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HF Flashcards

1
Q

Heart responds to increase demands 3 ways?

A

Increase HR (chronotrope)

Increasing contraction force (inotrope)

Increase preload/afterload

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2
Q

Causes of Systolic HF (reduced ejection fraction)

A

Reduction in muscle mas

Dilated cardiomyopathies

Ventricular hypertrophy

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3
Q

Causes of diastolic HF (preserved ejection fraction)

A

Increased ventricular stiffness (e.g., hypertrophy, myocardial dz, MI)

Mitral/triscuspid valve stenosis

Pericardial dz

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4
Q

Neurohormones that contribute to/exacerbate ventricular hypertrophy/remodeling?

A

Angiotensin 2

Epi/norepi

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5
Q

What neurohormone would be elevated in response to stress/stretch of ventricles?

A

B-type natriuretic peptide (BNP)

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6
Q

Heart’s intrinsic ability to incraese its force of contraction and SV in response to an increase in venous return (prelaod)

A

Frank Starling Mechanism

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7
Q

Decreased cardiac output causes increased prelaod/afterload… ultimately activating/causing?

A

Activates SNS

Activates RAAS

Ventricular hypertrophy

(all increase CO but lead to further destruction of the heart)

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8
Q

HF w/ preserved EF aka?

A

Diastolic dsfx (restriction inventricular filling)

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9
Q

HF w/ reduced ejection fraction aka?

A

Systolic dsfx (decerased contractility)

(70% of HF causes)

(clots are commonly formed in the “leftover, stagnant” blood)

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10
Q

HFpEF?

HFrEF?

A

HFpEF > 50

HFrEF < 40

(41-49 is borderline and are apporached similarly to HFpEF)

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11
Q

HF signs?

A 
S3 gallop
Edema (pulmonary, peripheral = cardinal finding)
Rales
Elevated BNP
Extremities, cool/cyanotic

JVD

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12
Q

WHAT DO ALL PTS W/ HF GET?

A

ACEI

long term mgmt of chronic HF (rec’d use w/ b-blocker an diuretic)

(also pts w/ L ventricular hypertrophy w/o HF symptoms)

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13
Q

Considerations w/ ACEI usage?

A

SCr and BUN slightly increase (up to 20% acceptable)

BUT caution w/ renal artery stenosis

SO monitor K, SCr, and BUN at baseline/two weeks

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14
Q

Blocks angiotension2 at AT1 receptor, preventing vasoconstriction

Block aldosterone secretion

A

ARBs

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15
Q

ACEI for HF?

A

Captopril
Enalapril
Lisinopril

Perindopril
Ramipril
Trandolapril

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16
Q

ARBs for HF?

A

Candesartan
Losartan
Valsartan

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17
Q

Inhibits neprilysin thus allowing vasodilators that are otherwise degraded by nephrilysin to proliferate

A

Sacubitril

Note: it’s a prodrug and combined with Valsartan

aka ARNI

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18
Q

Rec’d in ALL pts w/ HFrEF (unless CI)

Consider even if asymptomatic…

Decrease in ventricular arrhythmias

And when combiend with ACEI -> decrease mortality, hospitalization

A

Beta blocker

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19
Q

Beta blocker HF considerations?

A

Class 2,3 (Stage B/C/D)

Stable pt w/ euvolemia and no recent decompensation

START THE DOSE LOW AND INCREASE q 2 WEEKS

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20
Q

Beta cautions/precautions?

A

DM - can mask hypoglycemia

Asthma - can block bronchodilation, exacerbating asthma

Disrupts lipid metabolism

Drug w/drawal may angina, MI, SUDDEN death in pts with ischemic heart dz

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21
Q

Beta blockers for HF?

A

Carvedilol (mixed alpha/beta blocker)
Metoprolol
Bisoprolol

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22
Q

Chronic heart failure w/ fluid overload, USE FIRST!

But, no mortality benefit

Decreases JVD, pulmonary congestion, peripheral edema

SHould be used w/ other drugs (adjunct)

A

Diuretics

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23
Q

Which diuretics have a ceiling effect?

A

Loops

Furosemide peaks at 160-200

24
Q

Thiazides at not effective at lower CrCl (<30)?

A

Thiazide/thiazide like

EXCEPT

Metalozone (can be used under 30)

25
Q

Diuretics that eliminate catecholamine potentiation (decreasing BP)

AND block direct fibrotic actions on the myocardium

A

Potassium sparing diuretics

Aldosterone contributes to cardiac hypertrophy -> so blocking it contributes to added benefit

26
Q

What should be combined w/ ACEI/beta blockers for African American pts w/ NYHA Class 3,4 or HFrEF to reduce morbidity/mortality?

A

Hydralazine (BiDil)

27
Q

Vasodilator (v>a) with a short half life that must be administered IV

Tolerance rapidly develops

A

Nitroglycerin

28
Q

Preferred agent for preload reduction in pts w/ pulmonary congestion?**

A

nitroglycerin

29
Q

Used in ADHF (primarily in warm/wet)

Ideal for pts w/ ischemic heart dz, MI, HTN following bypass

A

Nitroglycerin

30
Q

DOC for most HTN emergencies

Mixed/balanced aterial-venous vasodilator

short half life/IV

Warm/wet ADHF

A

Nitroprusside

31
Q

Adverse effects include methemoglobinemia

PVC tubing/bags may absorb…

A

nitroglycerin

32
Q

Cyanide toxicity

May increase ICP

A

nitroprusside

33
Q

b-type natriuretic peptide -> vasodilation

Suppresses RAAS

Used for warm/wet ADHF

A

Nesiritide

34
Q

Inotropic agents mostly used for ADHF

Note that long term use of positive inotrope is not rec’d

A

Milrinone

Dopamine

Dobutamine

(digoxin is also an inotrope but not limited to use in ADHF)

35
Q

Cardiac glycoside that increases force of contractions (pos inotrope, sympathetic stimulant) that stimulates vagus nerve (parasympathetic effect)

Improves symptoms BUT no effect on mortality

A

digoxin – narrow therapeutic index

36
Q

Digoxin is an add on therapy for other HF drugs. If starting digoxin/beta blocker at same time, whcih do you start first?

A

Beta blocker, duh

37
Q

Monitoring parameters for digoxin?

Antidote?

A

Monitor EKG, serum electrolytes, digoxin levels, BUN, Cr

(narrow therapeutic index)

Antidote = Digoxin Immune Fab (Digibind)

38
Q

Dopamine usually avoided in ADHF, except?

A

when pt has significant systemic HOTN or cardiogenic shock w/ elevated ventricular filling pressures

39
Q

beta blocker (w/ some alpha 1 effects) used in ADHF

However, tachyphylaxis (decline in efficacy)

A

dobutamine

40
Q

Positive inotrope

Decreases SVP

No direct adrenergic effect which is beneficial for pts using a beta blocker

41
Q

Brief linear run through of the drug(s) associated with each stage of HF (A-D)

A

A (risk but no structural dz/ssx): ACEI/ARB

B (Structural heart dz but no ssx): ACEI/ARB + beta blocker

C (symptomatic): >50 EF = ACEI/ARB + beta blocker + diuretic
<40 EF = ACEI/ARB + beta blocker + diuretic(aldosterone antagonist) + consider digoxin/Bidil

D: give ‘em everything

42
Q

Regarding CHF, which drugs have effects on mortality?

A

ACEI/ARBs

Beta blockers

Aldosterone antagonists

Hydralazaine/isosorbide dinitate (for AAs)

(long way of saying Diuretics/Digoxin = no effect on mortality)

43
Q

provides an indirect estimate of L atrial pressure

Normal range?

A

pulmonary cap wedge pressure

normal 8-12, should be less than 18 for CHF

“congestion = elevated PCWP”

44
Q

volume of blood pumped by heart divided by BSA

CHF optimal metric?

A

cardiac index (CO/BSA)

CHF optimal > 2.2

“hypoperfusion = reduced CI”

45
Q

Positive inotrope rimarily used in ADHF w/ cold/dry pt…

Consider if receiving a b-blocker

No direct chronotropic effects

46
Q

Positive inotrope rimarily used in ADHF w/ cold/dry pt…

Positive inotrope, b agonist

A

Dobutamine

47
Q

Warm and wet get what drugs?

A

Diuretics and vasodilators

Think = they’re perfused but congested

48
Q

Cold and dry patients get what drugs?

A

Inotropes and vasodilators

Think = they’re underperfused but not congested

49
Q

Cold and wet (worst) patients get?

A

Inotropes and diuretics

Think = they’re underperfused and congested

50
Q

Vasodilator primarily used in warm/wet

Also ACS and HTN emergency

Free radicals = NO = relaxes smooth muscle

A

Nitroglycerin

51
Q

Vasodilator primarily used in warm/wet

HTN emergency

cyanide/thicyanate toxicity

A

Nitroprusside

52
Q

Vasodilator primarily used in warm/wet

Recombinant B-type natriuretic peptide

A

Nisiritide

53
Q

Generally Non-DHP CCBs should be avoided in HFrEF, except for?

A

Amlodipine can be considered

54
Q

Class 1,2 antiarrhythmics should be avoided in pts w/ HF… except for?

A

Amiodarone, dofetilide, sotalol

55
Q

This drug is indicated for reduction of claudication/PVD ssx but has a black box warning (contraindicated) for pts w/ HF

A

Cilostazol

Pharm 2 (5 decks)

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