
and shock
• Given by IV drip infusion
DOBUTAMINE
Also acts on dopaminergic receptors but
more cardioselective
Bipyridines what they do to the body
increase intracelular levels of cAMP =
increase intracellular levels of Ca⁺⁺ =
increase myocardial contractility
bipyridines long term use results in
significantly higher mortality than that seen in untreated
patients!
*ONLY used in short-term (acute) HF patients…
Frequently the D.O.C. at all stages of HF,
particularly in patients with low EF (what’s
this? what’s normal?)
Renin-Angiotensin Converting
Enzyme Blockers. Initiation of ACE-Inhibitor Rx after AMIs
is widely considered a standard of care**
-Often used as part of a progressive multimodal
Rx (huh?..we’ll discuss in a minute
losartan
cozaar. arb s. used as a replacement for ACE inhibitor in intolerant patientsmay also be used with ace inhibitors in decompensating patients
D.O.C. venous dilators
for acute CHF episodes
nitrates
patients intolerant of ace inhibitors and arbs or beta blockers. give
hydralazine or isosorbide
Why would you be giving negative
inotropes to patients in HF?
block chronic sympathetic stimulation and prevent apoptosis of myocyte. not for acute HF
aldosterone antagonist
prevent salt fluid retention myocardial hypertrophy and decrease K excretion. improve long term mortality
lcz 696
A 50/50 mix of Valsartan (about which you
have a perfect & complete understanding)
and Sacubitril
• Sacubitril is metabolized into a neprilysin
inhibitor
Neprilisyn
an enzyme which breaks down
atrial (ANP) & brain (BNP) natriuretic
peptides
• ANP is mostly released in response to
excessive blood volume (mostly in response
to excessive atrial “stretch”) and causes an
increase GFR, increase sodium loss, and decrease renin secretion
morphine. acute HF
Classically used in acute heart failure to reduce preload, heart rate, and (maybe?) afterload. • NO evidence it helps; substantial evidence it produces worse longterm outcomes
morphine chronic HF
– Lowers respiratory rate which decreases cardiac workload – Decreases preload and afterload (some…a good reason to say why you’re giving morphine…) – EASES ANXIETY! Do you understand where we’re going with thiS?
RHF SYMPTOMS
FATIGUE, INCREASE PERIPHERAL RESISTANCE,ENLARGED LIVER SPLEEN,DISTENDED JUGULAR VEIN, ANOREXIA,GI DIDTRESS, SWELLING IN HANDS DEPENDENT EDEMA
LEFT SIDED FAILURE
PAROXYSMAL NOCTURNAL DYSPNEA PULMONARY CONGESTION,CONFUSION,FATIGUE, RESTLESSNESS, CYANOSIS,ORTHOPNEA, Tachycardia
