Heart Failure handout Flashcards
Fill
Diastolic dysfunction
Eject
Systolic dysfunction
Definition of Heart Failure?
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
Which side of the heart has the failure?
Left Sided:
Includes Diastolic
DysfunctionSystolic Dysfunction
Description of Systolic Dysfunction?
ECHO:
EF < 40%**
Decrease contractility
Causes of Systolic Dysfunction?
CAD
Description of Diastolic Dysfunction?
Restriction in filling
ECHO: EF preserved
Causes of Diastolic Dysfunction?
↑ ventricular stiffness
Goals of Heart failure therapy?
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
Enalapril:
Starting Dose
Target Dose
Starting Dose: 2.5 mg BID
Target Dose: 10 mg BID
Lisinopril:
Starting Dose
Target Dose
Starting Dose: 5 mg daily
Target Dose: 20 mg (40mg) daily
Special Dose Requirements?
START THE ACE-I, increase does irrespective of BP as long the patient can tolerate—NOT FOR BLOOD PRESSURE)
Ace-I monitoring:
Serum creatinine, K+ and
BP 2 weeks after initiation and dose increase
Cough
Angioedema
ACE-I: Contraindications
Hx of angioedema
Bilateral renal artery stenosis (RAS)
Pregnancy
ARB : Benifits
↓ mortality in patients not taking ACE-I.
Intolerant to ACE-Is: When to Use ARBs
Angioedema*
Cough
*The use of an ARB should not be D/C because of angioedema from the ACE. *
Intolerant to ACE-Is: When NOT to use ARB?
!!!NOT!!!
Renal insufficiency
Hyperkalemia
ARB medication: No dosing
Losartan
Valsartan
Candesartan
ARB: Contraindication
Hx of angioedema
RAS
Pregnancy
ARB: Monitoring
Serum creatinine, K+, and BP 2 weeks after initiation and dose increase
Angioedema
β – Adrenergic Blockers:
Benefits
↓ mortality**
Everyone gets Beta blocker—the BACKBONE OF DRUGS ** Essentials
β – Adrenergic Blockers:
Drug:
Starting Dose
Target Dose
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”
β – Adrenergic Blockers:
Dosing
Must be clinically asymptomatic, stable, and dry - (no fluid)***
β – Adrenergic Blockers:
Monitoring
Monitoring: (monitor HF symptoms)
HR and BP
-Caution with marked bradycardia (< 90 mm Hg)
β – Adrenergic Blockers:
When can’t we use them if blood pressure is too low?
Systolic 90’s LEAVE IT ALONE!!!!
β – Adrenergic Blockers:
When can’t we use them if Heart rate is too low?
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
Sinful Recommendation for β – Adrenergic Blockers:
Don’t increase two drugs at the same time: ACE and Beta Blocker
What to check before increasing Beta Blocker?
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
The Randomized Cardiac Insufficiency Study (CIBIS III)
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
Use of β – Blockers and Concomitant Disease States:
Asthma!!
-β-blockers are recommended
Contraindicated in patients with asthma with active bronchospasm
Use of β – Blockers and Concomitant Disease States:
Diabetes
β-blockers are recommended
Use with caution in patients with recurrent hypoglycemia
Heart Failure trumps all diseasing:
DM – masks, hypoglycemia
Masks tachycadia– counsel
Use of β – Blockers and Concomitant Disease States:
Chronic Obstructive Pulmonary Disease (COPD)
β-blockers are recommended
Symptomatic Patients:
Loop Diuretics
When to use?
Should be given to all patients with current or prior HF and reduced LVEF who have evidence of fluid retention.
Symptomatic Patients:
Loop Diuretics
Benefits?
↓ pulmonary congestion/JVD (fluid in lungs)
Symptomatic Patients:
Loop Diuretics
Mortality
No effect on mortality*****WILL NOT SAVE YOU , only for symptoms
No effect on mortality*****WILL NOT SAVE YOU , only for symptoms
Symptomatic Patients:
Loop Diuretics
MEDICATIONS
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
Symptomatic Patients:
Loop Diuretics
Dosing
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
Symptomatic Patients:
Loop Diuretics
Monitoring
Signs of volume depletion
-Hypotension, dizziness, ↓ urine output, ↑ BUN/SCr (20-back off the dose)
Loop Diuretics: Dosing Considerations
Hospital dosing in acute HF:
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.
Thiazide Diuretics:
Medication
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*
Aldosterone Antagonists
When to use:
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
Aldosterone Antagonists
Benefits
↓ mortality
