HF Rx 2

Question 1

ace inbhibitor receptor blockers, bet blockers and aldosterone receptor block all cause

Answer 1

1. anti-remodeling
2. decreased hypertropy
3. decreased fibrosis
4. decreased apoptosis
5. all reduce morbity and improve survival

Question 2

what vasodilators can be used for HF?

Answer 2

1. arterial vasodilation (antihypertensives)
2. venous vasodilation (venodilators)
3. pulmonary arterial vasodilation

Question 3

Arterial vasodilation (antihypertensives)
Possible benefits?

Answer 3

1. Decrease in LV afterload
2. Reduced cardiac work
3. Less mitral regurgitation

Question 4

arterial vasodilation. Using hydralazine/isosirbide dinitrate in HFrEE

Answer 4

1. Hyd/ISDN < ACEI (V-HeFT II)

2. Hyd/ISDN+ACEI/BB in blacks good (A-HeFT)

Question 5

Venous vasodilation (venodilators)
can cause

Answer 5

Decrease in preload

Question 6

Pulmonary arterial vasodilation

can cause

Answer 6

Decrease in RV afterload

Question 7

electrical therapies

Answer 7

1. implanted cardioverter Defibrilators

2. Cardiact resynchronization therapy

Question 8

when do you use implanted cardioverter defibrilator?

Answer 8

1. patients with LVEF < 35%
2. prior dangerous heart rhythms
3. abort sudden cardiac death from ventricular tachycardia/fibrillation

Question 9

when do you use CRT (cardiac resynchronization therapy?)

Answer 9

1. For patients with QRS duration > 120 msec (bundle brank block)
2. Cause the LV lateral wall and septal wall to contract together, which produces a more efficient contraction / ↑ stroke volume
3. Usually placed with ICD

Question 10

Cardiac Resynchronization Therapy

Answer 10

1. Biventricular pacemakers (CRT or BiV)

2. LV lead placed through the coronary sinus

Question 11

how do you improve symptoms of HFrEF?

Answer 11

1. Diuretics (furosemide)

2. Digitalis PO (HFrEF with shock - dobutamine, milronone)

Question 12

how do you prolong survival for HFrEF?

Answer 12

1. ACE Inhibitors / Angiotensin Receptor Blockers
2. Beta Blockers
3. Aldosterone Receptor Antagonists
4. Other Vasodilators (hydralazine + nitrates)
5. Cardiac Resynchronization Therapy (biventricular pacing)
6. Implantable Cardioverter Defibrillator (ICD)

Question 13

For a chronic (stable) pt with HFrEF wnad LVEF < 40%?

Answer 13

1. BB
2. ACEI/ARB
3. aldosterone antagonist
4. hydralazine/ISDN
5. +/- digoxin
6. ICD/CRT

Question 14

Acute decompensated (hospitalized) HF treat with

Answer 14

1. IV diuretics
2. IV vasodilators (nitrates / nitroprusside, if BP allows)
3. Positive pressure ventilation (CPAP/BiPAP, intubation) for hypoxia
   May also reduce preload
4. IV inotropes for shock only
5. May need to cut back on beta-blockers (only in severe cases)

Question 15

Types of positive inotropic agents

Answer 15

1. Digoxin (PO) -
2. Dobutamine (IV)
3. Milrinone (IV)

Question 16

Milrinone

Answer 16

(IV) – phosphodiesterase inhibitor (effect is similar to dobutamine)

Question 17

Dobutamine

Answer 17

(IV) – β agonist (opposite of BB)

Question 18

Digoxin

Answer 18

(PO) - K/Na exchange

Question 19

Positive inotropic agents: clinical use: ACUTE:

Answer 19

1. IV agents used short term to reverse shock

2. Long-term they worsen remodeling

Question 20

Positive inotropic agents: clinical use: Chronic:

Answer 20

1. Digoxin has no effect on mortality but may reduce symptoms and hospitalization (also some decrease in heart rate in AFib)
2. In high doses causes dig toxicity (mostly arrhythmias)

Question 21

Beta-Agonism v. Antagonism: ACUTE v. CHRONIC

Answer 21

Acute: use epi, NE, dopamine, dubatamine

chronic: use carvedilol, metoprolo Succinate, Bisoprolol

Question 22

options for end stage HFrEF

Answer 22

1. transplantation
2. mechanical support (LVAD)
   (highly morbid)
3. inotrope infusion (may hasten death)
4. hospice