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Pharmacology II > Heart Failure 9-10-13 > Flashcards

Heart Failure 9-10-13 Flashcards

1
Q

Heart Failure

A

Clinical syndrome in which cardiac dysfunction, be it either systolic or diastolic, is associated with reduced exercise tolerance, ventricular arrhythmias, and shortened life span.

-Jay Cohn

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2
Q

causes of heart failure

A

Pathologic sympathetic activation
Increased load on the failing ventricle
Issues with renin-angiotension-aldosterone system

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3
Q

To decrease the pathologic sympathetic stimulation use

A

use beta blockers

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4
Q

Reduce the load on the failing heart using

A

diuretics

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5
Q

Systolic Heart Failure

A

Impaired left ventricular contractility.

Most common

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6
Q

Types of Heart Failure

A

Systolic & Diastolic

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7
Q

therapies for systolic heart failure

A

diuretics
ACEI
Digoxin and Nonspecific vasodilators

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8
Q

Diastolic Heart Failure

A

Problems with ventricular filling or inability of ventricle to relax

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9
Q

therapies for diastolic heart failure

A 
diuretics
vasodilators
inotropic drugs
beta blockers
hydralazine/nitrates
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10
Q

What are the guidelines for heart failure staging?

A

Stage A & B: at risk for heart failure

Stages C & D: obvious symptomatic heart failure

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11
Q

What is the initial treatment for systolic HF?

A

Diuretic + ACEI (or ARB)

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12
Q

What is the second treatment for systolic HF?

A

beta blocker

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13
Q

Stage A Heart Failure

A

At high risk for heart failure but without structural heart disease or symptoms of heart failure.

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14
Q

Who is at high risk for Stage A Heart Failure?

A 
hypertension
atherosclerotic disease
diabetes
obesity
metabolic syndrome

OR

patients using cardio toxins
……

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15
Q

Stage B Heart Failure

A

Structural heart disease but without symptoms of heart failure.

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16
Q

Who is at high risk for Stage B heart failure?

A

previous MI

LV remodeling including LVH……

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17
Q

Stage C Heart Failure

A

Structural heart disease with prior or current symptoms of heart failure.

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18
Q

Who has Stage C heart failure?

A

patients with known heart disease AND SOB and fatigue, reduced exercise tolerance.

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19
Q

Note NYHA Classes

A

I
II
III
IV

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20
Q

Stage D Heart Failure

A

refractory heart failure requiring specialized interventions.

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21
Q

Who has Stage D heart failure?

A

Patients who have marked symptoms at rest despite maximal medical therapy, e.g., those who are recurrently hospitalized…

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22
Q

What are the therapies for Stage A HF?

A 
Treat HTN
Encourage smoking cessation.
Treat lipid disorders.
Encourage regular exercise.
Discourage alcohol intake, illicit drug use.
Control metabolic syndrome
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23
Q

What pharmacological therapies are used for Stage A HF?

A

ACEI or ARB in appropriate patients for vascular disease or diabetes.

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24
Q

What are the treatments for Stage B HF?

A

All measures under Stage A.

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25
Q

What pharmacological therapies are used for Stage B HF?

A

…

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26
Q

What is the approach to treatment in Stage C HF?

A

All measures under Stages A and B…

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27
Q

What are the pharmacological therapies for Stage C HF?

A

aldosterone antagonist
ARB
……

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28
Q

What devices are used for Stage C HF?

A

Biventricular pacing

Implantable defibrillators

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29
Q

What is the approach to treatment in Stage D HF?

A

Appropriate measures under Stages A, B, and C

……

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30
Q

What does the use of diuretics do in heart failure?

A

Heart failure leading to fluid retention will see relief of symptoms but does not stop disease progression.

Should not be used alone to manage heart failure.

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31
Q

What diuretics should be used in HF paitents?

A

loop or thiazide-like diuretics

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32
Q

What diuretics should not be used in HF patients?

A

thiazide diuretics - hydrochlorothiazide

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33
Q

Furosemide

A

Furosemide
40 mg
one tablet twice a day

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34
Q

When Furosemide goes from IV to oral form you must __________ the dose.

A

Double.

Decreased bioavailability with the oral form.

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35
Q

What benefits are seen when ACEIs are used in heart failure?

A

RAAS activated in heart failure and degree of activation corresponds with prognosis. Benefits are seen in all subgroups but greater in sever heart failure.

Improve symptoms within days but more commonly with delay of 4-12 weeks.

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36
Q

How do you dose ACEIs in heart failure?

A

Titrate dose upward to those used in clinical trials:
Captopril 50 mg 3 times per day
Enalapril….

37
Q

Lisinopril

A

Lisinopril
40 mg
one tablet daily

38
Q

optimal dosing of Lisinopril

A

20-40 mg/day

39
Q

What are the benefits to use ARBs in heart failure?

A

Difficult to find equivocal evidence of superiority over ACEIs. ARB is a safe and effective alternative to ACEI in patients who cannot tolerate an ACEI.

40
Q

Do you combine an ACEI and ARB in HTN?

41
Q

Do you combine an ACEI and ARB in HF?

A

Relief in symptoms but mortality rate does not change.

42
Q

Valsartan

A

Valsartan
80 mg
one tablet twice a day

43
Q

Benefits of beta blockers in heart failure

A

slows progression of disease
decreases post MI mortality
Reverse cardiac remodeling

44
Q

How doe beta blockers slow progression of HF?

A

Sustained activation of sympathetic system increases myocardial O2 demand, renal retention of sodium, increased preload and afterload.

45
Q

How do beta blockers reverse cardiac remodeling?

A

significant decrease in systolic/diastolic volumes and increases in left ventricular ejection fraction.

46
Q

Goal of ejection fraction in HF

47
Q

How do you dose beta blockers in HF?

A

Initiate at low doses and gradually increase dosing over weeks to target doses

48
Q

What are the target doses of beta blockers in HF?

A

metoprolol ext rel. 200 mg/day

carvedilol 25 mg twice a day

49
Q

Carvedilol

A

Carvedilol
25 mg
one tablet twice per day

50
Q

How much can aldosterone increase in heart failure?

51
Q

How do aldosterone antagonists benefit HF patients?

A

Addition to standard treatment (25 mg/day of either agent) may significanlty reduce mortality.

52
Q

What must you check in aldosterone antagonists in HF patients?

A

Check electrolytes/creatinine within 1 week of start then monthly/bimonthly until patients potassium levels stable.

53
Q

Eplerenone

A

Eplerenone
50 mg
one tablet daily

54
Q

aldosterone antagonist used in HF

A

Eplerenone

55
Q

beta blocker used in HF

A

Carvedilol

56
Q

ARB used in HF

57
Q

What effects do vasodilators have in HF?

A

Can produce sustained improvement in LV ejection fraction.

58
Q

Who would benefit most from addition of hydralazine/nitrate combo in HF?

A

patients with persistant cardiac output and volume overload.

very helpful in AAs

may be helpful in patients who cannot tolerate ACEIs or ARBs due to renal impairment

59
Q

BiDil

A

BiDil

One tablet three times a day

60
Q

What is the hydralazine/nitrate combo used in HF?

61
Q

What is digoxin?

A

cardiac glycoside

62
Q

moa of cardiac glycoside

A

increased force of contraction and decreased rate of contraction

63
Q

How long does it take for digoxin to work?

A

T-half of 36 hours so steady state at approximately 2 weeks.

64
Q

What must you watch for with digoxin?

A

Narrow therapeutic range - watch for early signs of toxicity.

65
Q

Higher serum levels of digoxin are associated with…

A

increased mortality.

66
Q

What is the upper limit for digoxin?

A

Anywhere above 1 shows signs of toxicity.

67
Q

Serum levels of digoxin ____________________ with clinical efficacy.

A

do not correlate

68
Q

What effect does digoxin have on the heart?

A

negative chronotropic effect

69
Q

Who are candidates for digoxin?

A

Patients with …..

70
Q

Who do you NOT use digoxin with?

A

Asymptomatic patients with left ventricular dysfunction and normal sinus rhythm.

Primary therapy for stabilization of patients with acutely decompensated heart failure.

71
Q

ADR of digoxin

A

Bradycardia (or tachycardia) - do not give to those with a HR 120 bpm

72
Q

digoxin drug interactions which increase levels

A

..antacids
metoclopramide (Reglan)
St.John’s Wart

73
Q

digoxin drug interactions which decrease levels

A

amiodarone
alprazolam (Xanax)
verapamil
spironolactone (Aldactone)

74
Q

Digoxin

A

Digoxin
125 mcg
one tablet daily

75
Q

cardiac glycosides

76
Q

Always use the lower dose of digoxin in those people over the age of

77
Q

MOA of inotropes

A

stimulation of beta-1 receptors of the heart, comparatively mild chronotropic, hypertensive, arrhythmogenic and vasodilative effects

78
Q

inotropes

A

Dobutamine

Milrinone

79
Q

ADRs of inotropes

A

Increased heart rate, blood pressure, ventricular ectopic activity, hypotension; premature ventricular beats (~5%; dose related).

Beta blockers can antagonize the cardiac effects of dobutamine resulting in unopposed increased vascular resistance.

80
Q

Dobutamine

A

Dobutamine infusion

5 mcg/kg/minute

81
Q

What does Milrinone not work on?

A

adrenergic receptors

82
Q

What effects does milrinone have?

A

positive inotropic and vasodilatory effects

83
Q

Milrinone

A

Milrinone

50 mcg/kg IV over 10 minutes…

84
Q

MOA of B-Type Natriuretic Peptides

A

Increases intracellular levels of cGMP resulting in smooth muscle relaxation and arterial and venous dilation.

Reduction of pulmonary capillary wedge pressure and systemic arterial pressure.

85
Q

ADRs of B-Type Natiuretic Peptides

A

Hypotension

86
Q

Dosing of B-Type Natiuretic Peptide

A

Bolus and then infusion up to 96 hours.

87
Q

Class Drug of B-Type Natiuretic Peptide

A

Nesiritide (Natrecor)

88
Q

Mainstays of Heart Failure therapy

A 
ACE inhibitors
ARB
Beta-blockers
Diuretics
Digoxin

Pharmacology II (9 decks)

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