Management Of Heart Failure Flashcards
Therapeutic targets for HFpEF
Control congestion
Stabilization of heart rate and BP
Improve exercise tolerance
Lusitropic agents act by?
Enhancing the relaxation of cardiac myocytes. Examples
CCB, Beta blockers
This study showed reduction in hospitalization but no effect on all- cause mortality in HFpEF patients by candesartan
CHARM
Trial showed no difference in meaningful endpoints in patients treated with irbesartan?
I - PRESERVE
This study showed no role for Digoxin in patients with HFpEF
DIG trial
This trial concluded that there’s no role for all- cause mortality and cardiovascular mortality in patients being treated with nebivolol?
SENIORS
This trial showed that PDE5 inhibitors improved filling pressure and RV function but no role in improving FC, QOL, or other clinical surrogate parameters using sildenafil?
RELAX trial
This trial demonstrated no improvement in the primary
composite end-point, but did show a secondary signal of benefit on HF
hospitalizations, counterbalanced, however, by an increase in adverse
effects, particularly hyperkalemia. Using aldosterone antagonists?
TOPCAT
This trial showed that spironolactone improved echocardiographic indices of diastolic dysfunction but failed
to improve exercise capacity, symptoms, or quality-of-life measures.
ALDO-DHF
a heterogeneous clinical syndrome most often resulting in need for hospitalization due to confluence of interrelated abnormalities of decreased cardiac performance, renal dysfunction, and altera-
tions in vascular compliance.
ADHF (acute decompensated heart failure)
ADHF is associated with a short-term mortality of how many percent?
Long term mortality?
Short term 5-8%
Long term at one year 20%
A herbal form of ephedrine
Ma huang
Parameters associated with worse outcomes in ADHF?
BUN >43mg/DL (x .357 to convert to mmol/L)
SBP < 115 mmHg
Creatinine >2.75mg/dL (x88.4 to convert to mmol/L)
Elevetated trop I
reflect the interplay between abnormalities of
heart and kidney function, with deteriorating function of one organ while therapy is administered to preserve the other.
Cardiorenal syndrome
How many percent of ADHF patients have abnormal renal function at baseline?
30%
This investigation argues against using UF(ultra filtration) as a primary strategy in patients with ADHF
who are nonetheless responsive to diuretics.
CARRESS-HF
this trial showed that Nesiritide was not associated with an
increase or a decrease in the rates of death and rehospitalization and
had a clinically insignificant benefit on dyspnea. Renal function did not worsen but increased rates of hypotension were noted.
ASCEND-HF
This trial showed that Serelaxin improved dyspnea, reduced signs and symptoms of congestion, and was associated with less early worsening of
HF.
RELAX - AHF
This inotropic provides the advantage of sparing Beta 1 stimulation thus is good for patients taking beta blockers.
Milrinone
trial compared levosimendan against traditional noninotropic therapy and found a modest
improvement in symptoms with worsened short-term mortality and
ventricular arrhythmias.
REVIVE II
compared levosimendan with dobutamine, and despite an initial reduction in circulating B-type natriuretic peptide levels in the levosimendan group compared with patients in the dobutamine group,
this drug did not reduce all-cause mortality at 180 days or affect any secondary clinical outcomes.
SURVIVE
This drug is a calcium sensitizer that
provides inotropic activity, but also possesses phosphodiesterase-3
inhibition properties that are vasodilators in action
Levosimendan
This drug is a selective myosin activator prolongs ejection period and increases fractional shortening?
Omecamtiv mecarbil
Trial that studied on the effect of selective vasopressin 2 antagonist?
EVEREST
Study on Rolofylline for patients hospitalized with ADHF
PROTECT
Usual dose of dobutamine
2-20 ug/kg/min
Usual dose of Milrinone
Levosimendan
Omecamtiv mecarbil
Mil 0.375 -0.75 ug/kg/min
Levosi - 0.1 ug/kg/min range 0.05 - 0.2
Ome - N/A
Usual dose of
NTG
Nesiritide
Nitropruside
Serelaxin
NTG 10-20 ug/min
Nesi - bolus 2 ug/kg infusion 0.01 ug/kg/min
Nitrops - 0.3 ug/kg/min upto 5 ug
Serelax N/A
Furosemide usual dose?
Torsemide
Bumetanide
20-240 mg daily
Torse 10-100 mg daily
Bumet 0.5-5 mg daily
Cornerstone of HFrEF therapy?
Beta blockers and ACEI’s
Percent reduction of ACEI therapy in mortality?
Combination endpoint mortality and hospitalization?
Mortality 23%
Combined endpoint 35%
Additional percent mortality reduction by beta blockers?
35%
Benefits of ACEI and beta blockers extend to what NYHA calss?
Class IIIb to IV
True or false: ACEI exert their beneficial effect in HF as a class.
True
Beta blockers with benefit for HFrEF?
Carvedilol
Bisoprolol
Metoprolol succinate
This trial stated that it does not matter if patient is started first on ACEI or BB using Bisoprolol?
CIBIS III
In the absence of s/sx of hypotension pharmacotherapy may be uptitrated every?
Every 2 weeks
Aldosterone antagonism is associated with reduction in mortality in what NYHA stages of HFrEF?
Class II to IV
What agent blunts the neurohormonla escape phenomenon with long term use of ACEI?
ARBs
This trial suggested that addition of valsartan in patients already receiving
treatment with ACEIs and beta blockers was associated with a trend
toward worse outcomes?
Val - HeFT trial
This trial tested a direct renin inhibitor, aliskiren,
in addition to other heart failure medications, within a week after
discharge from a hospitalization for decompensated HFrEF.
ASTRONAUT
This agent inhibits sodium If channels to slow dwon HR without negative inotropic effect?
Ivabradine
This trial showed that Ivabradine reduced hospitalizations and
the combined endpoint of cardiovascular-related death and heart
failure hospitalization.
SHIFT
This drug is a mild inotropic, attenuates baroreceptor activity and is sympathoinibitory?
Digoxin
Drug Initiation dose. Target dose
Lisinopril
Enalaparil
Captopril
Trandolapril
Initiation Target
Lisi 2.5-5qd. 20-35 qd
Enalapril 2.5 bid. 10-20 bid
Captopril 6.25 tid. 50 tid
Trandolapril 0.5 to 1 qd. 4 qd
Drug. Initiation. Target
Losartan
Valsartan
Candesartan
Initiation. Trget
Losartan 50qd. 150qd
Valsartan. 40. Bid 160 bid
Candesartan 4-8 qd. 32 qd
Drug Initiation. Target
Eplerenone.
Spironolactone
Drug initiation. Target
Eplerenone. 25qd. 50qd
Spironolactone. 12.5 -25.qd 25 - 50qd
Drug. Initiation. Target
Metoprolo succ
Carvedilol
Bisoprolol
Drug intitation. Target
Metoprolol 12.5. - 25qd 200qd
Carvedilol 3.125 bid. 25 - 50 bid
Bisoprolol 1.25qd. 10 qd
Hydralazine plus isdn
Initiation
37.5/20 tid
Target.
75/40. Tid
Qid for fixed dose
Study that tested nonsecific immunomodulation in heart failure?
ACCLAIM-HF
Trials that tested low-dose rosuvastatin in patients
with HFrEF and demonstrated no improvement in aggregate clinical
outcomes.
CORONA
GISSI- HF
This trial showed that Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with
warfarin and treatment with aspirin.
WARCEF
EPA (eicosapentanoic acid) levels in HF patients should be? High or low?
High
Reversible HF has been described as a consequence of micronutrient deficiency such as?
Thiamine and selenium
This trial evaluated the effect of external counterpulsation in patients with CHF?
PEECH
This study investigated short-term
(3-month) and long-term (12-month) effects of a supervised exercise
training program in patients with moderate HFrEF. Exercise was
safe, improved patients’ sense of well-being, and correlated with a
trend toward mortality reduction.
HF-ACTION
Mechanisms of Anemia in patients with HF?
iron deficiency,
dysregulation of iron
metabolism, and
occult gastrointestinal bleeding.
demonstrated that treatment with darbepoetin alfa did not
improve clinical outcomes in patients with systolic heart failure
RED-HF
showed that sertraline was safe, but did not
provide greater reduction in depression or improve cardiovascular
status among patients with heart failure and depression compared with
nurse-driven multidisciplinary management.
SADHART- CHF
Antiarrhythmic drug in HF pateints should be restricted to?
Amiodarone and dofetilide
studied the effects of the novel antiarrhythmic agent
dronedarone and found an increased mortality due to worsening heart
failure.
ANDROMEDA
Single most important association of extent of dyssynchrony?
Widened QRS in the presence of LBBB
first study to demonstrate
a reduction in all-cause mortality with CRT(cardiac resynchronization therapy) placement in patients
with HFrEF on optimal therapy with continued moderate-to-severe
residual symptoms of NYHA class III or IV heart failure
CARE-HF
clinical trials have demonstrated disease-modifying properties of CRT
in even minimally symptomatic patients with HFrEF
RAFT
MADIT-CRT
Most benefit with CRT is seen whne QRS is how many ms?
> 149 ms wtih a LBBB pattern
Mode of death in approximately 1/2 of patients with HF?
SCD (sudden cardiac death)
Two most important factors to consider to administer ICD (implantable cardioverter-defibrilator)
- LVD despite optimal therapy with = 35% EF
2. Undelying etiologyt (post MI)
Type of myocardium that has abnormal function but maintained cellular function
Hybernating myocardium
Trial that evaluated the effect of CABG on HF patients
STITCH
technique character-
ized by infarct exclusion to remodel the left ventricle by reshaping it
surgically in patients with ischemic cardiomyopathy and dominant
anterior left ventricular dysfunction,
Surgical ventricular restoration
Type of MR where there is annular dilatation and leaflet noncoaptation in the setting of anatomically normal papillary muscles, chordal structures, and valve leaflets.
Functional MR
Most heart - failure related readmissions tend to occur within how many weeks?
Wtihin 2 weeks from discharge
