Chronic Heart Failure

Question 1

What is Heart failure?

Answer 1

– Inability to provide enough oxygenated blood to the rest of the body

Question 2

What is Preload?

Answer 2

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

Question 3

What is Afterload?

Answer 3

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

Question 4

What is Ejection fraction (%)?

Answer 4

– Amount of blood pumped / end diastolic volume

Question 5

What are two ways to lower mortality rate due to Chronic Heart Failure?

Answer 5

• Pharmacological

* Non-Pharmacological

Question 6

What are some of Pharmacological ways to tx HF?

Answer 6

• ACE I/ARBs
• BB
• Aldosterone Blockers
• Vasodilators

Question 7

Incidence of HF is Increasing at a dramatically fast rate, Why?

Answer 7

• Baby Boomers
• We do great job at tx’ing CAD
• Better screening, catching it earlier
• Untreated HTN
• Older life expectancy, more opportunity to develop HF

Question 8

What are ACC/AHA Stages of HF?

Answer 8

A. At high risk for HF but w/o structural heart disease or symptoms of HF (CAD, HTN, DM, Obese, Metabolic Syndrome OR Using Cadriotoxins, FHx)

Therapy: ACE I or ARBs for Vascular dz of DM

B. Structural heart disease but w/o s&s of HF (Previous MI LVH w/o symptoms)

Therapy: ACE I or ARBs + BB (to delay progression)

C. Structural heart disease but with prior or current symptoms of HF (Known Structural H. dz w/ symptoms ie: SOB, Fatigue, DOE)

Therapy: Diuretics (loop), ACE I or BB (Select pt’s Aldosterone, ARB’s digitalis, hydralazine/nitrates)

D. Refractory HF requiring specializing interventions (N-Stage HF – Marked Symptoms at rest despite maximum medical therapies)

Therapy: Hospice Care, Heart Transplant, IV Inotropes, Mechanical Support, Experimental Surgery or drugs

Question 9

What are NYHA functional classification?

Answer 9

Class I – Ordinary activity does not cause symptoms

Class II - Ordinary activity does not cause symptoms

Class III – Less than ordinary activity causes symptoms

Class IV – Symptoms are present at rest

Question 10

Types of HF?

Answer 10

– Systolic

– Diastolic

Question 11

About Systolic HF?

Answer 11

• EF < 40% → poor EF & CO
• Most common
• Problem with ejection of blood to the lungs or systemic circulation
• Result of hypertrophy and dilation of ventricle

Question 12

About Diastolic HF?

Answer 12

• EF >55% → normal EF w/ poor CO
• Inability of the heart to fill appropriately
• Usually results from stiffness of myocardium
• More difficult to treat
• Treatment not well defined

Question 13

What are the 4 compensatory mechanisms of HF?

Answer 13

• RASS
• SNS
• V. Hypertrophy
• Frank-Starling Law (increase End diastolic Vol.)

Question 14

How do Compensatory mechanisms affect Heart?

Answer 14

They delay symptoms as result of HF…….

Question 15

How doe Frank-Starling Law effect Heart?

Answer 15

For a very short time Heart will stretch longer (increase Radius of Ventricle/Increase End diastolic Vol.) to compensate for reduced CO.

Question 16

What’s the major contradiction of CCB’s in a pt w/ Systolic HF?

Answer 16

CCB’s can cause death if used in a pt w/ Systolic HF

Question 17

ACEi/ARBs MOA?

Answer 17

– Interference with RAAS ending with disrupting angiotensin II

– Produces decreases BP, Na/H2O retention

– Afterload reducer

Question 18

ACEi/ARBs Key PK notes?

Answer 18

– Highly excreated via kidneys; dose reductions often necessary as long as K is within normal limits

Question 19

ACEi/ARBs Dosing?

Answer 19

–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
          * Start at 5mg, double to 10mg, than double to 20mg……
          * Wait at least 2 weeks before you add BB (takes about 6 mo to reach goal)
          * Every two weeks, you should either do something w/ ACE I or BB. 
          * Never start ACE I & BB together at the same time unless you’re in hospital setting

Question 20

ACEi/ARBs ADRs?

Answer 20

– Cough (ACEi)
– Hyperkalemia
– Hypotension

Question 21

ACEi/ARBs Absolute contraindications?

Answer 21

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

Question 22

Which drug class is prefered in HF, ACEi or ARBS?

Answer 22

• ACE I are recommended no efficacy diff but a cost diff

Question 23

Which BB can be used for HF?

Answer 23

• Metoprolol succinate
• Bisoprolol
• Carvedilol 2/day

Question 24

What can BB cause?

Answer 24

HF is started in high dosage

Question 25

BB MOA?

Answer 25

– Blockage of beta receptors leading to decreased heart rate, BP, increase coronary artery blood flow

Question 26

BB Dosing?

Answer 26

* 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 27

Aldosterone Blockers Drugs?

Answer 27

– Spironolactone | – Eplirinone

Question 28

Aldosterone Blockers MOA?

Answer 28

* Competes with aldosterone for intracellular mineralcorticoid receptors → Na and H2O excreation (this also increases K in the blood) * Decreases preload

Question 29

Aldosterone Blockers Key PK notes?

Answer 29

– Highly protein bound – Primarily renally excreated – Aldosterone Blockers

Question 30

Aldosterone Blockers ADRs?

Answer 30

– Hyperkalemia | – Gynecomestia

Question 31

Aldosterone Blockers Absolute contraindication?

Answer 31

– Hyperkalemia

Question 32

Vasodilators Drugs?

Answer 32

– Hydralazine: direct arterial vasodilator | – Isosorbide dinitrate: direct vasodilator

Question 33

Vasodilators MOA?

Answer 33

* Predominately vasodilates in coronary, cerebral, and renal arteries * Converts into nitric oxide which produces vasodilation

Question 34

Vasodilators Key PK notes?

Answer 34

–Used in place of ACEi contraindications; not renal excreted • Evidence shows this drug combination is useful in African American patients with HF (along with other traditional meds-ACE, BB, etc).

Question 35

Vasodilators ADRs?

Answer 35

– Tolerance to nitrates | – hypotension

Question 36

When do you use Vasodilators?

Answer 36

When you can't use ACE I or ARDs

Question 37

Why would Vasodilators benefit being seen only in African Americans but not in Caucasians?

Answer 37

Because you're more likely to use ACE I or ARBs for Caucasian

Question 38

Which drug class is most effective in HF?

Answer 38

Loop Diuretics

Question 39

Loop Diuretics MOA?

Answer 39

– Exerts their action at the loop of Henle. Increase Na and H2O excreation. Since all diuretics reduce pre-load and edema why are loop diuretics prefered over other agents (such as thiazide diuretics)

Question 40

Loop Diuretics Key PK notes?

Answer 40

– May require higher than usual doses to induce diuresis in patients with renal failure

Question 41

Loop Diuretics Goal?

Answer 41

– After initial diuresis and reduction of fluid, try to get to the lowest dose possible or even consider discontinuing

Question 42

Loop Diuretics ADRs?

Answer 42

``` –Electrolyte imbalances (most common) • Hyperglycemia • Hyperuricemia • Hypokalemia • Hypomagnesemia ```

Question 43

Digoxin MOA?

Answer 43

–Positive inotropic activity and negative chronotropic activity • Increase in intracellular Na and Ca→ increase in force of contraction

Question 44

What is the driving force behind Digoxin producing negative chronotropic activity?

Answer 44

• Reduced intracellular K & Increases intracellular Ca+

Question 45

Which is more likely to have unintended toxicity using Digoxin?

Answer 45

• Elderly – Smaller VD leads to increased concentration in the blood

Question 46

Digoxin ADRs?

Answer 46

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

Question 47

Digoxin Additional comments?

Answer 47

– Hypokalemia increases the effects of digoxin – Hyperkalemia decreases the effects of digoxin – How can digoxin interfere with maximizing mortality reducing medications?