Treatment of Heart Failure

Question 1

What are the five basic principles

Answer 1

Make correct dx
Determine etiology of heart disease
Determine precipitating factors
Understand pathophysiology of HF
Understand mechanism of action of pharmacological therapy

Question 2

What are the indications for admission for management of Heart Failure

Answer 2

Acute MI, severe respiratory distress
Hypoxia, Hypotension, cardiogenic shock
Anasarca (diffuse swelling), syncope, heart failure refractory to oral medications

Question 3

What is the treatment of heart failure

Answer 3

Non-pharmacologic 
Quit-smoking
If overweight
Decrease caloric intake
AHA diet
Diet instructions by dietician to patient and spouse 2 gram Na diet

Question 4

What are other lifestyle choices you can do to tx the pt

Answer 4

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

Question 5

How should you tx your pt on discharge? How should you counsel the pt?

Answer 5

Diet- pt with spouse/ other 
Na restriction, calorie restriction (if overweight) 
Stimulants
Education
Rehab, exercise
Medications
ACE/ARB, B-blocker, ASA, Statin, nitro

Question 6

What is the conventional tx for acute heart failure?

Answer 6

Give diuretics to reduce the fluid overload
Give vasodilators to decrease preload and/or afterload
Give inotropes to augment the contracility

Question 7

Discuss the EBM classification of recommendations

Answer 7

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

Question 8

Discuss the classification of recommendations level A

Answer 8

Level A

Data from meta-analysis or multiple randomized clinical trials; multiple populations evaluated

Question 9

Discuss the classification of recommendations Level B

Answer 9

B- Data from single randomized studies; limited population evaluated

Question 10

Discuss the classification of recommendations level C

Answer 10

c- Only consensus opinion of experts, case studies, or standard of care, very limited of populations evaluated

Question 11

Discuss ACEI

Answer 11

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

Question 12

What are contraindications of ACEI

Answer 12

Angioedema, pregnancy, B/L RAS

Side effects Cough

Question 13

Discuss Mechanism of ARBS

Answer 13

Work at the level of the kidney to block the AT1 receptor w/o inhibiting kininase
Don’t get the cough

Question 14

Discuss benefits of B-blockers

Answer 14

Survival benefit in chronic Syst HF and dilated cardiomyopathy
Slow progression of disease and decrease hospitalization, improve Cardiac performance and sx of HF

Question 15

Discuss the hemodynamics of B-blockers

Answer 15

Decrease HR, antiarrhythmic properties
Anti ischemic
Blunts SNS effects of NE
Reverse Remodeling

Question 16

Do B-blockers improve mortality? Can they improve EF? What other medications can they be put on?

Answer 16

Yes they improve mortality; They improve the LVEF; Think Coreg, alpha1, beta1, beta2 receptor with vasodilator property and antioxidant

Question 17

When would a B-blocker be contraindicated in a B-blocker

Answer 17

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

Question 18

What is the purpose of diuretics

Answer 18

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

Question 19

What is the site of action of the diuretics?

Answer 19

LOH
Lasix, bumex, demadex
DT
Thiazide
Late DT
Spironolactone

Question 20

What is the function and MOA of Digitalis

Answer 20

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

Question 21

What is the action of spironolactone

Answer 21

Antagonizes the effects of aldosterone
Use with ACE, BB, diuretics, Dix
30-50% reduction in mortality
Watch K or creatinine
Lvl B

Question 22

What is the role of the inotropes

Answer 22

Increases the contractility of the heart 
Dobutamine (dobutrex) 
stimulating Beta1 and Beta2 receptors
Milrinone (primacor)
Inotropic vasodilator
Inhibits phosphodiesterase

Question 23

Discuss the ionotrophic effects of dopamine

Answer 23

Stimulates B1 receptor the higher the dose the more it stimulates alpha receptors
Useful for short term

Question 24

Discuss the roles of hydralazine plus isosorbide dinitrate and the health outcomes associated with this tx course

Answer 24

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

Question 25

Who responds better to hydralazine and isosorbide tx, African Americans vs white?

Answer 25

African-Americans

Question 26

Discuss CCB, their class, whether there is a benefit in HF pt’s

Answer 26

Class III, no benefit, not recommended as routine, tx for pts with HF associated with reduced EF

Question 27

What is the role of OMM in HF Lymph tx

Answer 27

Open thoracic inlet to decrease flow fascial restriction
rib raising
Diaphragm (abd) doming)
As effective as LE exercise for fluid movement
Effleurage/Petrissage