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CDL301 Cardiovascular Pharmacology > Lecture 5 LV Dysfunction and Heart Failure I > Flashcards

Lecture 5 LV Dysfunction and Heart Failure I Flashcards

1
Q

What is the NICE definition of heart failure

A

A complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired

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2
Q

What is the ESC definition of heart failure

A

An abnormality of cardiac structure or function which leads to failure of the heart to deliver oxygen at a rate commensurate with the requirement of the tissues despite normal filling pressures or only at the expense of increased filling pressures

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3
Q

How many patients per year in the UK experience heart failure

A

1 million

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4
Q

Heart failure will increase in incidence by 50% in the next 5 years T or F

A

T

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5
Q

What is the main risk factor of heart failure

A

Age – heart failure is a disease of ageing it is rare below 65 but extremely common in the over 85

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6
Q

Why is it thought that heart disease affects more men than women

A

Most likely underlying coronary artery disease which is more prevalent in males

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7
Q

What percentage of hospital admissions is accounted for by heart failure

A

5%

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8
Q

Heart failure accounts for 2% of the NHS budget. Where is most of this cost incurred

A

70% of heart failures cost to the NHS is on hospital admission

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9
Q

What is the prognosis of heart failure

A

Heart failure prognosis is extremely poor with an overage 30% mortality within 1 year

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10
Q

What causes the majority of heart failure

A

Left ventricular systolic dysfunction (LVSD)

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11
Q

Other than LVSD what other category of heart failure is there

A

Heart failure with preserved ejection fraction (HFPEF)

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12
Q

How can problems with diastole cause heart failure

A

Relaxation of the heart in diastole isn’t passive it’s an active energy dependent process requiring ATP. Thus patients can have problems with this and hence have heart failure with preserved ejection fraction

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13
Q

How can we classify heart failure based on its onset

A

Acute heart failure is when a patient suddenly deteriorates whereas chronic heart failure is a creeping worsening state that gradually gets worse over time

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14
Q

Give an example of a structural cause of heart failure

A

Mitral valve rupture can sometimes cause heart failure

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15
Q

What is the most common cause of heart failure

A

Coronary artery disease

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16
Q

Discuss why treatments of heart failure don’t target the heart itself

A

Drugs that stimulate the heart when its poorly contracting increase the energy requirements by the heart. When a patient is in heart failure a neurohumoral response triggered in response to decreased cardiac output this is an attempt to support the circulation. However this response can be derogatory and increased the demands of the heart. So instead treatments are therefore aimed at the response not at the heart itself.

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17
Q

What is the main target in heart failure treatment

A

The main approach is a vasodilator therapy that acts via neurohormonal blockade. This includes blocking the renin-angiotensin-aldosterone system and the sympathetic nervous system.

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18
Q

What is the difference between left ventricular dysfunction and heart failure

A

LV dysfunction is something you can measure by measuring the ejection fraction whereas heart failure is the clinical syndrome observed

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19
Q

What are the two broad effects of heart failure

A

Reduced cardiac output and increased filling pressures/preload

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20
Q

What causes reduced cardiac output in patients in heart failure and how does this present

A

Reduced cardiac output is often due to decreased ejection fraction. Patients will present with fatigue and exercise intolerance

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21
Q

What causes the increased filling pressures/preload in heart failure

A

There is an increased back pressure upstream of the ventricles because the ventricles aren’t clearing as much blood. This means that the veins leading to the ventricles increase in pressure

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22
Q

What symptom is associated specifically with LVSD in heart failure

A

Pulmonary oedema due to increased pressure in the left atria backtracking to the pulmonary veins subsequently increasing pressure in those vessels. This causes fluid to leave the vessels and enter the lungs

23
Q

How do patients with pulmonary oedema usually present

A

Patients are extremely uncomfortable and want to be sat up in order to decrease pulmonary pressure an used all respiratory muscles

24
Q

What is the dominant symptom in patients with heart failure and how does this present

A

The dominant symptom is venous congestion which presents as breathlessness during minor exertion

25
Q

What symptom is associated specifically with right ventricular dysfunction in heart failure and how does this present

A

Peripheral oedema due to increased pressure in the right atria backtracking to the all of the veins. This presents as swelling of the lower limbs and abdomen (Ascites)

26
Q

What is meant by anasarca

A

‘Michelin man effect’ where oedema has travelled far up the body

27
Q

Why is the increase in filling pressure that occurs in heart failure as a result of the ventricles diminished ability to clear blood of little benefit to patients

A

The steepness of the Frank-Starling curve is much shallower in these patients so therefore increases in preload/filling pressures wont increase cardiac output by any significant amount

28
Q

What is synonymous with preload

A

Filling pressure left ventricular end diastolic pressure end diastolic volume

29
Q

Diuretics and venodilators can cause hypotension in healthy patients why does this often not occur in patients in heart failure

A

Due to the much shallower Frank-Starling curve these drugs can shift patients out of pulmonary congestion with very little loss of cardiac output

30
Q

What are the main broad effects of diuretics

A

Cause the body to lose Na+ and water

31
Q

What are the main clinical indications for diuretics

A

Heart failure hypertension

32
Q

What are the 4 main classes of diuretics

A

Thiazide diuretics loop diuretics K+ sparing diuretics and aldosterone antagonists

33
Q

Which region of the nephron do thiazide related drugs act on

A

Distal tubule

34
Q

Which region of the nephron do loop diuretics act on

A

Loop of Henle

35
Q

Which classes of diuretics are relatively week

A

Thiazides and aldosterone antagonists

36
Q

Which diuretics are mainly used in hypertension and not heart failure

A

Thiazide diuretics

37
Q

Which diuretics are most commonly used in heart failure

A

Loop diuretics

38
Q

Which class of diuretics aren’t used in heart failure because there are better alternatives

A

K+ sparing diuretics

39
Q

Which class of diuretics have added value in heart failure patients and why

A

Aldosterone antagonists have added value in heart failure patients because as well as lowering blood volume they also supress the RAAS system. Hence they are ideal in the treatment of heart failure

40
Q

Give some examples of thiazide like drugs

A

Chlorothiazide Bendroflumethiazide chlortalidone

41
Q

What are the main loop diuretics

A

Furosemide and bumetanide

42
Q

Which class of diuretics have a strong diuretic effect

A

Loop diuretics

43
Q

Why are some patients on loo diuretics on massive doses

A

If the intrinsic function of the kidney is impaired as well/due to the heart failure then furosemide doesn’t work so well because it needs to be metabolised by the kidney first. Hence these patients are put on large doses

44
Q

Give some examples of K+ sparing diuretics

A

Spironolactone eplerenone amiloride triamterene

45
Q

Which K+ sparing diuretics are sometimes used in heart failure and why

A

Spironolactone and eplerenone have added value in that they are aldosterone antagonists. So therefore they are sometimes used in heart failure

46
Q

Amiloride if often used to treat patients in heart failure T or F

A

F

47
Q

Eplerenone is a much more expensive diuretic than spironolactone why are some patients switched onto this drug

A

Spironolactone is a pseudoestrogen that is associated with gynaecomastia and breast pain in males. Hence its sometimes necessary to switch patients to eplerenone

48
Q

What are the adverse effects of diuretics

A

Hypotension hypovolaemia hyponatraemia hypomagnesaemia hypocalcinaemia hyperuricaemia

49
Q

Which class of diuretics mainly causes hypotension and hypovolaemia

A

Loop diuretics

50
Q

What are the unique side effects with thiazide diuretics

A

Erectile dysfunction and impaired glucose tolerance

51
Q

What is the effect of isosorbide dinitrate

A

Causes vasodilation

52
Q

Below is some data from the isosorbide dinitrate/hydralazine trial comparing this combination therapy with placebo and another vasodilator prazosin. Describe what this data shows

A

Placebo group patients had a 50% mortality within 3 years. Prazosin treated patients has an almost identical mortality to placebo. Interestingly hydralazine/Isosorbide resulted in a 36% mortality reduction compared to placebo. Hence this treatment results in a significant risk reduction in mortality in heart failure patients. This is the first evidence that vasodilators actually increased outcomes and prognosis in patients with heart failure

53
Q

Hydralazine in combination with isosorbide dinitrate also increases LVEF T or F

A

T

54
Q

What treatment is used in heart failure patients if modern treatments fail

A

Hydralazine/isosorbide dinitrate

CDL301 Cardiovascular Pharmacology (17 decks)

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