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MD3001 > Pharmacological Treatment of Heart Failure > Flashcards

Pharmacological Treatment of Heart Failure Flashcards

1
Q

What is the prevalence of heart failure in the UK ? in the world ?

A

UK:
500 000 people
Worldwide:
over 23 million people

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2
Q

What are the aims of treatment (of left ventricular systolic dysfunction, since this is the part of cardiac failure that we are focusing on) ?

A
  • Relieve symptoms
  • Improve exercise tolerance
  • Reduce incidence of acute exacerbations
  • Reduce mortality
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3
Q

Identify strategies for treatment of LVSD.

A 
• ↑ cardiac contractility
• ↓ preload and/or afterload in order to ↓
cardiac work demand
– By relaxing vascular smooth muscle 
– By reducing blood volume
• Inhibit the RAAS
• Prevent inappropriate ↑ in heart rate
• Mobilise the oedematous fluids
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4
Q

Describe some of the non-pharmaceutical treatments of LVSD.

A
  1. Lifestyle factors – as per all CV conditions (stop smoking, reduce salt intake, increase exercise, possibly fluid restriction if moderate to severe heart failure), also remember mental health factors
2. “Device therapy”
• Pacing
• Cardiac Resynchronisation Therapy 
• Implantable Cardiac Defibrillators 
• Coronary revascularisation
• Heart transplant
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5
Q

What are the main classes of drugs used in chronic heart failure ? Give examples of each.

A

Loop diuretics
– e.g furosemide, bumetanide

ACE inhibitors
– e.g.ramipril, Lisinopril

Angiotensin II receptor blockers
– e.g candesartan, losartan

Beta-blockers
– bisoprolol, carvedilol

Aldosterone receptor antagonists
– e.g. spironolactone

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6
Q

What do loop diuretics, ACE inhibitors, Angiotensin II receptor blockers, beta-blockers, and aldosterone receptor antagonists do (counteract symptoms ? prolong life ? correct underlying cause ?)

A

These approaches can prolong life in heart failure and counteract some of the symptoms of heart failure BUT they don’t correct the underlying fault

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7
Q

What is the first step in the treatment of chronic heart failure ? What are the benefits of this ?

A

Unless contraindicated:
D = Diuretic (i.e. loop diuretics) (if fluid retention)
+A = ACE Inhibitor or ARB
+B = Beta-blocker

Shown to reduce mortality (i.e. prolong life) and improve quality of life.

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8
Q

Why wouldn’t diuretics be used unless there is fluid retention ?

A

Because the body thinks there is a hemorrhage is going on, which activate RAAS system.

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9
Q

What is the use and aim of loop diuretics in step 1 of HF treatment ?

A

Use – if clinical signs/symptoms of fluid overload/congestion
Aim – achieve a “dry” weight using the lowest diuretic dose possible.

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10
Q

How does the dosage of diuretics occur (when the patient has clinical signs/symptoms of fluid overload/congestion) ?

A

Patient self-management with education:
• daily weights–if varies in either direction, alter dose
• Symptom review–breathlessness, peripheral oedema (increase dose)
• Thirst level, dizziness, “washed out” (decrease dose)

GP – blood chemistry checks within a week of any dose change

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11
Q

What treatment is necessary if there are symptoms of fluid overload/congestion in step 1 of treatment for HF ?

A

Loop diuretics

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12
Q

List some of the common side-effects of loop diuretics.

A
  • Electrolyte disturbances– low K, Na, Mg, Ca
  • Hypotension
  • Renal impairment
  • Hypovolaemia! (because of profound diuresis)
  • Nocturia if taken too late in day (troublesome)
  • Acute gout common with high doses
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13
Q

What are the situations in HF where Renin Angiotensin System Inhibitors are used ? What are the benefits of it ?

A
  • Use in HF with reduced ejection fraction of all NYHA classes
  • Benefit is: Reduces morbidity/mortality
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14
Q

Give examples of loop diuretics.

A

Furosemide

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15
Q

Give examples of Aldosterone receptor antagonists.

A

Spironolactone

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16
Q

Give examples of ACE inhibitors.

A

Ramipril, lisinopril

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17
Q

Give examples of ARBs.

A

Candesartan, valsartan, (losartan)

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18
Q

Why are ACE inhibitors and ARBs used in HF ? (i.e. What are the effects of ACE inhibitors and ARBs on the body in heart failure ?)

A
  • Reduce salt and water retention
  • Reduce vasoconstriction
  • Reduce vascular resistance
  • Reduce afterload
  • Improve tissue perfusion
  • Reduces ventricular remodelling and hypertrophy
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19
Q

How are ACE inhibitors/ARBs dosed in the treatment of HF ?

A

• Start low dose, monitoring BP & blood chemistry and symptoms and uptitrating to maximum tolerated or target doses.

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20
Q

What are the demographics of effectiveness of ACE inhibitors ?

A

ACE inhibitors are less effective in African or Caribbean ethnicity (use ARBs instead)

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21
Q

What are the side effects of ACE inhibitors ? of ARBs ?

A

ACE inhibitors:
• Persistent dry cough, tiredness, rare but serious – angioedema

ARBs:
• Back/leg pain

Common to both:
• Dizziness
• Headache
• Risk of hyperkalaemia (care with drug which also raise K+) (Because of effect on aldosterone)
• Renal impairment - can be reno-protective also
• Avoid in bilateral renal artery stenosis
• teratogenic

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22
Q

Describe the counter-indications to ACE I and ARBs.

A
  • Severe bilateral renal artery stenosis
  • Severe aortic stenosis
  • Known history of angioedema
  • Pregnancy/risk of pregnancy
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23
Q

Why are ACEI and ARBs counterindicated for severe bilateral renal artery stenosis ?

A

Because in such situations, the renal artery is partially occluded so the body attempts to auto-regulate that through the release of angiotensin II to maintain a high P to keep a relatively significant blood flow through the kidneys.
ACEI and ARBs block angiotensin II so pressure drops in glomerulus, causing
reduced filtering P in the kidneys (renal blood flow can stop) .

24
Q

Why are beta blockers used in HF ? (i.e. What are the effects of beta blockers on the body in heart failure ?)

A
  • Allows ventricle to fill more completely during diastole
  • Some Beta-blockers (third generation beta blockers) cause vasodilation, ↓ afterload
  • Reduce renin release by kidney

EVEN THOUGH IT may slow HR, which could decrease CO

25
Q

Give examples of beta blockers.

A

Carvedilol, Bisoprolol

26
Q

How are beta blockers dosed in HF treatment ?

A

Start low, go slow

27
Q

What are the situations in HF where beta blockers are used ? What are the benefits of it ?

A 
Use: Start if reduced ejection fraction but stable NYHA class II-IV (NOT if decompensated heart failure) 
Benefit: Reduces mortality
28
Q

What are the cases in which one must be careful about prescribing beta blockers ?

A

– Seek specialist advice if severe HF, current exacerbation of HF, heart block or bradycardia, persisting signs of fluid overload, low BP (SBP<90mmHg)
– drug interactions: risk of bradycardia/AV block with: digoxin, amiodarone, verapamil, diltiazem

29
Q

Identify the main side effects of beta blockers.

A
  • Bradycardia /Heart Block (contra-indicated) (because they reduce HR and therefore can decrease CO)
  • Fatigue
  • Shortness of breath (Contra-indicated in Asthma)
  • Coldness of extremities
  • Impotence
  • Reduced libido
  • Dizziness
  • Blurred vision
30
Q

What is the second step in the treatment of chronic heart failure ? What are the benefits of this ?

A

Step 2 : Aldosterone antagonists
If on ACEI or ARB + Beta-blocker + diuretic
(“DAB”) and still symptoms.

31
Q

Give examples of Aldosterone antagonists.

A

Spironolactone, eplerenone

32
Q

What are the situations in HF where aldosterone antagonists are used ? What are the benefits of it ?

A 
Use: In NYHA class II-IV failure (effective in severe heart failure) 
Benefit: Reduces symptoms and mortality
33
Q

How are aldosterone antagonists dosed in HF treatment ?

A

Low doses used

34
Q

What is another name for aldosterone antagonists ?

A

MRA (mineralocorticoid receptor antagonists)

35
Q

True or False: chronic use of ace inhibitors causes increase in aldosterone over time.

A

True

36
Q

Identify some side effects of aldosterone antagonists.

A
  • Hyperkalaemia
  • hyponatraemia
  • Nausea
  • Hypotension
  • gynaecomastia (with spironolactone) (due to effect on estrogen and androgen receptors)
  • renal impairment
37
Q

How are HF drug adverse effects managed ?

A
  • Flexible dosing for DABs, may need to up and down titrate.
  • Review BP – may be low but is patient symptomatic? (if not, really about how low can you go)
  • Bradycardia – if symptomatic may need to stop beta-blocker or review any other rate controlling drugs patient on . If HR<45 BPM – stop beta-blocker, call specialist.
38
Q

What are treatment options if there is a concurrent (with HF) persistent water/sodium retention problem ?

A

Additional diuretics (e.g. thiazide-like diuretic such as metolazone)

39
Q

What are treatment options if there is a concurrent (with HF) angina ?

A

– Oral nitrates

– amlodipine (only this specific calcium channel blocker)

40
Q

What are treatment options if there is a concurrent (with HF) AF ?

A

– Digoxin

41
Q

When is digoxin used in the treatment of HF ?

A

If concurrent AF

If other treatment strategies failing (only for symptom control)

42
Q

What are the cons of using digoxin as a treatment for HF ?

A

Narrow therapeutic window

Shows no reduction in mortality rate

43
Q

What class of drugs does digoxin belong in ?

A

Cardiac glycosides

44
Q

Describe the mechanism of action of digoxin in AF.

A

↑ vagal efferent activity to the heart  ↓ SAN firing rate (↓ HR) and ↓ conduction velocity in the AV node

45
Q

Describe the mechanism of action of digoxin in HF.

A

Increases force of myocardial contraction
– inhibits Na/K pump, thus affecting Na/Ca exchanger, elevating intracellular calcium levels in Sarcoplasmic reticulum, then, when Calcium released results in strengthened contractibility
– i.e. indirectly increases calcium levels and subsequent storage in the SR

46
Q

Describe the side effects/toxicity of digoxin.

A
  • GI upset
  • dizziness
  • Conduction abnormalities
  • Blurred or yellow vision
47
Q

Define acute (decompensated) Heart Failure.

A

Sudden worsening of signs and symptoms of heart failure as a result of severe congestion of multiple organs.
Increased dyspnoea, oedema

48
Q

What are causes of acute/decompensated HF ?

A

MI, infection, anaemia, thyroid dysfunction, arrhythmia, uncontrolled hypertension, poor concordance

49
Q

What are the aims of treatment in acute/decompensated HF ?

A
  • Normalise ventricular filling pressures

* Restore adequate tissue perfusion

50
Q

What is the general treatment for acute HF ?

A

First Line Drug Treatments:
L - loop (IV loop diuretics)
M - morphine (IV opiates (e.g. morphine))
N - nitrates (IV, buccal or sublingual nitrates (Glyceryl trinitrates “GTN”)
O - oxygen
P - positioning

Second Line Drug Treatments (Intensive care units, Coronary Care Units only!):

  • Ionotropes
  • Vasopressors
51
Q

What is the use of each component of the first line drug treatment for acute HF ?

A

– IV loop diuretics
• Cause venodilation and diuresis
• Reduces pre-load

– IV opiates (e.g. morphine) 
• Reduce anxiety
• Vasodilates, reducing preload
• Reduces sympathetic drive
• NOT routinely offered

– IV, buccal or sublingual nitrates (Glyceryl trinitrates “GTN”)
• Reduces preload and afterload
• Vasodilates

– Oxygen
• Maintains O2 sats

– Positioning
• Keep patient upright

52
Q

Why do we use ionotropes in the treatment of acute HF ?

A

Because contractility of the heart has decreased so an increase in end diastolic pressure isn’t bringing about much of an increase in CO (Frank Starling mechanism doesn’t work so well). This is resulting in pulmonary congestion etc.

Inotropes can increase contractility of the heart

53
Q

What is the effect of inotropic agents on the heart in acute HF ?

A

↑ contractility will ↑ stroke volume, which ↑ CO
– ↑ clearance of pooled blood in the ventricles

As CO increases, baroreceptors sense change in MABP and ↓ sympathetic drive and so ↓ HR and ↓ TPR

54
Q

Identify the different drugs given in the second line of treatment of acute HF, and specify which receptor each drug works on.

A

INOTROPES (usually BETA AGONISTS)- in general, increase myocardial contractility

  • Dobutamine (beta 1 and 2)
  • Dopamine (DA > Beta > alpha)
  • Isoprenaline
  • Adrenaline (Beta>alpha)

VASOPRESSORS
-NA (alpha>beta)

55
Q

List the specific role of/clinical situation in which each of the drugs given in the second line of treatment of acute HF would be given.

A

INOTROPES
-Dobutamine: in patients with cardiogenic
shock to maintain blood pressure
-Dopamine: Increases renal perfusion at low doses, can increase BP at high doses
-Isoprenaline: in bradycardia/heart block emergencies
-Adrenaline

VASOPRESSORS
-NA: cause vasoconstriction, raise BP, used in severe septic shock

56
Q

What are the main drugs which act as vasodilators in HF ?

A

Nitrates

Third generation beta blockers

MD3001 (75 decks)

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