HF

Question 1

Heart Failure (Dev/Progression)

Answer 1

Activation of SNS (NE) and RAAS (Angiotensin II, Aldosterone)

Question 2

Drugs that Cause/Worsen HF

Answer 2

Negative Ionotropes (antiarrhythmics, B-blockers, nondihyropyridine CCB, itraconazole, terbinafine)
Cardiotoxic (doxorubicin, daunomycin, cyclophosphamide)
Na/Water Retention (NSAIDs, COX-2 inhibitors, glucocroticoids, androgens, estrogens, salicylates, Na-containing drugs, thiazolidinediones)

Question 3

HF Stage A Goals

Answer 3

Minimize impact of disease on heart, prevent development of HF, prolong survival

Question 4

HF Stage B Goals

Answer 4

Prevent or slow disease progression, cardiac damage, and symptom onset, prolong survival

Question 5

HF Stage C Goals

Answer 5

Minimize disability and symptums, slow disease progression, reduce/prevent hospitalizations/death, prolong survival

Question 6

HF Stage D Goals

Answer 6

Palliative improvement of quality of life

Question 7

HF Stage A Treatment

Answer 7

Address risk factors, ACE-I/ARB

Question 8

HF Stage B Treatment

Answer 8

ACE-I/ARB, B-blocker

Question 9

HF Stage C Treatment

Answer 9

ACE-I/ARB, B-Blocker, Diuretics (loop), Aldosterone receptor antagonists

Question 10

HF Stage D Treatment

Answer 10

Mechanical support, transplant, IV therapy, continue Stage C meds

Question 11

Angiotensin II in HF

Answer 11

Ups systemic vascular resistance, BP
Potentiates release of aldosterone, NE
Induces vascular hypertrophy and cardiac remodeling

Question 12

ACE-I/ARB in HF

Answer 12

ACE-I block creation of Angiotensin II
ARB block Angiotensin II receptor
Improves symptoms, slows disease progression, improves survival, reduces hospitalizations
MAY improve renal failure b/c improves CO/perfusion

Question 13

ARB/neprilysin inhibitor

Answer 13

Sacubitril (prevents breakdown of natriuretic peptides, INCREASES AT II, allows for improved diuresis) and valsartan (ARB, improves outcome)

Question 14

Hydralazine+isosorbide dinitrate

Answer 14

Good for African-American patients, pts intolerant to ACE-I/ARB
Nitrates=venous vasodilation
Hydralazine=direct arterial smooth muscle relax

Question 15

Hydralazine+isosorbide dinitrate (AE/dosing)

Answer 15

Start with low dose, 3-4x daily
AE: hypotension, headache, tachycardia, lupus
AVOID with ED medications

Question 16

BB in HF

Answer 16

Block influence of SNS (NE) on beta adrenergic receptors
Reduces ventricular remodeling, improves ventricular shape, reduces LV end systolic/diastolic volume
Improves EF, reduces all cause & HF hospitalization
Some decrease in all-cause mortality in SYSTOLIC HF (bisoprolol, metoprolol, carvedilol)

Question 17

BB in HF (dosing)

Answer 17

Start LOW once clinically stable & eurvolemic
Titrate slowly (weeks-months), 2x every 2-4 weeks as tolerated
May cause short-term worsening of symptoms

Question 18

BB in HF (adjustments)

Answer 18

Congestion–>increase diuretic and/or reduce BB
HR<50–>stop increasing BB
Increase until at target or repeated intolerance
Bisoprolol 10 mg daily
Carvedilol 25 mg twice daily
Metoprolol succinate 200 mg daily

Question 19

Aldosterone in HF

Answer 19

Na/water retention
electrolyte abnormalities
sympathetic potentiation
ventricular remodeling

Question 20

Aldosterone Antagonists/MRAs in HF

Answer 20

Inhibits aldosterone

Improves clinical outcomes, mortality

Question 21

Antiplatelets/anticoagulants in HF

Answer 21

Increased secondary risk of thromboembolic events
Role is debatable
Aspirin, wafarin based on OTHER concerns (afib/valve)

Question 22

Digoxin in HF

Answer 22

Positive ionotropic effect

Slows HR