Treatment of Heart Failure Part 2 (Johnston) Flashcards
Five basic principles of Heart Failure
- Make correct diagnosis-exclude mimics of HF
- Determine etiology of heart disease
- Determine precipitating factors
- Understand pathophysiology of HF
- Understand mechanism of action (MOA) of pharmacological therapy
Indications for admission to Hospital for Management of Heart Failure
- Acute myocardial ischemia
- Severe respiratory distress
- Hypoxia
- Hypotension
- Cardiogenic shock
- Anasarca–fluids accumulating everywhere
- Syncope
- Heart failure refractory to oral medications
Treatment of Heart Failure–non pharmacologic
- Quit smoking
- If overweight, decrease calorie intake, AHA diet, diet instructions by dietician to patient and spouse
- 2g Na diet
Other treatment for heart failure
- Fluid restriction if Na is less than 126 (less than 2 L/day)
- Avoid isometric activity–increases SVR and after load
- Encourage isotonic activity–walking, hiking, golf
- Stool softener–bc don’t want them to strain
- Subcut Lovenox–anticoagulant to prevent blood clots in thighs and pelvic area
- Oxygen for 24 hours
- Avoid alcohol–depresses contractility in cardiac disease
- Treat hypertension, hyperlipidemia, diabetes
Treatment and counseling before discharge from hospital
- Diet: patient with spouse/other; sodium restriction, calorie restriction if overweight; stimulants (coffee, tea)
- Education
- Rehab, exercise
- Medications: ACE/ARB, Beta blocker, ASA, statin, Nitro prn
2nd ICS LSB diastolic murmur indicates what kind of valvular disease?
-Aortic regurgitation
Options for treatment for hypotension/syncope for someone who is taking ARB, beta blocker and lasix
-Hold diuretics and reduce dose of ARB and beta blocker
CO=
SV x HR
Stroke volume is modulated by
- Preload
- Afterload
- Contractility
Conventional treatment for acute heart failure
- Decrease Diuretics–reduce fluid volume
- Decrease Vasodilators–decrease preload and/or after load
- Increase Ionotropes–augment contractility
Classification of recommendation–Evidence based medicine–Class I
-Evidence and/or agreement that therapy is beneficial, useful and/or effective; benefit 3+ risk
Classification of recommendation–Evidence based medicine–Class II (IIa vs IIb)
- conflicting evidence and/or divergence of opinion
- IIa) Weight of evidence/opinion in favor–benefit 2+ risk
- IIb) Less established evidence/opinion–benefit 1+ risk
Classification of recommendation–Evidence based medicine class III
-Evidence and/or agreement that therapy/prodcedure is NOT effective; may be harmful–no benefit
Classification of recommendation level of evidence: A
-Data from meta-analysis or multiple randomized clinical trials; multiple populations evaluated
Classification of recommendation level of evidence: B
-Data from single randomized trial or non-randomized studies; limited population evaluated
-Data from single randomized trial or non-randomized studies; limited population evaluated: C
-Only consensus of opinion of experts, case studies, or standard of care, very limited populations evaluated
Pharmacological treatment of heart failure
- ACE inhibitors or ARB
- Beta blockers
- Diuretics
- Spironolactone
- Digitalis
- IV ionotropes
- Hydralazine
- Nitrates
- CCB
- Sacubitril–valsartan Ivabradine
ACE inhibitors
- Block conversion of ANg1 to Ang II
- Useful for ALL NYHA functional classifications with SYSTOLIC heart failure
- Lower mortality and morbidity by 20% supported by several good drug trials
- Useful in preventing HF in high risk patients (ASHD, MD, HT) level of evidence A
- Recommend in patients with symptoms of HF, reduced EF, unless contraindicated: L of E: A
Use ACEI cautiously when
-renal insufficiency is present (creatinine greater than 2.5mg) or potassium greater than 5
ACEI absolute contraindications
- Pregnancy!!
- Angioedema
- Bilateral RAS (renal artery stenosis)
Side effect of ACEI
-cough
ACE vs ARB efficacy
- ARB is equivalent to ACE but not any better than ACE
- usually change from ACE due to cough
- ARB blocks AT1 and AT2
- ARB blocks AII at receptor without inhibiting kininase so don’t get cough because there is no accumulation of kinins that is present with ACEI
Don’t give ARB if
Patient had angioedema from ACE!
Beta blockers
- Survival benefit in chronic systolic HF and dilated cardiomyopathy
- Slow progression of disease and decrease hospitalization
- Improve cardiac performance and symptoms of HF
Beta blockers hemodynamics include
- Decrease heart rate
- Antiarrythmic properties
- Anti ischemic
- Blunts SNS effects of NE
- Reverse remodeling
Beta blockers clinical trials
- show decrease mortality
- CIBIS II (cardiac insufficiency Bisoprolol study)
US carvedilol HF program showed
- imporved LVEF and well being
- Coreg, alpha1, beta1, beta2 receptor with vasodilator property and antioxidant
Don’t use beta blockers in
-ustable patients (class IV heart failure!)
Beta blockers recommended for
- all stable patients with symptoms of HF, reduced EF, unless contraindicated
- Level of evidence: A!!
- Use in patients with NYHA class II and III
Diuretics uses
- to relieve congestive (pulmonary) symptoms by reducing preload
- Increase cardiac function
- Promote natriuresis, urinary Na excretion
- Inhibits NaCl resorption from AL or LOW
- best for pulmonary congestion
Diuretics increases risk of
-arrhythmia deaths without K+ sparing
Which diuretic works at AL of LOH?
- Lasix (furosemide)
- Bumex (bumetanide)
- Demadex (torsemide)
Which diuretic works at Distal Tubule?
- Metozalone
- Thiazide
Which diuretic works on Late DT?
-Spirinolactone
Dosage for Lasix drugs
- 10mg IV/hr or 40 mg IV every 8-12 hours
- Watch K, Mg, Na, BUN, creatinine
Digitalis
- Lanoxin
- Ionotropic agent DIG
- Improves quality of life associated with HF but no effect on survival
Digitalis MOA
- inhibits Na/K/ATPase
- increases contractile state by increasing intracellular calcium concentration
- Useful in atrial fibrillation to slow ventricular rate
Spironolactone
- Antagonizes effects of aldosterone
- Use in addition to standard care (ACE, BB, diuretic,dig)
- RALES study: 12.5-25 mg/day in Class III-IV patients–30% reduction in mortality
- Watch K closely if GFR is less than 30 cc/min or creatinine is greater than 1.6 mg/dl
- Level of evidence: B!!
New aldosterone antagonist
- eplerenone
- Watch K!!
African american patients do not utilize what drug component very well? so use what?
- Nitric oxide
- so use arterial vasodilators because they respond to these better to enhance NO utilization and also use venodilators
Ionotropes
- Increases contractility
- Dobutamine (Dobutrex): stimulating beta1 and beta2 receptors
- Milrinone: inotropic vasodilator, inhibits PDE
Dopamine
- Stimulates beta1 receptor
- 2-10 ug/kg/min
- Higher doses stimulate alpha receptors
- Useful short term
Hydralazine
Arterial vasodilator, reduces after load and SVR
Nitrates
Vasodilator to reduce preload or reduce venous return to increase CO
Hydrazine+Nitrate added to diuretics and dig may
- reduce mortality
- Increase EF
- Increase exercise tolerance
- Combination especially helpful in african american patients
Hydrazine plus isosorbide dinitrate/mononitrate
- Better response to hydrazine and isosorbide in African americans than in whites
- Nitroprusside
- Vasodilator–monitor BP closely!!
Hemodynamic effects of nitrates
- Venous vasodilation–decreased preload–>decreased pulmonary congestion, decreased ventricular size, decreased ventricular wall stress, decreased MVO2
- Coronary vasodilation: increased myocardial perfusion
- Arterial vasodilation: decreased afterload–>decreased CO, decreased BP
Calcium channel blockers
- Class III
- No benefit
- Not recommended as routine
- Treatment for patients with HF associated with reduced EF
Role of OMM in HF
- Lymph treatment
- Open thoracic inlet to decrease flow fascial restriction to allow better lymphatic
- If blocked will not have optimal fluid drainage
- ALways do this before (and after) lymph Tx so mobilized fluid has place in drain
- Rib raising: helps open chest cage for more optimal breathing efforts; mobilizes fluid
- Diaphragm doming: as effective as LE exercise for fluid movement
systolic murmur over base of heart indicates what kind of valvular disease
-Aortic stenosis
