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Cardiovascular Module > Heart Failure Pharmaco > Flashcards

Heart Failure Pharmaco Flashcards

1
Q

What is heart failure

A

Progressive disease with gradual reduction in cardiac performance due to inadequate cardiac output to provide oxygen

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2
Q

Most common cause of heart failure

A

Coronary artery disease

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3
Q

Major types of heart failure

A

Systolic heart failure

diastolic heart failure

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4
Q

Systolic heart failure

A

Reduced mechanical pumping action (contractility)

reduced ejection fraction

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5
Q

Diastolic heart failure

A

Stiffening and loss of adequate relaxation so reduced filling and cardiac output
reduced stroke volume

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6
Q

Goal of treatments

A

Reduce symptoms and slowing progression to heart failure

Manage Acute episodes

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7
Q

How can you increase contractility

A

By increasing sensitivity of cardiac tissues to released calcium

Increasing storage of calcium

Increasing release of calcium from Sarcoplasmic reticulum

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8
Q

Primary target of cardiac Glycosides and digoxin

A

Na/K ATPase which determines amount of extra cellular Na

Important because of NCX

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9
Q

Compensatory mechanisms of heart failure

A

RAAs system
Ventricular hypertrophy and remodeling
Hormones activation (NE, angiotensin II, aldosterone, vasopressin )
Pro inflammatory cytokines

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10
Q

Primary symptoms of heart failure

A

Tachycardia
Decreased exercise tolerance
Shortness of breath
Cardiomegaky

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11
Q

Symptomatic heart failure routine treatment t

A

ACE inhibitor
B blocker
Diuretics
Digoxin (to considerate for symptoms improvement )

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12
Q

Function of ACE inhibitors

A

Improve survival
Slow disease
Reduce hospitalization
Improve life quality

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13
Q

What can you replace ACE inhibitors with if not tolerated

A

Angiotensin II receptor blocker

hydrLazine and isosorbide dinitrate combination. Je

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14
Q

Type of B blockers that can prolong survival , reduce needs for hospitalization and transplantable cause reverse modeling of LV

A

Carvedilol ,?Metoprolol (CR/XR)

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15
Q

Drugs recommended when reduced ejection fraction

A

Carvedilol and metoprolol

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16
Q

Is therapy with diuretics mandatory

A

No only requires when there is peripheral edema / pulmonary congestion

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17
Q

Digoxin improves survival ?

A

No just help with symptoms

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18
Q

What drugs should be specifically added for African American with moderate to severe symptoms and in patients who still have symptoms after ACE and ARB and b blocker

A

Hydralazine

Nitrates

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19
Q

Cardiac glycosides types

A

Digoxin
Digitoxin
Ouabain
Marinobufagenin

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20
Q

Cardiac glycosides action

A 
Inhibit Na/K atpase So 
Increased cardiac contraction 
Increase CO
Increase ejection fraction 
Reduced sympathetic because better circulation 
Reduced peripheral resistance

So reduced HR
Less O2 demand

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21
Q

Digoxin therapy indication

A

Patients with severe left ventricular systolic dysfunction after ACE and diuretic therapy

When there’s heart heart failure with atrial fibrillation

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22
Q

When is digoxin not indicated

A

When diastolic or right sided heart failure

When mild to moderate HF

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23
Q

Digoxin pk

A

Very potent
narrow margin of safety
Long half life (36-40h)
Metabolized by liver

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24
Q

Digoxin elimination

A

Intact kidney so require dose adjustment based on creatinine clearance

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25
Q

Side effects of digoxin

A

Ventricular tachycardia
Arrythmias
Anorexia
Nausea

Vomiting 
Headache 
Fatigue 
Confusion 
Blurred vision 
Altered color perception
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26
Q

Management of digoxin toxicity

A

Discontinuing glycoside therapy
Serum k levels
K supplements

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27
Q

Factors predisposing to digitalis toxicity

A 
Hypokalemia
Hypervalcemia 
Hypomagnesemia 
Quinidine , verapamil, amiodarone 
Hypothyroidism 
Hypoxia 
Renal failure 
Myocarditis
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28
Q

Positive inotropic agents

A 
Digoxin 
Istaroxime
Bipyridines (inamrinone, Milrinone, enoximone, 
Levosimendan
B-adrenoreceptor agonists
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29
Q

Istaroxime action

A

Increases contractility by inhibiting Na/K Atpase but also enhance sequestration of CA2+ in SR

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30
Q

When to use istaroxime

A

Acute HF with reduced ejection fraction

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31
Q

Bipyridines

A

Inamrinone
Milrinone
Enoximone

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32
Q

Levosimendan action

A

Troponin system sensitized to Ca2+

Inhibit puosohodiesterase so vasodilation

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33
Q

Bipyridines actions

A

Inhibit PDE3-> vasodilation

Increase myocardial contractility

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34
Q

When are bipyridines used

A

IV for Acute heart failure

Severe exacerbation of chronic heart failure that do not respond to normal therapy

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35
Q

B adrenoreceptor agonist inotropic agents

A

Dobutamine

Dopexamine

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36
Q

Dobutamine action

A

Increase cardiac output and decrease ventricular filling pressure

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37
Q

Dopamin uses

A

Acute heart failure

raise blood pressure

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38
Q

Dopexamine

A

Act on B2 receptors in cardiac cells

Act on peripheral dopamin receptor and increase renal perfusion

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39
Q

Dopexamine side effects

A 
Angina 
Arrythmias 
Bradycardia 
Dyspnoea 
Headache 
MI
Nausea 
Réversible thrombocytopenia 
Sweating 
Tachycardia 
Tremor
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40
Q

Contra indications of dopexamine

A 
Aortic stenosis 
Hypertrophic cardiomyopathy 
Left ventricular outlet obstruction 
Phaeochromocytoma 
Thrombocytopenia
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41
Q

De rugs without inotropic effects

A 
Diuretics 
ACE inhibitors 
ARBs
Vasodilators 
Beta blockers
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42
Q

Diuretics

A

Furosemide
Spironolactone
Eplerenone

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43
Q

Diuretics

A

Furosemide

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44
Q

Are diuretics drugs of choice

A

Yes

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45
Q

Spironolactone and eplerone advantages

A

Decrease morbidity and mortality

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46
Q

What is heart failure

A

Progressive disease with gradual reduction in cardiac performance due to inadequate cardiac output to provide oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Most common cause of heart failure

A

Coronary artery disease

How well did you know this?
1
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2
3
4
5
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48
Q

Major types of heart failure

A

Systolic heart failure

diastolic heart failure

How well did you know this?
1
Not at all
2
3
4
5
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49
Q

Systolic heart failure

A

Reduced mechanical pumping action (contractility)

reduced ejection fraction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Diastolic heart failure

A

Stiffening and loss of adequate relaxation so reduced filling and cardiac output
reduced stroke volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Goal of treatments

A

Reduce symptoms and slowing progression to heart failure

Manage Acute episodes

52
Q

How can you increase contractility

A

By increasing sensitivity of cardiac tissues to released calcium

Increasing storage of calcium

Increasing release of calcium from Sarcoplasmic reticulum

53
Q

Primary target of cardiac Glycosides and digoxin

A

Na/K ATPase which determines amount of extra cellular Na

Important because of NCX

54
Q

Compensatory mechanisms of heart failure

A

RAAs system
Ventricular hypertrophy and remodeling
Hormones activation (NE, angiotensin II, aldosterone, vasopressin )
Pro inflammatory cytokines

55
Q

Primary symptoms of heart failure

A

Tachycardia
Decreased exercise tolerance
Shortness of breath
Cardiomegaky

56
Q

Symptomatic heart failure routine treatment t

A

ACE inhibitor
B blocker
Diuretics
Digoxin (to considerate for symptoms improvement )

57
Q

Function of ACE inhibitors

A

Improve survival
Slow disease
Reduce hospitalization
Improve life quality

58
Q

What can you replace ACE inhibitors with if not tolerated

A

Angiotensin II receptor blocker

hydrLazine and isosorbide dinitrate combination. Je

59
Q

Type of B blockers that can prolong survival , reduce needs for hospitalization and transplantable cause reverse modeling of LV

A

Carvedilol ,?Metoprolol (CR/XR)

60
Q

Drugs recommended when reduced ejection fraction

A

Carvedilol and metoprolol

61
Q

Is therapy with diuretics mandatory

A

No only requires when there is peripheral edema / pulmonary congestion

62
Q

Digoxin improves survival ?

A

No just help with symptoms

63
Q

What drugs should be specifically added for African American with moderate to severe symptoms and in patients who still have symptoms after ACE and ARB and b blocker

A

Hydralazine

Nitrates

64
Q

Cardiac glycosides types

A

Digoxin
Digitoxin
Ouabain
Marinobufagenin

65
Q

Cardiac glycosides action

A 
Inhibit Na/K atpase So 
Increased cardiac contraction 
Increase CO
Increase ejection fraction 
Reduced sympathetic because better circulation 
Reduced peripheral resistance

So reduced HR
Less O2 demand

66
Q

Digoxin therapy indication

A

Patients with severe left ventricular systolic dysfunction after ACE and diuretic therapy

When there’s heart heart failure with atrial fibrillation

67
Q

When is digoxin not indicated

A

When diastolic or right sided heart failure

When mild to moderate HF

68
Q

Digoxin pk

A

Very potent
narrow margin of safety
Long half life (36-40h)
Metabolized by liver

69
Q

Digoxin elimination

A

Intact kidney so require dose adjustment based on creatinine clearance

70
Q

Side effects of digoxin

A

Ventricular tachycardia
Arrythmias
Anorexia
Nausea

Vomiting 
Headache 
Fatigue 
Confusion 
Blurred vision 
Altered color perception
71
Q

Management of digoxin toxicity

A

Discontinuing glycoside therapy
Serum k levels
K supplements

72
Q

Factors predisposing to digitalis toxicity

A 
Hypokalemia
Hypervalcemia 
Hypomagnesemia 
Quinidine , verapamil, amiodarone 
Hypothyroidism 
Hypoxia 
Renal failure 
Myocarditis
73
Q

Positive inotropic agents

A 
Digoxin 
Istaroxime
Bipyridines (inamrinone, Milrinone, enoximone, 
Levosimendan
B-adrenoreceptor agonists
74
Q

Istaroxime action

A

Increases contractility by inhibiting Na/K Atpase but also enhance sequestration of CA2+ in SR

75
Q

When to use istaroxime

A

Acute HF with reduced ejection fraction

76
Q

Bipyridines

A

Inamrinone
Milrinone
Enoximone

77
Q

Levosimendan action

A

Troponin system sensitized to Ca2+

Inhibit puosohodiesterase so vasodilation

78
Q

Bipyridines actions

A

Inhibit PDE3-> vasodilation

Increase myocardial contractility

79
Q

When are bipyridines used

A

IV for Acute heart failure

Severe exacerbation of chronic heart failure that do not respond to normal therapy

80
Q

B adrenoreceptor agonist inotropic agents

A

Dobutamine

Dopexamine

81
Q

Dobutamine action

A

Increase cardiac output and decrease ventricular filling pressure

82
Q

Dopamin uses

A

Acute heart failure

raise blood pressure

83
Q

Dopexamine

A

Act on B2 receptors in cardiac cells

Act on peripheral dopamin receptor and increase renal perfusion

84
Q

Dopexamine side effects

A 
Angina 
Arrythmias 
Bradycardia 
Dyspnoea 
Headache 
MI
Nausea 
Réversible thrombocytopenia 
Sweating 
Tachycardia 
Tremor
85
Q

Contra indications of dopexamine

A 
Aortic stenosis 
Hypertrophic cardiomyopathy 
Left ventricular outlet obstruction 
Phaeochromocytoma 
Thrombocytopenia
86
Q

De rugs without inotropic effects

A 
Diuretics 
ACE inhibitors 
ARBs
Vasodilators 
Beta blockers
87
Q

Are diuretics drugs of choice

A

Yes

88
Q

Diuretics action in heart failure

A

Reduce venous pressure

Reduce ventricular preload

89
Q

Spironolactone and eplerone advantages

A

Decrease morbidity and mortality

90
Q

ACE inhibitors

A

Captopril

91
Q

ACE inhibitors actions

A

Versatile drugs that reduce peripheral resistance

Reduce afterload

Reduce salt and water retention -> reduce preload

Decreased angiotensin reduces sympathetic activity by decreasing NE release

Decrease long term remodeling of heart and vessels

92
Q

ARB examples

A

Losartan

Candensartan

93
Q

ARBs actions

A

Same action as ACE but limited

Only used when no tolerance for ACE

94
Q

Can you use aliskiren, a renin inhibitor normally used for hypertension?

A

Yes

95
Q

Actions of vasodilators

A

Reduce preload by venodilstion

Reduced afterload (arteriolar dilation )

Reduce damaging remodeling of heart

96
Q

Vasodilators examples

A

Hydralazine
Isosorbide dinitrate

Bosentan
Tezosentan

97
Q

Natriuretic peptide

A

Nesiritide

98
Q

Natriuretic action

A

Increase cGMP in smooth muscles and reduce venous and arteriolar tone

Cause diuresis

99
Q

When can you use natriuretic peptide

A

Only in acute cardiac failure

100
Q

Common adverse effect of vasodilators

A

Excessive hypotension (main one )

Renal damage
Deaths

101
Q

What is a useful diagnosis or prognostic test

A

Measurement of plasma BNP

Atrial natriuretic peptide and urodilatin produced in kidney. Carperitide and ularitide used as analogs of endogenous peptides

102
Q

Bosentan Tezosentan actions

A

Competitive inhibitors of endothelin

Not really working on humans

103
Q

What is bosentan approved for

A

Pulmonary hypertension

104
Q

Bosentan adverse effects

A

Teratogenic and hepatotoxic effects

105
Q

B blockers used in

A

Chronic heart failure

106
Q

Good b blocker

A

Bisoprolol
Carvedilol
Metoprolol
Nebivolol

107
Q

Mechanism of b blockers

A

Attenuate action of high concentration catecholamines

Up regulate b receptors

Decrease heart rate

Reduce remodeling of heart by inhibiting mitogenic activity of catecholamines

108
Q

Chronic heart failure stages

A

Stage À
Stage B
Stage C
Stage D

109
Q

Stage À

A

High risk but no signs or symptoms of heart failure

110
Q

Stage b

A

Evidence of heart failure but no symptoms of heart failure

111
Q

Stage c

A

Structural heart disease
Symptoms of failure
Symptoms responsive to therapy ohhh

112
Q

Stage D

A

Heart failure even after normal therapy

Special interventions like resynchronization therapy and transplant needed

113
Q

Stage C différent classes

A

Class I
class II
Class III
Class IV

114
Q

Stage C class I

A

No limitation to ordinary activities

Symptoms only with greater than ordinary exercise

115
Q

Stage C class II

A

Slight limitation of activities
Fatigue
Palpitations with normal physical activity

116
Q

Stage C class III

A

No symptom at rest but fatigue and shortness of breath , tachycardia occur with less than ordinary activity

117
Q

Stage C class IV

A

Symptoms even at rest

118
Q

Stage À management

A 
Treat : 
obesity 
Hypertension 
Diabetes 
Hyperlipidemia
119
Q

Stage B management

A

ACEI
ARBs
B blocker
Diuretics

120
Q

Stage C class II or III

A 
ACEI
ARBs
B blocker 
Diuretics 
Aldosterone antagonist
Digoxin 
CRT
 hydralazine / Nitrate
121
Q

Stage D Class IV

A

Transplant

LVAD

122
Q

Management of chronic heart failure

A

Sodium removal especially if edema - diuretics( thiazides if mild but mostly loop) , salt reduction in diet

hypokalemia treated by Potassium supplementsor ACEI or potassium sparing diuretic (spironolactone , eplerone)

Spironolactone and eplerone in moderate and severe heart failure to reduce morbidity and mortality

ACEI as first agent of left ventricular dysfunction but no edema

ARBs if not possible to use ACEI

Long acting nitrates (venous dilators) if there’s high filling pressure with dyspnea (pulmonary congestion )

Hydralazine (arteriolar dilation ) if there’s fatigue due to LV output

B blockers to raise ejection fraction, slow heart rate , reduce symptoms

123
Q

Acute heart failure causes

A

Generally in chronic heart failure
Due to exertion , emotion, excess salt , not taking medications, fever anemia etc
MI

124
Q

Management of emergency MI

A

Emergency revascularisation with coronary angioplasty and a stent or thromblytic agent

125
Q

Acute failure management

A

IV treatment in general for faster action

Diuretics - furosemide

+ inotropic agents - Dopamine or dobutamine or levosimendan when severe hypotension

If acute decompression - vasodilators like nitropusside, nutroglycerine, nesiritide

Vasopressin antagonist like conivaptan for hyponatremia

Cardiovascular Module (21 decks)

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