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Flashcards in Clinical Treatment of HF Deck (21):
1

Major goals of HF therapy (6)

  • Correction of the underlying cause of HF
    • e.g. revascularize in case of ischemia
  • Elimination of precipitating factors
  • Reduction of congestion (fluid optimization is a major part of HF therapy)
  • Improve flow (may be difficult to do medically)
  • Modulate neurohormonal action
    • Long-term stabilization, positive remodelling, increased survival.
  • Optimization of cardiac function

 

2

Major classes of medication for HF (4)

  • diuretics
  • vasodilators
  • neurohormonal antagonists
  • inotropes

3

Function of diuretics in tx of HF

  • reverse the sodium and fluid retention of HF
  • fxn @ far end of the frank-starling curve, such that significant decreases in pressure produce minimal changes in stroke volume (and thus CO)
  • symptoms of congestion can be reduced without major effects on blood flow

4

Fxn of various types of vasodilators in tx of HF

  • Vasodilators: arterial, venous, and pulmonary arterial vasodilation

  • Arterial: ↓ LV afterload, ↓ cardiac work, ↓ mitral regurgitation

  • Venous: ↓ preload

  • Pulmonary: ↓ RV afterload

     

5

Types of neurohormonal antagonsists

  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Aldosterone receptor blockers
  • Beta-blockers

6

ACE inhibitors fxn in tx of HF (+side effects)

  • block conversion of ATI to ATII→direct vasodilation, decreased aldosterone activation
  • Side effects: hypotension, worsening renal failure, hyperkalemia, cough (kinin production), angioedema

7

Angiotensin receptor blockers fxn in tx of HF

  • blocks receptor of ATII→ equivalent to ACE -Is, but without cough.

8

Aldosterone receptor blockers fxn in tx of HF

  • block aldosterone action in kidney→↓sodium→diuretic
  • anti-remodeling activity at the level of the heart

9

Beta-blockers fxn in tx of HF (+side effects)

  • antagonize effects of the sympathetic nervous system→↓chronotropy ↓inotropy (short term loss for long term gain)
  • Side-effects: bronchoconstriction

10

Fxn of Inotropes in tx of HF (& major types)

  • administered via IV agents short term in the ICU to reverse shock (long term—worsen remodelling ↑mortality)
  • Digoxin—K/Na exchanger
  • Dobutamine—beta agonist
  • Milrinone—PDEi (posphodiesterase inhibitor)

11

Electrical therapies used for HF (2)

  • defribrillators
  • resynchronization

12

Fxn of defribillators in tx of HF

  • for patients with LVEF 
  • Abort sudden cardiac death from ventricular tachycardia/fibrillation.

13

Fxn/procedure of resynchronization in tx of HF

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

  • For patients with QRS > 120 msec (bundle branch block)

  • Cause the lateral wall and septal wall to contract together, which produces:

    • More efficient contraction→↑stroke volume

    • May also improve mitral valve function→↓regurgitation

       

14

Advanced therapies for tx of HF

  • Transplantation: shortage of organs.
  • Mechanical support devices: often used as a bridge to transplantation or as a destination therapy.
  • Hospice: palliative advanced therapy→paradigm shift from quantity to quality of life

15

Therapy goals/Tx for Stage A HF

  • Stage A: at risk for HF but without structural disease or symptoms
  • Therapy goals: treat hypertension, smoking cessation, treat lipid disorders, regular exercise, discourage alcohol intake, drug use, control metabolic syndrome
  • Drugs: ACEi or ARB in appropriate patients.

 

16

Therapy goals/Tx for Stage B HF

  • Stage B: structural heart disease but without signs or symptoms of HF.
  • Therapy goals: same as stage A
  • Drugs: ACEi, ARB, beta-blockers
  • Devices: implantable defibrillators

 

17

Therapy goals/Tx for Stage C HF

  • Stage C: structural heart disease with prior or current symptoms of HF.
  • Therapy goals: same as stage A and B + dietary salt restriction.
  • Routine drugs: diuretics, ACEi, beta-blockers
  • Drugs in selected patients: aldosterone antagonist, ARBs, digitalis, hydralazine/nitrates
  • Devices: biventricular pacing, implantable defibrillators

 

18

Therapy goals/Tx for Stage D HF

  • Stage D: refractory HF requiring specialized interventions
  • Therapy goals: A, B, and C + end of life decisions regarding the appropriate level of care.
  • Options: compassionate end-of-life care/hospice or extraordinary measures
  • extraordinary measures: transplant, chronic inotropes, permanent mechanical support, experimental surgery/drugs.

 

19

Type of HF which most pharmacological treatments are used for

  • Most treatments are designed and indicated for patients with reduced ejection fraction (HFrEF)
  • However, 50% of pts w/HF have HFnEF (normal ejection fraction)

20

Tx for pts w/HFnEF

  • Trials for neurohormonal antagonists have not been successful in improving outcomes for patients with HF and normal ejection fraction.

  • ICD/CRT are not generally indicated in patients with LVEF > 35-40%

  • Therapy consists of treating the underlying disorder—hypertension, diabetes, kidney dysfunction, aortic stenosis.

  • Diuretics are used to keep volume normal (sodium retention is common)

  • Vasodilators are used to maintain normal blood pressure.

21

Conditions that most often lead to heart disease/HF (6)

  • Hypertension
  • Diabetes
  • Hyperlipidemia
  • Physical inactivity
  • Excessive alcohol intake
  • Excess dietary sodium