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Cardiovascular II Final Exam > Treatment of Heart Failure Part 2 (Johnston) > Flashcards

Treatment of Heart Failure Part 2 (Johnston) Flashcards

1
Q

Five basic principles of Heart Failure

A
  • 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
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2
Q

Indications for admission to Hospital for Management of Heart Failure

A
  • Acute myocardial ischemia
  • Severe respiratory distress
  • Hypoxia
  • Hypotension
  • Cardiogenic shock
  • Anasarca–fluids accumulating everywhere
  • Syncope
  • Heart failure refractory to oral medications
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3
Q

Treatment of Heart Failure–non pharmacologic

A
  • Quit smoking
  • If overweight, decrease calorie intake, AHA diet, diet instructions by dietician to patient and spouse
  • 2g Na diet
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4
Q

Other treatment for heart failure

A
  • 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
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5
Q

Treatment and counseling before discharge from hospital

A
  • 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
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6
Q

2nd ICS LSB diastolic murmur indicates what kind of valvular disease?

A

-Aortic regurgitation

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7
Q

Options for treatment for hypotension/syncope for someone who is taking ARB, beta blocker and lasix

A

-Hold diuretics and reduce dose of ARB and beta blocker

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8
Q

CO=

A

SV x HR

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9
Q

Stroke volume is modulated by

A
  • Preload
  • Afterload
  • Contractility
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10
Q

Conventional treatment for acute heart failure

A
  • Decrease Diuretics–reduce fluid volume
  • Decrease Vasodilators–decrease preload and/or after load
  • Increase Ionotropes–augment contractility
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11
Q

Classification of recommendation–Evidence based medicine–Class I

A

-Evidence and/or agreement that therapy is beneficial, useful and/or effective; benefit 3+ risk

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12
Q

Classification of recommendation–Evidence based medicine–Class II (IIa vs IIb)

A
  • 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
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13
Q

Classification of recommendation–Evidence based medicine class III

A

-Evidence and/or agreement that therapy/prodcedure is NOT effective; may be harmful–no benefit

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14
Q

Classification of recommendation level of evidence: A

A

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

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15
Q

Classification of recommendation level of evidence: B

A

-Data from single randomized trial or non-randomized studies; limited population evaluated

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16
Q

-Data from single randomized trial or non-randomized studies; limited population evaluated: C

A

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

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17
Q

Pharmacological treatment of heart failure

A
  • ACE inhibitors or ARB
  • Beta blockers
  • Diuretics
  • Spironolactone
  • Digitalis
  • IV ionotropes
  • Hydralazine
  • Nitrates
  • CCB
  • Sacubitril–valsartan Ivabradine
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18
Q

ACE inhibitors

A
  • 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
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19
Q

Use ACEI cautiously when

A

-renal insufficiency is present (creatinine greater than 2.5mg) or potassium greater than 5

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20
Q

ACEI absolute contraindications

A
  • Pregnancy!!
  • Angioedema
  • Bilateral RAS (renal artery stenosis)
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21
Q

Side effect of ACEI

A

-cough

22
Q

ACE vs ARB efficacy

A
  • 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
23
Q

Don’t give ARB if

A

Patient had angioedema from ACE!

24
Q

Beta blockers

A
  • Survival benefit in chronic systolic HF and dilated cardiomyopathy
  • Slow progression of disease and decrease hospitalization
  • Improve cardiac performance and symptoms of HF
25
Q

Beta blockers hemodynamics include

A
  • Decrease heart rate
  • Antiarrythmic properties
  • Anti ischemic
  • Blunts SNS effects of NE
  • Reverse remodeling
26
Q

Beta blockers clinical trials

A
  • show decrease mortality

- CIBIS II (cardiac insufficiency Bisoprolol study)

27
Q

US carvedilol HF program showed

A
  • imporved LVEF and well being

- Coreg, alpha1, beta1, beta2 receptor with vasodilator property and antioxidant

28
Q

Don’t use beta blockers in

A

-ustable patients (class IV heart failure!)

29
Q

Beta blockers recommended for

A
  • all stable patients with symptoms of HF, reduced EF, unless contraindicated
  • Level of evidence: A!!
  • Use in patients with NYHA class II and III
30
Q

Diuretics uses

A
  • 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
31
Q

Diuretics increases risk of

A

-arrhythmia deaths without K+ sparing

32
Q

Which diuretic works at AL of LOH?

A
  • Lasix (furosemide)
  • Bumex (bumetanide)
  • Demadex (torsemide)
33
Q

Which diuretic works at Distal Tubule?

A
  • Metozalone

- Thiazide

34
Q

Which diuretic works on Late DT?

A

-Spirinolactone

35
Q

Dosage for Lasix drugs

A
  • 10mg IV/hr or 40 mg IV every 8-12 hours

- Watch K, Mg, Na, BUN, creatinine

36
Q

Digitalis

A
  • Lanoxin
  • Ionotropic agent DIG
  • Improves quality of life associated with HF but no effect on survival
37
Q

Digitalis MOA

A
  • inhibits Na/K/ATPase
  • increases contractile state by increasing intracellular calcium concentration
  • Useful in atrial fibrillation to slow ventricular rate
38
Q

Spironolactone

A
  • 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!!
39
Q

New aldosterone antagonist

A
  • eplerenone

- Watch K!!

40
Q

African american patients do not utilize what drug component very well? so use what?

A
  • Nitric oxide

- so use arterial vasodilators because they respond to these better to enhance NO utilization and also use venodilators

41
Q

Ionotropes

A
  • Increases contractility
  • Dobutamine (Dobutrex): stimulating beta1 and beta2 receptors
  • Milrinone: inotropic vasodilator, inhibits PDE
42
Q

Dopamine

A
  • Stimulates beta1 receptor
  • 2-10 ug/kg/min
  • Higher doses stimulate alpha receptors
  • Useful short term
43
Q

Hydralazine

A

Arterial vasodilator, reduces after load and SVR

44
Q

Nitrates

A

Vasodilator to reduce preload or reduce venous return to increase CO

45
Q

Hydrazine+Nitrate added to diuretics and dig may

A
  • reduce mortality
  • Increase EF
  • Increase exercise tolerance
    • Combination especially helpful in african american patients
46
Q

Hydrazine plus isosorbide dinitrate/mononitrate

A
  • Better response to hydrazine and isosorbide in African americans than in whites
  • Nitroprusside
  • Vasodilator–monitor BP closely!!
47
Q

Hemodynamic effects of nitrates

A
  • 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
48
Q

Calcium channel blockers

A
  • Class III
  • No benefit
  • Not recommended as routine
  • Treatment for patients with HF associated with reduced EF
49
Q

Role of OMM in HF

A
  • 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
50
Q

systolic murmur over base of heart indicates what kind of valvular disease

A

-Aortic stenosis

Cardiovascular II Final Exam (13 decks)

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