Heart Failure Pharm Flashcards
What is heart failure?
AHA - Complex syndrome resulting from structural or functional impairment involving ventricular filling or ejection of blood
Highly lethal and incidence increasing; 5-year mortality ~50%; progressive disorder.
What are the primary signs and symptoms of heart failure?
- Fatigue
- Tachycardia
- Decreased exercise tolerance
- Shortness of breath
- Edema (peripheral and pulmonary)
- Enlarged Heart (Cardiomegaly)
These symptoms can vary based on the type of heart failure.
What is the difference between HFrEF and HFpEF?
- HFrEF: Heart Failure with reduced ejection fraction (systolic HF)
- HFpEF: Heart Failure with preserved ejection fraction (diastolic HF)
HFrEF is often due to myocardial infarction and afterload; HFpEF is due to myocardial hypertrophy and stiffening.
What is the common theme in heart failure?
Decreased cardiac output
The decrease in cardiac output triggers compensatory changes aimed at maintaining cardiac output.
What are factors affecting preload?
- Blood volume
- Venous return
- Sympathetic tone to veins
- Atrial contraction
Preload refers to the volume of blood in the ventricles at the end of diastole.
What are factors affecting afterload?
- Sympathetic tone to arteries (PVR)
- Vasoconstrictor hormones
- Pathology (vascular stiffening)
Afterload is the pressure against which the heart must work to eject blood.
What is the role of Angiotensin Converting Enzyme Inhibitors (ACEI) in heart failure treatment?
Decrease afterload, aldosterone, vasopressin levels, sympathetic nerve activity, and adverse remodeling of heart, blood vessels, and kidneys
Examples include Lisinopril and Enalapril; beneficial for all patients.
What are the adverse effects of Angiotensin Converting Enzyme Inhibitors (ACEI)?
- Hypotension
- Hyperkalemia
- Dry cough
- Dysgeusia
- Occasionally maculopapular rash
- Angioedema
Generally well-tolerated but can have significant side effects.
What are the benefits of Angiotensin Receptor Blockers (ARBs)?
Decrease mortality, especially in patients with severe heart failure
ARBs are beneficial for patients who cannot tolerate ACEI due to cough.
What is the expected effect of loop diuretics in heart failure treatment?
- Increased salt and water excretion
- Reduced preload and afterload
- Reduced pulmonary and peripheral edema
Furosemide is a common loop diuretic used for acute and chronic heart failure.
What is the role of Aldosterone Antagonists in heart failure treatment?
Competitive blockade of aldosterone receptor, reducing morbidity and mortality
Examples include Spironolactone and Eplerenone; adverse effects include hyperkalemia and leg cramps.
What is the main action of beta-adrenergic receptor blockers in heart failure?
Inhibits cardiotoxicity of catecholamines, decreases neurohumoral activation, and decreases heart rate
Examples include Metoprolol, Carvedilol, and Bisoprolol.
What is the new first-line drug for HFrEF?
Valsartan + sacubitril combination (ARNI)
Valsartan is an Angiotensin 1 inhibitor; sacubitril is a neprilysin inhibitor.
What are the adverse effects of Digoxin?
- GI effects
- Anorexia
- Nausea and vomiting
- Diarrhea
- Disorientation and hallucinations
- Visual disturbances
- Cardiac arrhythmias
Digoxin has a low therapeutic index and requires careful monitoring.
True or False: SGLT2 inhibitors can be used in heart failure management regardless of diabetic status.
True
They have shown decreased risk of worsening heart failure and mortality.
Fill in the blank: The primary compensatory response in heart failure is _______.
Prolonged sympathetic activation
This leads to various adverse remodeling effects.
What is the effect of elevated Angiotensin II in heart failure?
- Sodium retention
- Water retention
- Adverse remodeling of heart and blood vessels
This contributes to the progression of heart failure.
What is the effect of an efferent tone on the heart?
Facilitates muscarinic transmission at heart
What is the role of beta-adrenoceptor agonists?
Stimulation of adenylyl cyclase increases cAMP
What does cAMP activate?
cAMP-dependent protein kinase
What is the effect of protein kinase on L-type channels?
Increases Ca++ influx
What is Dobutamine used for?
Acute treatment of decompensated heart failure
What type of agonist is Dobutamine?
Beta-1-adrenoceptor selective agonist
What is the positive effect of Dobutamine?
Increases cardiac output (CO)
What are the clinical applications of Dobutamine?
- Acute decompensated heart failure
- Intermittent therapy in chronic heart failure to reduce symptoms
What is the major toxicity associated with Dobutamine?
Arrhythmias
What does Dopamine do at lower doses?
Vasodilation by stimulating dopamine receptors
What are the clinical applications of Dopamine?
- Acute decompensated heart failure
- Shock
What is the major toxicity associated with Dopamine?
Arrhythmias
What type of inhibitor is Milrinone?
Phosphodiesterase type 3 inhibitor
What does Milrinone increase?
cAMP levels
What are the clinical applications of Milrinone?
- Acute decompensated heart failure
- Intermittent therapy in chronic heart failure to reduce symptoms
What is the major toxicity associated with Milrinone?
Arrhythmias
What does Ivabradine block?
I_f (funny channel); hyperpolarization-activated cyclic nucleotide-gated channel (HCN); pacemaker channels
What is the effect of Ivabradine on heart rate?
Decreases heart rate
What is the effect of Ivabradine on contractility?
No effect on contractility
What are the criteria for Ivabradine approval?
- Stable, symptomatic heart failure
- EF 35%
- Normal sinus rhythm
- HR ≥ 70 bpm
- Beta-blocker at max dose or cannot be used
What is a key benefit of Ivabradine?
Reduces risk of hospitalization for worsening heart failure
What are the adverse effects of Ivabradine?
- Bradycardia
- Atrial fibrillation
- Hypertension
- Visual disturbances
What should be prescribed post-MI for asymptomatic patients with EF < 50%?
ACE inhibitors (ACEi)
What is recommended for early stage management of heart failure?
Lifestyle changes
Firstline drug for HFrEF
Valsartan + saculbitril combination (ARNi)
Sacubitril = proANP/proBNP degradation inhibitor (neprilysin inhibitor)
Dapagliflozin
Sodium-glucose transporter inhibitor - improves outcomes in HFrEF (promising results in HFpEF trials)
Decreased fluid and glucose induced oxidative stress on heart (reduced remodeling)
Hydralazine
Selective arteriole dilator
Digoxin
Positive inotropic
Digitalis - cardiac glycoside
Your 48 year old, Type I diabetic patient was recently diagnosed with systolic heart failure. Which of the following would be the best first choice drug in this patient
Lisinopril
Can precipitate DKA with dapaglifloxin in type I diabetes - only used in type II
MOA of dobutamine
Beta-one agonist
