Heart Failure

Question 1

What is preload?

Answer 1

Ventricular filling or left ventricular end-diastolic volume (LVEDV)

Question 2

What is afterload?

Answer 2

Left ventricular wall tension or stress during systole

Question 3

What is Heart Failure w/ reduced Ejection Fraction (HFREF)?

Answer 3

Systolic dysfunction, defined as an EJ <40%. Impaired cardiac output 2ndary to impaired myocardial contractility.

Question 4

What is Heart Failure w/ Preserved Ejection Fraction (HFPEF)?

Answer 4

Diastolic dysfunction, defined as an ejection fraction >40% + symptoms. Caused by impaired relaxation & filling of LV.

Question 5

What are the 3 therapeutic targets for heart failure?

Answer 5

Cardiorenal: diuretics
Cardiocirculatory: positive inotropes
Neurohormonal: neurohormonal inhibitors

Question 6

What are the non-pharmacological recommendations for systolic HF?

Answer 6

Physical activity
Dietary restriction
Smoking cessation
O2 therapy
Vaccinations
VTE prophylaxis

Question 7

What are the pharmacotherapeutic options for HF?

Answer 7

ACE-inhibitors
Neprilysin inhibitors
Beta-blockers
Loop diuretics
Aldosterone antagonists
ARBs
Digoxin
Nitrates and hydralzaine

Question 8

ACE-Inhib efficacy

Answer 8

1st line

• Reduces mortality & morbidity
• Reduces HF hospitalizations
• Slows progression of HF
• Improves symptoms
• Reduces ventricular remodeling

Question 9

ACE-Inhib for HF dosing

Answer 9

ALL pts w/ LV dysfunction (symptomatic & asymptomatic) get an ACE (any -pril b/c of class effect). Titrate to target dose: start low and slow & titrate dose every 3-7 days to target. Target dose is 20mg, max is 40mg. 40mg is not any better than 20mg

Question 10

ACE adverse effects

Answer 10

• Cough (d/t bradykinin)
• Hyperkalemia (if they have K >7, document it and start them on something else)
• Renal insufficiency
• Hypotension
• Neutropenia
• Angiodedma
• Taste distrubances

Question 11

What do you need to monitor in pts on ACE inhibitors?

Answer 11

BMP: creatinine & potassium

Vitals: BP

CBC: WBC

Question 12

Beta-blocker efficacy in HF

Answer 12

• Decreases mortality
• Decreases symptoms & hospitalizations
• Improved EF by 5-10%

Question 13

What classification of ACC/AHA do you add a beta blocker to their therapy?

Answer 13

ACC/AHA classification B: pts developed structural heart dz but no signs/symptoms

Question 14

How should you titrate beta blocker dosage?

Answer 14

Initiate @ low dose and titrate very slowly (every 2-4 wks). If beta blocker is held for >72 hrs, reinitiate @ 50% of previous dose. Use conversion table to change from IR to SR

Question 15

What are adverse effects of beta blockers?

Answer 15

• Hypotension
• Bradycardia
• Fluid retention
• Depression
• Sexual dysfunction

Question 16

What should you monitor in a pt on beta blockers?

Answer 16

Body weight: should not exceed 2# overnight or 3#/week

Vitals: BP & HR

Question 17

Diuretic MOA

Answer 17

Inhibits reabsorption of Na in renal tubules, increases Na & H2O excretion, Decreases preload