HF III - Clinical Tx of HF

Question 1

General goals of any therapy:

Answer 1

o ↑ Quantity of life (↑survival)
o ↑ Quality of life (↓ symptoms)
o ↓ financial/resource burden of disease

Question 2

HF specific goals:

Answer 2

o Correction of the underlying cause of HF
o Reduction of congestion
o Optimization of cardiac function

Question 3

diuretics

Answer 3

the sodium and fluid retention of HF
o Typically work at the far end of the frank-starling curve, such that significant decreases in pressure produce minimal changes in stroke volume (and thus CO). Thus, symptoms of congestion can be reduced without major effects on blood flow.

Question 4

vasodilators

Answer 4

arterial, venous, and pulmonary arterial vasodilation
o Arterial: ↓ LV afterload, ↓ cardiac work, ↓ mitral regurgitation
o Venous: ↓ preload
o Pulmonary: ↓ RV afterload

Question 5

ACE inhibitors:

Answer 5

block conversion of ATI to ATII→direct vasodilation, decreased aldosterone activation.
 Side effects: hypotension, worsening renal failure, hyperkalemia, cough (kinin production), angioedema

Question 6

Angiotensin receptor blockers:

Answer 6

block receptor of ATII→ equivalent to ACEIs, but without cough.

Question 7

Aldosterone receptor blockers:

Answer 7

block aldosterone action in kidney→↓sodium→diuretic.

Question 8

Beta-blockers:

Answer 8

antagonize effects of the SNS→↓chronotropy ↓inotropy (short term loss for long term gain)
 Side-effects: bronchoconstriction

Question 9

Inotropes

Answer 9

administered via IV agents short term in the ICU to reverse shock (long term—worsen remodelling ↑mortality)
o Digoxin—K/Na exchanger
o Dobutamine—beta agonist
o Milrinone—PDEi

Question 10

Electrical therapies

Answer 10

o Defibrillators: for patients with LVEF < 35% or with prior dangerous rhythms. Implanted.
 Abort sudden cardiac death from ventricular tachycardia/fibrillation.
o Resynchronization:
 Left ventricular lead placed from the RA through the coronary sinus over the epicardium of the LV (3 leads: RA, RV coronary sinus/LV)
 For patients with QRS > 120 msec (bundle branch block)
 Cause the lateral wall and septal wall to contract together, which produces
 More efficient contraction→↑stroke volume
 May also improve mitral valve function→↓regurgitation

Question 11

advanced therapies

Answer 11

o Transplantation: shortage of organs.
o Mechanical support devices: often used as a bridge to transplantation or as a destination therapy.
o Hospice: palliative advanced therapy→paradigm shift from quantity to quality of life.

Question 12

stage A: definition and drugs

Answer 12

at risk for HF but without structural disease or symptoms

o Drugs: ACEi or ARB in appropriate patients.

Question 13

Stage B: define and drugs

Answer 13

structural heart disease but without signs or symptoms of HF.
o Drugs: ACEi, ARB, beta-blockers
o Devices: implantable defibrillators

Question 14

Stage C: define and tx

Answer 14

structural heart disease with prior or current symptoms of HF.
o Routine drugs: diuretics, ACEi, beta-blockers
o Drugs in selected patients: aldosterone antagonist, ARBs, digitalis, hydralazine/nitrates
o Devices: biventricular pacing, implantable defibrillators

Question 15

Stage D: define and tx

Answer 15

refractory HF requiring specialized interventions
o Options: compassionate end-of-life care/hospice; extraordinary measures: transplant, chronic inotropes, permanent mechanical support, experimental surgery/drugs

Question 16

What kinds of treatments are used for patients with heart failure and relatively normal ejection fraction (HFnEF)?

Answer 16

o Trials for neurohormonal antagonists have not been successful in improving outcomes for patients with HF and normal ejection fraction.
o Similarly, ICD/CRT are not generally indicated in patients with LVEF > 35-40%
o Therapy consists of treating the underlying disorder—hypertension, diabetes, kidney dysfunction, aortic stenosis.
o Diuretics are used to keep volume normal (sodium retention is common)
o Vasodilators are used to maintain normal blood pressure

Question 17

prevention

Answer 17

•	Most of the conditions that predicate the development of HF are preventable with changes in diet and lifestyle.
o	Hypertension
o	Diabetes
o	Hyperlipidemia
o	Physical inactivity
o	Excessive alcohol intake
o	Dietary sodium