Heart Failure - treatment Flashcards
What is chronic heart failure characterised by?
Progressive cardiac dysfunction Breathlessness Tiredness Neurohormonal disturbance Sudden death
What is heart failure?
The state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only from high pressures
What are the two types of heart failure?
Systolic heart failure (HFrEF)
Diastolic heart failure (HFpEF)
What is systolic heart failure?
Decreased pumping function of the heart, which results in back up in the lungs and heart failure
What is diastolic heart failure?
A thickened and stiff heart that does not fill with blood properly which results in fluid backup in the lungs and heart failure
What are the risk factors for heart failure?
Coronary artery disease Hypertension Valvular heart disease Alcoholism Infection Diabetes Congenital heart defects Obesity Age Smoking High or low hematocrit level Obstructive sleep apnea
What is the number one risk for heart failure?
Hypertension
What is the pathological progression of cardiovascular disease?
Myocardial injury
Pathological remodelling
Low ejection fraction
Death
How does systolic dysfunction cause heart failure?
The heart can no longer pump out blood properly
As circulatory volume increases, the heart dilates, force of contraction weakens and cardiac output drops
Decreased cardiac output activates the RAAS further
This continuous to happen: RAAS activated, circulatory volume increases and cardiac performance decreases
Dilation of the heart causes hypertrophy of cardiac myocytes and then fibrosis
What are the two reasons for heart failure?
Sustained hypertension
Myocardial damage
What happens during heart failure?
Cardiac output falls
This is registered as decreased circulatory volume
Vasoconstrictor systems activate
RAAS activates
What does the RAAS do?
Retains salt and water
Peripheral vasoconstriction
What does the RAAS cause the release of?
Angiotensin II
Aldosterone
What does activation of the sympathetic system release?
Noradrenaline
Adrenaline
What does activation of the sympathetic system do?
Vasoconstriction
Renin release
Myocyte hypertrophy
What do atrial and brain natriuretic peptides do?
Vasodilation
Sodium excretion in the urine
How is salt and water excretion and vasodilation achieved?
Natriuretic peptide system
EDRF
What is the result of heart failure?
Heart that can’t pump blood sufficiently
Retention of salt and water resulting in pulmonary oedema
Myocyte death and fibrosis
What are the goals of heart failure management?
Improve symptoms
Improve survival
What medication is used to improve symptoms?
Diuretics
Digoxin
What medication is used to improve symptoms and survival?
ACE inhibitors/ARBs
Spironolactone
Valsartan-sacubitral
What medication is used to improve survival?
Beta blockers
Ivabradine
What is the treatment regime followed for heart failure?
Symptomatic treatment
Inhibition of detrimental neurohormonal adaptations
Enhancement of beneficial neurohormonal adaptations
Enhancement of cardiac function
What is involved in symptomatic treatment?
Loop diuretics
Mainstay of symptomatic treatment
Furosemide or Bumetanide
What is involved in blocking detrimental hormonal changes?
Sympathetic activation using beta blockers such as Carvedilol, Bisoprolol and Metoprolol
How are the effects of angiotensin II blocked?
ACE inhibitors such as Ramipril
Angiotensin antagonists such as Valsartan and Losartan
How are the effects of aldosterone blocked?
Spironolactone
How are the beneficial hormonal changes enhanced?
Natriuretic peptide system - ANP/BNP
Neprolysin prevents metabolism and enhances ANP/BNP action
How is cardiac function enhanced?
Positive inotropes - improve hearts ability to pump such as Digoxin
Vasodilators - nitrovasodilators reduce preload and afterload and atrial dilators have been shown to improve cardiac function too
Nam some nitrovasodilators
Isosorbide mono
Dinitrate
Name an atrial dilator
Hydralazine
What do loop diuretics do?
Remove excess salt and water
What are the adverse drug reactions for loop diuretics?
Dehydration Hypotension Hypokalaemia Hyponatraemia Gout Impaired glucose tolerance Diabetes
What should frusemide not be used with?
Amino glycosides Lithium NSAIDs Antihypertensives Vancomycin
What do ACE inhibitors do?
Prevent conversion of angiotensin I into angiotensin II
Reduce preload and after load to the heart
What do ACE inhibitors reduce in post MI patients?
Morbidity
Mortality
Onset of heart failure
What are the adverse drug reactions of ACE inhibitors?
First dose hypotension Cough Angioedema Renal impairment Renal failure Hyperkalaemia
What drugs should not be used with ACE inhibitors?
NSAIDs
Potassium supplements
Potassium sparing diuretics
What do ARBs do?
Selectively block the angiotensin II, AT1 receptors
When are ARBs used?
In ACE inhibitor intolerant patients
What are the roles of the AT1 receptor?
Vasoconstriction Vascular proliferation Aldosterone secretion Cardiac myocyte proliferation Increased sympathetic tone
What are the roles of AT2?
Vasodilation
Antiproliferation
Apoptosis
What is Valsartan-Sacubitril?
Combined valsartan, ARB and Neprilysin
What does Valsartan-Sacubitril do?
Blocks AT1 receptors
Stops breakdown of ANP and BNP
How should aldosterone antagonists be used?
In combination with ACE inhibitors if possible
What do beta blockers do?
Block the action of the sympathetic system
When should beta blockers be used?
When the patient has been selected by a specialist after they have been stabilised
What does Digoxin do?
Increases the availability of calcium in the myocytes
What negative effects can digoxin have?
Arrhythmias
Nausea
Confusion
What is monitored to see how the patient is reacting to heart failure management?
Symptomatic relief
Clinical relief
Weight
Patient education
What is monitored in symptomatic relief?
Shortness of breath
Tiredness
Lethargy
What is monitored in clinical relief?
Peripheral oedema
Ascites
Weight
