Clinical Treatment of Heart Failure

Question 1

Goals of patients in stage A & B is all about prevention. What about patients in stage C?

Answer 1

Control symptoms, prevent hospitalization/ mortality!

HFpEF: identify comorbitities, diuresis, quality of life
HFrEF: patient education, diuretics, beta blockers, etc

Question 2

What are the specific HF goals of Rx?

Answer 2

• Correction of underlying cause (if possible)
• Elimination of precipitating factors
• Reduction of congestion (ie. diuretics)
• Improve blood flow

Question 3

Again (from last lecture) what tests/ procedures are done?

Answer 3

• Vitals
• ECG
• CBC
• Chest X ray (CXR)
• BNP
• Echo
• Coronary angiogram

Question 4

What is the most common therapy for all HF patients?

Answer 4

Diuretics: reverses fluid retention

• Loop diuretics preferred because more potent
• Can be used chronically (oral) and acutely (IV in hospital)

Question 5

Okay so diuretics decrease venous congestion, but describe with a SV (y axis) end-diastolic pressure (x axis) the FUNDAMENTAL treatment of heart failure…

Answer 5

The graph is logarithmic (increases fast then slows down)
-So large increases in diastolic pressure don’t increase SV very much and screw over your heart. But this is how your body compensates to increase SV (Na retention)

-Decreasing end-diastolic pressure to a degree saves the heart with only minimal decrease in stroke volume

Question 6

Diuretics half short half lives and are pretty cheap, but what’s the big difference between furosemide vs bumetanide or torsemide

Answer 6

Furosemide doesn’t absorb as well in intestines

-bumetanide/ torsemide have better oral bioavailability

Question 7

Grandpa eats at the brazilian steakhouse again and can’t breath (HFrEF) and vomits all night because of food poisoning. What do you give him?

Answer 7

Don’t use diuretics because he’s dehydrated

- Use IV Fluids (has lower stroke volume because low fluid)

Question 8

Review: How does your body respond to low CO?

Answer 8

RAAS activation = vasoconstriction + Na retention > increased fluid volume/ pressure

Adrenergic = vasoconstriction + increase HR

Question 9

What medications block the RAAS pathway? How?

Answer 9

ACE inhibitors (“-pril”)

• Blocks conversion of ATI => ATII (Angiotensin Converting Enzyme)
• Effects: direct vasodilation, decreased aldosterone release

Question 10

What are the side effects of ACE inhibitors?

Answer 10

Hypotension
Worse renal function
Hyperkalemia
COUGH
Angioedema

Question 11

What other medications block the RAAS pathway by blocking the receptor of angiotensin II?

Answer 11

ARBS (“-sartan”)

Question 12

ARBS are essentially equivalent to ACE inhibitors. When would you decide to use these instead?

Answer 12

To avoid cough (not a side effect)

Question 13

He talked a lot about LCZ696 as a new hot medicine. What is it?

Answer 13

ARB + sacubutril (neprolysin inhibitor)

Supposedly had better effects in ACEI

Question 14

Mineralocorticoid Receptor Antagonists (MRA) are also pretty dope diuretics. What do they do?

Answer 14

The name just told you…

• block mineralocorticoids in kidney
• Also have some antifibrotic effects

=spironolactone and eplerene

Question 15

What medications do you use to block the adrenergic pathway? How do they work?

Answer 15

Beta blockers (“-olols”)
-antagonize sympathetic system
Beta 1 block:
-negative chronotrope (slow HR)
-negative inotrope (decrease metabolic demand)
[sometimes block alpha 1, beta 2]

Question 16

T/F: You should put someone on all three drugs (ACE/ARB, Beta blockers, aldosterone inhibitors) to reduce morbidity and death?

Answer 16

True

• Together they decrease remodeling best
  - hypertrophy
  - fibrosis
  - apoptosis

Question 17

If you have an african american patient that is using all three of these drugs and still has hypertension, what could you give him?

Answer 17

Hydralazine/ isosorbide dinitrate (arterial vasodilator)

There are other venous dilators and pulmonary arterial vasodilators too

Question 18

Again, what are the 2010 guidelines for treating someone with stage 3 (NYHA Class I-IV) HfrEF?

Answer 18

Loop diuretics +
ACEI or ARB or ARB-neprolysin inhibitor +
aldosterone antagonist +
hydral-nitrates (African Americans)

Question 19

Who should get an Implanted Cardioverter Defribillator (ICD)?

Answer 19

Patients with LVEF (left ventr. ejection fraction)

Question 20

What other electrical therapy can you use to restore ventricular synchrony? Who should get it?

Answer 20

Cardiac Resynchronization Therapy (CRT) aka Bi-ventricular pacemaker (BiV)
-Shocks ventrical/ septal wall to contract together

> Patients with left bundle branch block, QRS > 120 msec

Question 21

For an acute patient that comes in and is warm and wet (congested), you give IV diuretics. What about an acute patient that is cold and wet (ie. in shock)?

Answer 21

You need to give them a positive inotrope!

-also, address their precipitants to bring up their CO before using diuretics

Question 22

Alright ER doc, summarize your plan of action for an acute hospitalized HF patient?

Answer 22

1) IV diuretics
2) IV vasodilators (if BP allows)
3) Ventilation (for hypoxia)
4) cut back beta blockers (severe cases)
5) IV inotropes (shock only)

Question 23

So what’s the big difference between chronic vs. acute treatment

Answer 23

Chronic: trying to slow heart down (ie. beta blocker)
Acute: trying to stabilize (opposite effect of beta blocker)
-increase inotropy to bring SV back up

Question 24

What are some good positive inotropes to use in an acute setting?

Answer 24

Epinephrine
Norepinephrine
Dopamine
Dubutamine
Digoxin
(milrinone)

Question 25

What happens if the patient moves into stage D?

Answer 25

Transplantation
mechanical support (LVAD)
Supportive care (shorter life - better quality)
Inotrope infusion (shorter life - better quality)

Question 26

That was all HFrEF. But with HFpEF the problem is lusitropy. What do you do to treat them?

Answer 26

-ACEI and ARBs don’t work!
=volume control (diuretic/ vasodilators) and treat underlying disease (hypertension, diabetes, kidney dysfxn)

**Not much you can do with HFpEF