Treatment of CHF

Question 1

Class I CHF is defined by what?

Answer 1

Low ejection fraction

Question 2

Class I is treated by>

Answer 2

ACEi or ARBs

Question 3

Why are ACEi and ARBs good CHF treatments>

Answer 3

THey prevent and reverse the myogenic effects of ANgiotensin II such as:
hypertrophy of cardiac myocytes
hypertrophy of vascular smooth muscle
cardiac and ventricular fibrosis
atherosclerosis

Question 4

What effect do ACEi and ARBs have on Bradykinin

Answer 4

They increase its concentration, It is a vasodilator and also an antifibrotic mediator

Question 5

What are the harmful drug interactions with ACEi?

Answer 5

Diuretic therapies EXCEPT spironolactone

Question 6

Contraindications for ACEi and ARBs

Answer 6

angioedema (mostly just ACEi), pregnancy, renal insufficiency, hepatic insufficiency

Question 7

Keep in mind the pregnancy issue

Answer 7

ok

Question 8

Why were beta blockers previously contraindicated in CHF?

Answer 8

Because Beta receptors are the delivery site for sympathetic action on the heart so it makes sense that you wouldn’t want to block this if the pump is failing

Question 9

How are Beta blockers helpful in management of CHF

Answer 9

They attenuate the not so great effects of chronic high epinephrine and norepinephrine such as:
increased myocardial oxygen consumption
beta receptor downregulation 
arrhythmias
fibrosis and myocyte apoptosis

Question 10

Short term hemodynamic effects of beta blockers

Answer 10

reduced cardiac output and reduced blood pressure

Question 11

Long term effects of beta blockers in CHF?

Answer 11

increased CO, decreased LVEDP…it may get worse before it gets better

Question 12

Beta blockers in summary

Answer 12

Reverse desensitization, increase receptor number, restore fast signaling modes (contractility) over slow signaling modes (gene expression).

Question 13

What beta blockers are used in CHF

Answer 13

Metoprolol

Question 14

What drug do you add when pts become class II

Answer 14

diuretics

Question 15

What diuretics are most commonly used

Answer 15

High ceiling Diuretics like Furosemide or Bumetanide

Question 16

Explain teh diuretic effects of ACEi’s and ARBs

Answer 16

They reduce sodium retention by preventing aldosterone release, their effect is not always sufficient tp prevent edema, the dose of the diuretic should be lowered

Question 17

How to spironolactone and epelerone have benefits beyond their diuretic effect

Answer 17

Aldosterone can have mitogenic and fibrogenic effects on the myocardium that stimulate fibrosis- spironolactone blocks this

Question 18

Digoxin mechanism

Answer 18

inhibits the Na/K ATPase transporter which leads to increased intracellular calcium levels and increased ionotrophy (contractility)

Question 19

Digoxin toxicity

Answer 19

Very narrow therapeutic window and a great deal of variability b/w patients.
Arrhythmias, blurred vision, yellow halo, headache, fatigue, dizziness, seizures. Use Digi bind to reomve it in life threatening situations

Question 20

Digoxin drug interactions

Answer 20

tons of them. ANything that changes its metabolism may move it out of the therapeutic wondow.
Quinidine decreases levels, Amiodarone, VERAPAMIL

Question 21

Greatest benefit of digoxin sen in what pts

Answer 21

those with ejection fraction of 25% and less and with cardiac enlargement

Question 22

Add what to therapy for class III

Answer 22

Digoxin

Question 23

Add what to Therapy for class IV

Answer 23

Strong vasodilators transplants and deveices

Question 24

Hydralazine

Answer 24

vasodilator

Question 25

Dobutamine

Answer 25

Beta 1 and 2 agonist (1 more than 2) increased ionotropy and a vasodilator

Question 26

Milrinone

Answer 26

Phosphodiesterase inhibitor…enhances Cyclic AMP signaling

Question 27

Talk about ANP and BNP in general

Answer 27

Natriuretic peptides that are released from atria and ventricles in the heart when pressure and volume are high. They are elevated in CHF and they promote vasodilation..
They reduce preload, prevent renin release, inhibit sodium reabsorption, and cause afferent arteriolar vasodilation in the kidneys

Question 28

What is the synthetic B-type Natriuretic peptide

Answer 28

Nesirtide..used in class IV CHF