Heart Failure II Flashcards
BNP and NT pro-BNP levels at which to get an echo if the presentation fits
Nt-proBNP - 125+
BNP - 35+
Class I recommendations
Is recommended/Indicated
Negligent if not done
Class IIa recommendations
Should be considered - weight of evidence seems to suggest efficacy but no clear consensus
Class IIb recommendations
May be considered - efficacy is less well established
Class III recomendations
Evidence is against giving - not recommended
Lifestyle modifications of HFpEF - rule of twos
Sodium restriction of 2g/day
Restrict to 2 Liters of water/day
2 lbs. weight gain/week - concerning
Class I pharm indication for a patient with HFpEF
Thiazide or Loop Diuretics
Three Thiazide diuretics
Hydrochlorothiazide, Metolazone (Very potent), Chlorthalidone (IV)
2 things to check when putting a patient on a diuretic
Potassium and renal function
Potassium replacement for lasix
10mEq of K for 20mg of Lasix
Monitoring for diuresis
Daily weights
Keep track of lifestyle modification
BMP within a week of initiation to assess kidney function
Class IIa recommendations for HFpEF
SGLT2 inhibitors -gliflozin, Jardiance, Farxiga
Class IIb recomandations for HFpEF (3)
ARNi - Entresto
Aldosterone antagonist - Spironolactone, Eplerenone
ARB -sartan
Greater benefit if LVEF closer to 50%
5 lifestyle modifications for HFrEF
Tobacco and alcohol cessation
Sodium restriction
Daily weight monitoring
Weight loss in obese patients
Increase Exercise/Cardiac rehab
6 First line, class I recommendations for patients with HFrEF in stage C
ARNi in NYHA II-III
ACE OR ARB in NYHA II-IV
Beta blocker
Aldosterone antagonist
SGLT 2 inhibitor
Diuretics as needed
Condition to add second line therapy for HFrEF
Persistent HFrEF less than or equal to 40%
Condition to begin first line therapy for HFrEF
ACA/AHA Class C!!
Second line class I recommendation for African American patients in stage III-IV HFrEF
Hydral-nitrates - Hydralazine+Nitrates
Second line class I recommendation for NYHA I-III patients with HFrEF under 35% (more than 1 year survival)
Implantable cardioverter defibrillator
Second line, class I recommendation for NYHA II-III, Ambulatory IV, LVEF 35% or less
NSR and QRS 150+ with LBBB
Cardiac Resynchronization therapy
3 Class I, 3rd Line recommendations for refractory HFrEF
Mechanical circulatory support
Cardiac transplant
Palliative care (can be initiated before stage D)
3 ACEi’s for HFrEF
Enalapril, Captopril, Lisinopril
Take baseline K and Renal fxn, then in 2 weeks
ARBS for HFrEF - One condition and 3 recommendatons
Only if they cannot tolerate ACEi (angioedema, cough)
IIa - Keep on ARB if already on one at dx
IIb - Add to ACE if Aldosterone Antagonist is CI
III - Add to ACEi and Aldosterone Antagonist
3 BBs for HF
Carveidolol
Metoprolol Succinate (stays)
Bisoprolol
OTHERS NOT FOR HF
Caution with asthma
CI for aldosterone antagonists
Potassium over 5 and eGFR under 30
Entresto
Sacubatril and Valsartan
Limits breakdown of ANP and BNP
Used in place of ACEi - Need 36 hour washout period
CI in patients who have had angioedema with an ACEi
Hydralazine Nitrates for HFrEF
Second line
In addition to ACE and BB
Class I in black patients
Class IIa as replacement for ACE/ARB d/t intolerance or renal failure
Hydralazine and Isosorbide Dinitrate
Ivabradine (Corlanor)
MOA and One rec with 3 criteria
Works on SINUS node
Class IIa recommendation if:
Sinus rhythm
HR 70+ bpm
Maxed on BB or CI for BB (severe asthma)
Digoxin
Class IIb indication
If maxed out on everything else
CCBs in HFrEF
NO VERAPAMIL or DILTAEZEM
Amlodipine and Felodipine are GOOD
3 Medications to AVOID in HFrEF
Antiarrythmics
NSAIDs - chronic use
Thiazolidinediones (~glitazone)
NYHA classes to send to cardiac rehab
Class II or III
Cardiac resynchronization therapy
3rd line class I recommendation
For QRS over 120ms
NYHA III-IV Symptoms
Conditions for ICD placement for primary prevention of sudden cardiac death
LVEF 35% or less
NYHA class II or III
1+ year survival likelihood
HF symptoms for 40 days if d/t ischemia
HF symptoms for 90 days w/o ischemia
Conditions for ICD placement for secondary prevention
Implant immediately if SCA or sustained V-Tach
Implant immediately if unexplained syncope with LVEF 30% of less
Life-Vest for SCA prevention
Use while waiting to fulfill primary prevention criteria for ICD
Acute decompensated heart failure
Happens fast and can kill the patient
May be because patient stops meds or eats too much salt
May be tachyarrhythmia or MI
Presentation of acute decompensated HF
Pink frothy sputum
Sweaty - Ill appearing
Cyanosis
Rales
SOB, difficulty ambulating d/t SOB
Diagnostics for acute decompensated HF
EKG - For Cause
Echo, CXR, BNP, CMP, Cardiac enzymes, CBC
Management of ADHF
Airway/Oxygenation assessment
Vital signs
Cardiac monitoring
IV diuretics
Vasodilator
I/O monitoring
When to oxygenate
O2 sat is 94% or less
Diuretics for ADHF
Loop diuretics!!
Recourse in inadequate response to diuretic therapy in ADHF
Chlorothiazide IV
HCTZ
Metolazone
Aldosterone antagonist
Sodium restriction
Water restriction
Second diuretic
Vasodilators in ADHF
Only if BP is high - watch for what Lasix might do to BP
Nitroglycerin (esp. b/c they might be having an MI)
Morphine in ADHF
Helps vasodilate and and highly effective in reducing pulmonary edema
May decrease ventilatory drive
Natrecor
Recombinant BNP - not very effective
ACE/ARB BB for ADHF
Give once stable!!
BB CI in ADHF because we need the heart beating
NO BETA BLOCKER IN ANY ACUTE HEART FAILURE
Inotropic agents for ADHF
Milrinone and Dobutamine
Indicated for severe LV systolic dysfunction
Both can vasodilate
Hypotension w/ Milrinone
Hypertension w/ Dobutamine
Last ditch effort
Additional therapy for ADHF
Anti-coagulation/SCDs
Ultrafiltration to draw off fluid
Mechanical Cardiac Assistance
BiPAP
Hemodynamic findings of cardiogenic shock
Hypotension
Pulmonary Capillary Wedge Pressure over 15mmHg
Cardiac index under 2.2L/min/m2
Cardiac index
Cardiac output per minute per square meter of body surface area
2.6-4.2 is normal
CO/Body Surface Area
Presentation of cardiogenic shock
Mottled and pale
Hypotensive and tachycardic
Management of Cardiogenic shock
Cardiac enzymes
Coagulation
Anion gap
BNP
EKG
Stat Echo
CXR
Foley catheter
Pulmonary Artery catheter
Left heart cath
Similar to ADHF
Pulmonary wedge pressure
Indirect measurement of Left Atrial Pressure
Normally 8 to 10 mmHg
Inotropic agents for cardiogenic shock
Can cause the patient to loos fingers/toes
Push into LARGE vessels
Dopamine
Dobutamine
Norepinephrine
LAST RESORT
Start;Max;Add
Additional place to check for edema - one in women and one in men
Scrotal - men
Coccygeal - Women
