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pharmacology > Pharmacotherapy of Heart Failure Notes > Flashcards

Pharmacotherapy of Heart Failure Notes Flashcards

1
Q

What are the two types of heart failure? What pressure is associated with each?

A
  1. Systolic failure (High pressure)
  2. Diastolic failure (low pressure/relaxed)
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2
Q

2 characteristics of Systolic Heart failure

A
  1. reduced mechanical contractility
  2. reduced ejection fraction
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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

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4
Q

What is the mortality rate of heart failure?

A

5 year 50% mortality

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5
Q

MC cause of heart failure

A

CAD

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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

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7
Q

What are the three markers for heart failure

A
  1. HTN
    2.
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8
Q

What type of dysfunction is MC with acute heart failure?

A

Systolic dysfunction
w/ reduced CO and EF

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9
Q

What is the normal EF?

Not in HF

A

> 60%

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10
Q

what causes diastolic dysfunction?

list 2

A
  1. hypertrophy
  2. stiffening of the myocardium
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11
Q

what does the P in HFpEF stand for

A

“Huff puff”
Preserved

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12
Q

One ventricle heart failure can lead to ___

A

the other ventricle failiing

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13
Q

Main goal of heart failure pharmacology

emphasized by Dr. B

A

Reestablish adequate perfusion without further straining the heart

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14
Q

What happens to EF in diastolic dysfunction?

A

May be reduced or nromal

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15
Q

What kind of drugs does Diastolic dysfunction not respond to?

A

Positive inotropic drugs

Diastole is supposed to be in relaxation

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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)

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17
Q

What conditions can cause High Outpute Failure

list 4

A
  1. hyperthyroidism
  2. beriberi
  3. anemia
  4. arteriovenous shunts

aka- nutritional deficients, thyroid issues, lack of blood flow

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18
Q

Signs and symptoms of Heart failure

list 5

A
  1. tachycardia
  2. decreased exercise intolerance (rapid muscular fatigue)
  3. SOB
  4. Cardiomegaly
  5. Peripheral and pulmonary edema (may or may not be present)
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19
Q

What are the 4 primary factors of Cardiac performance

A
  1. preload
  2. afterload
  3. contractility
  4. Heart rate
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20
Q

What is the preload

A

the stretch of the heart

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21
Q

What happens to preload during heart failure

A
  1. stretch of the heart increases
  2. preload increases, contractile force _______
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22
Q

what is the range of pressure of preload that results in heart failure

A

> 20-25 mmHg

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23
Q

What happens to the heart during preload (of heart failure)

2 things (not including increased preload)

A
  1. increased fiber length
  2. increased filling pressure increases O2 demand in the myocardium2
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24
Q

What causes preload to increase during heart failure?

list 2

A
  1. increased blood volume
  2. increase venous tone
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25
Q

What is the goal of salt restriction and diuretic therapy in heart failure

(think preload)

A

reduction of high filling pressure

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26
Q

what can venodilator drugs do for heart failure?

A

reduce preload by redistributing blood away from the chest and into the systemic sx
(nitroglycerin)

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27
Q

what is afterload

A

the resistance that the heart must pump blood against

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28
Q

What represents the afterload?

A

aortic impedance and systemic vascular resistance

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29
Q

Think afterload

what does decreased CO in chronic failure lead to?

A

a reflex increase in systemic vascular resistance
-this is mediated by increase in sympathetic outflow, catecholamines and activation of RAAS and endothelin

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30
Q

What is increased systemic vascular resistance mediated by

A
  1. increased sympathetic outflow
  2. catecholamines
  3. Partial from activation of RAAS
  4. partial from activation of endothelin
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31
Q

aldosterone is the

A

“salt whisperer”
wants salt to stay in the body

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32
Q

what are some catecholamines

(list 3)

A
  1. dopamine
  2. norepinepherin
  3. epinepherine

They all will do the same thing in the body

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33
Q

what does chronic low-output failure do to intrinsic contractility

A

reduces intrinsic contractility

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34
Q

List 3 things that happen as contractility decreases?

A
  1. reduction in the velocity of muscle shortening
  2. reduction in the rate of intraventricular pressure development
  3. reduction of the stroke output
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35
Q

Can a heart in heart failure still increase contractility measure in response to inotropic drugs

A

yes

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36
Q

What is the carotid sinus firing refering to?

A

baroreceptrors in the carotids

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37
Q

what is the first compensatory mechanism that tries to maintain cardiac output (when dropping)

A

heart rate increase through sympathetic activation of B adrenoceptors

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38
Q

what does failure of the heart do to the heart rate?

A

decrease
-stroke volume also lowers

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39
Q

what does tachycardia do to diastolic filling and coronary flow?

A

Slows/limits
-this causes stress on the heart

40
Q

What type of drugs can help with tachycardia due to heart failure

A

bradycaric drugs

41
Q

What types of drugs are used first in chronic heart failure

list 4

A
  1. diuretics
  2. ACE inhibitors
  3. B-agonists
  4. B-blockers
42
Q

When are positive inotropic agents used for heart failure? what can it result in?

A

not the first or only drug
-CAN result in over therapy of heart failure pts

43
Q

what releases naturetic peptides?

A

cardiac myocytes

44
Q

What tissues do cardiac glycosides

A

all excitable tissues (including CNS and smooth muscle)

45
Q

What is the most common site of digitalis toxicity outside of the heart? what is the second mc?

A

GI tract
CNS

46
Q

A patient presents with GI symptoms, what medicine might they have a toxicity of?

A

Cardiac glycosides
(digitalis)

47
Q

What is the effect of K+ and digitalis?

A
  1. hyperkalemia (reduces actions of digitalis)
  2. Increased cardidac automaticity (from hyperkalemia), reduces toxic effect of digitalis
48
Q

what does hypokalemia do to digitalis

A

facilitates the enzyme inhibiting action of digitalis

49
Q

What does hypercalcemia do to cardiac glycosides

A

Increased the risk of digitalis-induced arryhthmia

50
Q

what is the etiology of cardiac glycoside poisoning

A

-hypokalemia (bc digitalis compounds compete with K+)
-Renal failure (decrease excretion)
-drug interaction (removes digoxin from the body)
-Dehydration

51
Q

What drugs can lower the renal elimination of cardiac glycoside?

list 4

A

1.verapamil
2.diltiazem
3.amiodarone
4.quinidine

52
Q

Symptoms of cardiac glycoside poisoning

list 7

A
  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
Q

ECG indication of Cardiac glycoside poisoning

List 5

A

-PVC
-T wave flattening
-scooped ST segment
-low QT
-high PR
-atrial tachy w av block

54
Q

Abnormal lab studies in cardiac glycoside poisoning

A
  1. serum digoxin concentration (6 hrs after ingestion)
  2. serum electrolyte levels (hyperkalemia)
  3. creatinine and blood urea nitrogen (renal funciton)
55
Q

Treatment of Cardiac glycoside poisoning

list 6

A
  1. anti-digoxin FAB fragments
  2. atropine (bradycardia)
  3. normalize serum K+
  4. magnesium
  5. Class 1b antiarrhythmias
  6. temporary cardiac pacing
56
Q

Types of drugs without positve inotropic effects used in heart failure

A
  1. diuretics
  2. ACE inhibitors (-pril)
  3. Angiotensin receptor antagonists (-sartans)
  4. Aldosteron antagonists (-one)
  5. B-blockers (-lol)
57
Q

vasodilators impact on HF

A
  1. reduction in preload
  2. reduction in afterload
58
Q

What 2 drugs can reduce damaging remodeling of the heart

A
  1. hydralazine
  2. isosorbide dinitrate
59
Q

what electrolyte can be removed to manage HF? what symptom is indicative of this treatment?

A

sodium
-salt removal through diuretic or restriction
-EDEMA

60
Q

what diuretic is typically required to treat mild heart failure?

A

furosemide
(thiazide diuretic occasionally)

61
Q

What does sodium loss do to potassium?

A

loss of potassium
hazardous if given certain drugs (digoxin)

62
Q

what situation is ACE inhibitor the first line tx for?

A

left ventricular dysfunction but no edema

63
Q

what two drug classes are first-line therapy for chronic heart failure

A

ACE inhibitor and Diuretic

64
Q

What is the impact of ACE inhibitors in pts with heart failure

A

reduction of preload and afterload
-slows the progress of ventricular dilation (slows heart failure)

65
Q

When are ARBS used? What symptom is associated

A

for patients who can’t tolerate ACE inhibitors (usually a cough)

66
Q

4 types of vasodilators

A
  1. selective arteriolar dilators
  2. venous dilators
  3. drugs with non-selective vasodilating effects
67
Q

If a patient has high filling pressures with dyspnea (main symptom) what type of drug should be used? Name 3 specific

A

venous dilators
1.isosorbide dinitrate
2.hydralazine
3.prazosin

these reduce filling pressure and relieves pulmonary congestion symptoms

68
Q

If a pt has fatigue from lower left ventricular output, what type of drug should be used? Name one

A

Arteriolar dilators
hydralazine (increases forward CO)

69
Q

Name 4 Beta Blockers that reduce HF mortality

A
  1. bisoprolol
  2. carvedilol
  3. metoprolol
  4. nebivolol
70
Q

when are B-Blocker drugs given for patients with heart failure? why?

A

-tachycardiac patients
reduces tachycardia which lowers the adverse effects of high catecholamine levels on the heart (worsens HF)

71
Q

When is digoxin indicated in treatment of HF?

A

Heart failure AND artrial fibrillation
-only when diuretics and ACE inhibitors failed

72
Q

What is the slow loading dose of digoxin?

when symptoms are mild

A

0.125 or 0.25 mg/d

73
Q

What is the rapid dose of digoxin?

A

0.5-0.75mg every 8 hours (x3 doses)
followed by 0.125 or 0.25mg/d

74
Q

what other situations can digitalis be useful in

A
  1. atrial arrhythmias
  2. paroxysmal atrial and atrioventricular nodal tachycardia
  3. WPW AND atrial fibrillation
75
Q

What is the best route of administration for treatment of acute HF

76
Q

what drugs are used for acute treatment of heart failure

A
  1. diuretics (furosemide)
  2. positive inotropic drugs (for severe hypotension) (dopamine, dobutamine)
  3. Vasodilators (nitroprusside, nitroglycerine)
77
Q

name 2 vasodilators used to treat acute heart failure

A

1.nitroprusside
2.nitroglycerine

reduces afterload, improves EF

78
Q

What is the MOA of Nitroglycerin

A
  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
Q

What system do vasodilators have a larger effect on?

A

the venous system

80
Q

Onset of Nitroglycerin

A

sublingual: 1-3 min
Translingual spray: ~60 minutes
Topical: 15-30 min
Transdermal: ~30 min
IV: immediate

81
Q

What is the half life of nitroglycerin

82
Q

What are indications of Nitroglycerin

A
  1. angina pectoris
  2. Prevention of angina petoris, acute decompensated heart fialure (esp w acute MI)
83
Q

Sublingual dosage of Nitroglycerin.
How often

A

0.3-0.4 mg every 5 minutes up to 3 doses

84
Q

What are the CI to nitroglycerin

A
  1. hypersensitivitiy
  2. other nitrates (any similar drug)
  3. use of PDE-5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil)
85
Q

Side effects of nitroglycerin

list 4

A
  1. CNS (headache)
  2. Hypotension
  3. syncope
  4. peripheral edema
86
Q

MOA of Nitroprusside

A

-peripheral vasodilator
-results in peripheral resistance, increased CO, decreased outload, reduced aortal and L ventricular impedance

87
Q

What is the impact in the body from taking Nitroprusside

A

reduced peripheral resistance
increase CO
Decreased afterload
reduced aortal and L ventricular impedance

88
Q

Onset of action of Nitroprusside

A

Hypotensive effect <2 minutes

89
Q

duration of Nitroprusside

A

1-10 minutes

90
Q

How is Nitroprusside metabolized

A

combines w hemoglobin to produce cyanide and cyanmethomoglobin

91
Q

Indications Of Nitroprusside

A

Acute decompensated heart failure
acute hypertension

92
Q

Dose of nitroprusside for acute hypertension

A

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
Q

Dose/administration of nitroprusside for acute decompensated heart fialure

A

IV
initial 5-10mcg/minute
titrated rapidly (up to q5min)
usual dose range: 5-300mcg/min
absolute MAX 400 mcg/min

94
Q

CI of nitroprusside

A

-tx of compensatory hypertension (aortic coarctation, arteriovenous shunting), acute HF w reduced systemic vascular resistence

95
Q

adverse reactions of

pharmacology (32 decks)

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