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Pharm 2024 > PPT 13: CHF > Flashcards

PPT 13: CHF Flashcards

Exam 2

1
Q

Define heart failure

A

Heart fails to meet the metabolic demands of tissues - CO inadequate

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2
Q

What is the most common cause of heart failure?

A

Coronary artery disease

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3
Q

Differentiate between systolic and diastolic heart failure

A

Systolic failure – reduced cardiac function
- Acute; heart walls thinned (less effective pumping)
↓ CO, ↓ Ejection fraction

Diastolic failure – reduced cardiac filling (can be peripheral)
- Chronic; heart more stiff/thicker walls (chronic HTN)
- ↓ CO, Normal Ejection fraction
- Does not respond well to positive inotropic drugs

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4
Q

Differentiate between symptoms of right vs left ventricular failure of CHF

A

Right ventricle – peripheral congestion
Left ventricle – pulmonary congestion

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5
Q

Heart failure where the normal CO not sufficient for demands of body

A

“High-output” failure (rare)
- Hyperthyroidism
- Beriberi
- Anemia
- Arteriovenous shunts
Responds poorly to inotropic agents – treat underlying cause

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6
Q

What are the 4 factors of cardiac performance?

A

CO = SV x HR
- Preload
- Afterload
- Contractility
- Heart Rate

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7
Q

Define the Frank-Starling Law

A

Strength of contraction increases when stretched (Rubber band analogy)
- End systolic volume (ESV)
- % of blood remains in ventricles
- ↑%, ↑ pressure

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8
Q

______ is the end diastolic pressure that stretches out ventricles

A

Preload

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9
Q

EDV =

A

Passive filling + atrial contraction + ESV

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10
Q

Stroke volume =

A

EDV – ESV

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11
Q

What is considered altered preload?

A

> 20-25 mm Hg – pulmonary congestion

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12
Q

What are ways to decrease preload?

A

salt restriction, diuretics, venodilation (Nitroglycerin)

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13
Q

_______ is the resistance against which heart must pump blood

A

Afterload

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14
Q

Afterload _____ as CO decreases

A

Increases

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15
Q

Describe the vicious spiral of progression of heart failure

A

Decreased CO
Increased NE, AII, ET
Increased Afterload
Decreased EF
(then back to top)

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16
Q

Contraction of myocytes is called

A

inotropy

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17
Q

What is the first compensatory mechanism to respond to decreased CO?

A

Increased HR

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18
Q

What increases CO? What decreases it?

A

Increases CO: increased preload, contractility, HR
Decreases CO: increased afterload

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19
Q

Discuss the compensatory responses of decreased cardiac output

A
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20
Q

What are the treatment targets for CHF?

A
  • Correcting failure of cardiac contractility (inotropy)
  • Reversing salt and water retention (diet)
  • Unloading stressed myocardium (B-blockers, Ca++ Channel blockers, and diuretics)
21
Q

Which drug therapies directed at non-cardiac targets may be more useful for long-term treatment of heart failure

A
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Aldosterone receptor antagonists
  • Vasodilators
22
Q

Discuss the normal control of cardiac contractility

A
  1. Trigger Ca++ enters cell
    - depends on number of L type channels, duration of channel opening, and sympathetic stimulation
  2. Binds to channel is SR, release stored Ca++
    - depends on amount stored and amount of trigger Ca++
  3. Frees actin to interact with myosin
  4. Removal of Ca++
    - SR Calcium ATPase
    - Na+/Ca2+ antiporter – sodium gradient
    - Na+/K+ ATPase: removes sodium
23
Q

What are the medications used to treat CHF?

A
  1. Calcium (Ca-Chloride, Ca-gluconate)
  2. Cardiac Glycosides (digoxin, digitoxin)
  3. PDE Inhibitors (Milrinone)
  4. Catecholamines
    Others:
    - ACE inhibitors and ARBs
    - Diuretics
    - Calcium sensitizers (Levosimendan)
    - Vasodilators
    - Beta blockers
24
Q

What are the 3 meds to avoid in heart failure? Why?

A
  1. NSAIDS (increases BP)
  2. Thiazolidinediones (fluid retention)
  3. Metformin (lactic acidosis)
25
Q

What are the medications used to treat acute HF?

A

IV treatment:
- Diuretics
- Dobutamine
- Vasodilators

26
Q

What is the option for treatment of HF with euvolemic hyponatremia?

A

Conivaptan – ADH inhibitor → removes water, not sodium via urine

27
Q

What are the non-pharmaceutical interventions for HF?

A
  1. LV Reduction Surgery (Batista Procedure)
    - Poor prognosis, discontinued
  2. Skeletal Muscle Augmentation (Cardiomyoplasty)
    - Invasive, high failure (23% mortality)
  3. Chronic Biventricular Resynchronization
  4. Cellular Cardiomyoplasty
  5. Cardioverter-Defribrilator
  6. Heart Transplant
28
Q

_______ is the only oral (+) inotropic agent for HF

A

Digoxin

29
Q

Digoxin has a ________ therapeutic index

A

narrow

30
Q

How does digoxin help treat HF?

A

Positive inotropic, cardiac glycoside
- inhibits Na+/K+ ATPase pump

31
Q

What are the electrical effects of digoxin?

A

↑PR, ↓QT
- digitalis effect = downward schwoop of ST segment (Salvador Dali)

32
Q

What are the EKG changes that occur with digoxin toxicity?

A

tachycardia, fibrillation, arrest

33
Q

What are the pharmacokinetics of digoxin?

A

A: Well absorbed (Foral = 65-80%) - (may be inactivated by gut bacteria in some)
D: Wide in tissues and CNS
M: Not extensive in humans
(T1/2 = 36-40 hours)
E: 2/3 excreted unchanged by kidneys

34
Q

Which electrolyte changes effect digoxin?

A
  1. Hyperkalemia
  2. Hypercalcemia
  3. Hypomagnesia
35
Q

What effect does hyperkalemia have on digoxin effects?

A
  • Potassium competes with digoxin
  • Excess K+, decreased effect
36
Q

What effect does hypercalcemia have on digoxin effects?

A

Increased risk of digoxin induced arrhythmias

37
Q

What effect does hypomagnesia have on digoxin effects?

A

Increased risk of digoxin induced arrhythmias

38
Q

How do phosphodiesterase inhibitors help treat HF?

A

Enzymes that inactivate cAMP and cGMP - positive inotropic effects, vasodilation
Increase contractility w/o inhibiting Na+/K+ ATPase (increase/prolong Ca++)
PDE3 specific

39
Q

Which phosphodiesterase inhibitor helps treat HF?

A

Milrinone

40
Q

What are the beta adrenergic stimulants used to treat HF?

A

β1 selective
- Dopamine
- Dobutamine most widely used (Increased CO and Decreased ventricular filling pressure)

41
Q

What is the advantage of using beta adrenergic stimulants over digoxin?

A

Less arrythmogenic than digitalis

42
Q

What are the positive inotropic drugs used to treat HF?

A

Digoxin, phosphodiesterase inhibitors, beta adrenergic stimulants, and calcium sensitizers

43
Q

What are the drugs w/o positive inotropic effects used to treat HF?

A

Diuretics, ACE inhibitors and ARBs, vasodilators, and beta blockers

44
Q

How are diuretics used to help treat HF?

A

Reduce salt and water retention
- Reduce preload
- Reduce edema
- Reduce cardiac size
- Improved efficiency of cardiac pump

45
Q

How are ACE inhibitors and ARBs used to help treat HF?

A

Reduce compensatory responses to failure

46
Q

How are vasodilators used to help treat HF?

A
  • Reduction in preload
  • Reduction in afterload
47
Q

How are beta blockers used to help treat HF?

A

Decreases stress on heart (force of contraction) and reduction in mortality
- Can’t be used for severe CHF or acute HF

48
Q

How are Ca++ sensitizers used to help treat HF?

A
  1. Positive inotropic - Bind troponin, stabilize Ca2+ bound conformation
  2. Vasodilatory - Open K+ channels (vasodilation)

(Not yet approved in USA)

Pharm 2024 (28 decks)

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