Heart Failure Flashcards
1
Q
Heart failure results from…
A
the inability of the heart to pump sufficient blood to meet the metabolic needs of the body.
2
Q
Systolic Dysfunction
A
reduced contractility and reduced ejection fraction
3
Q
Diastolic dysfunction
A
stiffening and loss of adequate relaxation, which reduces filling and CO
ejection fraction may be normal
4
Q
Systolic etiologies
A
- ischemic heart disease
- chronic HTN
- dilated cardiomyopathy
- myocarditis
5
Q
Diastolic etiologies
A
- HTN with LV Hypertrophy
- restrictive and hypertrophic cardiomyopathies
- fibrosis
- amyloidosis
- sarcoidosis
- constrictive pericarditis
- hemochromatosis
- valvular disease
- aging
6
Q
You will hear an S3 gallop in ______ heart failure
A
systolic
7
Q
You will hear an S4 gallop in ______ heart failure
A
diastolic
8
Q
_______ limits diastolic filling time and coronary flow, further stressing the heart.
A
Tachycardia
9
Q
Primary and signs and symptoms of all types of heart failure
A
- tachycardia
- decreased exercise tolerance
- shortness of breath
- cardiomegaly
- peripheral and pulmonary edema are often but not always present
10
Q
ACC/AHA Stage A HF
A
Patients at high risk for developing heart failure
Ex: HTN, ASCVD, DM, obesity, metabolic syndrome
11
Q
ACC/AHA Stage B HF
A
pts w/structural heart dz but no HF signs or symptoms
Ex: Previous MI, LVH, LV systolic dysfunction
12
Q
ACC/AHA Stage C HF
A
pts w/structural heart disease and current or previous symptoms
Ex: LV systolic dysfunction & symptoms like dyspnea, fatigue, and reduced exercise tolerance
13
Q
ACC/AHA Stage D HF
A
refractory HF requiring specialized interventions
Ex: pts with treatment refractory symptoms at rest despite maximal medical therapy: pts requiring recurrent hospitalization or who cannot be discharged without mechanical assist devices or inotropic therapy.
14
Q
NYHA Class I
A
no limitation of physical activity
ordinary physical activity does not cause symptoms
15
Q
NYHA Class II
A
slight limitation of physical activity
comfortable at rest
ordinary physical activity causes symptoms
16
Q
NYHA Class III
A
marked limitation of physical activity
comfortable at rest
less than ordinary activity causes symptoms
17
Q
NYHA Class IV
A
severe limitation and discomfort with any physical activity
symptoms present even at rest
18
Q
Goals of pharmacologic therapy of HFrEF
A
improve symptoms (risk of hospitalization)
slow or reverse deterioration in myocardial function, and reduce mortality
19
Q
Improvement in symptoms is achieved by which drugs?
A
- diuretics
- BB
- ACE-I
- ARBs
- ARNI (angiotensin receptor-neprilysin inhibitor)
- hydralazine plus nitrate
- digoxin
- aldosterone antagonists
20
Q
Prolonged survival rate has been documented with which drugs?
A
- Beta Blockers
- ACE-I
- ARNI
- hydralazine plus nitrate
- aldosterone antagonists
21
Q
T/F: drug therapy should be titrated as tolerated to target ranges for optimum clinical benefit
A
TRUE
22
Q
T/F: benefits observed from aggressive monitoring strategies suggest treatment beyond clincial congestion may improve outcomes
A
TRUE
23
Q
What medications would you use for Stage A HF pts?
A
ACE-I or ARB or BB
24
Q
What meds would you use for Stage B pts with HF
A
ACE-I or ARB as appropriate
BB as appropriate
In select patients:
- ICD
- Revascularization or valvular surgery as appropriate
25
What meds would you use in patients with **Stage C** HF
**HFrEF:**
- diuretics
- ACE-I or ARB
- BB
- Aldosterone antagonists
- Ivabradine
- Sacubitril/Valsartan
**In select pts:**
- hydralazine/isosorbide dinitrate
- Digitalis
- CRT
- ICD
- Revascularization or valvular surgery as appr.
**HFpEF:**
- Diuresis
- Guidelines driven indications for comorbidites
- **Aldosterone antagonism** to reduce HF hospitalizations
26
What meds would you give pts with **Stage D HF**?
- advanced care measures
- heart transplant
- temporary or permanent MCS (mechanical circulatory support)
- Experimental surgery or drugs
- Palliative care and hospice
27
**MOA:** **Decreases NaCl, KCl, Calcium, Magnesium reabsorption** in **thick ascending limb** of the loop of Henle in the nephron
What drug is this?
Furosemide
28
Effects of this drug:
- increased **excretion of salt and water**
- reduces **cardiac preload & afterload**
- reduces **pulmonary and peripheral edema**
**What drug is this?**
Furosemide
29
Clinical applications of Furosemide
* **Acute and chronic heart failure**
* severe hypertension
* edematous conditions
30
Toxicity:
hypovolemia, hypokalemia, orthostatic hypotension, ototoxicity, sulfonamide allergy
Furosemide
31
**MOA:** Decreases NaCl reabsorption in the **distal convoluted tubule**
**What drug?**
Hydrocholorothiazide (HCTZ)
32
Clinical applications of Hydrocholorothiazide (HCTZ)
* **mild chronic HF**
* mild-moderate hypertension
* hypercalciuria
* **has not been shown to reduce mortality**
33
Toxicity:
- hyponatremia
- hypokalemia
- **hyperglycemia**
- **hyperuricemia**
- **hyperlipidemia**
Hydrocholorothiazide
34
**MOA:** blocks cytoplasmic **aldosterone receptors** in **collecting tubules** of nephron, possible membrane effect
What drug?
Spironolactone (Aldosterone Antagonist)
35
Effects:
**- increased salt and water excretion**
**- reduces remodeling**
- reduces mortality
Spironolactone (Aldosterone Antagonist)
36
Clinical applications of **Spironolactone**
- **Chronic heart failure**
**-** aldosteronism (cirrhosis, adrenal tumor)
- hypertension
- **has been shown to reduce mortality**
37
Toxicity:
**Hyperkalemia:** risk increases if Creatinine \>1.6 mg/dL
Avoid is Baseline K+\> 5 mEq/L
- **Antiandrogen actions**
Spironolactone
38
What is the #1 recommended strategy to reduce the risk for hyperkalemia with aldosterone antagonists?
counsel pts to:
- **limit intake of high potassium-containing foods and salt substitutes**
- Avoid the use of over the counter NSAIDS
39
**MOA:** Inhibits angiotensin converting enzyme
**Effects:**
**- ateriolar and venous dilation**
**-** reduces **aldosterone secretion**
- reduces cardiac remodeling
ACE-I (angiotensin antagonists)
## Footnote
**Lisinopril**
40
Clinical applications:
- **chronic heart failure**
- diabetic renal disease
- **has been shown to reduce mortality**
ACE-I (Angiotensin Antagonists)
## Footnote
**Lisinopril**
41
Toxicity:
- **cough**
- **hyperkalemia**
- angioedema
Interactions: additive w/other angiotensin antagonists
ACE-I (Angiotensin Antagonist)
## Footnote
**Lisinopril**
42
**MOA:** Antagonize AII effects at AT1 receptors
Losartan
43
**Clinical applications:**
**-chronic heart failure**
- hypertension
- diabetic renal disease
- **has been shown to reduce mortality**
- **used in pts intolerant to ACE-I**
**Losartan (ARB)**
44
Can you use ACE-I and ARB together?
NO
45
Toxicity:
- hyperkalemia
- angioneurotic edema
Interactions:
- additive with other angiotensin antagonists
**Losartan (ARB)**
46
MOA: **neprilysin blocker**/ARB
ANRi: Sacubitril/valsartan
47
T/F: **discontinue ACE inhibitors** at least 3**6 hours before** initiating **sacubitril/valsartan** treatment
TRUE
48
MOA: competitively **blocks B-1 and A-1 receptors**
**Carvedilol** (Beta Blockers)
49
Effects:
- slowsl heart rate
- reduces blood pressure
- poorly understood effects
- reduces heart failure mortality
**Carvedilol** (Beta Blockers)
50
Clinical Applications:
- slows progression of **chronic heart failure**
- reduces mortality in moderate and severe heart failure
**Carvedilol (**Beta Blockers)
51
**Toxicity:**
- bronchospasm
- bradycardia
- AV block
- Acute cardiac decompensation
**Carvedilol** (Beta Blockers)
52
Select group of B blockers that have been shown to reduce heart failure mortality
Metoprolol
Bisoprolol
53
Which beta blocker is effective in both **systolic (HFrEF)** and **diastolic (HFpEF)** failure?
Nebivolol
54
**MOA:**
- **Releases Nitric Oxide (NO)**
- activates guanylyl cyclase
Isosorbide dinitrate
55
**Effects:**
- **Venodilation:** reduces preload and ventricular stretch
**Isosorbide dinitrate (Vasodilator)**
56
Clinical applications:
- **acute and chronic heart failure**
- angina
**Toxicity:**
- **postural hypotension, tachycardia, headache**
**Interactions:**
- additive with other vasodilators
- **synergistic with phosphodiesterase type 5 inhibitors**
**Isosorbide Dinitrate (Vasodilators)**
57
Clinical applications:
- **chronic failure in African Americans**
**\*\***Indicated in conjunction with standard heart failure therapy to improve survival and reduce hospitalizations in self identified African American patients
**Hydralazine**- Isosorbide Dinitrate
58
MOA: **increases NO synthesis** in endothelium
**Hydralazine (Aterilar Dilators)**
59
Effects:
- **reduces blood pressure and afterload**
- **increases Cardiac Output**
**Hydralazine (Arteriolar dilators)**
60
Clinical applications of Hydralazine
**Hydralazine plus nitrates** have reduced mortality
61
Toxicity:
- Tachycardia
- Fluid retention
- **Lupus-like syndrome**
Hydralazine (Arteriolar dilator)
62
MOA: rapid, powerful **vasodilation reduces preload and afterload**
**Nitroprusside**
63
**Clinical application:** acute severe decompensated failure
Nitroprusside
64
P-kinetics:
- IV only
- Duration: a few minutes
Nitroprusside
65
**Thiocyanate and cyanide toxicity**
Nitroprusside
66
**MOA:** Na+/K+ -ATPase inhibition results in reduced CA2+ expulsion and **increased Ca2+ stored in sarcoplasmic reticulum**
Digoxin
67
**Effects:**
- increases cardiac contractility
**\*\*cardiac parasympathomimetic effect (slowed sinus heart rate, slowed AV conduction)**
Digoxin (cardaic glycoside)
68
Clinical applications:
- chronic symptomatic **heart failure**
**- rapid ventricular rate in A-fib**
**-** has not been definitively shown to reduce mortality with HFrEF
Digoxin (cardiac glycoside)
69
Toxicity:
- **narrow margin of safety**
**- nausea, vomiting, diarrhea, cardiac arrhythmias**
Digoxin (Cardiac Glycoside)
70
MOA: **Beta 1 selective agonist**
- increases cAMP synthesis
**Dobutamine** (Beta-adrenoceptor agonist)
71
Effects: increases cardiac contractility, output
Dobutamine (Beta-adrenoceptor agonist)
72
Clinical Applications:
- **acute decompensated heart failure**
- intermittent therapy in chronic failure reduces symptoms
Dobutamine (Beta-adrenoceptor agonists)
73
**P-kinetics, Toxicities, Interactions:**
- IV only
- Duration a few minutes
**Toxicity:** arrhythmias
**Interactions:** additive with other sympathomimetics
Dobutamine
74
**MOA: dopamine receptor agonist, higher doses activate B and Alpha adrenoceptors**
**Effects:** increases renal blood flow, higher doses increase cardiac force and blood pressure
**Clinical applications: acute decompensated heart failure, shock**
**\*\*IV only**
**Toxicity:** arrhythmias
**Interactions:** additive with sympathomimetics
Dopamine (Beta-adrenoceptor agonists)
75
**Mechanism of Action:**
Phosphodiesterase type 3 inhibitors
decrease cAMP breakdown
**Effects:**
vasodilators, lower peripheral vascular resistance
increase cardiac contractility
**Clinical Applications:**
acute decompensated heart failure
increase mortality in chronic failure
**Toxicity:** arrhythmias
**Interactions:** additive with other arrhythymogenic agents
Inamrinone, Milrinone
76
MOA: activates BNP receptors, increases cGMP
Effects: **vasodilation + diuresis**
Clinical Applications: acute decompensated failure, **has not been shown to reduce mortality**
**\*\*IV only**
**Toxicity:** renal damage, hypotension, may increase mortality
**Nesiritide (Natriuretic Peptide)**
77
**MOA: prolongs diastolic time** by selectively and specifically **inhibiting the If current** within the HCN channel, **reducing heart rate.**
**Indication:** symptoms of heart failure that are **stable,** a **normal heartbeat** with a resting heart rate of atleast **70 beat**s per minute, **taking a beta blocker** at the **highest dose tolerated**
**\*\*hopefully reduces the risk of being hospitalized for worsening heart failure\*\***
Ivabradine
78
**Interactions:** avoid concomitant use with strong **CYP3A4 inhibitors**
Ivabradine
79
T/F: In patients with NYHA class II and III HF and iron deficiency (ferritin \<100 or 100-300 if transferrin saturation is \<20), IV iron replacement may be reasonable to improve functional status.
TRUE
80
In patients with HF and anemia, ________________ shoud not be used to improve morbidity and mortality
erythropoeitin-stimulating agents
81
In patients with HF, the optimal blood pressure in those with HTN shoud be less than \_\_\_\_\_\_
130/80
82
In pts with CVD and OSA, ______ may be reasonable to improve sleep quality and daytime sleepiness
CPAP
83
