3. Heart Failure Flashcards
1
Q
What is the simple definition of heart failure?
A
The inability of the heart to meet metabolic demands of the body.
2
Q
What is the function of the heart?
A
Pump oxygenated blood to the body and itself.
3
Q
What is normal cardiac output?
A
5-7 L/min
4
Q
What determines cardiac output?
A
CO = HR x SV
5
Q
What factors influence stroke volume?
A
- preload
- contractility
- afterload
6
Q
What is preload?
A
The amount of blood in the ventricle at the end of diastole.
7
Q
How is preload measured?
A
pulmonary capillary wedge pressure (PCWP)
8
Q
What is contractility?
A
The myocardium’s inherent ability to develop force and/or shorten independent of preload and afterload.
9
Q
How is contractility measured?
A
ejection fraction (EF)
10
Q
What is afterload?
A
The force which the ventricle has to work against to eject blood.
11
Q
How is afterload measured?
A
systemic vascular resistance (SVR)
12
Q
What does HFpEF stand for?
A
Heart failure with preserved ejection fraction
13
Q
What is HFpEF?
A
The inability of the heart to fill due to stiff ventricle.
14
Q
In HFpEF the compliance or relaxation of the ventricle is decreased. (T/F)
A
True
15
Q
What does HFrEF stand for?
A
Heart failure with reduced ejection fraction
16
Q
What is HFrEF?
A
The inability of the heart to contract or empty.
17
Q
What percentage is the threshold for determining reduced ejection fraction?
A
EF < 40%
18
Q
What is the most common cause of heart failure?
A
Myocardial ischemia and infarction
19
Q
With the exception of _______ or _______ _______, treatments of HF are targeted at decreasing morbidity and delay mortality.
A
- transplant
- mechanical support
20
Q
Early on compensatory mechanisms help increase ___ but ______ underlying disease.
A
- CO
- worsens
21
Q
The initial failure in LV performance __ wall stress. (↑/↓)
A
↑ wall stress
22
Q
What symptoms define functional class I HF?
A
No limitations of physical activity.
23
Q
What symptoms define functional class II HF?
A
Slight limitations of physical activity (on exertion)
24
Q
What symptoms define functional class III HF?
A
Marked limitations of physical activity (activities of daily living)
25
What symptoms define functional class IV HF?
Symptoms present at rest.
26
What are some non-pharmacological therapies?
- reduce salt intake
- fluid restriction
- weight loss for obese patients
- exercise training/ cardiac rehab
27
What medication decreases preload and/or afterload?
vasodilators
28
What are the vasodilators used in HF?
- ACE-I
- ARBs
- ARNI
- Hydralazine + ISDN
29
What medications are used to decrease SNS stimulation and/or lower HR?
SNS blockade
- beta blocker
- Ivabradine
30
What medications are used to reduce fluid volume?
diuretics
31
What diuretics are used in HF?
- Loop diuretics
| - spironolactone
32
What are contraindications of ACE-I?
- angioedema
- Anuric renal failure
- pregnancy
- bilateral renal artery stenosis
- K > 5.5
33
What are some ADRs of ACE-I?
- hypotension
- angioedema
- ↑ SCr
- rash
- cough
- neutropenia
- K retention
- dysgeusia
34
Which ACE-I are not prodrugs?
captopril or lisinopril
35
Food __ bioavailability of captopril. (↑/↓)
↓ bioavailability
36
ACE-I should be initiated at a ___ dose. (↑/↓)
↓ low dose
37
What labs should be monitored when starting an ACE-I?
- SCr
| - K+
38
What ACE-Is are good for liver dysfunction?
captopril or lisinopril
39
What are ADRs of ARBs?
- ↓ BP
- ↑ SCr
- rash
- ↑ K+
- angioedema
40
Why might a HF patient need an ARB?
Alternative to ACE-I in patients who are intolerant. (cough)
41
What is hydralazine?
A direct arterial vasodilator.
42
Hydralazine is a(n) ______ reducer.
afterload
43
What class(es) of HF is hydralazine commonly used in?
NYHA Class II-III
44
Hydralazine is used in combination with what?
nitrates
45
Why is hydralazine used in combination with nitrates?
prevents nitrate tolerance
46
What are the ADRs of hydralazine?
- ↓ BP
- NV
-
- HA
- "cardiac steal"
47
Short acting nitrates are used for HF patients. (T/F)
False: long acting
48
What are the long acting nitrate agents used in HF?
- isosorbide dinitrate
| - isosorbide mononitrate
49
Nitrates are a(n) _____ reducer.
preload
50
What class of HF are nitrates used in?
NYHA Class II-III
51
Nitrates are used in combination with _________.
Hydralazine
52
What are ADRs of nitrates?
- HA
- tachycardia
- ↓ BP
53
What is an ARNI?
Angiotensin Receptor and Neprilysin Inhibition
54
What are the ARNI agents?
Sacubitril/ Valsartan
55
How do beta blockers improve HF?
- inhibit SNS
- improve ventricular filling
- ↓ afterload and ↑EF
- ↓ remodeling
- ↓ hospitalization and mortality
56
What class HF should receive beta blockers?
NYHA Class II-III
57
What are the ADRs of beta blockers?
- ↑ SOB, edema, weight gain
- rales
- ↓ HR
- fatigue and depression
- impotence
58
What are the beta blockers used in HF?
- Carvedilol
- Metoprolol Succinate
- Bisoprolol
59
Beta blockers should be started in ___________ stable HF patients.
hemodynamically
60
How is beta blocker dose determined in HF?
- titrate up to target dose slowly
- no more than every 2 weeks as outpatient
- may need to increase diuretic to increase BB
61
What is Ivabradine?
Inhibitor of ion flow through the F-channel, reducing the slow diastolic depolarization of SA node cells, decreasing HR
62
What HF patients are recommended to receive Ivabradine?
- symptomatic CHF
- LVEF ≤ 35%
- HR ≥ 70 bpm
- maxed out on BB or CI for BB
63
What are the beneficial effects of diuretics in HF?
- ↓ preload
- ↓ congestive symptoms
- ↑ exercise tolerance
64
Diuretics are a plausible agent for monotherapy in HF. (T/F)
False: should not be used as monotherapy
65
What are some drawbacks of diuretic therapy in HF?
- no mortality data
- electrolyte depletion
- activate neurohormonal pathways
66
Which loop diuretic is most efficacious when given in equipotent doses?
None: they are equal in efficacy
67
Ethacrynic acid has no sulfonamide moiety. (T/F)
True
68
Loop diuretics can exacerbate what condition?
gout
69
What are ADRs of loop diuretics?
- skin reactions/ light sensitivity
- interstitial nephritis
- ototoxicity
- fluid and electrolyte abnormalities
- pancreatitis
- anemia
70
Aldosterone antagonists are also known as what?
K sparing diuretics
71
What class of HF should K sparing diuretics be used in?
NYHA Class II-IV
72
What are the ADRs of spironolactone?
- gynecomastia
- hirsutism
- hyperkalemia
73
Which K sparing diuretic reduces mortality in Class IV HF patients?
spironolactone
74
Which K sparing diuretic reduces mortality in Class II/III HF patients?
eplerenone
75
What are contraindications for K sparing diuretics?
- Hyperkalemia > 5.0 mmol/L
| - Renal insufficiency SCr > 2.5 mg/dL
76
What HF patients should receive loop diuretics?
CrCl < 30 mL/min
77
What should be monitored in HF patients on diuretics?
- daily weight
- fluid intake/ urine output/ CrCl
- dizziness, lethargy, BP
- SOB, dyspnea
- ankle edema
- muscle cramping, electrolyte imbalance
78
K should be given ____ if possible. (IV/PO)
PO
79
More than ___ mEq of K at one time will cause nausea.
60
80
Goal of administering K+ should be between __ and ___ mEq/L
4-5
81
What are the benefits of Digoxin in HF patients?
- ↑contractility
- ↑ vagal tone
- ↑ FC
- ↑ exercise capacity
82
Digoxin is appropriate for use in what class of HF?
NYHA Class II-IV
83
What is the desired therapeutic level of Digoxin in HF?
0.5 - 1.0 ng/mL
84
What changes should be monitored in Digoxin use in HF?
- renal failure
| - potassium
85
What medications are used to treat arrhythmias in A.fib?
- digoxin
- beta-blockers
- amiodarone
- dofetilde
86
What medications are used to treat ventricular arrhythmias?
AMIODARONE
87
Every HF patient ( without CI) should be on what medications?
- Beta-blocker
| - ACE-I, ARB, and/or hydralazine+nitrate
88
What medications should be considered for HF patients who are not getting relief with the typical regimen?
- ASA and statin: ischemic CM only
- spironolactone
- diuretics for symptoms
- digoxin
89
What medications should be not used/ used with caution in HF patients?
- corticosteroids
- NSAIDs
- non-dihydropyridine CCB
- Imatinib
- Metformin
- TZDs
- Ampethamines
- Licorice
90
What are the measurable signs of low-perfusion HF?
- SBP < 90 mmHg
- MAP < 70 mmHg
- Cl < 2.2
- ↑ SCr
- low serum Na
91
What are some symptoms of low-perfusion HF?
- cool/ clammy extremities
- AMS
- decreased urine output
92
What is a main treatment of low-perfusion HF?
inotrope therapy
93
What are the measurable signs of pulmonary congestion?
- PCWP > 18 mmHg
- JVD
- increased body weight
- rales
- hypoxemia
- respiratory acidosis
94
What are symptoms of pulmonary congestion?
- dyspnea at rest
- orthopnea
- cough
95
What are the conventional treatments of ADHF?
- reduce fluid volume
- decrease afterload/preload
- augment contractility
96
What medications reduce fluid volume in ADHF?
loop or thiazide diuretics
97
What medications decrease afterload/ preload in ADHF?
vasodilators: NTG, nesiritide, nitroprusside or milrinone
98
What medications are used to augment contractility in ADHF?
inotropes: dopamine, dobutamine, milrinone
99
What are the parameters for Forester Classification Subset I?
- Cardiac index > 2.2
| - PCWP < 18 mmHg
100
What are the parameters for Forester Classification Subset II?
- Cardiac index > 2.2
| - PCWP > 18 mmHg
101
What are the parameters for Forester Classification Subset III?
- Cardiac index < 2.2
| - PCWP < 18 mmHg
102
What are the parameters for Forester Classification Subset IV?
- Cardiac index < 2.2
| - PCWP > 18 mmHg
103
Decompensated patients respond very well to large oral doses of loop diuretics. (T/F)
False: respond poorly
104
ADHF have ____ oral absorption due to ______.
- poor
| - ascites
105
ADHF pharmacodynamic/kinetic issues can be overcome by what?
IV administration
106
How can diuretic resistance be overcome in ADHF patients?
- increase oral furosemide
- change to oral bumetanide or torsemide
- switch to IVP furosemide
- increase IV frequency
- continuous IV infusion
107
What are the advantages of continuous IV infusion in ADHF patients?
- less rebound Na retention
- decreased braking phenomenon
- 100% bioavailability
- easy up titration
- less tinnitus
108
What are the IV vasodilator agents?
- nitroglycerin
- nitroprusside
- nesiritide
109
What are the indications and precautions of IV vasodilators?
- failure to diuresis at high doses of loop diuretics
- place in therapy: "warm and wet" patients
- BP must be adequate enough to sustain infusion
110
Why are inotropes used in ADHF?
Improvement of hemodynamics and to avoid end organ damage secondary to hypoprofusion/ ischemia in the short term
111
When should you consider an inotrope in ADHF patient?
ADHF patients that exhibit signs of low perfusion (shock)
- SBP < 90 mmHg
- narrow pulse pressure
- cool extremities
- acute mental status change
- acute renal dysfunction
112
What are inotropes?
- beta AGONISTS
| - phosphodiesterase inhibitors (PDI)
113
What is the MOA of inotropes?
- increased contractility
| - increased CO
114
What is the MOA of dobutamine?
stimulates β1 receptors (some stimulation of β2 and α to lesser extent)
115
What is Milrinone?
phosphodiesterase 3 inhibitor
116
What are the ADRs of milrinone?
- low BP
- increased HR
- arrhythmias
- thrombocytopenia
- increased mortality and hospitalization
117
At dopamine doses above __ mcg/kg/min, vasoconstriction can occur.
10
118
What are vasopressors?
- dopamine
- phenylephrine
- norepinephrine
- epinephrine
119
What do vasopressors do?
cause vasoconstriction and increase systemic vascular resistance
