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CVB by Minnie- 2024 Update > SM 144a - Heart Failure Treatment > Flashcards

SM 144a - Heart Failure Treatment Flashcards

1
Q

Where do potassium-sparing diuretics exert their effect?

List some relevant examples

A

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
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2
Q

List the 4 factors that precipitate acute deompensation of heart failure

A
  • 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**

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3
Q

The overarching goal of HF_EF treatment is to block the neurohormal response and prevent _________

A

The overarching goal of HFrEF treatment is to block the neurohormal response and prevent maladaptive myocardial remodeling

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4
Q

What is the most important acute treatment for a patient with heart failure who is cold and wet?

A

Vasodilators = most important acute treatment

(Diuresis is not possible until perfusion improves)

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5
Q

What drugs are used to treat Stage A heart failure?

A
  • 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
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6
Q

Where do spironolactone and eplerenone act?

A

Location 4 (Specifically, the collecting duct of the kidney)

They prevent aldosterone from binding to its receptor

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7
Q

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)?

A

CRT-P: Cardiac resynchronization therapy (Pacing only)

OR

CRT-D: Carciac resyncrhonization therapy (Pacing + Defibrillator)

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8
Q

List some diuretics that act on the distal convoluted tubule

A
  • Thiazide diuretics
    • Hydrochlorothiazide
    • Chlorthalidone
    • Chlorthiazide
    • Metolazone
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9
Q

What is the mechanism of action of Ivabradine?

What are the effects on the heart?

A

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]

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10
Q

Beta-blockers decrease cardiac contractiliy.

Why then, are they recommended in patients with heart failure?

A

Beta blockers…

  • Combat the maladaptive neurohormonal response by blocking sympathetic outflow
    • Inhibit myocardial toxicity, arrhythmia
    • Inhibit RAAS activation
      • Inhibit vasoconstriction
      • Inhibit Na+ retention
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11
Q

Which patients with acute decompensated HF should recieve positive inotropes?

List some relevant drug examples

A

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
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12
Q

What medical therapies are considered in patients with HFpEF?

A

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
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13
Q

What therapy is recommended for patients with HFrEF who have ejection fraction <35% despite optimal doses of first and second line therapy?

A

Implantable cardioverter defibrillator

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14
Q

Where do loop-diuretic exert their effects?

List some relevant examples

A

Ascending loop of Henle

  • Furosemide
  • Bumetanide
  • Trosemide
  • Ethycrinic Acid (no sulfa)
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15
Q

Which beta-adrenergic agonist is equally a beta-1 and beta-2 agonist?

What is the effect on the CV system?

A

Dobutamine

  • Increased HR
  • Increased contractility
  • Vasodilation
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16
Q

Which drug inhibits neprilysin?

What is the effect?

A

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

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17
Q

Which medication types are considered first line for everyone with HFrEF?

A

Diruetic + ACE-I or ARB + Beta-Blocker

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18
Q

What are the treatment goals of stage D heart failure?

A
  • Control symptoms
  • Improve HRQOL
  • Reduce hospital readmissions
  • Establish patient’s end of life goals

Stage D: Refractory (decompensated) heart failure

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19
Q

What drugs are used to treat stage C heart failure?

A
  • HFrEF
    • First line
      • Diuretics
      • ACE-I or ARB
      • Beta Blocker
    • Second line
      • Aldoseterone antagonist (aka MRA)
      • Ivabradine
      • Hydralazine + Nitrate
      • Digoxin (last resort)
  • 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
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20
Q

What is the most important acute treatment for a patient with heart failure who is cold and dry?

A

These patients are in end-stage heart failure

  • Increase vasodilators
  • Increase inotropes
  • Consider ventricular assist devices, cardiac transplantation, comfort measures, palliative care
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21
Q

Which drugs act at location 3?

A

ARBs (-sartan drugs)

ARB = Angiotensin II Receptor Blocker

22
Q

Which drugs at location 4?

A

MRAs (Spironolactone, eplerenone)

Mineralcorticoid Receptor Antagonists

Aldosterone is a mineralcorticoid; these drugs prevent aldosterone from binding to its receptor

23
Q

What are the treatment goals of Stage A heart failure?

A
  • 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*
24
Q

Which beta-adrenergic agonist is equally a beta-1 and alpha-1 agonist?

What is the effect on the CV system?

A

Norepinephrine

  • Increased HR
  • Increased contractility
  • Vasoconstriction
25
Q

What is neprilysin?

How does it affect CVD mortality?

A

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)

26
Q

What are the treatment goals of stage B heart failure?

A
  • 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*
27
Q

What therapies are recommended for patients with HFrEF who have persisting symptoms despite optimal doses of ACE-I or ARB and Beta-Blockers?

A

Second line therapy

  • Aldosterone antagonist (MRA)
  • Hydralazine + isosorbide dinitrate
    • Especially in Black patients
  • Ivabradine (SA-node inhibitor)
28
Q

Which vasodilator is a pure arterial vasodilator?

A

Hydralazine

29
Q

Which drug acts at location 1?

A

Aliskiren

Inhibits renin -> Renin cannot convert angiotensinogen to Angiotensin I

30
Q

Describe the mechanism of action of Sacubitril

A

Sacubitril inhibits neprilysin (an endopeptidase that degrades natriuretic peptides)

-> Increased natriuretic peptides -> Diuresis, natriuresis, and vasodilation

Note: Preparation of this drug is sacubitril-valsartan

31
Q

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)?

A
  • Digoxin
  • LV assist device
  • Transplantation
32
Q

What is the mechanism of action of milrinone?

What is the effect on the CV system?

A

Milrinone is a phosphodiesterase inhibitor. It works intracellularly (bypasses the beta receptor) by increasing cAMP

Increase contractility, vasodilation

33
Q

Which vasodilators are given to decompensated heart failure patients who are warm and wet?

A

Nitroglycerine or Nesiritide

(But do not give nesiritide to patients who are hypotensive)

34
Q

Where does lisinopril act?

A

Location 2

Inhibits Angiotensin Converting Enzyme (ACE)

35
Q

Where does Aliskiren act?

A

Location 1 - Inhibits renin

36
Q

Which patients benefit most from hydralazine + isosorbide dinitrate therapy?

A

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

37
Q

What are the indications for an implantable cardiac defibrillator?

A

NYHA Class I-III

Used to prevent sudden cardiac death, especially if LV Ejection Fraction <35%

38
Q

List the signs of fluid congestion (5)

A

JAR-O’s

Increased JVP

Ascites

Rales

Orthopnea

Leg swelling

39
Q

Which vasodilators are pure venodilators?

A

Nitrates

40
Q

Which vasodilator is given to decompensated heart failure patients who are cold and wet or cold and dry?

A

These patients have high SVR and low CO

Give Nitroprusside to lower SVR and increase CO

41
Q

How is stage D heart failure treated?

A
  • 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
42
Q

Which medication, used in acute decompensated HF, works intracellularly to increase cAMP, thus promoting increased cardiac contractility and peripheral vasodilation?

A

Phosphodiesterase inhibitors

(Amrinone, milrinone - only milrinone is used clinically)

43
Q

Where do valsartan and losartan act?

A

Location 3

Prevent Angiotensin II from binding to its receptor

44
Q

What drugs are used to treat stage B heart failure?

A
  • 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
45
Q

List the signs of poor perfusion (6)

A

CHOP-RU

Cool extremities

Hypotension

Obtunded/Sleepy

Narrow Pulse Pressure

Worsening Renal failure

Decreased Urine output

46
Q

A patient with acutely decompensated heart failure is experiencing pulmonary edema.

How should they be treated?

A

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
47
Q

What are the treatment goals of stage C heart failure?

A
  • 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*
48
Q

What are the indications for cardiac resynchronization therapy in patients with heart failure?

A
  • 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
49
Q

Which beta-adrenergic agonist is a beta-1 (and slight alpha-1) agonist?

What is the effect on the CV system?

A

Dopamine

  • Increased HR
  • Increased contractility
  • Vasoconstriction at high doses
50
Q

What is the most important acute treatment for a patient with heart failure who is warm and wet?

A

Diuresis = the most important acute treatment

Follow with Beta-blocker, ACE-I or ARB, Spironolactone

51
Q

Which drugs act at location 2?

A

ACE inhibitors (-pril drugs)

Prevent ACE from converting Angiotensin I to Angiotensin II

CVB by Minnie- 2024 Update (43 decks)

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