Heart failure treatment

Question 1

What are the goals of HF treatment?

Answer 1

Correct underlying cause (ie. Revascularization if ischemia), eliminate precipitating factors (ie. Infection, anemia), reduce congestion, improve blood flow

Question 2

What tests can be done to rule out reversible causes of HF?

Answer 2

BP/HR (hypertension)
EKG (tachyarrhythmia, AFib, PVCs)
CMP, CBC (renal failure, liver dysfunction, anemia, infxn, DM, …)
CXR (coexistant lung disease, for future comparison)
BNP / NT-proBNP, troponin (prognosis)
Echo (dilation, LV function, wall motion, PHTN, prognosis)
Coronary angiogram v. CTA, stress testing, MRI (ischemia, scar)
Thyroid function tests
Iron studies (hemochromatosis, iron deficiency)
BP/HR (hypertension)
EKG (tachyarrhythmia, AFib, PVCs)
CMP, CBC (renal failure, liver dysfunction, anemia, infxn, DM, …)
CXR (coexistant lung disease, for future comparison)
BNP / NT-proBNP, troponin (prognosis)
Echo (dilation, LV function, wall motion, PHTN, prognosis)
Coronary angiogram v. CTA, stress testing, MRI (ischemia, scar)
Thyroid function tests
Iron studies (hemochromatosis, iron deficiency)

Question 3

Diuretic actions in HF

Answer 3

Reverses fluid retention by increasing Na loss. Most common HF therapy. Decrases dyspnea and edema without effecting stroke volume too much

Question 4

Classes of diuretics

Answer 4

Loops diuretics (preferred due to potency), thiazide diuretics

Question 5

Diuretics side effects

Answer 5

dehydration, hypokalemia, sulfa, tinnitis

Question 6

What are common neurohormonal antagonists used in HF?

Answer 6

ACE inhibitors, ARBs (Angiotensin II receptor blockers), MRA (mineralcorticoid receptor antagonists), Beta antagonists

Question 7

What do ACE inhibitors do? Examples

Answer 7

Block conversion of ATI to ATII. Effects:Direct vasodilation and Decreased aldosterone activation. …prils (lisinopril, enalapril, benazepril)

Question 8

Side effects of ACE inhibitors

Answer 8

Hypotension, Worsening renal function (afferent vasocontraction), Hyperkalemia, Cough (kinin potentiation): ~20%, Angioedema: <1% can occur after months of use

Question 9

Angiotensin II receptor blocker (ARBs) actions. Examples

Answer 9

Block the receptor of angiotensin II, with similar results to ACEI. Used when patients develo ACEI cough. Sartans (valsartan, candesartan, losartan)

Question 10

ARBs side effects

Answer 10

NO cough, Hypotension, Worsening renal function (afferent vasocontraction),Hyperkalemia

Question 11

Mineralocorticoid Receptor Antagonists (MRA) actions. Examples

Answer 11

Blocks mineralcorticoid receptor. In kidney, ACEI/ARB aldosterone block is incomplete. MRA is a diuretic. Also has antifibrotic effects. Spironolactone and eplerenone

Question 12

MRA side effects

Answer 12

Hyperkalemia and gynecomastia (spiro only)

Question 13

Beta-Blockers actions and examples

Answer 13

Antagonizes effects of sypathetic system (epinephrine/norepinephrine). A beta1 blockade produces negative chronotrope (slows HR, less arrhythmia) and negative inotrope (decreased metabolic demand). Alpha1 blockade produces vasodilation. Olols- metoprolol, carvedilol, bisoprolol

Question 14

Beta blocker side effects

Answer 14

Short term negative inotrope results in long term fluid retention, hypotension, decreased CO. Also bronchoconstriction

Question 15

Benefits of arterial vasodilators in HF and examples of drugs

Answer 15

antihypertensives- decreased LV afterload, reduced cardiac work, less mitral regurgitation. Hydralazine/isosorbide dinitrate in HFREF

Question 16

Benefits of venous vasodilators in HF

Answer 16

decreased preload

Question 17

Benefits of pulmonary arterial vasodilation in HF

Answer 17

decreased in RV afterload

Question 18

Implanted cardioverter defibrillator (ICD)

Answer 18

electrical therapy used in patients with LVEF<35% or dangerous heart rhythms. Aborts sudden cardiac dath from ventricular tachycardia/fibrillation

Question 19

Cardiac resynchronization therapy (CRT)

Answer 19

Biventricular pacemakers with LV lead placed through coronary sinus. Used in patients with long QRS (bundle branch block). Causes LV lateral and septal wall to contract, producing a more efficient contraction and increased stroke volume

Question 20

Treatment of chronic HFrEF

Answer 20

BB, ACEI/ARB, Aldosterone antagonist, Hydralazine/ISDN, +/- digoxin, ICD/CRT

Question 21

Treatment of acute HFrEF

Answer 21

IV diuresis, Nitrates (vasodilators), CPAP/BiPAP (positive pressure ventilation for hypoxia), Pressors, shock with IV inotropes

Question 22

Treatment of chronic HFpEF

Answer 22

Control risk factors (diabetes, HTN, obesity) and control volume status

Question 23

Treatment of acute HFpEF

Answer 23

IV diuresis, Nitrates, CPAP/BiPAP

Question 24

Positive inotropic agents

Answer 24

Digoxin (PO) - K/Na exchange, Dobutamine (IV) – β agonist (opposite of BB), Milrinone (IV) – phosphodiesterase inhibitor (effect is similar to dobutamine)

Question 25

Positive inotropic agents use in HF

Answer 25

Acute: IV agents used to reverse shock. Chronic: digoxin may reduce symptoms. Long term actually worsens HF

Question 26

Options for end stage HFrEF

Answer 26

Transplant, Mechanical support (LVAD), inotrope infusion (may hasten death), hospice

Question 27

Which Rx improve symptoms only in HFrEF

Answer 27

Diuretics and Digitalis

Question 28

Which Rx prolong survival in HfrEF

Answer 28

ACEI/ARB, Beta blockers, aldosterone receptor antagonists, vasodilators, CRT, ICD