Treatment of HF Flashcards
Goals of HF treatment
1) Correct underling cause of HF (revascularization for ischemia)
2) Eliminate precipitating factor (infection/anemia)
3) reduce congestion
4) improve blood flow- modulate neurohormonal or devices
Purpose of diuretics
Reverse fluid rentention (Na loss)
most common HF therapy
Dosing of diuretics
Used chronically + acutely
PO at baseline
IV in hospital (higher dose for renal problem)
Side effects of diuretics
dehydration
hypokalemia
sulfa
tinnitus
loop diuretics
furosemide
torsemide
bumetanide
non-sulfa = ethacrinic acid
Mechanism of diuretics
1) incr salt + water excretion
2) decr intravasc fluid volume
3) decr venous congestion
4) decr dyspnea/edema
Effect of diuretics on Starling curve
slight decr in SV for LV end diastolic presure
Furosemide vs. Bumetanide vs. Torsemide
location of metabolism
furo= renal bumet = hepatic torsemide = hepatic
ACE inhibitors
- prils (lisinopril, enalapril, benazepril)
what do ACE inhibitors do?
inhibit ACE (block AT1 to ATII)
Effects of ACE inhibitors
1) direct vasodilation
2) decr aldosterone activation
Side effects of ACE inhibitors
1) hypotension
2) worsening renal function (afferent vasconstriction)
3) hyperkalemia
4) cough (kinin)
5) angioedema
ARB = angiotensin receptor blockers
- sartans (valsartan, candesartan, losartan)
what do ARB do?
block receptor of angiotensin II
vasodilation
salt/water excretion
K+ retention
ARBs equivalent to ___
ACE inhibitor
When do you choose ARB vs. ACE inhibitors
when patients develop cough to ACE inhibitor
side effects of ARBs
similar to ACE inhibitor BUT NO COUGH
Neprilysin inhibitor
New drug = valsartan (ARB)+ socubutril
superior to enalapril (ACE inhibitors)
Names of mineraocorticoid receptor antagonists
spironolactone
eplernone
function of MRA
block aldosterone receptor
Side effects of MRA
hyperkalemia (K+ retention)
gynecomastia (spironolactone only)
Beta blockers name
-olols (metoprol, carvedilol, bisoprolol)
effect of beta blockers
antagonize effects of sympathetic system (NE/epi)
blocks beta1 and a1 receptor
decr HR, decr arrhythmia, decr metab demand
Side effects of beta blockers
1) negative inotrope (short term loss for long-term gain)
- fluid retention
- hypotension
- decr CO –> cardiogenic shock
2) bronchoconstriction by blocking beta2
which type of beta blockers to use for asthma
specific beta1 blockers
3 major drugs for heart failure
1) ACE inhibitor
2) Beta blockers
3) angiotensin receptor blockers
why use vasodilators for HF?
1) arterial vasodilation (antihypertensives)
- decr LV afterload
- decr cardiac work
- less mitral regurg
2) venous vasodilation
- decr preload
3) pulm arterial vasodilation
- decr RV afterload
Which GDMT drug plan for NYHA class 1?
1) ACE inhibitor or ARB
2) Beta blocker
Which GDMT drug plan for volume overload, NYHA Class 2-4
1) ACE inhibitor or ARB
2) Beta blocker
3) Loop diuretics
Which GDMT plan for african americans, NYHA Class 3-4
1) ACE inhibitor or ARB
2) Beta blocker
3) Hydral isosorbide dinitrate
Which GDMT for class 2-4 with creatinine >30 mL/min and K+ < 5.0 mEq/dL
1) ACE inhibitor or ARB
2) Beta blocker
3) aldosterone antagonist
when do you use ICD?
1) patients with LVEF <35% or prior dangerous arrhythmia
what is the purpose of ICD?
abort sudden cardiac death from v-tach or v-fib
What is a biventricular pacemaker
Leads attach to
1) RA
2) Septum
3) lateral wall of LV
when do you use biventricular pacemaker
for patients with QRS > 120 msec (BBB)
causes LV wall and septum to contract together to incr SV
What drugs do you use for chronic HFrEF to improve symptoms?
1) diuretics (furosemide)
2) digitalis (HFrEF with shock- dobutramine, milronone)
What treatments do you use for chronic HFrEF to prolong survival
1) ACE inhibitors/ ARB
2) Beta blockers
3) Aldosterone receptor antagonists
4) other vasodilators (hydralazine + nitrate)
5) biventricular pacer (CRT)
6) ICD
If patient comes in warm and wet how do you treat them?
1) dry out with diuretic to decr congestion
2) +/- vasodilate
if patient comes in cold and wet how do you treat them?
1) warm up (inotrope) –> incr ejection fraction
2) dry out with diuretic
3) +/- vasodilate
if patient comes in cold and dry how do you treat them?
bad situation
LVAD
transplant
hospice
How do you treat acute HF?
1) IV diuretics
2) IV vasodilators (nitrates if BP allows)
3) Positive pressure (CPAP/BiPAP) for hypoxia (also reduce preload)
4) IV inotropes for shock only
What are positive inotropic agents?
1) digoxin (PO) K+/Na+ blocker
2) Dobutamine (IV) - beta agonist
3) milrinone (IV) PDE inhibitor (simil to dobutamine)
when do you use positive inotropic agents?
acute = reverse shock (long term worsen remodeling)
chronic = Digoxin has no effect on mortality but decr symptoms and hospitalization (decr HR in AFib
Effect of positive inotropic agents on Starling curve
shift upward,
incr HR incr SV incr CO
improve shorterm
For asymptomatic HF what do you use
ACE inhibitor/ARB
Beta blocker
for chronic stable HF what do you use
guideline therapy for HFrEF stable
for acute HF what do you use
decr beta blocker or stop it
for end stage heart failure options?
1) transplant
2) LVAD
3) inotrope infusion - hasten death
4) hospice
how to treat HFpEF chronic
1) treat undelrying disorder (HTN, diabetes, renal)
2) diuretics to keep volume normal (Na retention common)
3) vasodilators to maintain normal BP
how to treat HFpEF acute
1) IV diuresis
2) nitrates (if BP allows)
3) CPAP/BiPAP
