- prils (lisinopril, enalapril, benazepril)

Treatment of HF Flashcards by A B

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

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Purpose of diuretics

Reverse fluid rentention (Na loss)

most common HF therapy

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Dosing of diuretics

Used chronically + acutely
PO at baseline
IV in hospital (higher dose for renal problem)

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Side effects of diuretics

dehydration
hypokalemia
sulfa
tinnitus

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loop diuretics

furosemide
torsemide
bumetanide

non-sulfa = ethacrinic acid

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Mechanism of diuretics

1) incr salt + water excretion
2) decr intravasc fluid volume
3) decr venous congestion
4) decr dyspnea/edema

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Effect of diuretics on Starling curve

slight decr in SV for LV end diastolic presure

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Furosemide vs. Bumetanide vs. Torsemide

location of metabolism

furo= renal
bumet = hepatic
torsemide = hepatic

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ACE inhibitors

prils (lisinopril, enalapril, benazepril)

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what do ACE inhibitors do?

inhibit ACE (block AT1 to ATII)

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Effects of ACE inhibitors

1) direct vasodilation

2) decr aldosterone activation

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Side effects of ACE inhibitors

1) hypotension
2) worsening renal function (afferent vasconstriction)
3) hyperkalemia
4) cough (kinin)
5) angioedema

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ARB = angiotensin receptor blockers

sartans (valsartan, candesartan, losartan)

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what do ARB do?

block receptor of angiotensin II

vasodilation
salt/water excretion
K+ retention

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ARBs equivalent to ___

ACE inhibitor

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When do you choose ARB vs. ACE inhibitors

when patients develop cough to ACE inhibitor

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side effects of ARBs

similar to ACE inhibitor BUT NO COUGH

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Neprilysin inhibitor

New drug = valsartan (ARB)+ socubutril

superior to enalapril (ACE inhibitors)

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Names of mineraocorticoid receptor antagonists

spironolactone

eplernone

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function of MRA

block aldosterone receptor

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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