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Cardiology > Tx of CHF > Flashcards

Tx of CHF Flashcards

1
Q

Nesiritide

A

B-type Natriuretic peptide for CHF

  • used when PT is refractory to nitroglycerin
  • Veno- and Vasodilation!
  • increases GFR
  • suppresses RAAS and sympathetic NS
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2
Q

Advantages of ACE Inhibitors?

A
  • decrease mortality post MI
  • Preserve renal function in diabetics
  • no effect on lipids or sexual function

*For CHF - prevent cardiac and vascular fibrosis and remodeling

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3
Q

Potassium-sparing diuretics commonly used in combo w/ loop diuretics

A
  1. Spironolactone (Aldo inhibitor)
  2. eplerenone (Aldo inhibitor)
  3. Triamterene and Amiloride (Not used in CHF)
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4
Q

Adverse effects of ACE Inibitors

A
  1. Hypotension
  2. Na+ depletion
  3. Dry cough
  4. Hyperkalemia
  5. Angioedema
  6. renal insufficiency
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5
Q

Pharmalogical effect of ACE Inhibitors

A

Prevent conversion of ATI to Angiotension II:

  • Natriuresis (excretion of Na+ and water)
  • decrease TPR
  • decrease alosterone, and further Na+ excretion
  • increase bradykinin levels (prevents breakdown)
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6
Q

Effect of Natruretic peptides in CHF

A

Promote vasodilation, venodilation, and natriuresis

  • reduce preload
  • counter balance RAAS
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7
Q

How is digoxin therapy monitored?

A

Monitor plasma levels and clinical presentation to guide therapy

*Because digoxin has so much variability between individuals

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8
Q

Tx for PT w/ dyspnea on moderate/minimal exertion, orthopnea (supine dyspnea), Paroxysmal nocturnal dyspnea (PND) and edema?

A

(Stage C)

  1. ACE I/ ARB
  2. Diuretic
  3. Digoxin
  4. Beta-Blocker
  5. Spironolactone
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9
Q

Name the diuretics discussed in lecture (7)

A
  1. Furosemide
  2. Bumetanide
  3. Spironolactone
  4. Eplerenone
  5. Triamterene
  6. Amiloride
  7. Metolozone
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10
Q

T or F: Diuretics improve survival and or prognosis

A

FALSE!

Diuretics do NOT improve survival or prognosis (except for spironolactone and eplerenone- via blocking aldosterone)

*ACE inhibitors do

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11
Q

Effect of direct arterial vasodilators in CHF

A

Reduces afterload (TPR) to increase ventricular (cardiac) output

*need to combine arterial vasodilators with venodilator to reduce both preload and afterload

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12
Q

What are commonly used “high Ceiling” diuretics?

A
  1. Furosemide (loop-type)

2. Bumetanide (loop-type)

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13
Q

Side Effects of Angiotensin Receptor Antagonists (ARBs)?

A
  1. First dose hypotension
  2. Hyperkalemia
  3. Hepatic dysfunction
  4. FETOTOXICITY
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14
Q

Beta Blockers approved for CHF

A
  1. Metroprolol
  2. Carvedilol
  3. Bisoprolol
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15
Q

Drugs that interact with digoxin

A
  1. Quinidine (via decreasing elimination)
  2. Amiodarone (Via decreasing elimination)
  3. Verapamil (slows HR and digoxin tox)
  4. Diuretics (increase potential for arrhythmias due to hypokalemia)
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16
Q

Milrinone

A

Phosphodiesterase inhibitor

*Short term IV use only!
(long term PO use increases mortality in CHF)
* Doesn’t cause receptor desensitization like dobutamine but still can cause arrhythmias.

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17
Q

Adverse effects of Digoxin

A
  1. Atrial and Ventricular Arrhthmias
  2. Visual changes (blurry, yellow-green halo)
  3. Headache
  4. Fatigue, drowsiness, confusion
  5. Seizures
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18
Q

Toxicity (adverse effects) associated with hydralazine

A
  1. Nausea
  2. Anorexia
  3. Drug-induced lupus (+FANA)
  4. Exacerbation of Angina
19
Q

Drugs used to manage advanced CHF

A
  1. Nitrates (Nitrogylceryn, Nitroprusside)
  2. IV Inotropic agents
    - Beta-agonists (Dobutamine)
    - PDE inhibitors (Milrinone)
  3. Nesirtide (B-type natriuretic peptide)
  4. Cardiac transplantation/extracorpeal bridging devices
20
Q

Tx for PT at rest w/ advanced CHF

A

(Stage D)

  1. ACE I/ ARB
  2. Diuretic (combinations)
  3. Digoxin
  4. Spironolactone
  5. Short-term inotropic therapy
  6. Transplantation
  • no beta-blocker
21
Q

Disadvantages of Hydralazine

A
  1. Variability in effective dose

2. Stimulates RAAS (-> peripheral edema, circulatory congestion)

22
Q

Contraindications for ACE inhibitors?

A

Fetotoxicity: Do not give to pregnant women, those expecting to conceive, or those breastfeeding

23
Q

Effect of spironolactone and eplerenone

A

Aldosterone inhibitors

24
Q

Combination diuretic therapy for CHF

A
  1. Loop diuretic + Metolozone (thiazide)

2. Loop diuretic + Spironolactone

25
Q

Dobutamine

A

Beta-agonist (b1>b2 + a1)

  • Short term “bridge” use due to desensitization and arrhythmias
  • use w/ b-blocker can cause vasoconstriction! (due to unopposed a1 agonist effect)
26
Q

MOA for Digoxin

A

Increases intracellular availability of Ca2+ by inhibiting Na/K+ ATPase

-increased intracellular Na+ regulates 2 different Na+/Ca2+ exchangers

**positive inotropic effect (increases CO at any level of preload)

27
Q

Adverse effects of diuretics

A
  1. Electrolyte imbalances
  2. hypokalemia
  3. hyponatremia (low sodium)
  4. dehydration
  5. Hypotension
  6. Ototoxicity (hearing loss w/ loop diuretics)
28
Q

Name a vasodilator that acts directly on arterial smooth muscle and that is effective in CHF

A

Hydralazine

29
Q

Drug interactions w/ diuretics

A

NSAIDS

  • reduce efficacy of diuretics by promoting fluid retention
30
Q

Drug used to neutralize serum digoxin in life-threatening toxicities?

A

Digibind

*an Antibody for digoxin! (used in emergency situations)

31
Q

Effect of diuretics

A

Promote Na+ and water excretion

  • Reduce edema and pulmonary congestion
  • Reduce preload

*Cardiac output NOT increased

32
Q

Beta blocker approved for HTN but not for CHF due to it’s extended action?

A

Nebivolol

  • it potentiates NO in vasculature
33
Q

Which is better in CHF; ACE I or ARB?

A

Currently ACE inhibitors are preferred unless PT can’t tolerate side effects

34
Q

T or F: ACE I and ARBs also have diuretic effects

A

T

  • the effect may not be enough to prevent edema
  • adjust dose of diuretic when used in conjunction with these to prevent azotemia (increased blood-nitrogen levels)
35
Q

Additional effect of Spironolactone and eplerenone

A

Prevent the mitogenic and fibrogenic effects of myocardium that cause worsened LV function

  • block aldosterone which has these effects
36
Q

Who responds less favorably to ACE inhibitors?

A

African Americans and Volume-dependent hypertensives (low-renin)

*use thiazide and ACEI to increase effectiveness

37
Q

Tx for PTs at risk for CHF

A

(Stage A - At risk)

  1. Preventative measures (HTN, lipids, smoking, no alcohol)
  2. ACE I/ARB and Beta-Blocker
38
Q

Tx for asymptomatic PT w/ a low ejection fraction

A

(Stage B)

  1. Diuretic
  2. ACE I/ARB
  3. Beta-Blocker
39
Q

T or F: Digoxin will relieve the congestive symptoms seen in CHF

A

False

Digoxin alone will not.
- Digoxin in combination with vasodilator and Diuretic will.

40
Q

When are the effects of digoxin best seen in CHF patients?

A

In late stage

(Digoxin works best when EF

41
Q

Current paradigm for treating CHF

A

Focused on inhibiting hormones that cause a decline in cardiac function

  • I.e. EARLY tx w/ ACEI/ARB, Aldosterone antagonists, and Beta-blockers
42
Q

Why are ACEI and ARBs used so early (I.e. before symptomatic) in CHF patients

A

To prevent cardiac and vasculature fibrosis and remodeling responsible for the progression in disease.

  • includes hypertrophy and athersclerosis
43
Q

How do Beta-blockers paradoxically help tx CHF?

A

They reduce the deleterious effects of chronic high levels of sympathetic activity

  • I.e. they reduce:
  • B-receptor down regulation
  • arrhythmias
  • increased O2 consumption/ischemia

Cardiology (15 decks)

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