Pharmacotherapy of Heart Failure Notes Flashcards
1
Q
What are the two types of heart failure? What pressure is associated with each?
A
- Systolic failure (High pressure)
- Diastolic failure (low pressure/relaxed)
2
Q
2 characteristics of Systolic Heart failure
A
- reduced mechanical contractility
- reduced ejection fraction
3
Q
2 characteristics of Diastolic Heart failure
A
(HFpEF)
1. stiffening and loss of relaxtion
2. reducing filling and CO
3. EF is reduce
4
Q
What is the mortality rate of heart failure?
A
5 year 50% mortality
5
Q
MC cause of heart failure
A
CAD
6
Q
What are the overal and subsequent 2 therapy goals of pharmacotherapy of heart failure
A
Overall: increase perfusion
1. Reducing symptoms and slowing progression
2. Managing acute epidsode of decompensated failure output
7
Q
What are the three markers for heart failure
A
- HTN
2.
8
Q
What type of dysfunction is MC with acute heart failure?
A
Systolic dysfunction
w/ reduced CO and EF
9
Q
What is the normal EF?
Not in HF
A
> 60%
10
Q
what causes diastolic dysfunction?
list 2
A
- hypertrophy
- stiffening of the myocardium
11
Q
what does the P in HFpEF stand for
A
“Huff puff”
Preserved
12
Q
One ventricle heart failure can lead to ___
A
the other ventricle failiing
13
Q
Main goal of heart failure pharmacology
emphasized by Dr. B
A
Reestablish adequate perfusion without further straining the heart
14
Q
What happens to EF in diastolic dysfunction?
A
May be reduced or nromal
15
Q
What kind of drugs does Diastolic dysfunction not respond to?
A
Positive inotropic drugs
Diastole is supposed to be in relaxation
16
Q
What is High Output failure? What is the cause?
A
Rare failure
caused by demands of body being HIGH, this increases the CO (despite being insufficient)
17
Q
What conditions can cause High Outpute Failure
list 4
A
- hyperthyroidism
- beriberi
- anemia
- arteriovenous shunts
aka- nutritional deficients, thyroid issues, lack of blood flow
18
Q
Signs and symptoms of Heart failure
list 5
A
- tachycardia
- decreased exercise intolerance (rapid muscular fatigue)
- SOB
- Cardiomegaly
- Peripheral and pulmonary edema (may or may not be present)
19
Q
What are the 4 primary factors of Cardiac performance
A
- preload
- afterload
- contractility
- Heart rate
20
Q
What is the preload
A
the stretch of the heart
21
Q
What happens to preload during heart failure
A
- stretch of the heart increases
- preload increases, contractile force _______
22
Q
what is the range of pressure of preload that results in heart failure
A
> 20-25 mmHg
23
Q
What happens to the heart during preload (of heart failure)
2 things (not including increased preload)
A
- increased fiber length
- increased filling pressure increases O2 demand in the myocardium2
24
Q
What causes preload to increase during heart failure?
list 2
A
- increased blood volume
- increase venous tone
25
What is the goal of salt restriction and diuretic therapy in heart failure
| (think preload)
reduction of high filling pressure
26
what can venodilator drugs do for heart failure?
reduce preload by redistributing blood away from the chest and into the systemic sx
(nitroglycerin)
27
what is afterload
the resistance that the heart must pump blood against
28
What represents the afterload?
aortic impedance and systemic vascular resistance
29
# Think afterload
what does decreased CO in chronic failure lead to?
a reflex increase in systemic vascular resistance
-this is mediated by increase in sympathetic outflow, catecholamines and activation of RAAS and endothelin
30
What is increased systemic vascular resistance mediated by
1. increased sympathetic outflow
2. catecholamines
3. Partial from activation of RAAS
4. partial from activation of endothelin
31
aldosterone is the
"salt whisperer"
wants salt to stay in the body
32
what are some catecholamines
| (list 3)
1. dopamine
2. norepinepherin
3. epinepherine
| They all will do the same thing in the body
33
what does chronic low-output failure do to intrinsic contractility
reduces intrinsic contractility
34
List 3 things that happen as contractility decreases?
1. reduction in the velocity of muscle shortening
2. reduction in the rate of intraventricular pressure development
3. reduction of the stroke output
35
Can a heart in heart failure still increase contractility measure in response to inotropic drugs
yes
36
What is the carotid sinus firing refering to?
baroreceptrors in the carotids
37
what is the first compensatory mechanism that tries to maintain cardiac output (when dropping)
heart rate increase through sympathetic activation of B adrenoceptors
38
what does failure of the heart do to the heart rate?
decrease
-stroke volume also lowers
39
what does tachycardia do to diastolic filling and coronary flow?
Slows/limits
-this causes stress on the heart
40
What type of drugs can help with tachycardia due to heart failure
bradycaric drugs
41
What types of drugs are used first in chronic heart failure
| list 4
1. diuretics
2. ACE inhibitors
3. B-agonists
4. B-blockers
42
When are positive inotropic agents used for heart failure? what can it result in?
not the first or only drug
-CAN result in over therapy of heart failure pts
43
what releases naturetic peptides?
cardiac myocytes
44
What tissues do cardiac glycosides
all excitable tissues (including CNS and smooth muscle)
45
What is the most common site of digitalis toxicity outside of the heart? what is the second mc?
GI tract
CNS
46
A patient presents with GI symptoms, what medicine might they have a toxicity of?
Cardiac glycosides
(digitalis)
47
What is the effect of K+ and digitalis?
1. hyperkalemia (reduces actions of digitalis)
2. Increased cardidac automaticity (from hyperkalemia), reduces toxic effect of digitalis
48
what does hypokalemia do to digitalis
facilitates the enzyme inhibiting action of digitalis
49
What does hypercalcemia do to cardiac glycosides
Increased the risk of digitalis-induced arryhthmia
50
what is the etiology of cardiac glycoside poisoning
-hypokalemia (bc digitalis compounds compete with K+)
-Renal failure (decrease excretion)
-drug interaction (removes digoxin from the body)
-Dehydration
51
What drugs can lower the renal elimination of cardiac glycoside?
| list 4
1.verapamil
2.diltiazem
3.amiodarone
4.quinidine
52
Symptoms of cardiac glycoside poisoning
| list 7
1. GI tract symptoms (n/v, diarrhea, pain, anorexia)
2. visual damage
3. xanthopsia (yellow tinted vision)
4. photophobia
5. blurry vision w yellow tints and halos
6. disorientation
7. palpations
53
ECG indication of Cardiac glycoside poisoning
| List 5
-PVC
-T wave flattening
-scooped ST segment
-low QT
-high PR
-atrial tachy w av block
54
Abnormal lab studies in cardiac glycoside poisoning
1. serum digoxin concentration (6 hrs after ingestion)
2. serum electrolyte levels (hyperkalemia)
3. creatinine and blood urea nitrogen (renal funciton)
55
Treatment of Cardiac glycoside poisoning
| list 6
1. anti-digoxin FAB fragments
2. atropine (bradycardia)
3. normalize serum K+
4. magnesium
5. Class 1b antiarrhythmias
6. temporary cardiac pacing
56
Types of drugs without positve inotropic effects used in heart failure
1. diuretics
2. ACE inhibitors (-pril)
3. Angiotensin receptor antagonists (-sartans)
4. Aldosteron antagonists (-one)
5. B-blockers (-lol)
57
vasodilators impact on HF
1. reduction in preload
2. reduction in afterload
58
What 2 drugs can reduce damaging remodeling of the heart
1. hydralazine
2. isosorbide dinitrate
59
what electrolyte can be removed to manage HF? what symptom is indicative of this treatment?
sodium
-salt removal through diuretic or restriction
-EDEMA
60
what diuretic is typically required to treat mild heart failure?
furosemide
(thiazide diuretic occasionally)
61
What does sodium loss do to potassium?
loss of potassium
hazardous if given certain drugs (digoxin)
62
what situation is ACE inhibitor the first line tx for?
left ventricular dysfunction but no edema
63
what two drug classes are first-line therapy for chronic heart failure
ACE inhibitor and Diuretic
64
What is the impact of ACE inhibitors in pts with heart failure
reduction of preload and afterload
-slows the progress of ventricular dilation (slows heart failure)
65
When are ARBS used? What symptom is associated
for patients who can't tolerate ACE inhibitors (usually a cough)
66
4 types of vasodilators
1. selective arteriolar dilators
2. venous dilators
3. drugs with non-selective vasodilating effects
67
If a patient has high filling pressures with dyspnea (main symptom) what type of drug should be used? Name 3 specific
venous dilators
1.isosorbide dinitrate
2.hydralazine
3.prazosin
| these reduce filling pressure and relieves pulmonary congestion symptoms
68
If a pt has fatigue from lower left ventricular output, what type of drug should be used? Name one
Arteriolar dilators
hydralazine (increases forward CO)
69
Name 4 Beta Blockers that reduce HF mortality
1. bisoprolol
2. carvedilol
3. metoprolol
4. nebivolol
70
when are B-Blocker drugs given for patients with heart failure? why?
-tachycardiac patients
reduces tachycardia which lowers the adverse effects of high catecholamine levels on the heart (worsens HF)
71
When is digoxin indicated in treatment of HF?
Heart failure AND artrial fibrillation
-only when diuretics and ACE inhibitors failed
72
What is the slow loading dose of digoxin?
| when symptoms are mild
0.125 or 0.25 mg/d
73
What is the rapid dose of digoxin?
0.5-0.75mg every 8 hours (x3 doses)
followed by 0.125 or 0.25mg/d
74
what other situations can digitalis be useful in
1. atrial arrhythmias
2. paroxysmal atrial and atrioventricular nodal tachycardia
3. WPW AND atrial fibrillation
75
What is the best route of administration for treatment of acute HF
IV
76
what drugs are used for acute treatment of heart failure
1. diuretics (furosemide)
2. positive inotropic drugs (for severe hypotension) (dopamine, dobutamine)
3. Vasodilators (nitroprusside, nitroglycerine)
77
name 2 vasodilators used to treat acute heart failure
1.nitroprusside
2.nitroglycerine
| reduces afterload, improves EF
78
What is the MOA of Nitroglycerin
1. forms NO. In smooth muscle, NO activates cGMP, which leads to dephsophorylation of MLCK--leads to smooth muscle relaxation
2. reduces cardiac oxygern demand by decreasing preload, slightly reduce afterload, dilates coronary arteries (increases flow to ischemic regions)
79
What system do vasodilators have a larger effect on?
the venous system
80
Onset of Nitroglycerin
sublingual: 1-3 min
Translingual spray: ~60 minutes
Topical: 15-30 min
Transdermal: ~30 min
IV: immediate
81
What is the half life of nitroglycerin
~1-4 min
82
What are indications of Nitroglycerin
1. angina pectoris
2. Prevention of angina petoris, acute decompensated heart fialure (esp w acute MI)
83
Sublingual dosage of Nitroglycerin.
How often
0.3-0.4 mg every 5 minutes up to 3 doses
84
What are the CI to nitroglycerin
1. hypersensitivitiy
2. other nitrates (any similar drug)
3. use of PDE-5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil)
85
Side effects of nitroglycerin
| list 4
1. CNS (headache)
2. Hypotension
3. syncope
4. peripheral edema
86
MOA of Nitroprusside
-peripheral vasodilator
-results in peripheral resistance, increased CO, decreased outload, reduced aortal and L ventricular impedance
87
What is the impact in the body from taking Nitroprusside
reduced peripheral resistance
increase CO
Decreased afterload
reduced aortal and L ventricular impedance
88
Onset of action of Nitroprusside
Hypotensive effect <2 minutes
89
duration of Nitroprusside
1-10 minutes
90
How is Nitroprusside metabolized
combines w hemoglobin to produce cyanide and cyanmethomoglobin
91
Indications Of Nitroprusside
Acute decompensated heart failure
acute hypertension
92
Dose of nitroprusside for acute hypertension
Initial: 0.3-0.5 mcg/kg/min, titrated 0.5/mcg/minute every few minutes to acheive effect
max dose: 10mcg/kg/min for max of 10 min
Max dose: 2mcg/kg/min (some people do it to avoid toxicity)
93
Dose/administration of nitroprusside for acute decompensated heart fialure
IV
initial 5-10mcg/minute
titrated rapidly (up to q5min)
usual dose range: 5-300mcg/min
absolute MAX 400 mcg/min
94
CI of nitroprusside
-tx of compensatory hypertension (aortic coarctation, arteriovenous shunting), acute HF w reduced systemic vascular resistence
95
adverse reactions of
