Heart Failure handout

Question 1

Fill

Answer 1

Diastolic dysfunction

Question 2

Eject

Answer 2

Systolic dysfunction

Question 3

Definition of Heart Failure?

Answer 3

ACC/AHA defines heart failure as “a complex clinical syndrome that can result from any structural* or functional* cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

Question 4

Which side of the heart has the failure?

Answer 4

Left Sided:

Includes Diastolic

DysfunctionSystolic Dysfunction

Question 5

Description of Systolic Dysfunction?

Answer 5

ECHO:

EF < 40%**

Decrease contractility

Question 6

Causes of Systolic Dysfunction?

Answer 6

CAD

Question 7

Description of Diastolic Dysfunction?

Answer 7

Restriction in filling

ECHO: EF preserved

Question 8

Causes of Diastolic Dysfunction?

Answer 8

↑ ventricular stiffness

Question 9

Goals of Heart failure therapy?

Answer 9

Block the compensatory neurohormonal activation caused by ↓ CO↑ CO, ↓ afterload, and ↓ preload

Slow progression of cardiac dysfunctionImprove quality of life, ↓ hospitalizations

Decrease mortality/prevent premature death

Question 10

Enalapril:

Starting Dose

Target Dose

Answer 10

Starting Dose: 2.5 mg BID

Target Dose: 10 mg BID

Question 11

Lisinopril:

Starting Dose

Target Dose

Answer 11

Starting Dose: 5 mg daily

Target Dose: 
 20 mg (40mg) daily

Question 12

Special Dose Requirements?

Answer 12

START THE ACE-I, increase does irrespective of BP as long the patient can tolerate—NOT FOR BLOOD PRESSURE)

Question 13

Ace-I monitoring:

Answer 13

Serum creatinine, K+ and
BP 2 weeks after initiation and dose increase

Cough

Angioedema

Question 14

ACE-I: Contraindications

Answer 14

Hx of angioedema

Bilateral renal artery stenosis (RAS)

Pregnancy

Question 15

ARB : Benifits

Answer 15

↓ mortality in patients not taking ACE-I.

Question 16

Intolerant to ACE-Is: When to Use ARBs

Answer 16

Angioedema*

Cough

*The use of an ARB should not be D/C because of angioedema from the ACE. *

Question 17

Intolerant to ACE-Is: When NOT to use ARB?

!!!NOT!!!

Answer 17

Renal insufficiency

Hyperkalemia

Question 18

ARB medication: No dosing

Answer 18

Losartan

Valsartan

Candesartan

Question 19

ARB: Contraindication

Answer 19

Hx of angioedema

RAS

Pregnancy

Question 20

ARB: Monitoring

Answer 20

Serum creatinine, K+, and BP 2 weeks after initiation and dose increase

Angioedema

Question 21

β – Adrenergic Blockers:

Benefits

Answer 21

↓ mortality**

Everyone gets Beta blocker—the BACKBONE OF DRUGS ** Essentials

Question 22

β – Adrenergic Blockers:

Drug:

Starting Dose

Target Dose

Answer 22

Metoprolol succinate
Starting Dose
12.5 mg – 25 mg daily

Target Dose:
200 mg daily

Carvedilol
Staring Dose
3.125 mg BID

Target Dose
25 mg BID (wt 85 kg)

Bisoprolol (not uses in US)

“only approved for systolic”

Question 23

β – Adrenergic Blockers:

Dosing

Answer 23

Must be clinically asymptomatic, stable, and dry - (no fluid)***

Question 24

β – Adrenergic Blockers:

Monitoring

Answer 24

Monitoring: (monitor HF symptoms)

HR and BP
-Caution with marked bradycardia (< 90 mm Hg)

Question 25

β – Adrenergic Blockers: When can't we use them if blood pressure is too low?

Answer 25

Systolic 90’s LEAVE IT ALONE!!!!

Question 26

β – Adrenergic Blockers: When can't we use them if Heart rate is too low?

Answer 26

Increase Beta blocker over Ace : Hear Rate (different) –to low heart rate less than 60. You may increase the dose of beta blocker if less than 60’s) If the HR is in the 50’s

Question 27

Sinful Recommendation for β – Adrenergic Blockers:

Answer 27

Don’t increase two drugs at the same time: ACE and Beta Blocker

Question 28

What to check before increasing Beta Blocker?

Answer 28

Before increin: Renal Function, K+, cough, and BP (blood pressure—how low is too low ( Systolic 90’s LEAVE IT ALONE!!!!) Do not have to wait to get target does for ACE or beta blocker –for the next visit

Question 29

The Randomized Cardiac Insufficiency Study (CIBIS III)

Answer 29

To assess whether a β – blocker as initial therapy in chronic heart failure is useful In the intent-to-treat population, non-inferiority was met with bisoprolol as initial therapy compared to enalapril

Question 30

Use of β – Blockers and Concomitant Disease States: Asthma!!

Answer 30

-β-blockers are recommended Contraindicated in patients with asthma with active bronchospasm

Question 31

Use of β – Blockers and Concomitant Disease States: Diabetes

Answer 31

β-blockers are recommended Use with caution in patients with recurrent hypoglycemia Heart Failure trumps all diseasing: DM – masks, hypoglycemia Masks tachycadia-- counsel

Question 32

Use of β – Blockers and Concomitant Disease States: Chronic Obstructive Pulmonary Disease (COPD)

Answer 32

β-blockers are recommended

Question 33

Symptomatic Patients: Loop Diuretics When to use?

Answer 33

Should be given to all patients with current or prior HF and reduced LVEF who have evidence of fluid retention.

Question 34

Symptomatic Patients: Loop Diuretics Benefits?

Answer 34

↓ pulmonary congestion/JVD (fluid in lungs)

Question 35

Symptomatic Patients: Loop Diuretics Mortality

Answer 35

No effect on mortality*****WILL NOT SAVE YOU , only for symptoms No effect on mortality*****WILL NOT SAVE YOU , only for symptoms

Question 36

Symptomatic Patients: Loop Diuretics MEDICATIONS

Answer 36

Furosemide Bumetanide Torsemide Effective in compromised renal function Get to know, the dose generally, The NYAII symptomes does go back an forth. Work when crcl is low or renal impairment. <30Cr/min --Work

Question 37

Symptomatic Patients: Loop Diuretics Dosing

Answer 37

Determined based on clinical response Titrate to achieve dry weight (ALWAYS BASED ON DRY WEIGHT) - 1 – 2 lbs of weight loss per day - In an acute exacerbation: goal is to be 1 liter negative May consider thiazide for diuretic resistance

Question 38

Symptomatic Patients: Loop Diuretics Monitoring

Answer 38

Signs of volume depletion -Hypotension, dizziness, ↓ urine output, ↑ BUN/SCr (20-back off the dose)

Question 39

Loop Diuretics: Dosing Considerations Hospital dosing in acute HF:

Answer 39

Use 40 mg IV as a single bolus dose If patient is taking furosemide: double the first hospital dose If PO: double the patient’s home dose If IV: IV to PO conversion is 1:2 (i.e.e 10 mg IV =? If the fluid retensiotn is reoccuring, that when we consider diuretics.

Question 40

Thiazide Diuretics: Medication

Answer 40

Chlorthalidone Hydrochlorothiazide * Metolazone + * ↓ effectiveness if CrCl < 30 mL/min + Can be used in compromised renal function Thazides do not work in people who have compromised renal function, CrCrl <30mL/min, the only one that works is METALAXONE -more than 30 (any of them work) -**Thiazide first 30mins prior to the LOOP***

Question 41

Aldosterone Antagonists When to use:

Answer 41

``` Should be given to all symptomatic patients with NYHA class II-IV and who have LVEF < 35% taking ACE-I, β – blocker, and diuretics (ALL THREE) than add Spirinolactone ```

Question 42

Aldosterone Antagonists Benefits

Answer 42

↓ mortality