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Flashcards in Clinical Treatment of Heart Failure Deck (39):
1

What are the major goals of therapy?

↑ quantity of life (improve survival)
↑ quality of life (reduce symptoms)
Decrease societal / financial burden of disease

2

How to therapeutically approach HF?

-Correction of the underlying cause of HF
-Elimination of precipitating factors (infection, anemia, etc)
-Reduction of congestion
-Improve blood flow:
Modulate neurohormal activation
Devices / transplantation

3

What lab studies could rule out reversible causes of HF?

-Vitals BP / HR (hypertension)
-EKG (tachyarrhythmia, AFib, PVCs)
-CMP, CBC (renal failure, liver dysfunction, anemia, infxn)
-CXR (coexistant lung disease, for future comparison)
-BNP / NT-proBNP, troponin (prognosis)
-Echo (dilation, LV function, wall motion, PHTN, prognosis)
-Coronary angiogram v. CTA, stress testing, MRI (ischemia, scar)
-Thyroid function tests
-Iron studies (hemochromatosis, iron deficiency)

4

How do you reduce congestion?

Diuretics, Reverses fluid retention (Na loss)

5

The most common HF therapy

Diuretics

6

Pharmacokinetics of diuretics

Can be used chronically and acutely
Typically PO dose at baseline
Often use IV in the hospital (PO not absorbed, worsening renal function, also need higher dose)
Side effects: dehydration, hypokalemia, sulfa, tinnitis

7

Diuretics method of action

increase Salt (+Water) Excretion->decrease Intravasc Fluid Vol->decrease Venous Congestion->decrease dyspnea/edema

8

What are ACE inhibitors?

- …prils (lisinopril, enalapril, benazepril)
-Block conversion of ATI to ATII

9

Effects of ACEIs

Direct vasodilation
Decreased aldosterone activation

10

Side effects of ACEIs

Hypotension
Worsening renal function (afferent vasocontraction)
Hyperkalemia
Cough (kinin potentiation): ~20%
Angioedema: <1%, can occur after months of use

11

What are ARBs?

-…sartans (e.g. valsartan, candesartan, losartan)
-Effect: Block the receptor of angiotensin II

12

Clinical use of ARBs

-In studies have been equivalent to ACEI
-Controversial whether use in combination (ARB + ACEI) provides added benefit
-Generally used when patients develop cough to ACEI

13

Side effects of ARBs

ARBs do not produce kinin potentiation (no cough)
Otherwise side effects are similar to ACEI

14

What are Mineralocorticoid Receptor Antagonists (MRA)?

-Spironolactone and eplerenone
-Effect: Block mineralocorticoid receptor
Kidney: ACEI/ARB aldosterone block is incomplete
Produces additional sodium loss (diuretic), Antifibrotic

15

Side effects of MRAs

Hyperkalemia (requires close monitoring)
Gynecomastia (spiro only)

16

What are beta-blockers?

-olols (metoprolol, carvedilol, bisoprolol)
-Effect: Antagonize effect of sypathetic system (epinephrine/norepinephrine)
*β1 blockade:
-Negative chronotrope (slow heart rate, less arrhythmia)
-Negative inotrope (decreased metabolic demand)
-[α1 blockade: vasodilation]

17

Side effects of beta-blockers

Negative inotrope: short-term loss for long-term gain
Fluid retention
Hypotension
Decreased cardiac output, even cardiogenic shock
Bronchoconstriction

18

End result of Adrenergic and RAAS blockers?

-Anti-Remodeling Decreased:
Hypertrophy
Fibrosis
Apoptosis
-All 3 REDUCE MORBIDITY AND IMPROVE SURVIVAL

19

What are the different Vasodilators for HF?

Arterial vasodilation (antihypertensives)
Venous vasodilation (venodilators)
Pulmonary arterial vasodilation

20

Effect of pulmonary arterial vasodilation

Decrease in RV afterload

21

Effect of Venous vasodilation (venodilators)

Decrease in preload

22

Benefits of arterial vasodilatation

Decrease in LV afterload
Reduced cardiac work
Less mitral regurgitation

23

Use of Hydralazine / isosorbide dinitrate in HFREF

Hyd/ISDN < ACEI (V-HeFT II)
Hyd/ISDN+ACEI/BB in blacks good (A-HeFT)

24

What is an ICD?

Implanted Cardioverter Defibrillators
Patients with LVEF <=35% or prior dangerous heart rhythms
Abort sudden cardiac death from ventricular tachycardia / fibrillation

25

What is CRT therapy?

Cardiac Resynchronization Therapy
Biventricular pacemakers (CRT or BiV)
LV lead placed through the coronary sinus

26

Indication for CRT use

For patients with QRS duration > 120 msec (bundle brank block)

27

CRT mechanism of action

Cause the LV lateral wall and septal wall to contract together, which produces a more efficient contraction / ↑ stroke volume
Usually placed with ICD

28

Rx options for chronic (stable) HFrEF

BB
ACEI/ARB
Aldosterone antagonist
Hydralazine / ISDN
+/-Digoxin
ICD/CRT

29

Rx options for Acute decompensated HF

IV diuretics
IV vasodilators (nitrates / nitroprusside, if BP allows)
Positive pressure ventilation (CPAP/BiPAP, intubation) for hypoxia
May also reduce preload
IV inotropes for shock only
May need to cut back on beta-blockers (only in severe cases)

30

Types of Positive Inotropic Agents

Digoxin (PO) - K/Na exchange
Dobutamine (IV) – β agonist (opposite of BB)
Milrinone (IV) – phosphodiesterase inhibitor (effect is similar to dobutamine)

31

Clinical use of positive inotropic agents

ACUTE: IV agents used short term to reverse shock
Long-term they worsen remodeling
CHRONIC: Digoxin has no effect on mortality but may reduce symptoms and hospitalization (also some decrease in heart rate in AFib)
In high doses causes dig toxicity (mostly arrhythmias)

32

T or F: inotropic agents Improve symptoms short-term
Long-term HF is worsened

True

33

Beta-Agonism v. Antagonism:

ACUTE v. CHRONIC, respectively

34

Stages of HF

Asymptomatic HF (late “prevention”)
Chronic stable HF (ambulatory)
Acute decompensated HF (hospitalized)
End-stage heart failure (advanced)

35

What is LVAD?

Left Ventricular Assistance Device mechanical circulatory device that is used to partially or completely replace the function of a failing heart, can be used in CHF

36

Options for end-stage HFrEF

Transplant
LVAD
Inotrope infusion
Hospice

37

What can you do to improve Sx in HFrEF?

Diuretics (furosemide)
Digitalis PO (HFrEF with shock - dobutamine, milronone)

38

What can you do to prolong survival in HFrEF?

ACE Inhibitors / Angiotensin Receptor Blockers
Beta Blockers
Aldosterone Receptor Antagonists
Other Vasodilators (hydralazine + nitrates)
Cardiac Resynchronization Therapy (biventricular pacing)
Implantable Cardioverter Defibrillator (ICD)

39

Therapy for HFpEF

-treating the underlying disorder (hypertension, diabetes, kidney dysfunction)
-Diuretics are used to keep volume normal (sodium retention is common)
-Vasodilators are used to maintain normal blood pressure
-neurohormonal antagonists (e.g. ACEI, ARB) not successful