SM 144a - Heart Failure Treatment Flashcards
Where do potassium-sparing diuretics exert their effect?
List some relevant examples
The collecting duct
-
Most commonly used in HF - May also prevent hypertropy and fibrosis of the heart, due to anti-aldosterone effects (MRAs)
- Spironolactone
- Eplerenone
- Other potassium-sparing - rarely used in HF
- Amiloride
- Triamterene
List the 4 factors that precipitate acute deompensation of heart failure
-
Increased metabolic demands
- Fever, infection, anemia, tachycardia, hyperthyroid, pregnancy
-
Increased circulating volume (preload)
- Dietary sodium, fluid intake, renal failure
-
Increased afterload
- Systemic HTN (LV)
- Pulmonary embolism (RV)
-
Decreased Cardiac Output
- Decreased contractility (MI, ischemia, negative inotropes, alcohol)
- Decreased stroke volume
- Abnormal HR
**Medication adherence barriers can cause all of the above**
The overarching goal of HF_EF treatment is to block the neurohormal response and prevent _________
The overarching goal of HFrEF treatment is to block the neurohormal response and prevent maladaptive myocardial remodeling
What is the most important acute treatment for a patient with heart failure who is cold and wet?
Vasodilators = most important acute treatment
(Diuresis is not possible until perfusion improves)
What drugs are used to treat Stage A heart failure?
- ACE-I or ARB in appropriate patients
- Statins as appropriate
- Stage A = high risk with no symptoms*
- ex: Patients with HTN, diabetes, atheroslcerotic disease, obesity, metabolic syndrome*
- Goals:*
- Prevent vascular, coronary artery disease
- Prevent LV structural abnormalities
- Heart healthy lifestyle
Where do spironolactone and eplerenone act?
Location 4 (Specifically, the collecting duct of the kidney)
They prevent aldosterone from binding to its receptor
What therapy is recommended for patients with HFrEF who have persisting symptoms despite optimal doses of first and second line therapy, and have a QRS >120 ms (longer than normal)?
CRT-P: Cardiac resynchronization therapy (Pacing only)
OR
CRT-D: Carciac resyncrhonization therapy (Pacing + Defibrillator)
List some diuretics that act on the distal convoluted tubule
- Thiazide diuretics
- Hydrochlorothiazide
- Chlorthalidone
- Chlorthiazide
- Metolazone
What is the mechanism of action of Ivabradine?
What are the effects on the heart?
Ivabradine slows down the heart
- SA node inhibitor
- Inhibits the If to slow down phase 4 depolarization
- -> Slows down heart rate
[Note: only use in patients with HFrEF if HR is still high after administering a beta-blocker]
Beta-blockers decrease cardiac contractiliy.
Why then, are they recommended in patients with heart failure?
Beta blockers…
-
Combat the maladaptive neurohormonal response by blocking sympathetic outflow
- Inhibit myocardial toxicity, arrhythmia
- Inhibit RAAS activation
- Inhibit vasoconstriction
- Inhibit Na+ retention
Which patients with acute decompensated HF should recieve positive inotropes?
List some relevant drug examples
Positive inotropes should only be used as a bridge to mechanical therapy or heart transplant
-
Dobutamine: Most commonly used for acute decompensated HF
- Beta-1 and Beta-2 agonist
-
Dopamine
- Beta-1 agonist (some alpha-1)
-
Norepinephrine
- Beta-1 and alpha-1 agonist
What medical therapies are considered in patients with HFpEF?
Note: there is insufficient evidence to say that medical therapy improves outcomes in patients with HFpEF
- Treat underlying etiologies (comorbidities)
- HTN
- Diabetes Melitus
- Obesity
- Atrial Fibrillation
- Coronary Artery Disease
- Volume control
- Spironolactone (or other MRA)
- Reduce maladaptive neurohomonal response that leads to myocardial remodeling
What therapy is recommended for patients with HFrEF who have ejection fraction <35% despite optimal doses of first and second line therapy?
Implantable cardioverter defibrillator
Where do loop-diuretic exert their effects?
List some relevant examples
Ascending loop of Henle
- Furosemide
- Bumetanide
- Trosemide
- Ethycrinic Acid (no sulfa)
Which beta-adrenergic agonist is equally a beta-1 and beta-2 agonist?
What is the effect on the CV system?
Dobutamine
- Increased HR
- Increased contractility
- Vasodilation
Which drug inhibits neprilysin?
What is the effect?
Sacubitril inhibits neprilysin (preparation: sacubitril-valsartan)
Neprilysin normally degrades natriuretic peptides. Sacubitril prevents this, thus increasing levels of natriuretic peptides and promoting diuresis, natriuresis, and vasodilation
Which medication types are considered first line for everyone with HFrEF?
Diruetic + ACE-I or ARB + Beta-Blocker
What are the treatment goals of stage D heart failure?
- Control symptoms
- Improve HRQOL
- Reduce hospital readmissions
- Establish patient’s end of life goals
Stage D: Refractory (decompensated) heart failure
What drugs are used to treat stage C heart failure?
- HFrEF
- First line
- Diuretics
- ACE-I or ARB
- Beta Blocker
- Second line
- Aldoseterone antagonist (aka MRA)
- Ivabradine
- Hydralazine + Nitrate
- Digoxin (last resort)
- First line
- HFpEF
- Diuretics
- Address comorbidities (HTN, AF, CAD, DM)
- (There is less evidence to support medical therapy in HFpEF patients)
- Stage D: Patients with known structural heart disease + signs and symptoms*
- Ex: HFrEF, HFpEF*
- Goals:*
- Control symptoms
- Prevent hospitalization
- Prevent mortality
- Patient education
- Improve Health-Related Quality of Life
What is the most important acute treatment for a patient with heart failure who is cold and dry?
These patients are in end-stage heart failure
- Increase vasodilators
- Increase inotropes
- Consider ventricular assist devices, cardiac transplantation, comfort measures, palliative care
Which drugs act at location 3?
ARBs (-sartan drugs)
ARB = Angiotensin II Receptor Blocker
Which drugs at location 4?
MRAs (Spironolactone, eplerenone)
Mineralcorticoid Receptor Antagonists
Aldosterone is a mineralcorticoid; these drugs prevent aldosterone from binding to its receptor
What are the treatment goals of Stage A heart failure?
- Prevent vascular, coronary artery disease
- Prevent LV structural abnormalities
- Heart healthy lifestyle
- Stage A = high risk with no symptoms*
- ex: Patients with HTN, diabetes, atheroslcerotic disease, obesity, metabolic syndrome*
Which beta-adrenergic agonist is equally a beta-1 and alpha-1 agonist?
What is the effect on the CV system?
Norepinephrine
- Increased HR
- Increased contractility
- Vasoconstriction
What is neprilysin?
How does it affect CVD mortality?
Neprilysin is an enzyme (endopeptidase) that degrades and inactivates natriuretic peptides
Increased neprilysin = decreased natriuretic peptides = worse CVD outcomes
Inhibiting neprilysin lowers CVD mortality
(ex: Sacubitril-valsartan)
What are the treatment goals of stage B heart failure?
- Prevent HF symptoms
- Prevent further cardiac remodeling
- Stage B: Strucutral heart disease but without signs or symptoms of heart failure*
- Ex: Patients with previous MI, LV remodeling (LVH, low EF), asymptomatic valvular disease*
What therapies are recommended for patients with HFrEF who have persisting symptoms despite optimal doses of ACE-I or ARB and Beta-Blockers?
Second line therapy
- Aldosterone antagonist (MRA)
- Hydralazine + isosorbide dinitrate
- Especially in Black patients
- Ivabradine (SA-node inhibitor)
Which vasodilator is a pure arterial vasodilator?
Hydralazine
Which drug acts at location 1?
Aliskiren
Inhibits renin -> Renin cannot convert angiotensinogen to Angiotensin I
Describe the mechanism of action of Sacubitril
Sacubitril inhibits neprilysin (an endopeptidase that degrades natriuretic peptides)
-> Increased natriuretic peptides -> Diuresis, natriuresis, and vasodilation
Note: Preparation of this drug is sacubitril-valsartan
What therapy is recommended for patients with HFrEF who have persisting symptoms despite optimal doses of first and second line therapy, and have a QRS <120 ms (normal)?
- Digoxin
- LV assist device
- Transplantation
What is the mechanism of action of milrinone?
What is the effect on the CV system?
Milrinone is a phosphodiesterase inhibitor. It works intracellularly (bypasses the beta receptor) by increasing cAMP
Increase contractility, vasodilation
Which vasodilators are given to decompensated heart failure patients who are warm and wet?
Nitroglycerine or Nesiritide
(But do not give nesiritide to patients who are hypotensive)
Where does lisinopril act?
Location 2
Inhibits Angiotensin Converting Enzyme (ACE)
Where does Aliskiren act?
Location 1 - Inhibits renin
Which patients benefit most from hydralazine + isosorbide dinitrate therapy?
Patients with HFrEF who have persisting signs and symptoms despite taking diuretic + ACE-I or ARB + Beta blocker
Black paients especially benefit from hydralazine + isosorbide dinitrate therapy
What are the indications for an implantable cardiac defibrillator?
NYHA Class I-III
Used to prevent sudden cardiac death, especially if LV Ejection Fraction <35%
List the signs of fluid congestion (5)
JAR-O’s
Increased JVP
Ascites
Rales
Orthopnea
Leg swelling
Which vasodilators are pure venodilators?
Nitrates
Which vasodilator is given to decompensated heart failure patients who are cold and wet or cold and dry?
These patients have high SVR and low CO
Give Nitroprusside to lower SVR and increase CO
How is stage D heart failure treated?
- Heart transplant
- Chronic inotropes
- Mechanical Circulatory Support
- Experimental surgery or drugs
- Palliative care and hospice
- ICD deactivation
- Stage D: Refractory (decompensated) heart failure*
- Goals:*
- Control symptoms
- Improve HRQOL
- Reduce hospital readmissions
- Establish patient’s end of life goals
Which medication, used in acute decompensated HF, works intracellularly to increase cAMP, thus promoting increased cardiac contractility and peripheral vasodilation?
Phosphodiesterase inhibitors
(Amrinone, milrinone - only milrinone is used clinically)
Where do valsartan and losartan act?
Location 3
Prevent Angiotensin II from binding to its receptor
What drugs are used to treat stage B heart failure?
- ACE-I or ARB in all patients
- Beta blockers in some patients
Stage B: Strucutral heart disease but without signs or symptoms of heart failure
- Ex: Patients with previous MI, LV remodeling (LVH, low EF), asymptomatic valvular disease*
- Goals:*
- Prevent HF symptoms
- Prevent further cardiac remodeling
List the signs of poor perfusion (6)
CHOP-RU
Cool extremities
Hypotension
Obtunded/Sleepy
Narrow Pulse Pressure
Worsening Renal failure
Decreased Urine output
A patient with acutely decompensated heart failure is experiencing pulmonary edema.
How should they be treated?
Treatment = LMNOP
-
Loop Diuretics
- Venodilation immediately, natriuresis later
-
Morphine
- Venodilation
-
Nitrates
- Venodilation
-
Oxygen
- Decrease sensation of dyspnea, increase O2
-
Positive Pressure Ventilation
- Increase O2, cardiac contractility
What are the treatment goals of stage C heart failure?
- Control symptoms
- Prevent hospitalization
- Prevent mortality
- Patient education
- Improve Health-Related Quality of Life
- Stage D: Patients with known structural heart disease + signs and symptoms*
- Ex: HFrEF, HFpEF*
What are the indications for cardiac resynchronization therapy in patients with heart failure?
- NYHA Class II-IV with persistent symptoms despite medical management
(Any of the following are signs of interventricular and intraventricular electrical and mechanical dyssynchrony)- EV <35%
- QRS >150 ms [or 120 according to the picture on p. 4 of the SM 144a LG?]
- Left bundle branch block
Which beta-adrenergic agonist is a beta-1 (and slight alpha-1) agonist?
What is the effect on the CV system?
Dopamine
- Increased HR
- Increased contractility
- Vasoconstriction at high doses
What is the most important acute treatment for a patient with heart failure who is warm and wet?
Diuresis = the most important acute treatment
Follow with Beta-blocker, ACE-I or ARB, Spironolactone
Which drugs act at location 2?
ACE inhibitors (-pril drugs)
Prevent ACE from converting Angiotensin I to Angiotensin II
