Heart Failure TX

Question 1

Indications for admissions in HF

Answer 1

o	AMI
o	Severe respiratory distress
o	Hypoxia
o	Hypotension
o	Cardiogenic shock
o	Anasarca – fluid accumulation every
o	Syncope
o	Heart failure refractory to oral medications

Question 2

Non-pharmacologic treatment of HF

Answer 2

o Quit smoking
o Overweight
• Decrease caloric intake
• AHA diet
• Diet instructions by dietician to patient and spouse
o 2 g Na+ diet
o Fluid restriction if Na is less than 126 meq/L; <2 L/d
o Avoid isometric activity – increase SVR and afterload
o Encourage isotonic activity – walking, hiking, golf
o Stool softener – reduce valsava
o Subcut lovenox
o Oxygen for 24 hours
o Avoid etOH – depresses contractility in cardiac disease
o Tx HTN, hyperlipidemia, diabetes

Question 3

Patient counseling prior to discharge from hospital

Answer 3

o Diet
o Education
o Rehab, exercise
o Medications: ACE/ARB, Beta blocker, ASA, statin, Nitro prn

Question 4

Conventional treatment for acute HF

Answer 4

o Diuretics
• Reduce fluid volume

o Vasodilators
• Decrease preload and/or afterload

o Inotropes
• Augment contractility

Question 5

ACEI

Answer 5

• Block conversion of Ang I to Ang II
• Useful for all NYHA functional classifications with systolic heart failure
• Lower mortality and morbidity by 20% supported by several good drug trials
• Useful in preventing HF in high risk patients (ASHD, MD, HT) level of evidence A
• Recommended in patients with symptoms of HF, reduced EF, unless contraindicated: L of E: A
• Caution with renal insufficiency (Cr >2.5 mg) or potassium greater than 5 mEq/L
• Contraindicated:
• Angioedema
• pregnancy
• Bilateral Renal artery stenosis
• Side Effect – cough

Question 6

ARB

Answer 6

o Ang Receptor Blocker (ARB)
• Intolerant to ACEI, change to ARB
• Block AT1 and AT2 receptors, not on ACE

Question 7

Beta blockers

Answer 7

• Survival benefit in chronic systolic HF and dilated cardiomyopathy
• Slow progression of disease and decrease hospitalization
• Improve cardiac performance and symptoms of HF
• Hemodynamics include:
• Decreased HR
• Antiarrhythmic properties
• Anti-ischemic
• Blunts SNS effects of NE
• Reverse remodeling
• Don’t use in unstable patients – Class IV

Question 8

Diruetics

Answer 8

“give them when they’re wet”
•	To relieve congestive (pulmonary) symptoms by reducing preload
•	Increase cardiac function
•	Promote natriuresis, urinary Na excretion
•	Inhibits NaCl resorption from AL or LOH
•	Increase risk of arrhythmia deaths without K+ sparing
•	Site of Action
•	AL of LOH – watch K, Mg, Na, BUN, Cr
o	Lasix (furosemide)
o	Bumex (bumetanide)
o	Demadex (torsemide)
•	DT
o	Zaroxolyn (metolazone)
o	Thiazide
•	Late DT
o	Aldactone (spironolactone)

Question 9

Digitalis

Answer 9

• Inotropic agent (DIG)
• Improves quality of life associated with HF, no effect on survival
• MOA: inhibits Na/K ATPase
• Increase contractile state by increasing intracellular Ca2+ concentration
• Useful in A fib to slow ventricular rate

Question 10

Spironolactone

Answer 10

• Antagonizes effects of Aldosterone
• Use in addition to standard care – ACEI, BB, diuretic, DIG
• Reduction in morality
• Watch K closely if GFR less than 30 cc/min or Cr >1.6 mg/dL

Question 11

Inotropes

Answer 11

• Increase contractility
• Dobutamine (Dobutrex)
• Stimulating beta 1 and beta 2 receptors
• Milrinone (Primacor)
• Inotropic vasodilator
• Inhibits phosphodiesterase
• Don’t give with PDE-I
• Dopamine – for hypotensive

Question 12

Hydrazine Plus Isosorbide Dinitrate

Answer 12

• Hydralazine – arterial vasodilator, reduces afterload and SVR
• Nitrates – vasodilator to reduce preload or reduce venous return to increase CO
• When both are added to diuretics and DIG may:
• Reduce mortality (especially in African americans)
• Increase EF
• Increase exercise tolerance

Question 13

CCB

Answer 13

• Class III
• No benefit
• Not recommended as routine
• Tx for patients with HF associated with reduced EF

Question 14

OMM in HF

Answer 14

o Open thoracic inlet
• If blocked will not have optimal fluid drainage
• Always do this before lymph treatment so mobilized fluid has a place to drain
o Rib Raising
• Helps open chest cage for more optimal breathing efforts
• Mobilizes fluid
o Diaphragm doming
• As effective as LE exercise for fluid movement
o Effleurage/Petrissage – deep and shallow stroking of extremities
• Can reduce edema of extremities by helping move fluid centrally
• Cervical stoking – opposite of MF stretching, push toward occiput from chest
• Open thoracic duct

Question 15

Pulse deficit

Answer 15

not all heart beats get through to periphery