Treatment of Heart Failure Flashcards
HF definition
Clinical syndrome or condition caused by the heart’s inability to generate a sufficient CO to meet metabolic demands of the body, characterized by:
- signs and sxs of intravascular and interstitial volume overload (SOB, rales, edema)
- Manifestations of inadequate tissue perfusion (Fatigue, poor exercise tolerance)
Etiology of HF
MC–Coronary Artery Disease
HTN
Idiopathic dilated cardiomyopathy
Alcohol Abuse
Ventricular Workload Determinants
Preload
Afterload
Contractility
Heart Rate
(think Frank Starling Curve)
Compensatory responses that are detrimental in HF
Increase preload through Na and water retention
Vasoconstriction (will eventually increase afterload, decrease SV)
Tachycardia and increased contractility due to SNS activitation (shortens diastolic filling time, precipitation of ventricular arrhythmias)
Ventricular hypertrophy and remodeling
Stages of Heart Failure
Stage A
- Pt at high risk of developin gHF but without structural heart diseae or sx of HF
- i.e. pts with HTN, atherosclerotic disease, DM, obesity, metabolic syndrome, cardiotoxins, or FHx
Stage B
- Pts iwth structural HD, but no signs or sx of HF
- Pts with previous MI, LV remodeling including LVH/low EF, asymptomatic valvular heart dz
Stage C
- Patients with structural heart disease with current or prior sx of HF
- Patients with known structural heart disease and SOB and fatigue, reduced exercise tolerance
Stage D
- Pts with refractory HF requiring specialized interventions
- pts with marked sx at rest despite maximal medical therapy (i.e. can’t be safely discharged from hospital w/o specialized measures
New York Heart Association Functional Classification
Class I: With cardiac disease, but no limitations
Class II: pts iwth cardiac disease with slight limitaitons. Ordinary activity results in sxs
Class III: Marked limitation, but still comfortable at rest. Less than ordinary activity is sx’tic
Class IV: Inability to carry out physical activity, sxs present even at rest
Drugs that may precipitate or exacerbate HF
Negative Inotropic Effect
Antiarrhythmics
Beta Blockers
CCB
Drugs that may precipitate or exacerbate HF
Cardiotoxic and Sodium and Water
Cardiotoxic–chemo agents, EtOH, amphetamines
NSAIDS
Glucocorticoids
Androgens, estrogens
Drugs with high sodium content
Treatment principles of HF
optimize preload
reduce afterload
increase contractility
ACEI in HF
Dec preload, Dec afterload
Recommended for all pts
Can be useful to prevent HF with high risk
Beta Blockers in HF
For all stable pts
“reverse remodeling”
Diuretics in HF
Mild overload–thiazide
Moderate overload–loop
Severe–IV furosemide
Digoxin in HF
Inc myocardial contractility
Antiarrhythmic for pts with A fib
Add digoxin for pts who remain symptomatic despite optimal ACEI (or ARB), BB, and diuretic
Be aware of toxicity and drug interactions
Other HF Therapies
Spironolactone (Adolsterone Antagonist)
Angiotension II Receptor Blockers (ARBs)
Hydralazine/Isosorbide (dec nitrate tolerance)
Therapy Recommendations for Stage A
- ACEI or ARB to prevent HF in pts at high risk (Hx of atherosclerotic vascular dz, DM, or HTN with CV RFs)
- Tx HTN and dyslipidemia
- Control metabolic syndrome
- Encourage exercise, smoking cessation
- Discourage smoking and drugs
