Heart Failure / Arrythmias Flashcards
How many new canadians are diagnosed with HF every yea?
100,000
What is the mortality rate of HF after 5 years?
50%
True or false: HF has the same mortality rate of certain cancers?
False-higher
What is stroke volume and what three parameters affect it?
SV= volume of blood ejected per heartbeat
dependent on preload, stretch(contractibility), and afterload
What is the relationship between stretch and force?(Frank-Sterling law)
the greater the stretch the greater the force of contraction
What will the body do to maintain cardiac output?
NorE, angiotensin 2, aldosterone, vasopressin, inflammatory
How can the heart remodel to maintain cardiac output?
the Left ventricle will grow bigger to get better force BUT this allows for less blood to actually enter the ventricle
What are the common causes of heart failure?
tachycardia, valve disease, CAD, LVH
What is the definition of heart failure?
Sx/signs= LV hypertrophy, low pressure and dysfunction
AND also need one of increased natriuretic peptides, evidence of pulmonary congestion
What are common sx of HF?
SOB
orthopnea
fatigue
WEIGHT GAIN
ankle swelling
nightime SOB, cough, bloating
What are some specific signs of HF?
third heart sound, pulmonary edema, , elevated jugular pressure
What levels of proBNP and BNP is high enough to diagnose HF?
Pro= >125
BNP>50
What does BNP do in the body?
excrete sodium and water and dilate vessels
What other conditions raise BNP?
A fib
What condition can lower BNP?
obesity
A patient is asymptomatic and has raised BNP. Will he be diagnosed with HF?
NO
How much of a BNP drop do we need to discharge a patient?
> 30%
What is the EDS criteria for entresto?
BNP levels too high
How can we test to see systemic and pulmonary congestion in HF?
x-ray, heart catheterization, measure pressure in those areas, ECHO
A patient comes in and is wondering what a ECHO is for as they have been recently diagnosed with HF. What do you tell them?
give info on size of heart, pumping capacity, locate damage,
WHat is a normal ejection fraction?
50-70%
A patient comes in and reports they have been diagnosed with HF-pEF. What would their ejection fraction be?
> 50%
What is generally wrong with the heart if preserved ejection fraction?
heart is stiff/problem with ventricle relaxing
Which people are more likely to get HF-pEF?
women, old
I am a patient with HF-mEF. what is my ejection fraction?
40-49%
What ejection fraction is clinical HF-rEF?
<40%
What is generally wrong with the heart if HF-rEF?
problem with contractility.
In some patients they can get HF with improved EF. Where did they start and where are they now with ejection fraction?
was at <40% now at >40 with at least 10% increase
What are the classes of HF?
1= no limitation
2=slight limitation
3=marked limitation
4- sx at rest
What is the four pillar approach to HF?(<40%)
ARNI/ARB/ACE
Beta blocker
MRA
SGLT2i
What is the RAAS system and what drugs inhibit this?
RAAS makes angiotensin 2 to make aldosterone to retain salt and water.
MRA and ACE stop it
Why does ACEi have cough?
bradykinin increase
What is the benefit of an ACE?ARB?
lower preload and afterload= lowers mortality and hospitalizations
What difference in dosing for ACE occurs in HF rather than HTN?
BID dosing
Which ACE inhibitor is recommended in HF?
any of them
At what GFR can we not use ACE?
30 ml
What what K level is ACE an issue?
> 5.2
WHat drug interaction with ACE is an issue?
trimethoprim, high K stuff
What side effects are we concerned about with ACE?
cough, hypotension, angioedema, high K
When would we use an ARB for HF?
if cough is an issue
Any statistical difference between ACE and ARB ?
No
How is ARB dosed in HF?
BID
What is an ARNI and where does it act?
sacubatril and valsartan
sacubatril stops BNP breakdown= pee out and dilate
What benefit does ARNI do for patients with HF?
lower hospitalizations and decreased mortality
Compared to ACE, what adverse effects do entreso have?
more hypotension, less kidney injure and cough
When to we switch to an ARNI from an ACE?
if still symptomatic on ACE
If we are switching from an ACE to an ARNI what must we do?
wait 36 hours-56
What is the issue with entreso?
priceyyyyy
What is EDS criteria for Entreso?
symptomatic, <40%, not stable on ACE, or super high BNP
What is the monitoring for entreso?
kindly function and K+
How much is target entreso dose?
200mg BID
What is the benefit of a beta blocker for heart failure?
lowers mortality and hospitalizations
What is target dose for beta blockers?
Carvedilol= 25 BID
Bis=10
metoprolol=200
Who can’t get a beta blocker?
av block, HR<50, uncontrolled asthma,
What is a weird side effect of beta blockers?
HF sx may get worse before better
What beta blockers is generally better for HF?
Carvedilol-BUT non specific
A patient also needs an MRA for HF why?
neurohormonal benefit (RAAS)
What MRA’s are available for HF?
spironolactone-25-50
eplerenone= 50mg
What contraindications for MRA’s and what drug interaction are we worried about?
> 6 of K
digoxin with spironolactone
What monitoring must be done for MRA?
K
renal function
Why is eplerenone better than spironolactone?
only acts on aldosterone
spirinolactone= ED, man boobs
At what point of GFR should you not use spironolactone for HF?
<30 ml/min GFR
True or false: We use MRA for the benefit of blood pressure lowering.
False- for neural hormonal
How does SGLTi help with HF?
lots of stuff, lowers preload, afterload,
True or false empagliflozin lowers mortality.
False only dapagliflozin
Does SGLTi lower volume?
Not statisically
Will the SGLTi help with A1C if diabetic and heart failure?
- yes but loses that ability if low kidney function
What side effects can occur with SGLTi?
genital infections, UTI, DKA
At what renal disease can you not use SGLTi?
empa=<20
Dapa<25
A patient that is on quadruple, optimized therapy, no a fib, and has a high heart rate. >70 bpm What should be added?
ivabradine
How does ivarbradine work?
works on SA node and lets heart fill with blood by lowering HR
A patient has a heart rate of 89 bpm but is in a fib, can we give ivabradine?
No
True or false: Ivabradine lowers mortality.
no, only hospitalizations
What is target dose for ivabradine?
7.5 mg BID
What drugs are we worried about interactions with ivabradine?
ketoconazole, clarithromycin, amiodaron, digoxin, simvastatin
S/e of ivabradine?
a fib, light flashes
When is it a good idea to add digoxin?
in HF-rEF in sinus with mod sx and FOR SURE in HFrEF and chronic AF
Does digoxin lower mortality in HF?
no
What is the mechanism of action of digoxinin heart failure?
increase parasympathetic and increases heart contractility
What DI are there with digoxin?
amiodarone, b blockers, ccb
What s/e of digoxin?
a fib, anorexia, dizzy
Which is better ivabradine and digoxin?
equal for reducing hospitalization
iva= less interactions and dose adjustments
dig= more data
If vericuguat was given to patient with HF, what can we assume happened?
recent hospitalized (last 6 months) due to decompressed HF
How does vericiguat work?
increases NO work
Is it okay to be on a boner pill and vericiguat?
FUCK no
When to use hydralazine-nitrates for HF?
Black on optimal with sx or can’t handle AC/ARB/ANRI
What is the MOA of hydralazine and nitrates?
vasodilator and heart ability to pump
nitrates= low in HF that’s why they get them
If giving nitrate for HF what mist we ensure?
12 hour free interval
For HF-pEF patient what drugs should they use?
treat comorbidities= HTN, DM,
candesartan + spirinolactone+SGLT2i= lower hospitalizations
entresto= only for US-Not sig
For HF-mEF patients what drugs should they be on?
all four but no mortality reduction
What is percent error on ECHO for ejection fraction?
10%
If you were in HF-rEF but since became improve (>50%) what should you do for medications?
CONTINUE QUAD therapy
What is the benefit of adding a diuretic for HF?
lower preload by removing water and sodium and edema lowering
lower hospitalizations
Where do loop diuretics act?
ascending limb
If you have a very low renal function do you need to adjust furosemide dosing?
no
What are the loop diuretics and what are their optimal dosing?
furosemide-20-40 OD or BID
butemanide-10
ethacrynic acid=200BID
If a patient has a sulfa allergy do we need to take them off furosemide?
prob not but if needed go to ethacrynic acid
Im a patient on furosemide. What is the process for weighing myself?
wake, void, weigh nude/minimal clothing
Im a patient on furosemide. I have been weighing myself and this morning I noticed an increase of weight of 3 lbs. What should I do?
need to go for an assessment
Is it acceptable to combine loop and thiazide? if so what thiazide?
yes-metolazone
What can happen with chronic loop diuretics use?
rebound Na retention= resistance
If using a diuretic and digoxin what are we concerned about?
toxicity with digoxin if hypokalemia
How much fluid should you take in a day if in HF?
2 l/day
How much salt should you have in a day If in HF?
2-3 g /day
What drugs can exacerbate HF?
high sodium drugs
cancer
change fluid-CS, NSAIDs, CCB,
To overcome the issue of NSAIDS with heart failure can you increase the dose for a shorter duration?
NO- dose dependent
Is it wise to use alternative medicine for HF?
NO
What is the percentage of people that are not on optimized therapy for HF?
2/3
How much does risk reduce for HF with pharmacists being involved on the healthcare team?
30%- for hospitalizations
What benefit does adding a pharmacist on team for HF?
more optimized therapy= less hospitalizations
When would we know that cough is caused by congestion vs drug?
drug= dry persistent cough
congestion= productive cough, usually nocturnal or othopnea only
What form of edema suggests HF?
BILATERAL
How can patients improve their ankle edema?
raise legs for 1 hour prior to bed time
If the patient is hypovolemic what might we do for them?
tell them to drink 1.5-2 l of fluids a day, decrease dose (hold for 2 days or decrease furosemide by 1/2 for 2-3 days
If hypervolemic, what might we do for them?
lower fluids, lower salt
What medications can exacerbate HF?
Sodium, NSAIDS, CS, estrogens, recent initiation of beta blocker
If we increased a patients furosemide dose 2 times what is the next step if not euvolemic?
add metolazone
When should you take a diuretic?
morning BUT not after midafternoon
What is target HR for HF patients?
50-60 bpm
If a patient with heart failure is experiencing hypotension what should we do?
can reduce diuretic, CCB, or switch from carvedilol because it reduces blood pressure much more
If a patient with heart failure is experiencing bradycardia what do you do?
take at night, lower dose, titrate
If a patient with heart failure is experiencing issues with potassium what do you do?
if high= lower diet, no NSAIDs,
low= increase ACE, start MRA
What heart failure Meds are a part of SADMANS
ACE, ARB, ARNI
MRA
SGLT2
Diuretics
What are foods high in potassium?
potatoes, tomatoes, bananas
What percent lose of GFR is acceptable from a drug?
30%
What is the difference between atrial fibrillation vs flutter?
fibrillation= multiple loci so they quiver
flutter=still contract but way too fast, AV node isn’t filtering
How much of the ejection fraction is due to the atrial kick?
20%
True or false AF is life threatening and must be treated as soon as possible.
False= just associated with risk of other conditions
What change to the ECG will happen with A fib?
no p wave
How fast is atrial rate in a fib?
350-600
How fast is ventricular rate in a fib
120-180= reduced because its not filling enoughh
Over the age of 60 what is prevalence of AF? what about 80 years?
60-5%
80- 10%
What is your increased risk of thromboembolic events and stroke if having a fib?
thrombi-1.5-4 x
stroke-3-5 fold
What are sx of a fib?
chest pain, palpitations, fatigue, dyspnea
What is the difference between valvular and non-valvular a fib?
valvular= valve disease, repair, or prothetic
non valve= none of it
What anticoagulant for valvular a fib?
warfarin
What is lone atrial fibrillation?
no clinical or ECG findings of CVD, pulmonary disease, no enlargement, or under the age of 60
What is paroxysmal a fib?
can last for 7 days
What is persistent a fib?
last for 1 year
What is longstanding persistent a fib?
greater than 1 year
What type of a fib does triggers usually cause?
paroxysmal
What type of a fib does substrates cause?
permanent
What are some possible substrates for a fib?
remodelling, HTN, obesity, sleep apnea
What are some possible triggers
stimulants, alcohol, no sleep, stress
What percentage of unknown causes of strokes do asymptomatic a fib cause?
10%
What is the CHADS2 score?
C-recent CHF=1 point
H- HTN=1 point
A- Age>75= 1 point
D- diabetes= 1 point
S2= history of stroke=2 points
If I had a CHADS2 score of 4 what is my risk?
8%
each point is about 2 % risk
WHat parameters indicate OAC for a fib?
> 65
or if had stroke, HTN,HF, DM, hyperthyroid
What parameters indicate anti platelet for a fib?
if CAD
How much does warfarin reduce risk of stroke?
66%
Which anticoagulant is preferred for a fib?
DOAC
What population gets better benefit from DOACs for a fib?
> 85
If you have obesity why is your risk of stroke and bleed?
lower stroke
but higher bleed
At what BMI is warfarin needed?
> 50
What BMI is it indicated for caution with apixaban and edoxaban
40-49
What is usually dose of dabigatran for a fib?
150 mg BID
What is usually dose of rivaroxaban for a fib?
20 mg daily
What is usually dose of apixaban for a fib?
5 mg BID
What is usually dose of edoxaban for a fib?
60mg daily
At what renal function do you need to stop using MOST of the anticoags?
<30 ml/min
What drug can you give to more renal disease(30-40) for anticoagulation without adjustment?
apixaban- need 2 out of renal disease, >80, or underweight to change dose
What drug needs food for better bioavailability?
rivaroxaban
Which DOACs are we concerned with CYP interactions
apixaban and rivaroxaban
What is the antidote for dabigatran
idarucizumab
What is antidote for other DOACS?
Andexanet
How much does bleed risk increase with triply therapy?
double
If paroxysmal AF what do we do?
if low recurrance= ADD prn
high= ADD scheduled and maybe catheter ablation
When is rate controlled method preferred in a fib?
if permanent
What do we use for reducing rate in a fib patients?
B blocker s or Non-CCB (amlodipine, nifedipine, felodipine)
If still no heart rate control for a fib after Beta blocker
digoxin if >40% EF
can use amiodarone or digoxin at <40%
When would we prefer beta blocker in a fib?
<40% EF
When can you do rhythm control for a fib?
recent diagnose= 1 year, lots of recurrence, hard to rate control
When do you have to anticoagulate before doing rhythm control?
if in a fib for 24-48 hours
need anticoagulant for 3 weeks before than 4 weeks after
How can we speed up the timeline to see if we can do rhythm control?
do a TEE to see if clot in heart
Who are most likely to maintain normal sinus rhythm?
short AF, recent, HF, angina, hypotension
WHat are the two ways of doing cardio version?
drugs or electrical
Which way to cardiovert is better?
electrical= more effective
What drugs can cardiovert?
amiodarone
good= ibutelide, procainamide, flecainide
Side effects of the drugs that can cardiovert?
pro arrhythmia, left ventricular depression
If cardioverting what drug MUST be used as well (not necessarily anticoagulant)
B blockers
Non-CCB
What initiates heart beat?
SA node
What is the path of electrical impulses in the heart?
SA node- AV node- Bundle of his- Bundle branches- Purkinje fibers
If the SA node fails what then makes the heart beat?
AV node
What ions are high in the cell and what ions are high outside?
In=potassium
Out= sodium and calcium
Explain the steps to forming an action potential?
Na channels open and it comes in
at peak then it closes and K and Ca channels open
then steep repolarization after a while as just k channels are open
What is the absolute refractory period?
time when it cannot be re-excited
What is the relative refractory period?
time after absolute refractory period but needs higher voltage to initiate another impulse
What does the p wave represent?
atrial depolarization
When does atrial repolarization happen?
in QRS
What does QRS complex mean?
ventricles depolarize
What does t wave represent?
ventricle repolarization
What are the two causes of arrhythmias?
generational=automaticty
Conduction= re-entral
What is needed for re entry arrhythmias?
2 pathways for impulse
one is blocked
slow conduction in the other
Which group of class 1 antiarrhythmic drugs is the most potent?
Class 1 C
What are the class 1A antiarrythmics?
procainamide
quinidine
What are the class 1B antiarrythmics?
Lidcaine
What are the class 1C antiarrythmics?
flecanide
propafenone
What are the class 2 antiarrythmics?
B blockers
What are the class 3 antiarrythmics?
amiodarone, sotalol
How do the class 3 antiarrythmics work?
block potassium channels= prolong refractory period
What are the class 4 antiarrythmics?
CCB= verapamil, diltiazem
How does digoxin work for antiarrythmias?
stop Na K pump
At what heart rate will you become symptomatic?
<50
What can cause irreversible AV block?
heart attack
How do we treat AV block?
pacemaker
What is sick sinus syndrome?
pauses, dropped beat = SLOW heart rate
What is SVT?
re-entry tachy
narrow QRS, no p waves
What do we do for SVT?
1st= vagal maneuvers
2nd= adenosine’s blocker
What is a form of SVT that we have learned?
A fib
What is PVC and what do we do for it?
asymptomatic usually from MI
do nothing
What is VT and what do we do for it?
worse than PVC
cardiovert
procainamide, amiodarone, lidocaine if stable
What is the most effective drug for prevention of VT recurrences?
amiodarone
Which population usually get VT?
MI, drug overdose
What is TDP?
life threatening with long QT
How do we treat TDP?
Mag sulfate or cardiovert
If Vt what is ALWAYS given?
b blocker
What instrument can help prevent VT?
ICD= sense arrhythmias, correct it and send info to doctor
If they have an ICD can they stop their meds?
NO
What monitoring is required for amiodarone?
ECHO
Derm- examination
AST/ALT
Neurologic
Eyes
Pulmonary tests
What weird skin thing can amiodarone cause?
blue/grey skin/ UV insensitivity
Which type of drugs has a higher incidence of TDP?
potassium channel blockers= sotalol
What is the definition of Qtc prolonged for both men and women?
men=470
women=480
At what QTc prolongation do we need to be concerned?
> 500
What score can we use to see risk of QTc prolongation?
Tisdale risk score
What are some possible risk factors for QTc prolongation?
> 68
female
loop diuretic
low K
prolongation
MI
HF
1 prolongation drug
2 prolongation drug
sepsis
Are smart watches true detectors of arrhythmias?
no but getting better
