Heart Failure - Treatment Flashcards
Learning Outcomes
What is heart Failure Characterised by?
–by progressive cardiac dysfunction
–breathlessness
–tiredness
–neurohormonal disturbances
–sudden death
What is congestive heart failure defined as?
Heart unable to pump blood that meets the demands of the tissues or it can do so but only from high pressures.
What are the two types of heart failure?
Systolic heart failure - Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure
Diatolic heart failure
(HFrEF - heart failure with presereved ejection fraction)
Diastolic Heart Failure - Thickened and stiff heart muscle
- Heart does not fill properly with blood
- Fluid back up in the lungs and hear failure
(HFpEF) - Heart failure with preserved ejection fraction
Risk factors for heart failure
- Coronary artery disease
- Hypertension (LVH)
- Valvular heart disease
- Alcoholism
- Infection (viral)
- Diabetes
- Congenital heart defects
- Other:
–Obesity
–Age
–Smoking
–High or low hematocrit level
–Obstructive Sleep Apnea
What is the effect of heart failure on Frank - Starling Law?
Failing heart causes the relationship to be lost - amount of stretch is no longer proportional to the force of contraction
Circulatory volume increases - heart dilates - force of contraction reduces and there is a further drop in cardiac output.
Activation of the RAAS (renin angiotensin aldosterone system)
When does heart failure usually occur?
Following sustained hypertension
As a result of myocyte damage - MI
What is the result of a reduced cardiac output on blood pressure?
What is the effect of –Atrial and Brain Natriuretic Peptides?
- Potent vasodilators and natriuretic peptides
- Short halflife
What are the drugs for the treatment of symptoms?
- Diuretics
- Digoxin
What is the treatment for the improvement of symptoms and survival?
- ACE inhibitors/ARBs
- Spironolactone
- Valsartan-sacubitril
What are the goals of treatment?
- Symptomatic treatment
- Inhibition of detrimental neurohormonal adaptations
- Enhancement of beneficial neurohormonal adaptations
- Enhancement of cardiac function
Give examples of loop diuretics
–FUROSEMIDE or BUMETANIDE
How is sympathetic activation blocked?
Beta blockers - in this case:
–CARVEDILOL, BISOPROLOL and METOPROLOL are beta blockers which are of proven benefit in the treatment of CHF
What are the two types of drugs that block the effects of angiotensin 2?
Ace inhibitors (Rampril)
Angiotensin antagonists
How is aldosterone blocked?
Spironolactone - Produces a significant reduction in morbidity
What are the beneficial hormonal changes that we want to enhance?
Natriuretic peptide system
What metabolises brain and heart natriuretic peptides?
Neutral endopeptidse
What is the effect of digoxin?
Enhances cardiac function - improves cardiac statue
Digoxin toxicity is a very likely
What is the effect of vasodilators?
Reduce preload and afterload - improving cardiac function
–Hydralazine an arterial dilator has also been shown to improve cardiac function
Give examples of vasodilators
ISOSORBIDE MONO or DINITRATE
How do loop diuretics work?
Inhibit the sodium potassum chlorine transporter in the loop of henle- inducing profound diuresis.
What are the adverse drug reactions for diuretics?
–Dehydration
–Hypotension
–Hypokalaemia, Hyponatraemia
–Gout
–Impaired glucose tolerance, diabetes
What are the drug drug interactions wih frusemide?
What are the drugs needed for reducing mortality?
- Angiotensin Blockade
- Beta receptor blockade
- Aldosterone blockade
- ANP/BNP enhancement
What are the relevant ACEi?
RAMIPRIL, ENALAPRIL, LISINOPRIL
What are the adverse drug reactions of ACEi?
–First dose hypotension
–Cough
–Angioedema
–Renal impairment
–Renal failure
–Hyperkalaemia
What are the drug drug interactions with ACEi?
–NSAIDs acute renal failure
–Potassium supplements hyperkalaemia
–Potassium sparing diuretics hyperkalaemia
How does the effectiveness of ARB’s compare with ACEi?
NOT as effective
What is the role of AT1 and AT2 receptors?
ARB’s act on the AT1 receptor
What is the effect of neprilysin?
Stops break down of BNP and ANP by neutral endopeptidases
What is Valsartan - Sacubitril?
Combined valsartan and ARB and Neprilysin
What is the effect of spironolactone?
Aldosterone antagonist
Potassium sparing diuretic
Acts in distal tubule
Used in combination with loop diuretics
Particularly useful in resistant oedema
Proven to reduce mortality when used in combination with ACEI’s
What is the major risk attached to beta blockers?
May precipitate severe deterioration in CHF
When type of onset are beta blockers used for?
–Should be used only when a patient has been stabilized and not during an acute presentation
What is the aim of ivabradine?
To improve survival
What is the effect of Ivabridine?
Specific inhibitor of current in sinoatrial node
- No action on other channels in the heart or vascular system.
- Does not modify myocardial contractility and intracardiac conduction, even in patients with impaired systolic function.
Whos is Ivabridine recommended for?
Stable chronic HFrEF
Maximum tolerated dose of beta blockers
In sinus rhythm
Have a heart rate of 70 bpm or greater at rest
What are the effects of Digoxin?
Increases the availability of calcium in the myocyte
No effect on mortality but it can reduce hospitilisations
Narrow therapeutic index
What are the side effects of digoxin?
Arrhythmias
Heart block
Nausea
Confusion
What is the purpose of warfarin in the treatment of heart failure?
–Dilated ventricle gives rise to thrombus formation and thrombo-embolic events
–Warfarin has proven value in preventing these events
What is the therapeutic regime?
Where ARNI is the Valsartan and Salcubitril (Neprilysin)
How do you monitor benefit?
Measuring weight is the only effective way to measure the loss on body fluids - urine volumes are unreliable
