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R-Cradio-illness > Heart Failure Treatment > Flashcards

Heart Failure Treatment Flashcards

1
Q

Chronic heart failure is a syndrome characterised by what?

A 
Progressive cardiac dysfunction 
Breathlessness
Tiredness
Neurohormonal disturbances
Sudden death
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2
Q

What are the types of heart failure and their features?

A

Systolic HF - decreased pumping function of the heart which results in fluid back-up in the lungs and heart failure

Diastolic HF - involves a thickened and stiff heart muscle, as a result the heart does not fill up with blood properly which results in fluid back-up in the lungs and heart

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3
Q

What percentage of the population are affected by chronic heart failure?

A

2-10%

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4
Q

What is the 5-year mortality of heart failure?

A

50%, rising to 80% in a year for some patients

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5
Q

What are the risk factors for heart failure?

A 
Coronary artery disease 
Hypertension
Valvular heart disease 
Alcoholism
Infection
Diabetes
Congenital heart defects
Obesity
Age
Smoking 
High or low haematocrit level 
Obstructive sleep apnoea
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6
Q

What is the basic pathological progression of cardiovascular disease?

A

Cause/risk factor
Myocardial injury, neurohormonal stimulation and myocardial toxicity
Pathological remodelling
Low ejection fraction, resulting in symptoms (dyspnoea, fatigue, oedema etc.)
Chronic heart failure

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7
Q

What is involved in neuroendocrine activation in heart failure?

A

Salt and water retention

Activation of:
RAAS
Sympathetic system
Endothelin system 
Natriuretic peptide system ANP/BNP
EDRF
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8
Q

What are the two main aims of treatment for heart failure?

A

To improve symptoms

To improve survival

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9
Q

What are the types of treatment regimens for heart failure?

A

Inhibition of neurohormonal adaptations
Enhancement of beneficial neurohormonal adaptations
Enhancement of cardiac function

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10
Q

What drugs are used for symptomatic heart failure treatment?

A

Diuretics
Digoxin
ACE inhibitors/ARBs

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11
Q

How do loop diuretics treat heart failure?

A

Removes excess salt and water - induce profound diuresis
Inhibit the Na-K-CL transporter in the loop of Henle
Prevent reabsorption of 20% of filtered sodium and water
Work at low glomerular filtration rates

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12
Q

What can be used in diuretic resistant patients?

A

A combination of thiazide diuretics

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13
Q

What are the potential adverse drug reactions of loop diuretics?

A 
Dehydration
Hypotension
Hypokalaemia
Hyponatraemia
Gout 
Impaired glucose tolerance/diabetes
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14
Q

What are the potential drug-drug interactions of loop diuretics?

A

Furosemide and aminoglycosides - aural and renal toxicity
Furosemide and lithium - renal toxicity
Furosemide and NSAIDs - renal toxicity
Furosemide and anti-hypertensives - profound hypotension
Furosemide and vancomycin - renal toxicity

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15
Q

What drugs are used to block the effects of angiotensin II in the RAAS?

A

ACEIs e.g. ramipril

Angiotensin antagonists e.g. valsartan, losartan

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16
Q

What drug can be used to block the effects of aldosterone?

A

Spironolactone

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17
Q

What is the risk reduction carried by ACEIs?

A

35%

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18
Q

What pathophysiologies do ACEIs interfere with?

A

Pathophysiology of coronary ischaemia and renal insufficiency

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19
Q

Give examples of ACEIs

A

Ramipril
Enalapril
Lisinopril

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20
Q

How do ACEIs work?

A

Competitively block angiotensin converting enzyme to prevent the conversion of angiotensin I to angiotensin II
Reduce preload and afterload on the heart

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21
Q

What effect do ACEIs have on CHF patients?

A

Significantly reduce morbidity and mortality

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22
Q

What effect do ACEIs have on post-MI patients?

A

Reduce morbidity, mortality and onset of HF

23
Q

What are the potential adverse drug reactions of ACEIs?

A 
First dose hypotension
Cough 
Angioedema
Renal impairment
Renal failure 
Hyperkalaemia
24
Q

What are the potential drug-drug interactions of ACEIs?

A

NSAIDs - acute renal failure
Potassium supplements - hyperkalaemia
Potassium sparing diuretics - hyperkalaemia

25
Q

How do angiotensin receptor blockers work?

A

Selectively block the angiotensin II AT1 receptor

26
Q

When are ARBs recommended in heart failure?

A

In ACEI intolerant patients

27
Q

What is sacubitril-valsartan?

A

Combination drug of ARB and neprilysin inhibitor

28
Q

How does sacubitril-valsartan work?

A

ARB (valsartan) blocks AT1 receptor

Neprilysin is responsible for the degradation of ANP and BNP, sacubitril inhibits neprilysin

29
Q

What is spironolactone?

A

Potassium sparing diuretic

30
Q

How does spironolactone work?

A

Inhibits the actions of aldosterone

Acts in the distal tubule

31
Q

How is spironolactone used in heart failure?

A

Used in combination with loop diuretics

Particularly useful in resistant oedema

32
Q

When does spironolactone reduce mortality?

A

When used in combination with ACEIs

33
Q

Heart failure usually occurs following what?

A

Sustained hypertension or myocardial damage
Cardiac output falls and body registers this as a loss in circulatory volume, RAAS and vasoconstrictor systems are activated

34
Q

What does activation of the RAAS cause?

A

Release of angiotensin II and aldosterone

This results in salt and water retention, vasoconstriction and hypertrophy and fibrosis of cardiac myocytes

35
Q

What does activation of the sympathetic system cause in heart failure?

A

Release of noradrenaline and adrenaline which cause vasoconstriction, renin release and myocyte hypertrophy

36
Q

What relationship is lost (Frank Starling law) in a failing or damaged heart?

A

If the muscle of a healthy heart is stretched it will contract with greater force and pump out more blood - lost in HF

37
Q

What happens in heart failure as circulatory volume increases?

A

Heart dilates, force of contraction weakens and cardiac output drops further
Decreased cardiac output then activates the RAAS further

38
Q

Why is the heart further weakened as it starts to dilate?

A

Cardiac myocytes undergo hypertrophy and then fibrosis as the heart dilates so it is further weakened

39
Q

How do positive inotropes improve HF?

A

Improve the ability of the heart to pump - increase availability of calcium in the myocyte

40
Q

What positive inotrope is used in HF?

A

Digoxin

41
Q

How do nitrovasodilators work?

A

By reducing preload and afterload to improve cardiac function

42
Q

What nitrovasodilators are used in HF?

A

Isosorbide mononitrate

Isosorbide denigrate

43
Q

What beta blockers have proven benefit in HF?

A

Carvedilol
Bisprolol
Metoprolol

44
Q

What is the relative risk reduction carried by beta blockers?

A

38%

45
Q

What might beta blocker use precipitate in CHF?

A

Severe deterioration

46
Q

What is the reduction in morbidity and mortality in mild/moderate and severe heart failure caused by beta blockers?

A

30%

47
Q

When is ivabradine used in HF?

A

If intolerant to beta blockers

48
Q

How does ivabradine work?

A

Specific inhibitor of the If current in the sinoatrial node

49
Q

What does ivabradine not modify?

A

Myocardial contractility and intra-cardiac conduction

50
Q

What are the potential adverse drug reactions of digoxin?

A

Arrhythmias
Nausea
Confusion

51
Q

What are the disadvantages of digoxin?

A

No effect on mortality

Narrow therapeutic index

52
Q

What is the normal therapeutic regime for heart failure treatment?

A 
Furosemide and/or thiazide
Furosemide and pulse metolazone 
ACEI/ARB 
Carvedilol, bisoprolol, metoprolol, or ivabradine if intolerant
Digoxin 
Warfarin
53
Q

How is warfarin useful in heart failure treatment?

A

Dilated ventricle gives rise to thrombus formation and thrombi-embolic events, warfarin has a proven value in preventing these events

54
Q

How can you monitor/improve the benefit of heart failure treatment?

A

Symptomatic relief - dyspnoea, tiredness, lethargy etc.
Clinical relief - peripheral oedema, ascites, weight
Monitor weight regularly - have patients perform daily. weight assessment and increase medications according to symptoms/weight
Patient education

R-Cradio-illness (27 decks)

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