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CRS2 > Management of Heart Failure 1 and 2 > Flashcards

Management of Heart Failure 1 and 2 Flashcards

1
Q

Which types of drugs improve contractility?

A
  • Positive inotropes:
    • Digoxin (digitalis glycosides)
    • Pimobendan (Vetmedin)
    • Dobutamine
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2
Q

Effects of digoxin?

A
  • Positive inotropic agent
  • Negative chronotropic agent
  • Increases vagal tone
  • Decreases sympathetic tone
  • Alters baroreceptor sensitivity
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3
Q

Side-effects of digoxin?

A
  • Predominantly renal excretion (avoid drug or decrease dose in RF)
  • Narrow therapeutic range - digoxin toxicity!
  • Gastrointestinal side effects
  • Induce dysrhythmias at higher doses
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4
Q

What are the clinical signs of digoxin toxicity?

A

Off food, lethargy, depression, borbgrgymi , arrhythmias can all occur before the classical V and D.

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5
Q

What are the recommended serum levels of digoxin?

A
  • Measure serum digoxin level
  • Aim for 0.5ng/ml – 1ng/ml
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6
Q

What are the effects of Pimobendan?

A
  • Inodilator
  • Calcium-sensitizing drug (Positive inotrope)
  • PDE III inhibitors (Vasodilation)
  • Antithrombotic activity
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7
Q

Which types of drug help the heart relax?

A
  • Positive lusitropes:
    • Calcium channel blockers (diltiazem, verapamil)
    • Beta blocker (propranolol, atenolol)
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8
Q

What are the uses of Atenolol?

A
  • Heart rate control
  • Anti-arrhythmic
  • Reduce LVOFTO
  • Decrease myocardial oxygen demand
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9
Q

What are the goals of therapy for congestive heart failure?

A
  • Control Salt & Water Retention
  • Improve Pump Function
  • Reduce Workload (decrease afterload, decrease physical activity and stress)
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10
Q

With ACVIM stage B1 heart patients (asymptomatic patients with no radiographic or echocardiographic evidence of cardiac remodelling), how would you manage these cases?

A
  • No treatment - but consider
  • Weight control
  • Regular re-assessment
  • Client education
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11
Q

With ACVIM stage B2 heart patients (asymptomatic patients with radiographic or echocardiographic evidence of left-sided heart enlargement), how would you manage these?

A
  • No treatment - but consider
  • Pimobendan
  • Weight control
  • Regular re-assessment
  • Client education
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12
Q

With ACVIM stage C patients (clinical signs of congestive heart failure), how would you manage them?

A
  • Remove fluid - diuretic traditionally used
  • Act at kidney to increase urine output
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13
Q

Which types of diuretics are used in CHF?

A
  • Loop
    • Furosemide
    • Torasemide
  • Potassium Sparing
    • Spironolactone
    • Amiloride
  • Thiazide
    • Hydrocholorothiazide
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14
Q

Markers elevated in cardiac failure?

A

Natriuretic peptides – BNP, ANP

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15
Q

Markers elevated in myocardial disease?

A
  • Troponins
  • Important in human medicine
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16
Q

Which co-existing diseases may contribute to failure?

A
  • Hypothyroidism
  • Cushing’s disease
  • Complications
    • Renal insufficiency
    • Hepatic insufficiency
      • NB may affect treatment used
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17
Q

What can cause worsening of left-sided congestive heart failure despite therapy?

A
  • Worsening of disease
    • Rupture of CT, atrial tear
  • Furosemide resistance?
  • Compliance?
  • R sided failure and poor GI drug absorption?
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18
Q

What would you do in a case of worsening left-sided congestive heart failure despite therapy?

A
  • Changes to treatment
    • Increase dose / frequency of frusemide
    • Increase dose / frequency of ace inhibitors
    • Increase dose of pimobendan
  • Consider adding other drugs
    • Antidysrhythmic / negative chronotropes
    • Sildenafil if pulmonary hypertension
    • Hydrochlorothiazides
    • Omega 3 fatty acids
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19
Q

Emergency congestive heart failure therapy for decompensation?

A
  • Furosemide
  • Oxygen supplementation
  • Pimobendan if systolic dysfunction (all CDVD and DCM cases)
  • Cage rest
  • Avoid stress
  • Sedation as necessary (Butorphanol 0.1 - 0.2mg/kg)
  • Glyceryl trinitrate ointment
  • Monitor renal values / electrolytes
  • Antidysrhythmic medication if necessary
20
Q

What is an Intractable cough?

A

Cough despite standard therapy

21
Q

Causes of an Intractable cough?

A
  • Unstable LCHF
  • Enlarged LA
  • Bronchomalacia
  • Chronic airway disease
22
Q

Diagnosis of an Intractable cough?

A
23
Q

Treatment of an Intractable cough if a result of unstable left-sided congestive heart failure?

A
  • Further alterations to treatment regime
24
Q

Treatment of an Intractable cough if a result of an enlarged left atrium?

A
  • Reduce LA size with therapy
    • Standard therapy
    • Afterload reducers – amlodipine, hydralazine
  • Bronchomalacia, airway collapse, concurrent bronchitis
    • Bronchodilators
    • Inhalers, theophylline
25
Q

What should you stress the importance of to owners of animals in heart failure?

A
  • A regular daily routine
  • The administration of prescribed medication
  • A consistent exercise schedule
  • The possible side/toxic effects of medications
  • Maintaining appetite
26
Q

Problems with diuretics?

A

Volume depletion could cause…

  • Potential hypovolaemia
  • Cause/exacerbate azotaemia
  • Stimulate RAAS
27
Q

What is the viscious cycle of heart failure?

A

heart failure > decreased CO > compensatory mechanisms (increased sympathetic activity, increased RAAS, increased ADH) > excessive vasoconstriction, sodium and water retention > increased preload and afterload > continuous cycle

28
Q

What do vasodilators do?

A

Dilate Arteries, Veins or Both

29
Q

What do venous dilators do?

A
  • Decrease preload
  • Reduce fluid build up
    • E.g. Glyceryl trinitrate
30
Q

What do arterial dilators do?

A
  • reduce afterload
    • Increase output
    • Reduce valve leakage
      • E.g. Hyralazine
31
Q

When is congestive heart failure treated and how?

A
  • Class II and III
  • Clinical signs of Congestive Heart Failure.
    • Remove fluid
    • Vasodilate
      • ACE inhibitor now used
32
Q

What do ACE inhibitors do?

A
  • Theoretical benefits
  • Veno and arterial vasodilation
  • Decreased salt and water retention
  • Local ACE and myocardial remodelling
  • Causes efferent arteriolar dilation causing a reduced glomerular filtration rate
  • (inhibit angiotensin converting enzyme from converting angiotensin I to angiotensin II and entering the RAAS system)
33
Q

Describe how the RAAS increases BP?

A
  • Angiotensinogen converted to Angiotensin I (by renin), then to Angiotensin II (by Angiotensin Converting Enzyme)
  • Angiotensin II causes peripheral vasoconstriction = increased BP
  • Angiotensin II also causes aldosterone secretion = salt and water retention = increased blood volume = increased BP
34
Q

Contra-indications for ACE inhibitors?

A
  • Fixed CO – AS, HOCM
  • Renal dysfunction??
  • K-sparing diuretics
  • NSAIDs??
35
Q

List ACE inhibitors.

A
  • Imadipril
    • Prilium
  • Enalapril
    • Enacard
  • Benazepril
    • Benfortin
    • Nelio
    • Prilben
    • Fortekor
    • Kelapril
  • Ramipril
    • Vasotop
  • Causes efferent arteriolar dilation causing a reduced glomerular filtration rate
36
Q

What should you bear in mind when using ACE inhibitors?

A
  • Azotaemia
  • Hypotension
  • Monitor renal parameters regularly
  • Benazepril may be more suitable for patients with renal disease, as less dependant on renal excretion
37
Q

How is stage B2 and C (clinical signs of congestive heart failure) treated?

A
  • Role of pimobendan (Vetmedin)
    • Inodilator
    • Positive inotrope
    • Vasodilator
38
Q

Activity of pimobendan?

A
  • Inodilator
  • Calcium-sensitizing drug
    • Positive inotrope
  • PDE III inhibitors
    • Vasodilation
  • Antithrombotic activity
  • ‘Feel good’ factor ? mechanism
39
Q

What is stage D heart failure classed as?

A

Stage D - Advanced

  • Obvious clinical signs with minimal exercise
  • Progressively worsens
  • Obvious clinical signs at rest
  • Progressively worsens
  • Death
40
Q

Goals of emergency CHF treatment?

A
  • Treatment of life-threatening CHF is 1st priority!
  • Take into consideration which other concurrent diseases may be present
  • Current medication
41
Q

What is used for emergency treatment of CHF?

A
  • Furosemide
    • 2mg/kg IV initally then
    • 1mg/kg hourly afterwards until respiratory rate and effort reduce (up to 4 doses in cats more as necessary in dogs)
  • Oxygen supplementation
  • Pimobendan if systolic dysfunction (all CDVD and DCM cases)
  • Cage rest
  • Avoid stress
  • Sedation as necessary (Butorphanol 0.1 - 0.2mg/kg)
  • Glyceryl trinitrate ointment
  • Monitor renal values / electrolytes
  • Antidysrhythmic medication if necessary
  • If blood pressure allows gradually start low dose ACEI and wean up after 24-48 hrs
  • Start spironolactone 2mg/kg SID
  • IF AF rate not started to reduce after a few hours then start digoxin
  • Wean patient from i/v furosemide to oral doses twice – three times daily
42
Q

Other options for treatment of CHF?

A
  • Low salt diet
  • Exercise regime
  • Aspirate fluid
  • Exercise:
    • Within the dog’s capacity
    • CONSISTENCY DAY TO DAY
    • Do not allow to become exhausted
    • Why are we treating dogs
      • make them live longer
      • make them feel better
43
Q

What might be used to treat or prevent feline thromboembolic disease?

A

Clopidogrel

  • Inhibits platelet aggregation
  • No EBM as yet
  • Appears relatively safe
    • Mild neutropaenia in some cases
  • Very bitter in taste
  • 18.75mg / cat / day

Aspirin

  • Inhibition of platelet aggregation
  • Low dose ¼ 75mg tablet every 3 days
  • No EBM to report efficacy
  • Care
    • Gastric ulceration
    • GIT upsets
    • Renal compromise
44
Q

What is the name given to drugs that improve contractility?

A

Positive ionotropes

45
Q

What is the name given to drugs that help the heart relax?

A

positive lusitropes

46
Q

What do positive and negative chronotropes do?

A

Positive chronotropesincrease heart rate; negative chronotropes decrease heart rate

CRS2 (64 decks)

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