HF and ACS

Question 1

HF key concepts

Answer 1

diastolic dysfunction (R sided HF, problems with ventricular filling)
systolic dysfunction (L sided HF, problems with myocardial contractility, most trials for this)

Question 2

neurohormonal model

Answer 2

neurohormone activation: Norepi, Angiotensin II, aldosterone and proinflammatory cytokines
targeted pharmtherapy antagonizes this activation

Question 3

HFpEF

Answer 3

HF with preserved EF

Question 4

HFrEF

Answer 4

HF with reduced EF

most trials include pt’s with this

Question 5

NYHA Functional Classification 1

Answer 5

patients with cardiac dx but without limitations of physical activity

Question 6

NYHA Functional Classification 2

Answer 6

patients with cardiac dx that results in slight limitations of physical activity, ordinary activity causes fatigue

Question 7

NYHA Functional Classification 3

Answer 7

pt’s with cardiac dx that results in marked limitation of physical activity; pt’s comfortable at rest

Question 8

NYHA Functional Classification 4

Answer 8

pt’s with cardiac dx that results in inability to carry on physical activity without discomfort; symptoms at rest

Question 9

NYHA classes general

Answer 9

classifies symptomatic HF, based on clinician’s subjective evaluation
symptoms may change over short time

Question 10

ACC/AHA stages A-D

Answer 10

A - pt’s at risk for developing HF
B - pt’s with structural heart dx (but no HF S/S’s)
C - pt’s with structural heart disease and current/previous symptoms
D - refractory HF
these won’t change unlike NYHA

Question 11

stage A tx

Answer 11

ACEI/ARB if vascular dx or DM, statins as appropriate

Question 12

Stage B tx

Answer 12

ACEI/ARB, BB

Question 13

stage C HFpEF tx

Answer 13

diuresis to relieve symptoms of congestion, follow guidelines for comorbidities

Question 14

stage C HFrEF tx

Answer 14

diuretic for fluid retention, ACEI/ARB, BB, aldosterone antag for everyone
add hydralazine/digitalis in select pt’s

Question 15

newer agents for systolic dysfunction

Answer 15

Ivabradine, Sacubitril/Valsartan

Question 16

diuretics

Answer 16

evidence of (or h/x) fluid retention
many req chronic diuresis
daily morning weight measurements
dec preload and afterload

Question 17

ceiling effect

Answer 17

if occurs, give ceiling dose more frequently, rather than incing dose

Question 18

ACEI

Answer 18

cornerstone of HF therapy
use with BB unless CI’ed (add BB after titrating to Mac ACEI dose or earlier, even if final ECAI dose is < recommended max)
all ACEIs dosed daily are available from $5-25/mo

Question 19

hypotension in ACEIs

Answer 19

spread doses of other vasoactive meds throughout day (not all at same time)
or start on captopril, titrate to max, then switch to ACEI with qd dosing

Question 20

3 BB with dec mortality in HF

Answer 20

bisoprolol, carvedilol and metoprolol succinate (not IR tartrate)

Question 21

BB in HF

Answer 21

continue long term tx even if symptoms don’t improve
abrupt withdrawal may cause acute decompensation (TAPER)
benefits due to class effect
minor adverse effects: bronchospasm, worsening glu tolerance (but not sweating), sex dysfxn in males

Question 22

ARBs

Answer 22

as with ACEI, start BB before reaching max ARB dose

doenst inhibition’s bradykinin metabolized so no inc bradykinin

Question 23

hyperkalemia in epleronone

Answer 23

serum K > 6 (serious) - DC ARA

serum K > 5/5 (mild) - DC ARA or dec dose

Question 24

obtaining levels of digitoxin

Answer 24

first dose 3-5 days after starting
check levels 5-7 days after dose changes
draw at least 6-8 hrs after previous dose

Question 25

ACS

Answer 25

stable and unstable angina, NSTEMI and STEMI

Question 26

O2 in AMI

Answer 26

administer supplemental O2 to AMI pt’s with sat <90%, resp distress or other high risk ft’s of hypoxemia
may have - effects in coronary pt’s (inc coronary vascular resistance, dec coronary bf, inc risk of mortality and significantly larger infarct sizes than in non-O2 group)

Question 27

traditional NSAIDs (not aspirin) and COX-2 inhibitors for ACS

Answer 27

actually enhance platelet aggregation by inhibiting synthesis, should be avoided in AMI pt’s
low dose aspirin is OK for anti-platelet effect

Question 28

BB in ACS

Answer 28

begin within 24 hr min all AMI pt’s except: signs of HF, low-output state, inc risk of cardiogenic shock or other CI’s
AMI its with stable HF should be cont’ed on metoprolol succinate, carvedilol or bisoprolol
avoid IV - may inc risk of shock

Question 29

RAAS inhibitors

Answer 29

ACEI: start in all pt’s with LVEF < 40% and cont indefinitely, start in hospital with captopril (tid) or enalapril (bid) and switch to long-acting ACEI at max
ARB: use in those intolerant to or with CI to ACEI
ARA: add to those on therapeutic doses of ACEI and BB

Question 30

acute anti-platelet for ACS

Answer 30

give non-enteric coated chewable aspirin (162-324 mg)
324 not same as 325
don’t order enteric coated ASA acutely (delayed absorption)
in pt’s with allergy or intolerance to ASA give Clopidogrel

Question 31

chronic anti-platelet for ACS

Answer 31

give ASA 81-325 mg PO daily indefinitely + for up to 12 mo, either of the P2Y12 ASA rec inhibitors: Clopidogrel or Ticagrelor

Question 32

parenteral anticoags in ACS

Answer 32

in addition to anti platelet therapy, recommended for all pt’s