HF and ACS Flashcards
HF key concepts
diastolic dysfunction (R sided HF, problems with ventricular filling) systolic dysfunction (L sided HF, problems with myocardial contractility, most trials for this)
neurohormonal model
neurohormone activation: Norepi, Angiotensin II, aldosterone and proinflammatory cytokines
targeted pharmtherapy antagonizes this activation
HFpEF
HF with preserved EF
HFrEF
HF with reduced EF
most trials include pt’s with this
NYHA Functional Classification 1
patients with cardiac dx but without limitations of physical activity
NYHA Functional Classification 2
patients with cardiac dx that results in slight limitations of physical activity, ordinary activity causes fatigue
NYHA Functional Classification 3
pt’s with cardiac dx that results in marked limitation of physical activity; pt’s comfortable at rest
NYHA Functional Classification 4
pt’s with cardiac dx that results in inability to carry on physical activity without discomfort; symptoms at rest
NYHA classes general
classifies symptomatic HF, based on clinician’s subjective evaluation
symptoms may change over short time
ACC/AHA stages A-D
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
stage A tx
ACEI/ARB if vascular dx or DM, statins as appropriate
Stage B tx
ACEI/ARB, BB
stage C HFpEF tx
diuresis to relieve symptoms of congestion, follow guidelines for comorbidities
stage C HFrEF tx
diuretic for fluid retention, ACEI/ARB, BB, aldosterone antag for everyone
add hydralazine/digitalis in select pt’s
newer agents for systolic dysfunction
Ivabradine, Sacubitril/Valsartan
diuretics
evidence of (or h/x) fluid retention
many req chronic diuresis
daily morning weight measurements
dec preload and afterload
ceiling effect
if occurs, give ceiling dose more frequently, rather than incing dose
ACEI
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
hypotension in ACEIs
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
3 BB with dec mortality in HF
bisoprolol, carvedilol and metoprolol succinate (not IR tartrate)
BB in HF
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
ARBs
as with ACEI, start BB before reaching max ARB dose
doenst inhibition’s bradykinin metabolized so no inc bradykinin
hyperkalemia in epleronone
serum K > 6 (serious) - DC ARA
serum K > 5/5 (mild) - DC ARA or dec dose
obtaining levels of digitoxin
first dose 3-5 days after starting
check levels 5-7 days after dose changes
draw at least 6-8 hrs after previous dose
