Heart Failure Flashcards
Clopedigrel blocks ________ and tirofiban blocks _________.
Clopedigrel: P2Y12
Tirofiban: GP IIb/IIIa
Tirofiban stops fibrin from TYing platelets together.
What three measures by the heart in response to decreased arterial pressure (i.e. in heart failure) are like drinking salt water when you’re thirsty?
- increased sympathetic drive (baroreceptor reflex)
- cardiac dilation
- anti-diuresis (RAAS)
How does the Frank-Starling Law apply to heart failure drugs?
It’s aimed at getting the ranges capable stroke volume to a better level with respect to ranges of venous blood pressure.
What bottle of diuretics gets opened when the HF is severe?
Spirolactone, K-sparing
What are the first line two groups for HF for addressing fluid retention?
Loops, thiazides.
You’ve given diuretics for the fluid retention and how they’re arrhythmic. What’s happened?
Diuretics have lead to an electrolyte imbalance.
3 symptoms of thiazides that aren’t hypokalaemia, hyponatraemia or metabolic alkalosis.
gout, impotence, glucose intolerance
Think about it - why thiazides instead of loops for HF?
Loops are really more for serious fluid retention or oedema, they’re much stronger.
Thiazides and loops. Which one causes impotence and which one hypovolaemia?
(Otherwise the same side effects).
Loops (stronger): hypovolaemia
Thiazides: impotence.
What 2 side effects of ACEIs aren’t dry cough, hyperkalaemia or first-dose hypertension?
Rashes
RARE angiooedema
T or F: ACEIs are a cornerstone of HF therapy?
TRUE.
What are the only two side effects listed for ARBs? (wha..)
hyperkalaemia
RARE angioedema
Why are ACEIs loved more than ARBs?
Bradykinins are thought to reduce cardiac remodelling.
What’s the significance of bradykinin in HF?
More kinins helps reduce cardiac remodelling. Hence ACEI>ARBs.
Why is B2 blockage BAD in HF and normal B2 stimulation GOOD?
B2 - lungs and arteriolar SMCs (among other places).
B2 - stimulation
What Bblockers are appropriate for HF because they show (dose dependent) B1 selectivity?
I met a guy who ate too many biscuits which prolly attentuated his health.
Bisoprolol, atenolol and metaprolol
Which Bblockers are preferred in HF?
prolly not atenolol
bisoprolol and metaprolol.
What are the only real indications for B-blockers in HF
HF with A-fib to improve ventricular filling.
Diastolic HF to improve ventricular filling.
What CV does the slow titration of dose MAJORLY apply to?
Beta-blockers.
If you hear carvedilol, just know:
new Bblocker with good vasodilation and a1 block (to balance out the negative ionotropy…)
In systolic HF, the what is a short term risk other than bradyarrhythmia, hypotension or worse HF?
Worsened renal failure.
What’s an example of a sympathomimetic?
Like someone who pretends to be sympathetic but then just dobs you in?
Dobutamine
What’s dobutamine?
B1 agonsit (sympathomimetic)
What’s the rational for spironolactone added to ACEI therapy?
undermines “aldesterone escape”, where aldesterone will return to pre-treatment levels.
What does digoxin ideally do?
Increases cardiac output but slows it down. Thus reduces the baroreceptor reflex and sympathetic drive AND improves renal blood flow, settling RAAS.
Why doesn’t digoxin prolong life?
No effect on cardiac remodelling.
Why does inhibiting the Na/K ATPase increase contractility? (digoxin)
More Na+ in the cell for the preferable Na/Ca2+ pump, so more calcium gets pumps into the cells. Better calcium accumulation.
Digoxin: renal or hepatic excretion?
RENAL. Renal function important.
Digoxin in a PK nightmare.
Absorption?
Half life?
Distribution time?
Variable absorption
Half life 1-1.5 days
6 hour distribution time
Bonus: maintenance dose requires testing and renal function analysis.
What are 3 cons of digoxin?
Highly sensitive to electrolyte imbalances
Very narrow therapeutic index
High risk of arrhythmia
No food syndrome - nausea, anorexia, vomiting, diahhorea
What’s the major digoxin risk?
Arrhythmia
In case you see milrinone, that’s:
Milrinone: HF drug: positive ionotrope (calcium)
You’ve got a patient on ACEI + BB + Diuretic. You’re starting low and going slow. You hit a bump in the road wrt dosin - which stays the same while the others’ doses are reduced?
The beta blocker. The beta blockers stays the same.
Fine tuning can take months of monitoring.
Do I add digoxin yet doctor? I know it’s not severe yet but…
Only in A-fib or when ACEI+diuretics isn’t working.
OMG there’s a-fib with rapid ventricular fibulation?
Which drug bursts into the room and asks really confidently “Did someone say…….
….. DIGOXIN?”
Acute cardiogenic pulmonary oedema. What comes between frusemide and positive ionotropes?
If I got pulmonary oedema I’d feel MOC’D by nature.
morphine then organic nitrates then constant positive oxygen then dopamine.
Acute cardiogenic pulmonary oedema. What comes between frusemide and positive ionotropes?
morphine, organic nitrates, CPAP then dopamine.
