Chronic Heart Failure

Question 1

Heart Failure

Answer 1

inability to provide enough oxygenated blood to the rest of the body

Question 2

Preload

Answer 2

Amount of blood at end of diastole (end diastolic volume)

People with CHF they are going to have high preload due to the hearts inability to pump the blood out to the body

Question 3

Afterload

Answer 3

Amount of pressure the heart has to pump up against for systole

Question 4

Ejection Fraction %

Answer 4

Amount of blood pumped / end diastolic volume

% of the volume that is pumped out of the ventricle

Question 5

Background of HF

Answer 5

Prevalence: 5 million people in the US
Incidence: 500,000 new cases/year in the US
Incidence is increasing at a dramatically fast rate
Better medicines
Obesity/ poor diet/ sedentary lifestyle
Better access to medical care
Cheaper medication that are effective

Question 6

Mortality Rate for CHF

Answer 6

Mortality rate is estimated at 50% after 5 years of heart failure
Ways to lower mortality rate

Pharmacological:
ACE-I/ ARB , Beta Blockers, Spironolactone, Hydralazine and nitrates— vasodilators . Aldosterone Blockers

Non-Pharmacological
Biventricular pacing, implantable cardiac defibrillators

Question 7

Morbidity for CHF (5)

Answer 7

More than $25 billion a year is spend on heart failure management
QOL progressively gets worse:
Ability to exercise
Walking
Difficulty breathing/shortness of breath/edema
Frequent hospitalizations

Question 8

Risk Factors of CHF (10)

Answer 8

CAD
HTN
Male
Valve disorders
Pregnancy
Smoking
Rx Drug induced--> NSAIDs, Steroids, 
Alcohol/Illicit drug use---> Cocaine
Pericarditis
Hyperthyroidism
Diabetes
Obesity

Question 9

Presentation of CHF (7)

Answer 9

SOB
Dyspnea on exertion
Edema- peripheral and/or pulmonary
Need for multiple pillows at night to sleep
Easily fatigued
Ascites
Hepatomegaly
Heart murmurs

Question 10

NYHA Functional Classification for HF

Answer 10

Class 1- Ordinary activity does not cause symptoms
Class 2- Ordinary activity causes symptoms
Class 3- Less than ordinary activity causes symptoms
Class 4- symptoms present at rest

Question 11

ACC/AHA Stages of HF

Answer 11

A- at high risk for HF but w/out structural heart disease or symptoms of HF
B- Structural heart disease but w/out signs or symptoms of HF
C- Structural heart disease with prior or current symptoms of HF
D- Refractory HF requiring specialized interventions

Question 12

Systolic Heart Failure (3)

Answer 12

Most common
Problem with ejection of blood to the lungs or systemic circulation
Result of hypertrophy and dilation of ventricle

Question 13

Diastolic Heart Failure (4)

Answer 13

Inability of the heart to fill appropriately
Usually results from stiffness of myocardium
More difficult to treat
Treatment not well defined
A-Fib, Arrhythmias

Question 14

What are the 4 compensatory mechanisms of HF

Answer 14

RAAS is turned on= Water retention– make more blood
Ventricular Hypertrophy- Aldosterone is also secreted causing hypertrophy
Releasing renin converts angiotensinogen to angiotensin 1
SNS= increase CO, vasoconstrictor, and cause hypertrophy
Frank starling Law– increases what your ventricles to hold

Question 15

Mortality reducing agents used in HF (4)

Answer 15

ACE/ARBs
BB
Aldosterone blocking agents
Vasodilators (hydralazine/nitrates) in african americans

Question 16

Morbidity reducing agents used in HF

Answer 16

All of the drugs listed above also reduce morbidity along with:
Digoxin
Diuretics

Question 17

3 Beta Blockers used for HF

Answer 17

Metoprolol succinate
Bisoprolol
Carvedilol

Question 18

Beta Blocker MOA

Answer 18

MOA: blockage of beta receptors leading to decreased heart rate, decreased blood pressure, increased coronary artery blood flow

Question 19

Dosing for Beta Blockers

Answer 19

Dosing: can be used in stage A or B, should be used in stage C; goal dosing are essential in maximizing mortality/morbidity benefit
Metoprolol succinate: 6.25-12.5 mg/day; goal 200 mg/day
Bisoprolol: 1.25 mg/day; goal 10 mg/day
Carvedilol: 3.125 mg twice daily; goal 25 mg twice daily

Question 20

ADR for BB

Answer 20

Bradycardia
Worsening of HF if dose is started too high or up titrated too quickly
Respiratory issues

Question 21

Why don’t we use metoprolol tartrate in managing HF?

Answer 21

MERIT HF clinical trial showed metoprolol succinate is superior to metoprolol tartrate

Question 22

MOA for ACEI/ ARBs

Answer 22

MOA: Interference with RAAS ending with disrupting angiotensin II
Produces decreases BP, Na/H2O retention
Afterload reducer

Question 23

Dosing for ACEI/ ARBs

Answer 23

Dosing: used in all stages of HF
All ACEi/ARBs have been used in HF
Goal doses are essential in maximizing mortality/morbidity benefit
Lisinopril: start at 5 mg daily, goal dose of 20-40 mg daily
*Double the dose until you get to the target dose every 2 weeks
(max benefit for lowering the mortality)

Question 24

4 Contraindications for ACE/ ARBs

Answer 24

Pregnancy
Hyperkalemia (K>5.0 meq/L)
Bilateral renal artery stenosis
Angioedema

Question 25

ADRs for ACE-I & ARBs

Answer 25

Hyperkalemia Cough (ACEi) Hypotension

Question 26

MOA of Aldosterone Blockers

Answer 26

MOA: spironolactone or eplirinone Competes with aldosterone for intracellular mineralcorticoid receptors → Na and H2O excreation (this also increases K in the blood) Decreases preload

Question 27

Dosing used for Aldosterone Blockers

Answer 27

used in stage C and D HF 12.5-25 mg/day- spironolactone 25 mg/day- eplerenone

Question 28

ADR and Contraindications for Aldosterone Blockers

Answer 28

Hyperkalemia Gynecomestia contraindication hyperkalemia

Question 29

MOA of Vasodilators

Answer 29

Hydralazine: direct arterial vasodilator Predominately vasodilates in coronary, cerebral, and renal arteries Isosorbide dinitrate: direct venodilator Converts into nitric oxide which produces vasodilation Key PK notes: used in place of ACE-I contraindications; not renally excreted

Question 30

ADR for Vasodilators

Answer 30

Tolerance to nitrates | hypotension

Question 31

MOA of Loop Diuretics

Answer 31

MOA: exerts their action at the loop of Henle. Increase Na and H2O excretion. Since all diuretics reduce pre-load and edema why are loop diuretics preferred over other agents (such as thiazide diuretics) Key PK notes: May require higher than usual doses to induce diuresis in patients with renal failure

Question 32

Adverse Drug Reactions of Loop Diuretics

Answer 32

``` Electrolyte imbalances (most common) Hyperglycemia Hyperuricemia Hypokalemia hypomagnesemia ```

Question 33

Dosing for Loop Diuretics

Answer 33

Initial dosing: Should only be used for symptomatic HF (C or D) Furosemide: 10-40 mg/day Bumetanide: 0.5-1 mg/day Torsemide: 10-20 mg/day Goal: after initial diuresis and reduction of fluid, try to get to the lowest dose possible or even consider discontinuing

Question 34

MOA of Digoxin

Answer 34

MOA: positive inotropic activity and negative chronotropic activity Increase in intracellular Na and Ca→ increase in force of contraction What is the driving force behind digoxin producing negative chronotropic activity? Key PK notes: Large VD, larger in obese/smaller in elderly Which is more likely to have unintended toxicity? Primarily renally excreted

Question 35

Dosing of Digoxin

Answer 35

Dosing: recommend low dose for normal renal function→ 0.125 mg/day (should only be used in symptomatic HF- stage C/D) Elderly or renal insuficiency → 0.125 mg every other day Monitor digoxin levels only for toxicity (>2 ng/dl), not efficacy literature shows worse outcomes with higher normal levels when compared to lower normal levels (i.e. 0.5-1 ng/dl vs 1.5-2 ng/dl)

Question 36

ADR of Digoxin

Answer 36

``` High potential for digoxin toxicity Electrolyte disturbances Hypomagnesemia Hypokalemia Bradycardia GI disturbances (most common side effect) ```