Heart Failure

Question 1

American College of Cardiology Foundation/AHA

Stage A HF

Answer 1

High risk for development of heart failure; no underlying structural cardiac disease (hypertension, diabetes mellitus, hyperlipidemia, etc.)
Lifestyle modification
ACEIs or ARBs are drug of choice in patients with diabetes.

Question 2

American College of Cardiology Foundation/AHA

Stage B HF

Answer 2

Structural heart disease but asymptomatic
Correlates to NYHA Stage I
ACEIs or ARBs for all patients
Beta blockers in most pts (carvedilol, metoprolol succinate, or bisoprolol)
NonDHP CCBs (verapamil, diltiazem) have negative inotropic effects and may be HARMFUL in asymptomatic patients with low LVEF and no symptoms of HF after MI

Question 3

American College of Cardiology Foundation/AHA

Stage C HF

Answer 3

Structural heart disease with past or current symptoms of heart failure
Correlates to NYHA Stage II, III
ACEIs or ARBs and beta blockers
Loop Diuretics for volume overload (NYHA class II-IV pts)
Digoxin = 3rd line drug, Indicated for worsening HF due to LVD despite ACEI, BB, & diuretic therapy
Persistently symptomatic, African-American, NYHA class II-IV patients = Add hydralazine and isosorbide

Question 4

American College of Cardiology Foundation/AHA

Stage D HF

Answer 4

Refractory heart failure
Correlates to NYHA Stage IV

ACEIs or ARBs and beta blockers 
Loop Diuretics for volume overload (NYHA class II-IV pts)
Digoxin = 3rd line drug, Indicated for worsening HF due to LVD despite ACEI, BB, & diuretic therapy
Persistently symptomatic, African-American, NYHA class II-IV patients = Add hydralazine and isosorbide 

Inotropes: dobutamine (hospitalized patient)
Ventricular assist device, transplantation, hospice

Question 5

CPAP can

Answer 5

Increase LVEF and improve functional status in patients with HF and sleep apnea

Question 6

Loop diuretic

Answer 6

Mechanism of Action:
Inhibit reabsorption of sodium and chloride in proximal and distal tubules and loop of Henle.

Clinical use:
Edema, HF, Renal Disease, Cirrhosis

Contraindications:
Anuria
Hepatic coma
Severe electrolyte depletion
Hypersensitivity to loop diuretics or sulfonamides

Adverse Events:
Electrolyte and volume depletion

Question 7

furosemide (Lasix)

Answer 7

Loop diuretic

Start low for HF at 40mg twice daily, titrate dose to promote wt loss of 0.5 to 1 kg daily

Question 8

bumetanide (Bumex)

Answer 8

Loop diuretic

Has more effect on reabsorption of chloride.

Question 9

demadex (Torsemide)

Answer 9

Loop diuretic

Question 10

edecrin (Ethacrynic Acid)

Answer 10

Loop diuretic

Contraindicated in infants

Question 11

Digoxin

Answer 11

MOA:
Highly selective inhibitors of the ATPase system.
Inhibition of this pump results in sodium and calcium buildup inside the cell, which leads to increased contractility of heart muscle.
Serum concentrations greater than 1 mg/mL increase mortality.
Initiate therapy at the lowest dose possible.
Benefits are best in patients with: severe HF, enlarged heart, third heart sound, and in patients who do not respond to ACEIs and BBs.
A/e:
Gastrointestinal (GI) most common: anorexia, nausea/vomiting, diarrhea
Central nervous system: fatigue, disorientation, depression, hallucinations, visual disturbances – yellow vision and green halos around lights

Toxicity: atrial arrhythmias/tachycardia in children
Cardiac: bradycardia, premature ventricular contractions, junctional and AV block arrhythmias

Avoid using in patients with normal left ventricular systolic function.