Heart failure treatment

Question 1

when does R heart failure only commonly occur?

Answer 1

in severe lung disease
not likely to be asked about in cardiovascular system question

heart failure tends to refer to LV heart disease

Question 2

two types of heart failure?

Answer 2

systolic and diastolic

Question 3

systolic heart failure (HFrEF - heart failure reduced ejection fraction)

Answer 3

heart has turned into a skinny bag that cannot function properly

Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure
LVSD

usually occurs following myocardial damage ie post MI

Question 4

diastolic heart failure (HFpEF - Heart Failure with a Preserved Ejection Fraction ie it is normal)

Answer 4

Involves a thickened and stiff heart muscle due to high BP

As a result, the heart releases all the blood but it does not fill with blood properly as it can’t relax properly

This results in fluid backup in the lungs and heart failure

heart failure usually occurs following sustained hypertension

Question 5

Chronic heart failure

Answer 5

2-10% of population affected

People with severe heart failure are very symptomatic – QOL affected greatly.

Peripheral oedema, if severe, can reduce mobility

Question 6

risk factors for heart failure

Answer 6

Coronary artery disease
previous MI
Hypertension (LVH)
Valvular heart disease
Alcoholism – v common cause
Infection (viral)
diabetes
congenital heart defects

then general:- age, obesity, smoking, obstructive sleep apnoea

Question 7

what is the most severe risk factor of heart failure

Answer 7

hypertension

LV diastolic dysfunction can be prevented if hypertension is tackled aggressively

Question 8

frank starling law and systolic dysfunction?

Answer 8

if the muscle of a healthy heart is stretched it will contract with greater force and pump out more blood.
Failing or damaged heart - lose this relationship

Healthy heart – contraction force is in proportion with the amount it is stretched

Damaged heart - More you stretch the heart due to increased circulatory volume (H20 and salt retention) the weaker the force of contraction and CO drops further

drop in CO activates vasoconstrictor system (sympathetic) and RAAS

Question 9

how does a drop in CO due to HF cause further problems?

Answer 9

drop in CO activates RAAS system which then increases plasma vol and therefore increases venous return so cardiac performance deteriorates further

Question 10

how does the heart weaken

Answer 10

As the heart starts to dilate the cardiac myocytes undergo hypertrophy and then fibrosis and thus the heart is further weakened

myocytes that become hypertrophic become ischaemic and die

Question 11

The RAAS system causes the release of what?

Answer 11

angiotensin II – causes vasoconstriction

aldosterone

Question 12

what does the Natriuretic peptide system ANP/BNP

Answer 12

cause salt watter loss

Question 13

what does EDRF do?

Answer 13

muscle relaxation

vasodilation

Question 14

treatment options to improve SYMPTOMS of heart failure? (2)

Answer 14

diuretics - no other drug that alters physical state of patient like them - gets rid of excess fluid so they don’t have peripheral oedema - also improves exercise capacity

digoxin - slows and controls heart rate

Question 15

treatment options to improve SYMPTOMS AND SURVIVAL of heart failure? (3)

Answer 15

ACE inhibitors/ARBs

Spironolactone – mineralocorticoid - steroid hormone

Valsartan-sacubitril – expensive, inhibits the breakdown of natriuretic peptides resulting in varied effects including increased diuresis, natriuresis, and vasodilation.

Question 16

treatment to improve HF survival

Answer 16

beta blockers

ivabradine

Question 17

symptomatic treatment?

Answer 17

Loop Diuretics
FUROSEMIDE or BUMETANIDE

Furosemide- start on IV then move onto oral con is that they can;t leave house due to a lot of diuresis (urine output increases)

Bumetanide - takes 10 hours to reduce diuresis - Have to use these in the morning and early afternoon – so they don’t have to get up during the night to urinate – high fall risk at night etc for elderly

Question 18

treatment options for blocking detrimental hormonal changes?

Answer 18

sympathetic activation by cavedilol, bisoprolol, metoprolol beta blockers - proven benefit in treatment of chronic HF

Question 19

which two drugs can block the affects of angiotensin II

Answer 19

ACE Inhibitors (Ramipril )

Angiotensin antagonists (Valsartan, Losartan) but these are not as effective (ELITE II)

Question 20

which drug can block the affect of aldosterone?

Answer 20

SPIRONOLACTONE

Question 21

what is the treatment option if a patient is resistant to diuretics

Answer 21

use a diuretic in combination with thiazide diuretics - powerful combo - 5/10 litres a day - diuresis induced

Question 22

how can a patient become resistant to diuretics?

Answer 22

Patients become resistant to furosemide because the body is trying to maintain balance by retaining more salt water

Question 23

ADRs related to diuretic use (6)

Answer 23

Dehydration
Hypotension
Hypokalaemia
Hyponatraemia
Gout - formation of crystals in the joints 
Impaired glucose tolerance, diabetes

Question 24

drug-drug interactions
furosemide and…

1. aminoglycosides
2. lithium
3. NSAIDs
4. antihypertensives
5. vancomycin

Answer 24

1. aural (ear) and renal toxicity
2. renal toxicity
3. renal toxicity
4. profound hypotension
5. renal toxicity

Question 25

4 ways to reduce mortality?

Answer 25

angiotensin blockade - induces vasodilation - lowers BP beta receptor blockade - lowers heart rate ANP/BNP enhancement - vasodilation, natriuresis, and inhibition of RAA and sympathetic systems.

Question 26

define natriuresis

Answer 26

process of sodium excretion in the urine through the action of the kidneys it lowers the conc of Na+ in the blood and also tends to lower blood vol because osmotic forces drag H20 out of the body's blood circulation and into the urine along with the Na+

Question 27

which drugs prevent the conversion of angiotensin I to II by blocking the angiotensin converting enzyme?

Answer 27

Ramipril Enalapril Lisinopril by doing this they reduce the preload and after load on the heart

Question 28

what does using ACE inhibitors do for:- patients with chronic HF post MI patients which studies looked into this?

Answer 28

CHF - reduces morbidity, mortality Post MI - reduces morbidity, mortality, onset of heart failure studies:- CONCENSUS, SOLVD,

Question 29

ADRs with ace inhibitors

Answer 29

``` First dose hypotension Cough Angioedema Renal impairment Renal failure Hyperkalaemia ```

Question 30

NSAIDs and ACEI

Answer 30

could be life threatening - acute renal failure NSAIDs - aches and pains - elderly

Question 31

role of angiotensin I

Answer 31

``` Vasoconstriction Vascular proliferation Aldosterone secretion Cardiac myocyte proliferation Increased sympathetic tone ```

Question 32

role of angiotensin II

Answer 32

Vasodilation Anti-proliferation Apoptosis

Question 33

how can beta blockers kill patients with severe HF

Answer 33

patients with severe HF rely on adrenergic system to survive. A beta blocker flattens them quickly and they die

Question 34

what do you need to do before putting a patient on a beta blocker

Answer 34

stabilise them - should not be used during an acute presentation need to get rid of peripheral oedema etc first

Question 35

ivabradine

Answer 35

specific inhibitor of the pacemaker current in the SA node (binds to If receptors in pacemaker) - slows heart rate reduces mortality and hospitalisations in people that cannot tolerate beta blockers (ie get too tired/lethargic) – it isn’t as effective though

Question 36

warfarin

Answer 36

Anticoagulant - used if there is high risk of thromboembolic disease - prevents stroke Dilated ventricle gives rise to thrombus formation and thrombo-embolic events

Question 37

how do you monitor someone with HF

Answer 37

HF is evident due to fluid retention monitor by measuring weight on daily basis - see how many kilos of weight they're losing each day through urine/bowel movements etc

Question 38

benefits of monitoring patient

Answer 38

Symptomatic relief SOB, tiredness, lethargy Clinical relief Peripheral oedema, ascites, weight Monitor weight regularly Patient performs daily weight assessment Increase medication according to symptoms or weight Patient education