Heart Failure Flashcards
T/F patients with heart failure all have volume overload
FALSE
why the term “heart failure” is actually preferred over CHF
volume coming into ventricles (end diastolic pressure)
preload
resistance - left ventricle must overcome to circulate load
afterload
percent of left ventricular blood ejected during each systolic contraction
ejection fraction (EF)
What is a normal EF?
60%
How is EF calculated?
stroke volume/end-diastolic volume
HFrEF
systolic dysfunction
heart failure with reduced ejection fraction
Disease that might lead to HFrEF
cardiomyopathies, CAD, valve diseases, arrhythmias
HFpEF
diastolic dysfunction
heart failure with preserved ejection fraction
Problem with HFpEF is _______ and problem with HFrEF is _________
1) filling (diastolic dysfn)
2) ejection (systolic dysfn)
Disease that might lead to HFpEF
chronic hypertension, aortic stenosis, cardiomyopathies (hypertrophic or restrictive)
What is the Frank-Starling mechanism?
the ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return
(i.e. incr. venous return to the heart –> incr. SV)
Symptoms of HF
FACES
Fatigue Activity decrease Cough (esp. supine) Edema Shortness of breath
What is the DIET approach to pt. w/ HF?
Diagnose
Initiate (drugs)
Educate (diet, lifestyle)
Titrate (adjust drugs)
What is EF in HFrEF?
= 40%
What is EF in HFpEF?
> /= 50%
Which type of HF has actually been studied in clinical trials?
Only HFrEF (systolic HF)
To date, efficacious therapies have not been identified for HFpEF (diastolic HF)
**HFpEF is a dx of exclusion
Stage A HF (ACC-AHA Classification)
High risk for HF, no SHD
HTN, CAD, DM, obesity, metabolic syndrome
Stage B HF (ACC-AHA Classification)
Asymptomatic HF, +SHD
previous MI, LVH, or low EF, asx valvular dz
Stage C HF (ACC-AHA Classification)
Symptomatic HF, +SHD
SOB, fatigue, reduced exercise tolerance
Stage D HF (ACC-AHA Classification)
Refractory end-stage HF, +SHD
sx at rest despite maximal medical therapy; recurrent hospitalizations
When would you use diuretics in HF?
symptomatic benefit in pt. w/ current or prior sx of HF and reduced LVEF who have evidence of fluid retention
should use used along with salt restriction
(in general should not be only therapy in stage C)
What is a ceiling dose?
eventually, if you keep pushing the dose, you don’t get a greater benefit (this is when you would add another drug)
**Pt. with HF need higher doses of diuretics to get same response, and have diminished responses to ceiling doses
T/F, you cannot use thiazide and loop diuretics in combination
FALSE
esp. in pt. with HF that have diuretics resistance to loops, you may need to a thiazide in combo
What monitoring should be done in pt. on diuretics?
electrolytes (esp. potassium)
loop diuretics are more powerful than thiazides and must be used with caution to avoid dehydration
What is the key point to remember when tx pt. with diuretics?
SODIUM RESTRICTION!
if they aren’t restricting sodium, the diuretics may not work b/c water will follow sodium
Nitroglycerine class
Nitrate - vasodilator
Nitroglycerine MOA (HF)
decreases preload
stimulates NO
Nitroglycerine indications (HF)
warm and wet acute decompensated HF (ADHF), ACS
Nitroglycerine adverse effects
hypotension, reflex tachycardia, HA, tachyphylaxis
Nitroprusside class
direct vasodilator
Nitroprusside MOA
decreases preload and afterload
stimulates NO
Nitroprusside indications
warm and wet acute decompensated HF (ADHF), alternative to inotropes in cold and wet ADHF
Nitroprusside adverse effects
hypotension or cyanide or thiocyanate toxicity
Nesiritide class
vasodilator, cardiac glycoside
Nesiritide MOA
decreases preload and afterload
Nesiritide indications
warm and wet acute decompensated HF (ADHF), alternative to inotropes
Nesiritide adverse effects
primarily hypotension (up to 1 hr), tachycardia
When would you Rx inotropes?
as a LAST resort w/ HF
they have a lot of serious s/e and should NEVER be used in an out-patient setting
What are the inotrope drugs talked about in class?
dobutamine (B1 agonist) and milrinone (PDE inhibitor –> incr CO)
ARNI
angiotensin receptor/neprilysin inhibitor
newest drug to hit the market and is going to replace ACEI
significantly decreases mortality rates
Which therapy combo has the highest reduction in mortality rates in HF pt?
BB + ACEI/ARB + ICD (implantable cardioverter-defibrillator)+ HF educations + anticoagulation for AF
When are ACEI indicated with HF?
Should be used in all pt. with a reduced EF to prevent HF
Recommended for all pt. with HFrEH
ACEI s/e
hypotensions, cough, renal effets, angioedema, teratogenic, hyperkalemia, rash and taste disturbance, transient incr. in serum creatinine
What do you need to monitor with on ACEI/ARB?
BP
BMP (electrolytes) w/in 1-2 wks
When is SCr concerning with ACEI/ARB tx?
a rise of >/= 0.5 needs evaluation
although expect a transient 20-30% incr in SCr after starting drugs
serum creatinine measures kidney fn
What do you need to remember when starting ACEI?
start SLOW
titrate every 2-4 wks toward target dose
T/F you cannot use ACEI and ARB together?
TRUE
it can be harmful to use them in combo
When would you use ARB is therapy?
- pt. with HFrEF who are ACEI intolerant
- reasonable as alternatives to ACEI as first line therapy in HFrEF
- pt. w/ a hx of MI and reduced EF, should be put on ACEI/ARB to prevent HR
How should you initiate ARB tx?
slowly
What is the recommendation for using ARB and ARNI in combo?
ARNI should NOT be administered concomitantly with ACE inhibitors or within 36 hr of the last dose of an ACEI
When are aldosterone antagonists recommended clinically?
- pt. with class II-IV HF who have LVEF = 35%
- pt. following an acute MI who have LVEF = 40% with sx of HF or DM
Which aldosterone antagonists are commonly used for HF?
Spironolactone/Eplerenone are “easy” drugs to prescribe for HF!!!
single dose once daily, no titration necessary
What are the cautions with aldosterone antagonists?
1) significant risk of hyperkalemia ( > 5%), needs close monitoring!!!
2) 10% risk of gynaecomastia w/ spironolactone (< 1% with eplerenone)
C/I to eplerenone
1) serum potassium > 5.5 mEq/L at initiation
2) creatinine clearance = 30 mL/min (can start at lower dose if CrCl 31-49 mL/min)
3) concomitant use of CYP3A4 inhibitors
C/I to spironolactone
1) serum potassium > 5 mEq/L at initiation
2) serum creatinine >2.5 mg/dL at initiation
3) renal insufficiency
Monitoring with aldosterone antagonists
1) titrate every 4-8 wks twd target dose
2) monitor BMP 3-7 days after start of therapy, the once monthly for 3 mo., then periodically as needed
(significant rights of hyperkalemia)
When should you use BB clinically in regards to HF?
1) in pt. w/ MI and reduced EF, use BB to prevent HF
2) in all pt. with reduced EF
(use of 1 of the 3 BB proven to reduce mortality is recommended for all stable pt)
What are the 3 BB proven to reduce mortality in pt. at risk for HF?
bisoprolol, carvedilol, and metoprolol succinate
What is a good alternative if pt. is hypotensive on carvedilol or cannot tolerate lower BP?
metoprolol succinate
**also good for pt. w/ Afib, COPD, asthma
adrenergic activation is lethal in __________
chronic HF
(why we use beta-blockers)
*pt. with highest NE levels have worst prognosis
BB C/I
1) cardiogenic shock
2) symptomatic bradycardia
3) 2nd/3rd degree heart block w/out pacemaker
4) severe reactive airway dz
- use w/ considerable caution in pt. w/ < 55 bpm or SBP < 80 mmHg
- NOT recommended in pt. with asthma with active bronchospasm
BB s/e
1) fatigue, weakness, lassitude
2) fluid retention
3) bradycardia
4) volume overload vs. COPD
Introducing BB to pt.
titrate every 2-4 wks toward target dose
may need to adjust diuretic dose
Monitoring with BB
BP, HR, HF sx, weights
Hydralazine class
arteriolar dilator
antioxidant (inhibits destruction of NO)
Isosorbide dinitrate (ISDN) class
venous dilator
large and small a. dilator
NO doner
BiDil
NO enhancer
**This is a combination drug that is a fixed dose of isosorbide dinitrate + hydralazine
Hydralazine s/e
hypotension, HA, tachycardia (less in HF), lupus like syndrome (+ANA)
Nitrates s/e
hypotension, HA, flushing, tolerance
Hydralazine, ISDN, BiDil are NOT recommended unless
pt. are unable to tolerate ACEI
When is Digoxin recommended?
HF with concurrent Afib
**controversy to use in normal rhythm (SE risk vs. benefit)
Digoxin MOA
unclear
- prob. NOT d/t positive inotropic effect
- likely benefits from neurohormonal inhibition
Target peak concentration (Cp) of Digoxin
0.5-0.8 ng/mL
T/F in clinical trials Digoxin use showed an increase rate of survival
FALSE
No survival benefit was seen at 4 yrs (although it did reduce symptomatic progression)
Clinical benefits seen from digoxin use
1) improved sx
2) improved exercise tolerance
3) improved QOL
4) decr. hospitalizations
***there is NO survival benefit
Digoxin s/e
CNS = HA, dizziness, halos, changes in yellow/green color perception
GI = anorexia, N/V, diarrhea, constipation
Cardiac = bradycardia (AV block), HR < 50, incr. PR interval
Risk factors for digoxin toxicity
renal insufficiency, hypokalemia/hyperkalemia, drug interactions
Digoxin interactions
See incr. serum concentration w/ amiodarone, erythromycin, itraconazole, omeprazole
See decr. serum concentrations w/ antacids, colestipol, laxatives
Which HF drugs should be considered in AA population?
hydralazine/ISDN
If EF < 35% despite optimized std therapy, consider
ICD
Tx protocol of HFpEF
1) tx physological factors (BP, HR, blood volume, ischemia)
2) tx dz known to cz HFpEF (HTN, CAD)
3) use of anticoagulation and anti-arrhythmic recommendations apply to all pt. w/ HF
**lack of randomized controlled trials
Hawthorn (Crataegus oxycantha) uses
CHF, angina, arrhythmias, hyperlipidemia, Buerger’s dz
Hawthorn (Crataegus oxycantha) adverse effects
hypotension, palpitations, progression of HF
Crataegus oxycantha interactions
1) w/ BB, CCB, PDE-5 inhibitors, nitrates - decreases BP, dizziness, and/or light headedness
2) w/ antiplatelet/anticoagulants - incr. bleeding risk
Hypericum uses
depression, anxiety, sleep d/o, HIV
Hypericum s/e
arrhythmia and HTN
Hypericum interactions
w/ Digoxin, Statins, Verapamil, Warfarin, ARB, BB - decr. levels of drug
CAMs that may be mechanistically harmful in HF
aconite, ginseng, gossypol, gynura, licorice, lily of the valley, tetrandrine, yohimbine
