Clinical Treatment of Heart Failure Flashcards Preview

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Flashcards in Clinical Treatment of Heart Failure Deck (26):
1

What is the most common HF therapy and what does it do?

Diuretics: Reverses the sodium and fluid retention of HF
- treatment of volume overload

2

What can you augment diuretics with?

thiazide diuretic

3

Do you use diuretics chronically or acutely?

Both:

- Typically PO dose at baseline, adjust to patient need
- Often used IV in the hospital

4

Which part of the Frank-starling curve do diuretics work?
why is this significant?

Typically work at the far end of the Frank-Starling curve,

- such that significant decreases in pressure produce minimal changes in stroke volume (and thus cardiac output).
→ Thus, symptoms of congestion can be reduced without major effects on blood flow

5

How do diuretics treat volume overload?

↑ salt/water excretion
↓ intravascular fluid vol
↓ venous congestion
↓ dyspnea edema

6

describe 2 methods that the body senses ↓ CO and how it resolves it

↓ CO

1. Juxtaglomerular apparatus in kidney senses lower flow → RAAS activation
2. Carotid sinus/aortic baroreceptors sense lower pressure → ANS/ adrenergic activation

7

What does activating the RAAS result in?

1. vasoconstriction
2. ↑ sodium retention → ↑ volume
- ↓ LV squeez (systolic HF)
- ↑ stiffness (diastolic HF)

8

ACE inhibitors
- end in?
- block what?

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

9

ACE inhibitors effects

 Direct vasodilation
 Decreased aldosterone activation

10

ACE inhibitors side effects

 Hypotension
 Worsening renal function (afferent vasocontraction)
 Hyperkalemia
 Cough (kinin potentiation)
 Angioedema

11

ANGIOTENSIN RECEPTOR BLOCKERS (ARBS)
- end in?
- block what?

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

- In studies have been equivalent to ACEI
- Generally used when patients develop cough to ACEI

12

ARBS side effects

ARBs do not produce kinin potentiation (no cough)

 Otherwise side effects are similar to ACEI

13

ALDOSTERONE RECEPTOR BLOCKERS

Spironolactone and eplerenone

14

ALDOSTERONE RECEPTOR BLOCKERS effects

Block effect of aldosterone on the kidney
• ACEI/ARB aldosterone block is incomplete
• This Produces additional sodium loss (diuretic)
• Antifibrotic

15

ALDOSTERONE RECEPTOR BLOCKERS side effects

Hyperkalemia (requires close monitoring)

16

BETA-BLOCKERS
- end in?
- block what?

…olols (metoprolol, carvedilol, bisoprolol)

Antagonize effect of sympathetic system (epinephrine/norepinephrine)

• β1 blockade:
– Negative chronotrope (slow heart rate, less arrhythmia)
– Negative inotrope (decreased metabolic demand)


*note: [α1 blockade: vasodilation]

17

BETA-BLOCKERS
side effects

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

Bronchoconstriction

18

ACEI + Angiotensin receptor blockers (similar)
Beta Blockers
Aldosterone receptor blockers
- all contribute to do what?

All 3 reduces morbidity and improve survival
- ↓ hypertrophy, fibrosis, apoptosis

19

What class and level are:
ACEI
Beta Blockers
ARBs

Class I level A

20

Class class is digoxin?

Class IIb level B

21

What is the difference between arterial, venous, and pulmonary arterial vasodilation?

 Arterial vasodilation (antihypertensives)
- Decrease in LV afterload
- Reduced cardiac work
- Less mitral regurgitation
 Venous vasodilation
- Decrease in preload
 Pulmonary arterial vasodilation
- Decrease in RV afterload

22

2 types of electrical therapies for HFrEF

Implanted Cardioverter Defibrillators

Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)

*note: CRT/BiV are usually placed with ICD

23

What types of pts receive:
- Implanted Cardioverter Defibrillators
- Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)

Implanted Cardioverter Defibrillators
 Patients with LVEF 120 msec (bundle brank block)

24

Cardiac Resynchronization Therapy / Biventricular Pacemakers (CRT or BiV)
- how is it set up?
- what does it do

Left ventricular lead placed from the RA through the coronary sinus over the epicardium of the LV
- (3 leads: RA, RV, cor sinus/LV)

Cause the LV lateral wall and septal wall to contract together, which produces
 a more efficient contraction / ↑ stroke volume
 may also improve mitral valve function / ↓ regurgitation

25

Effects of Inotropic agents

↑ contractility (SV-VEDP curve increases closer to norm range)
↑ HR
Improves symptoms short term
Long-term HF is worsened

26

For HFrEF
which drugs:
- Improve symptoms?
- Prolongs survival?

 IMPROVE SYMPTOMS
Diuretics (furosemide)
Inotropes (for HFrEF - digitalis PO [acute HF w/ shock: dobutamine, milronone)

 PROLONG SURVIVAL (for HFrEF)
ACE Inhibitors (prils – e.g. lisinopril)
Angiotensin Receptor Blockers (sartans – e.g. valsartan)
Beta Blockers (olols – e.g. carvedilol, metoprolol)
Aldosterone Antagonists (spironolactone, eplerenone)
Vasodilators (nitrates, hydralazine, …)
Cardiac Resynchronization Therapy (biventricular pacing)
Implantable Cardioverter Defibrillator (ICD) [does not improve symptoms]

*note: these drugs reduce remodeling, so they help symptoms too