Heart Failure - Dahl 2 Flashcards
What is the difference between ACC/AHA Stage B and C?
Stage B. Pre-Hf
with no symptoms but starting to have signs: structural heart disease, increased filling pressure, increased BNP, persistent high troponin
Stage C: symptomatic HF
with structural heart disease
What are structural heart diseases?
-Reduced ejection fraction (left or right)
-ventricular hypertrophy
-chamber enlargement
-wall motion abnormalities
-valvular heart disease
What are evidence for increased filling pressure?
-increased BNP or troponin (no other diagnosis causing their increase)
-hemodynamic measurement
-doppler echo imaging
BNP > 35, NT-pro BNP > 125
–> not for HF, but for early signs of pathology
What causes increased levels of BNP?
HF
-acute coronary syndrome (sudden reduced blood flow to the heart - heart attack)
-LV hypertrophy
-valvular heart disease
-pericardial heart disease
-atrial fibrillation
-myocarditis
-chemotherapy
also: age, renal disease, anemia, sleep apnea, severe pneumonia, sepsis, burn
What type of natriuretic peptide lab is ordered for a patient on Entresto (valsartan/sacibitril)?
-use NT pro-BNP, BNP would cause lab confusion in the first 8-10 weeks
bc sacubitril is a neprilysin inhibitor
neprilysin breaks down BNP
(BNP is an angiotensin II antagonist and causes Na to stay in the urine -> diuretic -> lower BP)
Identifying Labs and drugs to avoid
Example: patient with a HR of 50 -> avoid BB
Which drugs may worsen Heart failure?
-Pioglitazone (TZD’s) due to fluid retention
-Meloxicam (NSAIDs): vasoconstriction of the afferent arteriole of the kidney -> water retention, decrease response to diuretic therapy
Dose exchange of loop diuretics
Furosemide: 2:1
PO: 40mg -> IV: 20 mg
Bumetanide: good oral bioavailability
PO: 1mg -> IV: 1 mg
Torsemide: good oral bioavailability
PO: 20 mg -> IV: 20 mg
What is the place in therapy for loop diuretics?
all symptomatic patients (fluid retention) should have scheduled loop or PRN to help strive for euvolemia
-decrease in mortality is uncertain
What causes diuretic resistance?
-diuretic doesn’t work
-large sodium intake
-NSAIDs
-poor renal function or perfusion
Why may it be useful to add a thiazide to a loop?
-loops block Na reabsorption in the loop of Henle
-the kidney tries to compensate and increases the Na reabsorption in the distal tube
-> add thiazide to block Na reabsorption in the distal tube
-Guidelines: RESRVE for patients who are diuretic resistant to moderate to high loop doses
ADE of loops
hypovolemia, hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypouricemia, renal dysfunction
