Chapter 31: Chronic Heart Failure Flashcards
(176 cards)
1
Q
What is heart failure (HF)?
A
A condition where the heart cannot supply sufficient oxygen-rich blood to the body due to impaired left ventricle function
2
Q
What are the two main types of heart failure classification?
A
- Ischemic
- Non-ischemic
3
Q
What is ischemic heart failure caused by?
A
Decreased blood supply to the heart, such as from a myocardial infarction (MI)
4
Q
What is a common cause of non-ischemic heart failure?
A
Long-standing uncontrolled hypertension
5
Q
What are common symptoms of heart failure?
A
- Shortness of breath (SOB)
- Edema
6
Q
What does heart failure symptomatology often relate to?
A
Fluid overload
7
Q
What is the role of echocardiography in diagnosing heart failure?
A
It estimates left ventricular ejection fraction (LVEF)
8
Q
What does LVEF indicate?
A
How much blood is pumped out of the left ventricle with each contraction
9
Q
What LVEF percentage indicates systolic dysfunction?
A
An EF < 40%
10
Q
What is heart failure with reduced ejection fraction (HFrEF)?
A
Heart failure characterized by an ejection fraction less than 40%
11
Q
What is the focus of the chapter regarding heart failure?
A
Heart failure with reduced ejection fraction (HFrEF)
12
Q
What biomarkers are referenced in the ACC/AHA staging system?
A
BNP and NT-proBNP
13
Q
What is Stage A in the ACC/AHA staging system?
A
At risk for HF, but without symptoms, structural heart disease or elevated biomarkers
14
Q
What characterizes Stage B in the ACC/AHA staging system?
A
Pre-HF; structural heart disease, abnormal cardiac function or elevated biomarkers, but without signs or symptoms of HF
15
Q
What are the limitations of physical activity in NYHA Class I?
A
No limitations of physical activity
16
Q
What are the limitations of physical activity in NYHA Class II?
A
Slight limitation of physical activity
(Comfortable at rest, but ordinary physical activity results in symptoms of HF.)
17
Q
What are the limitations of physical activity in NYHA Class III?
A
Marked limitation of physical activity
(Comfortable at rest but minimal exertion causes symptoms of HF.)
18
Q
What are the limitations of physical activity in NYHA Class IV?
A
Unable to carry on any physical activity without symptoms of HF or symptoms at rest
Symptoms may include shortness of breath while sitting.
19
Q
What is the normal range for BNP?
A
< 100 pg/mL
20
Q
What is the normal range for NT-proBNP?
A
< 300 pg/mL
NT-proBNP is used alongside BNP to distinguish causes of dyspnea.
21
Q
What are signs of right-sided heart failure?
A
- Orthopnea: SOB when lying flat
- Paroxysmal nocturnal dyspnea (PND): Nocturnal cough and SOB
- Bibasilar rales: Crackling lung sounds heard on lung exam
- S3 gallop:
It is a common symptom of left-sided heart failure.
22
Q
What are common general signs and symptoms of heart failure?
A
- Dyspnea (SOB at rest or upon exertion)
- Cough
- Fatigue, weakness
- Reduced exercise capacity
These symptoms can significantly impact a patient’s quality of life.
23
Q
What are signs of right-sided heart failure?
A
- Peripheral edema
- Ascites
- Jugular venous distention (JVD)
- Hepatojugular reflux (HJR)
- Hepatomegaly
24
Q
What is cardiac output (CO)?
A
The volume of blood that is pumped by the heart in one minute.
25
What determines cardiac output (CO)?
Heart rate (HR) and stroke volume (SV).
26
What is stroke volume (SV)?
The volume of blood ejected from the left ventricle during one complete heartbeat.
27
How is cardiac index (CI) calculated?
CI = CO / BSA
28
What is the formula for cardiac output (CO)?
CO = HR x SV
29
What is the compensatory mechanism in low cardiac output states?
Activation of neurohormonal pathways to increase blood volume or the force or speed of contractions.
30
What are the consequences of chronic compensatory mechanisms in heart failure?
Myocyte damage and cardiac remodeling.
31
What are the main pathways activated in heart failure?
* Renin-angiotensin-aldosterone system (RAAS)
* Sympathetic nervous system (SNS)
* Vasopressin
32
What effects does angiotensin II (Ang II) have?
* Causes vasoconstriction
* Stimulates release of aldosterone and vasopressin
33
What does aldosterone do?
* Causes sodium and water retention
* Increases potassium excretion
34
What are the effects of vasopressin?
* Causes vasoconstriction
* Causes water retention
35
What is the effect of norepinephrine (NE) and epinephrine (Epi) release?
* Increase in HR
* Increase in contractility (positive inotropy)
* Vasoconstriction
36
What should patients with HF monitor daily?
Body weight in the morning after voiding and before eating.
37
When should a provider be notified regarding weight changes in HF patients?
If weight increases by 2 - 4 pounds in one day or ≥ 5 pounds in one week
38
What is the recommended sodium intake restriction for patients with hypertension?
Less than 1,500 mg/day
39
What is the recommended fluid intake for stage D HF?
1.5 - 2 L/day
40
What lifestyle changes should patients with HF make?
* Stop smoking
* Limit alcohol intake
* Do not use illicit drugs
41
What vaccinations are recommended for patients with HF?
* Influenza (annually)
* Pneumococcal vaccines per ACIP guidelines
42
What type of supplementation is reasonable to reduce mortality and cardiovascular hospitalizations in HF patients?
Omega-3 fatty acid (fish oil)
43
Which natural products may improve HF symptoms?
* Hawthorn
* Coenzyme Q10
44
What are common drug classes that can cause or worsen heart failure?
| **D**rug **I**nformation **NATION**
* Dipeptidyl peptidase 4 inhibitors
* Immunosuppressants
* Non-dihydropyridine CCBs
* Antiarrhythmics
* Thiazolidinediones
* Itraconazole
* Oncology drugs
* NSAIDs
45
Which antiarrhythmics are preferred in patients with HF?
* Amiodarone
* Dofetilide
46
What is the main goal of guideline-directed medical therapy (GDMT) for HFrEF?
To reduce morbidity and mortality through specific drug classes.
47
Name the four main drug classes in GDMT for HFrEF.
* RAAS inhibitor (ARNI, ACE inhibitor, or ARB)
* Evidence-based beta-blocker
* Aldosterone receptor antagonist (ARA)
* Sodium-glucose cotransporter 2 (SGLT2) inhibitor
48
What is the recommended approach for initiating medications in HFrEF?
Medications may be started simultaneously at low doses or sequentially.
49
What is the aim of titrating medications in HFrEF treatment?
To achieve target doses as tolerated.
50
Which drug class is confirmed to have a mortality benefit?
* Evidance based Beta-blockers.
* RAAS inhibitors
* Aldosterone receptor antagonist
* SGLT2i
51
What is the role of loop diuretics in heart failure treatment?
They help manage symptoms but do not provide mortality benefit.
52
What is recommended in all HF patients regardless of symptom severity?
An ARNI, ACE inhibitor, or ARB
53
What are the effects of RAAS activation inhibition?
Decreased preload and afterload, decreased cardiac remodeling, improved left ventricular function, decreased morbidity and mortality
54
What should be the goal when titrating doses of RAAS inhibitors?
Titrate to the target dose, as tolerated, not to a goal BP
55
What is the risk of combining more than one RAAS inhibitor with an ARA?
Increased risk of hyperkalemia and renal insufficiency
56
Which medication combination has a higher frequency of angioedema?
ACE inhibitor or neprilysin inhibitor
57
What is Entresto composed of?
Neprilysin inhibitor (sacubitril) and ARB (valsartan)
58
In which patients is an ARNI indicated?
NYHA Class II - IV patients
59
What is the preferred first-line treatment for HFrEF?
ARNI (Entresto)
60
What is the target dose for Sacubitril/Valsartan (Entresto)?
97/103 mg BID
61
What is a boxed warning for Sacubitril/Valsartan (Entresto)?
Can cause injury and death to the developing fetus in the 2nd and 3rd trimesters. (Discontinue as soon as pregnancy is detected.)
62
What are contraindications for Sacubitril/Valsartan (Entresto)?
* Do not use with or within 36 hours of an ACE inhibitor
* Do not use if history of angioedema
* Do not use with aliskiren in diabetes
63
What are the warnings associated with Sacubitril/Valsartan (Entresto)?
* Angioedema
* Hyperkalemia
* Renal impairment
* Hypotension/dizziness
64
What side effects can occur with Sacubitril/Valsartan (Entresto)?
Cough
65
What should be monitored when a patient is on Sacubitril/Valsartan (Entresto)?
* Blood pressure
* Potassium
* Renal function
* Signs/symptoms of HF and angioedema
66
What do ACE inhibitors block?
The conversion of angiotensin I to Ang II
67
What do Angiotensin Receptor Blockers (ARBs) block?
Angiotensin II from binding to the angiotensin II type-1 (AT1) receptor
68
What is one effect of both ACE inhibitors and ARBs?
Vasoconstriction and decreased aldosterone secretion
69
What additional effect do ACE inhibitors have related to bradykinin?
They block the degradation of bradykinin
70
What are common side effects of ACE inhibitors?
Cough and angioedema
71
What boxed warning is associated with ACE inhibitors?
Can cause injury and death to the developing fetus when used in the 2nd and 3rd trimesters
72
What is the target dose for Enalapril?
10-20 mg PO BID
73
Enalapril brand name
Vasotec
74
What contraindications are associated with ACE inhibitors?
* History of angioedema
* Use within 36 hours of sacubitril/valsartan
* Use with aliskiren in diabetes
75
What warnings are associated with ACE inhibitors?
* Angioedema
* Hyperkalemia
* Renal impairment
* Hypotension/dizziness if volume-depleted
76
What is the target dose for Lisinopril?
40 mg daily
77
Lisinopril brand name
Zestril
78
What is the target dose for Losartan?
50-150 mg daily
79
Losartan brand name
Cozaar
80
What is the target dose for Valsartan?
160 mg BID
81
Valsartan brand name
Diovan
82
What is a key difference between ACE inhibitors and ARBs regarding side effects?
ARBs have less cough and less angioedema
83
What is a potential drug interaction concern with ACE inhibitors and ARBs?
Risk of hyperkalemia
84
What can NSAIDs do when used with ACE inhibitors or ARBs?
Increase risk of renal impairment
85
What effect can ACE inhibitors and ARBs have on lithium levels?
Decrease renal clearance of lithium and increase risk of lithium toxicity
86
What are beta-blockers?
Beta-adrenergic receptor antagonists that antagonize the effects of catecholamines at beta-1, beta-2, and/or alpha-1 adrenergic receptors.
87
What are the effects of beta-blockers?
They reduce vasoconstriction, improve cardiac function, and decrease morbidity and mortality.
88
Who should use beta-blockers?
They are recommended for all heart failure (HF) patients.
89
Which beta-blockers are recommended in HF guidelines?
* Bisoprolol
* Carvedilol (IR and CR)
* Metoprolol succinate ER
90
When should beta-blockers be discontinued?
Only during acute decompensated HF if hypotension or hypoperfusion is present.
91
What is the target dose for Metoprolol succinate?
200 mg daily.
92
What is a boxed warning associated with beta-blockers?
Do not discontinue abruptly; gradually taper over 1-2 weeks.
93
Name a contraindication for beta-blockers.
Severe bradycardia.
94
What are warnings associate with beta-blockers?
* They can worsen hypoglycemia and mask hypoglycemic symptoms.
* Caution use with bronchospatic diseases (asthma & COPD)
* Caution use with Raymaud's
95
What are common side effects of beta-blockers?
* Bradycardia
* Hypotension
* CNS effects (e.g., fatigue, dizziness, depression)
* Impotence
* Cold extremities
96
What monitoring is required for patients on beta-blockers?
Heart rate (HR), blood pressure (BP), and signs/symptoms of heart failure.
97
What is the IV:PO ratio for Metoprolol?
1:2.5.
98
What is a unique dosing instruction for Toprol XL?
Can be cut in half; do not crush or chew.
99
What should be taken with all forms of Carvedilol?
Take with food to increase absorption and reduce the risk of orthostatic hypotension.
100
What is a notable side effect of Carvedilol?
Edema and weight gain.
101
What is a key interaction of beta-blockers?
Can enhance the hypoglycemic effects of insulin.
102
Carvedilol IR Target dose
=< 85 kg: 25 mg BID
>85 kg: 50 mg BID
103
What do aldosterone receptor antagonists (ARAs) compete with at receptor sites?
They compete with aldosterone at the distal convoluted tubule and collecting ducts of the nephron.
104
What effects do ARAs have on sodium and water retention?
They inhibit sodium and water retention
105
In which patients should ARAs be used as first line?
Patients with NYHA Class II - IV HF
106
What is the target dose for spironolactone?
25-50 mg daily
## Footnote
Starting dose is 12.5-25 mg daily.
107
What are the main side effects of spironolactone?
Gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
108
What is the main advantage of eplerenone over spironolactone?
Eplerenone is selective and does not exhibit endocrine side effects
109
What should be monitored when using spironolactone or eplerenone?
BP, K, renal function, fluid status, s/sx of HF
110
What is a contraindication for using ARAs?
Hyperkalemia, severe renal impairment, Addison's disease
111
What are the main side effects of ARAs?
* Hyperkalemia
* Increased SCr
* Dizziness
112
What is the mechanism through which SGLT2 inhibitors benefit heart failure treatment?
Reduced sodium reabsorption, diuresis, decrease in preload and/or afterload
113
Which SGLT2 inhibitors are recommended first line for HF?
* Dapagliflozin (Farxiga) 10 mg PO daily
* Empagliflozin (Jardiance) 10 mg PO daily
114
What is the dosing range for sotagliflozin?
200 - 400 mg PO daily
## Footnote
Sotagliflozin is a dual SGLT1/2 inhibitor.
115
What should be avoided when using SGLT2 inhibitors for HF?
Initiation if eGFR < 20 - 25 mL/min/1.73 m²
## Footnote
Cutoffs are medication-specific.
116
What is the primary action of loop diuretics?
Block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle
117
What electrolytes are excreted by loop diuretics?
* Sodium
* Potassium
* Chloride
* Magnesium
* Calcium
* Water
118
What condition do loop diuretics primarily help alleviate?
Congestive symptoms by reducing fluid volume
119
Do loop diuretics improve survival rates?
No, they are often required for symptom control but do not improve survival
120
What is the recommended approach to dosing loop diuretics?
Use the lowest effective dose to prevent over-diuresis
121
What can be done in case of poor response to loop diuretics?
Adding a thiazide diuretic, such as metolazone, can be useful
122
What are the side effects associated with loop diuretics?
* Decrease electrolytes: K, Mg, Na, Cl, Ca
* Increase electrolytes/labs: HCO3, UA, BG, TGs, Tota cholesterol
* Orthostatic hypotension
* Photosensitivity
*
123
What are the warnings associated with loop diuretics?
* Sulfa allergy
* Ototoxicity including hearing loss, tinnitus, and vertigo
* Acute kidney injuri
124
What should be monitored while using loop diuretics?
* Renal function
* Fluid status (input/output, weight)
* Blood pressure
* Electrolytes
* Signs/symptoms of heart failure
125
What is the oral equivalent dosing for furosemide 40 mg?
20 mg of torsemide, 1 mg of bumetanide, or 50 mg of ethacrynic acid
126
Fill in the blank: Furosemide IV:PO ratio is ______.
1:2
127
What should be avoided when using loop diuretics?
NSAIDs due to sodium and water retention which can impair the effectiveness of loop diuretics
128
True or False: Loop diuretics can alter lithium levels.
True
129
A patient is on furosemide 40 mg IV BID. What is the equivalent oral dose of bumetanide?
4 mg PO bumetanide
130
What should be done with furosemide injection to avoid crystallization?
Store at room temperature; do not refrigerate
131
What is the light sensitivity requirement for bumetanide and furosemide injections?
They are light-sensitive and should be stored in amber bottles
132
What is hydralazine?
A direct arterial vasodilator which reduces afterload.
133
What do nitrates do in the body?
Increase the availability of nitric oxide, causing venous vasodilation and reducing preload.
134
What is the combination of hydralazine and nitrates used for?
Improving survival in heart failure, especially in patients who cannot tolerate ACE inhibitors.
135
What is BiDil indicated for?
Self-identified Black patients with NYHA Class III or IV heart failure who are symptomatic despite optimal treatment.
136
Is monotherapy with hydralazine or oral nitrates appropriate for heart failure treatment?
No, there is no role for monotherapy with either.
137
What is the preferred formulation of hydralazine and nitrates for systolic heart failure?
Isosorbide Dinitrate/Hydralazine (BiDil).
138
What are common side effects of hydralazine?
* Peripheral edema
* headache
* flushing
* palpitations
* reflex tachycardia
139
What is a warning associated with hydralazine?
Drug-induced lupus erythematosus (DILE) which is dose and duration related.
140
What is a significant drug interaction to avoid with BiDil?
PDE-5 inhibitors or riociguat.
141
What are side effects of nitrates?
* Hypotension.
* Headache
* Dizziness
* Tachyphylaxis
* Syncope
142
What is the recommended nitrate-free interval to prevent tachyphylaxis?
10-12 hours.
143
What are the recommended indications for Ivabradine?
Adjunct treatment in symptomatic (NYHA Class II - III) stable chronic HF (EF ≤ 35%)
144
What must patients be receiving before starting Ivabradine?
GDMT, including target or maximally-tolerated doses of beta-blockers (unless contraindicated)
145
What is the target resting heart rate (HR) for patients on Ivabradine?
Between 50-60 BPM
146
What are some side effects of Ivabradine?
* Bradycardia
* Hypertension
147
What should be monitored in patients taking Ivabradine?
* HR
* ECG
* BP
148
What are the warnings associated with Ivabradine?
* Bradycardia
* Increase risk of AF
149
What effect does Digoxin have on the Na-K-ATPase pump?
Inhibits it, causing a positive inotropic effect (increased CO)
150
What is the negative chronotropic effect of Digoxin attributed to?
Its parasympathetic effect, which slows AV nodal conduction
151
How does Digoxin improve effect heart failure patients?
* reduce HF related hospitalizations
* improve symptoms
* Exercise tolerance
* Quality of life
152
What is a common reason for adding Digoxin to treatment regimens?
Ventricular rate control in patients with atrial fibrillation (AF)
153
What is the typical dose of Digoxin for chronic heart failure?
0.125-0.25 mg PO daily
154
What is the therapeutic range of Digoxin for heart failure?
0.5-0.9 ng/mL
155
What should be done with Digoxin dosing when switching from PO to IV?
Decrease dose by 20-25%
156
What are the contraindications for Digoxin?
Ventricular fibrillation
157
List some common side effects of Digoxin.
* Dizziness
* Visual/mental disturbances
* Headache
* Nausea/Vomiting
* Diarrhea
158
What should be monitored when a patient is on Digoxin?
* Electrolytes
* Renal function
* Heart rate
* ECG
* Blood pressure
* Digoxin level
159
What are the symptoms of Digoxin toxicity?
* Nausea/Vomiting
* Loss of appetite
* Abdominal pain
* Blurred/double vision
* Greenish-yellow halos
* Confusion
* Delirium
* Bradycardia
* Life-threatening arrhythmias
160
What can increase the risk of Digoxin toxicity?
Hypokalemia, hypomagnesemia, and hypercalcemia
161
What is the antidote for Digoxin toxicity?
DigiFab
162
What should be done to digoxin dose when starting amiodarone?
Reduce digoxin dose by 50%
163
What is Vericiguat and its mechanism of action?
A soluble guanylate cyclase stimulator that increases cyclic GMP leading to smooth muscle relaxation and vasodilation
164
What is a boxed warning associated with Vericiguat?
Do not use if pregnant; contraception required during use and for one month after stopping treatment
165
What are the contraindications for Vericiguat?
Do not use with riociguat
166
List some side effects of Vericiguat.
* Hypotension
* Anemia
* Dyspepsia
167
When should potassium levels be checked?
With changes in renal function and after any change in diuretic, ARNI, ACE inhibitor, ARB or ARA dose.
168
What can aggravate hypokalemia?
Magnesium deficiency.
169
What is the most commonly used potassium supplement?
Potassium chloride (KCl).
170
What is the initial dosing for the prevention of hypokalemia with potassium chloride?
20-40 mEq/day in 1-2 divided doses.
171
What is a warning associated with potassium chloride?
Risk of hyperkalemia; use caution in renal impairment and with disorders that alter potassium levels.
172
How should potassium chloride be taken to minimize gastrointestinal irritation?
With meals and a full glass of water.
173
What is the mEq of KCl oral solution 10%?
20 mEq/15mL
174
What is the calculation for converting Klor-Con to KCl 10% oral solution for a patient taking 60 mEq/day?
45 mL of KCl 10% oral solution.
175
Why should all patients with heart failure be assessed for anemia?
Anemia is associated with HF disease severity and mortality.
176
What treatment is recommended for patients with HFrEF and iron deficiency?
Intravenous iron treatment to improve exercise capacity and quality of life.
