Treatment of Heart Failure Flashcards
What are the five basic principles
Make correct dx Determine etiology of heart disease Determine precipitating factors Understand pathophysiology of HF Understand mechanism of action of pharmacological therapy
What are the indications for admission for management of Heart Failure
Acute MI, severe respiratory distress
Hypoxia, Hypotension, cardiogenic shock
Anasarca (diffuse swelling), syncope, heart failure refractory to oral medications
What is the treatment of heart failure
Non-pharmacologic Quit-smoking If overweight Decrease caloric intake AHA diet Diet instructions by dietician to patient and spouse 2 gram Na diet
What are other lifestyle choices you can do to tx the pt
Fluid restrictions if Na is less than 126 Avoid isometric activity (increase SVR and afterload) Encourage isotonic activity Stool softener Subcut Lovenox O2 for 24 hours Avoid EtOH Treat HTN, HLD, DM
How should you tx your pt on discharge? How should you counsel the pt?
Diet- pt with spouse/ other Na restriction, calorie restriction (if overweight) Stimulants Education Rehab, exercise Medications ACE/ARB, B-blocker, ASA, Statin, nitro
What is the conventional tx for acute heart failure?
Give diuretics to reduce the fluid overload
Give vasodilators to decrease preload and/or afterload
Give inotropes to augment the contracility
Discuss the EBM classification of recommendations
Class 1- evidence and agreement that therapy procedure is beneficial, useful and/or effective benefit 3+ risk
Class II- conflicting evidence and/or divergence of options
II(a)- weight of evidence/ opinion in favor- benefit 2+ risk
II)b) less established evidence/opinion- benefit 1+ risk
Class III- evidence and/or agreement that procedure is not effective may be harmful
Discuss the classification of recommendations level A
Level A
Data from meta-analysis or multiple randomized clinical trials; multiple populations evaluated
Discuss the classification of recommendations Level B
B- Data from single randomized studies; limited population evaluated
Discuss the classification of recommendations level C
c- Only consensus opinion of experts, case studies, or standard of care, very limited of populations evaluated
Discuss ACEI
Block conversion of angiotensin I to ANGII
Lower mortality and morbidity by 20%
Useful in preventing HF in high-risk pts (level A)
Recommended in pts with sx of HF, reduced EF, unless contraindicated: L of E: A
Problems with renal insufficiency
What are contraindications of ACEI
Angioedema, pregnancy, B/L RAS
Side effects Cough
Discuss Mechanism of ARBS
Work at the level of the kidney to block the AT1 receptor w/o inhibiting kininase
Don’t get the cough
Discuss benefits of B-blockers
Survival benefit in chronic Syst HF and dilated cardiomyopathy
Slow progression of disease and decrease hospitalization, improve Cardiac performance and sx of HF
Discuss the hemodynamics of B-blockers
Decrease HR, antiarrhythmic properties
Anti ischemic
Blunts SNS effects of NE
Reverse Remodeling
Do B-blockers improve mortality? Can they improve EF? What other medications can they be put on?
Yes they improve mortality; They improve the LVEF; Think Coreg, alpha1, beta1, beta2 receptor with vasodilator property and antioxidant
When would a B-blocker be contraindicated in a B-blocker
Don't use in an unstable pt (recommended for all stable pt with sx of HF, EF, lvl A) Useful in NyHA class II and III pts
What is the purpose of diuretics
Relieve pulmonary symptoms, increase cardiac function, promote natriuresis, urinary Na excretion
Inhibits NaCl resportion from AL or LOW
Increase risk of arrhythmia deaths w/o K+ sparing
What is the site of action of the diuretics?
LOH Lasix, bumex, demadex DT Thiazide Late DT Spironolactone
What is the function and MOA of Digitalis
Inotropic agent; improves sx but not mortality of heart failure
MOA
Inhibits Na/K ATPase causing reversal of the NA CA2+ transporter leading to increased contractility
What is the action of spironolactone
Antagonizes the effects of aldosterone Use with ACE, BB, diuretics, Dix 30-50% reduction in mortality Watch K or creatinine Lvl B
What is the role of the inotropes
Increases the contractility of the heart Dobutamine (dobutrex) stimulating Beta1 and Beta2 receptors Milrinone (primacor) Inotropic vasodilator Inhibits phosphodiesterase
Discuss the ionotrophic effects of dopamine
Stimulates B1 receptor the higher the dose the more it stimulates alpha receptors
Useful for short term
Discuss the roles of hydralazine plus isosorbide dinitrate and the health outcomes associated with this tx course
Hydralazine Arterial vasodilator, reduces afterload and SVR Nitrates Vasodilators to reduce preload or reduce venous return to increase CO When combined Reduce mortality Increase EF Increase exercise tolerance
Who responds better to hydralazine and isosorbide tx, African Americans vs white?
African-Americans
Discuss CCB, their class, whether there is a benefit in HF pt’s
Class III, no benefit, not recommended as routine, tx for pts with HF associated with reduced EF
What is the role of OMM in HF Lymph tx
Open thoracic inlet to decrease flow fascial restriction
rib raising
Diaphragm (abd) doming)
As effective as LE exercise for fluid movement
Effleurage/Petrissage
