Week 238 - Heart Failure Mx

Question 1

List the 2 main symptom relieving drugs used in heart failure

Answer 1

> Diuretics

> Digoxin

Question 2

How does Digoxin work?

Answer 2

Increases contractility force (by increasing calcium movement into myocardium)
Slows electrical conduction through the AV node to slow HR

Question 3

Give common indications and one contraindication for digoxin

Answer 3

Rapid atrial rhythms e.g. AF, atrial flutter, Atrial tachycardia
Contraindicated in heart block

Question 4

How do ACEIs work?

Answer 4

Reduce the conversion of angiotensin I to II by blocking ACE produced by the lungs.
Inhibit breakdown of Bradykinin (an inflammatory mediator) we in causes vascular dilatation to increase blood flow
Increases preload and afterload!

Question 5

What is special about Captopril besides being the very first ACEI?

Answer 5

The only ACEI used in paediatrics now

Question 6

Give at least 3 contraindications for ACEIs

Answer 6

• cough
• hypotension
• aortic or mitral stenosis
• bilateral renal artery stenosis
• creatinine >220
• pregnancy. - hereditary/idiopathic angioedema

Question 7

What stimulates renin release from the kidneys?

Answer 7

Reduced blood flow through renal arteries

Question 8

Where in the kidneys is renin released from?

Answer 8

Juxtaglomerular apparatus

Question 9

List 2 indications for ACEIs besides HF

Answer 9

1st line anti-hypertensive >55

Reduced proteinuria

Question 10

Define the term preload

Answer 10

Tension on the myocardium (heart walls) when filled with blood I.e. End diastole

Question 11

Define the term afterload

Answer 11

Tension/stress on the heart walls during contraction

Question 12

What must you monitor 7-10 days after starting ACEIs?

Answer 12

Renal function (U&Es) as if creatinine raises too high (>~300) must stop

Question 13

Which two Angiotensin II Antagonists (ARBs) have most evidence for benefit in HF?

Answer 13

Candesartan

Valsartan

Question 14

What 4 other meds is an ARB usually added to in HF and what does it add therapeutically to the mix?

Answer 14

ACEIs, diuretics, digoxin and beta-blockers

It is cardioprotective

Question 15

What is the most commonly used mineralcorticoid receptor blocker /aldosterone antagonist in HF?

Answer 15

Spironalactone

Question 16

What adverse effect can Spironalactone (and digoxin) have in men and how can it be reduced?

Answer 16

Gynaecomastia and breast pain due to the steroid nucleus (pharmacologically)
Eplerenone has less effect in this respect

Question 17

How do beta blockers act?

Answer 17

By reducing vasoconstriction (they effect beta-adrenoceptors have in peripheral vessels)

Question 18

Which beta blockers have most evidence of benefit?

Answer 18

Bisoprolol
Carvedilol
Metoprolol
Nebivilol

Question 19

In what circumstance is labetalol particularly indicated?

Answer 19

Reducing HTN in pregnancy (acts as both alpha and beta adrenoceptor blocker)

Question 20

List at least 3 contraindications for beta-blockers

Answer 20

Asthma (and severe COPD)
Cardiac conduction defects (e.g. Heart block as with digoxin)
Severe HF
Severe peripheral vascular disease
Raynaud's Disease

Question 21

How does Ivabradine work?

Answer 21

Slows heart rate in sinus rhythm (NOT AF) by inhibiting If “funny” channel in sinus node
By slowing the HR is reduces the oxygen demand on the myocardium (used in angina Tx also)

Question 22

What class of drug is the only one that can be prescribed in diastolic heart failure with any confidence?

Answer 22

Diuretics

Question 23

How does Spironalactone act?

Answer 23

It’s a potassium sparing diuretic

Question 24

List the main disease-modifying pharmacological treatments used in the management of (systolic) heart failure

Answer 24

ACEIs
Angiotensin II Receptor Blockers/antagonists (ARBs)
Beta-Blockers
Mineralcorticoid Receptor Antagonists
Ivabradine

Question 25

Name 2 novel anticoagulants used in the prevention of thrombosis in AF instead of warfarin. What is the the major advantage over warfarin?

Answer 25

Rivaroxaban Dabigatran Advantage: monitoring of INR is unecessary

Question 26

What are the two most important medications to put someone on newly diagnosed with LVF i.e. Have prognostic benefit?

Answer 26

ACEIs and Beta-Blockers (Only need to add diuretics / digoxin when relevant Sx present e.g. Swelling and rapid or rapid and irregular atrial rhythms)

Question 27

What two important pieces of advice / information must you discuss with patients newly started on HF medications?

Answer 27

To come back if any adverse side effects appear e.g. Hypotension, cough Inform them that they will unlikely notice any/much benefit once the medications are started but that they are intended to benefit them long term

Question 28

Which 2 loop diuretics are used in LVHF?

Answer 28

Furosemide and Bumetanide

Question 29

If symptoms persist after introduction of ACEIs or ARBs and beta-blockers (ignoring loop diuretics) what other medications might a specialist add to the prescription?

Answer 29

Spironalactone Isosorbide mono- or dinitrate and hydralazine Ivabradine or Digoxin (depending on whether or not in sinus rhythm)

Question 30

Besides reducing oedema how does furosemide act?

Answer 30

As a vasodilator

Question 31

Which type of diuretic are used mainly in HF in the UK?

Answer 31

Loop (furosemide and Bumetanide) Thiazide diuretics used more in controlling HTN

Question 32

Where do Loop and Thiazides diuretic act respectively?

Answer 32

Loop - loop of Henle Thiazides distal convoluted tubule (Both act to reduced sodium resorption)

Question 33

Give 4 side effects of thiazide diuretics?

Answer 33

``` Electrolyte disturbance (low sodium and potassium Na/K transporter) Gout (high urate) Hyperglycaemia Deranged lipids (Loop low K too but not as severely) ```

Question 34

If thiazides (or thiazide related meds) are used in HF which do NICE recommend?

Answer 34

Chlortalidone (non-thiazide) -longer duration of action Indapamide - less metabolic disturbance Bendroflumethiazide only if pt already on

Question 35

How do opiates such as diamorphine and morphine help in the management of Acute LVF?

Answer 35

Acute LVF can be very frightening and is an medical emergency Diamorphine / Morphine can be used to reduce anxiety and alleviate respiratory distress

Question 36

What are the key elements in the management of Acute LVF?

Answer 36

Oxygen - beware, too much O2 can vasoconstrict & complicate Monitor: Sats, BP, Heart rhythm, urine output Meds: diamorphine, antiemetics (metoclopramide), furosemide, nitrates (GTN or isosorbide dinitrate) ALL iv