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Flashcards in Congestive Heart Failure Deck (63):
1

Thiazide diuretic drugs

Chlorthalidone
Hydrocholorthiazide
Metolazone

2

Loop diuretic drugs

Ethacrynic acid
Furosemide
Torsemide

3

Thiazide description for CHF

Relieve pulmonary congestion and peripheral edema
Decrease symptoms of volume overload (orthopnea)

Decrease plasma volume -> decrease venous return (preload) -> decreased workload and O2 demand
Decrease afterload

Only give if you see edema

4

Loop Description for CHF

Relieve pulmonary congestion and peripheral edema
Decrease symptoms of volume overload (orthopnea)

Decrease plasma volume -> decrease venous return (preload) -> decreased workload and O2 demand
Decrease afterload

5

Loop vs Thiazide CHF

Loop more effective than thiazides
Thiazides: patients with hypertensive heart disease (with congestive symptoms) -ineffective by itself due to its weak diuretic effect

6

Aldosterone antagonist drugs

Eplerenone
Spironolactone

7

Sironolactone

decreases cardiac fibrosis and remodeling

8

Aldosterone antagonist description CHF

Prevents sodium retention, myocardial hypertrophy and potassium loss
(When combined with ACE-I's -> decreases M & M of severe HF)

9

Aldosterone antagonist indication CHF

Advanced heart disease or patients with LV dysfunction after an MI (these patients have elevated aldosterone due to angiotensin stimulation and reduced hepatic clearance)

10

Aldosterone antagonist adverse CHF

Hyperkalemia
GI: gastritis, PUD
CNS: lethargy, confusion
Endocrine: gynecomastia, decreased libido, menstrual irregularities
Contraindicated in patients on potassium supplements

11

ACE-I drugs

Captopril
Enalapril
Lisinopril

12

ACE-I description CHF

**DOC in heart failure**
Dilates arterioles and veins

13

ACE - I mechanism CHF

Decreases PVR -> decreases BP/afterload -> increases CO
Decreases sodium and water retention -> decreases preload

Decreases long term remodeling

14

ACE-I indication CHF

Patients with symptomatic heart failure
Asymptomatic patients with decreased LVEF or history of MI
High risk patients: diabetes, HTN, atherosclerosis, obesity

15

ACE-I pk CHF

Oral- food decreases absorption
Pro-drugs except captopril

16

ACE-I adverse CHF

Persistent dry cough
Hypotension
Renal insufficiency
Hyperkalemia
Angioedema
**Teratogenic**

17

ACE-I contraindications CHF

Pregnancy
Bilateral Renal artery stenosis
Hyperkalemia

18

ARB drugs

Candesartan
Valsartan

19

ARB description CHF

Losartan is used for HTN
Candesartan is used for CHF

20

ARB mechanism CHF

Block AT-I receptor
No effect on bradykinin

21

ARB Indication CHF

Intolerant to ACE-I's
(cough/angioedema)

22

ARB adverse CHF

Same as ACE-I but no cough
Hypotension
Renal insufficiency
Hyperkalemia
Teratogenic

23

ARB contraindications

Pregnancy
Bilateral renal artery stenosis
Hyperkalemia

24

Direct vasodilator drugs

Hydralazine
Nitrates (isosorbide dinitrate)

25

Direct vasodilator description/mechanism CHF

Increase vasodilation -> decrease preload
Increase arterial dilation -> decrease PVR and afterload
Hydralazine dilates arterioles
Nitrates dilate the veins and venules
***Give in african americans***

26

Direct vasodilators indication CHF

Patients that are intolerant to ACE-I's or Beta blockers or black patients with advanced HF (adjuvant Tx)

Sustained improvement of LVEF when both oral vasodilators are combined

27

Direct vasodilator adverse CHF

HA, dizziness, hypotension
Hydralazine can also cause tachycardia, peripheral neuritis and a lupus like syndrome

28

Hydralazine adverse

HA, dizziness, hypotension
Tachycardia, peripheral neuritis, lupus like syndrome

29

Beta blockers for CHF

Carvedilol
Metoprolol

30

Beta blockers description CHF

Can reverse cardiac remodeling and reduce mortality

31

Beta blockers mechanism CHF

Decrease HR and RAAS (-ve inotrope)
Prevents deleterious effects of NE on cardiac muscle fibers
(renin inhibition and decreased HR)

32

Beta blockers indication CHF

Heart disease (stage B and C) in addition to an ACE-I

33

Beta blockers PK CHF

Start at low dose -> gradually titrate to effective dose (to avoid sudden exacerbation of sx)

34

Beta blockers adverse CHF

Initial treatment can cause fluid retention

35

Beta blockers contraindication CHF

Use cautiously in patients with asthma or severe bradycardia

36

Digoxin class

Inotropic agent: Cardiac glycoside

37

Digoxin description CHF

+ve inotrope
-ve chronotropic

From foxglove plant
Widely used in the treatment of HF

Very narrow therapeutic window

***Decrease sx of HF and hospitalization
Increase exercise tolerance
Does NOT increase survival ****

Indicated in patients with ***heart failure with A fib **** along with ACE-I and beta blocker

38

Digoxin mechanism CHF

Inhibits Na/K ATPase -> decreased sodium gradient -> indirect inhibition of Na/Ca2 exchange -> **increased cytoplasmic calcium therefore increased contractility**

Decreases SNS, RAAS, and PVR =-> decreases HR

Enhanced vagal tone -> decreased O2 demand

Decreased conduction through AV node increases the effective refractory period

39

Digoxin PK CHF

Widely distributed including the CSF

Accumulates in muscle -> high Vd; requires a loading dose

Sensitivity varies* between patients and may change during therapy

***Hypokalemia -> digoxin toxicity (competes with K for binding sites on ATPase)

***Hypercalcemia or decreased magnesium facilitate digoxin action
***High calcium increases chance atrial arrhythmia Mg does opposite

40

Digoxin adverse CHF

Extensive inhibition of ATPase can lead to dysrhythmias

Toxicity (very common):
Atrial arrhythmia-> slow
Anorexia, nausea, vomiting, HA, fatigue, confusion, blurred vision, **altered color perception, halos on dark objects**

Treatment of toxicity:
Withdraw or reduce dose
Monitor ECG, plasma concentration and K levels
***V tach-treat with lidocaine and Mg or increase potassium concentration***
severe- treat with digitalis antibodies

41

Digoxin contraindications CHF

**Diastolic or right side heart failure**
Uncontrolled hypertension
Bradyarrhythmias

Quinidine, Verapamil and Amiodarone and NSAIDs displace digoxin from tissue protein binding sites and compete for renal excretion

Digoxin levels affected by hyperthyroidism, hypothyroidism

42

Milrinone and Inamrinone CHF description

Inotropic agents
PDE-3 inhibitor (phosphodiesterase inhibitors)
Good for acute/short term in increasing CO

43

Milrinone and Inamrinone mechanism CHF

Inotropic agents
Increase cAMP -> +ve inotropic effects and increase CO (similar to Beta 1)
Systemic and pulmonary vasodilation -> decrease preload and afterload

Slight increase in AV conduction

44

Milrinone and Inamrinone Adverse CHF

Short term only, long term decreases life
Can cause thrombocytopenias

45

Dopamine description CHF

Inotropic agent
Used in the treatment of shock that persists after volume replacement

Stimulates both adrenergic and dopaminergic receptors

46

Dopamine Mechanism CHF

Inotropic agent
Low dose -> D1 dilates renal and mesenteric blood vessels

***Intermediate dose -> dopaminergic and beta 1 receptors -> increase force and rate of contraction and renal vasodilation****

High dose : alpha 1 receptors -> vasoconstriction (not helpful in CHF)

47

Dobutamine Description CHF

Inotropic agent
Beta agonist
Recemic mixture

Used in short term management of patients with cardiac decompensation

48

Dobutamine Mechanism CHF

+ve inotropic effects and vasodilation

Increased cAMP [Gs] -> phosphorylation of calcium channels with increased calcium entry into myocardium -> increased contraction

Little or no effect on HR

49

Glucagon Description CHF

Inotropic agent
**Acute cardiac dysfunction from beta blocker overdose**

50

Glucagon mechanism CHF

Gs-> increased cAMP -> contractility (without using beta receptors)
Inotropic and chronotropic effects
Give when you gave someone too many beta blockers

51

Systolic failure

Want to increase volume, give inotropes
-use diuretics, beta blockers, inotropes, Spirinolactone, ACE-I, direct vasodilators

52

Diastolic failure

Want to slow heart, block calcium channels
Use diuretics to decrease afterload
Use Calcium blockers to slow heart and increase filling
Use Beta blockers to slowdown heart

53

CHF Stage A

High risk of developing heart failure (selected patients receive ACE-I's/ARB's)

54

CHF stage B

Asymptomatic heart failure (selected patients receive ACE-I's / ARBs or beta blockers)

55

CHF stage C

Symptomatic heart failure (routine drugs include diuretics, ACE-I and beta blocker)

56

CHF stage D

Refractory end stage heart failure (end of life care or extraordinary measures)

57

Systolic failure definition

Contarctility and ejection fraction are reduced

58

Diastolic failure definition

Stiffening and loss of adequate relaxation -> abnormal ventricular filling and reduced CO even though the EF may be normal (does not respond to +ve inotropic agents)

59

Symptoms of heart failure

tachycardia, decreased exercise tolerance, dyspnea, peripheral and pulmonary edema

60

CHF

abnormal increase in blood volume and interstitial fluid leading to dyspnea and peripheral edema

61

Physiological compensation for CHF

Chronic activation of SNS and RAAS associated with tissue remodeling -> additional neurohormonal activation -> vicious cycle -> death

62

Goal of treatment of CHF

minimize the compensatory mechanisms-> reduce symptoms, slow progression and manage acute episodes

63

Do not use what drugs with diastolic failure?

+ve inotropic agents (increase outflow obstruction)