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HfrEF Rx

NYHA Class I-IV Stage C: ACEI/ ARB and Beta-blocker
For all volume overload, NYHA Class II-IV: add loop diuretics.
For symptomatic AA Class III-IV: add hydral-nitrates.
For Class II-IV with >30ml/min creatine and <5mEq/dL K+, add aldosterone antagonist.



Hydralazine: arterial vasodilation (po TID/ QID, SLE and headache)
Isosorbide Dinitrate: venous dilation (TID, hypotension, headache, and dizziness)
Improved EF, but ACEI better in reducing mortality, unless in AA receiving BB, ACEI, and Aldosterone antagonist.


ACEI and Dosing

Block ACE and Kinase II. Reduced mortality and hospitalizations. Recommended to reduce morbidity and mortality unless contraindicated.


Angiotensin II

Increase arteriolar constriction, CO, Na Resorption, Na and H2O retention, ADH, and thirst.


ACEI Patient Considerations

Side effects: cough, hyperkalemia, angiedema, renal dysfunction, neutropenia, hypotension.
Monitoring: Chemistry-7 with MG and Ca and BP once every 2 weeks x 1 month, then monthly; CBC once a month.
DDI: Lithium, NSAIDS, Salt Substitutes, Loop diuretics, K+sparing diuretics.
Contraindications: Pregnancy, bilateral renal artery stenosis, renal failure, angioedema, hyperkalemia.


ARBs (Angiotensin Receptor Blockers)

Dosing: Candesartant work.
Indicated when patient is intolerant to ACEI.


ARBs Patient Consideration

Similar to ACEI, but without the cough.


Beta-receptors Biological Response

Cardiac myocyte growth, positive inotropic and chronotropic response, and if overstimulated myocyte toxicity and apoptosis. Too much stimulation = increase in NE= decrease in survival.


Benefits of Beta-Blocker

Prevent downregulation of B1 receptors, apoptosis/oxidative stress, increased arrhythmia potential, hypertrophy/fibrosis.


Classes of Beta-Blocker

First generation: non-selective for B1 and B2 blockade, no ancillary properties (pro and tim)
Second: Selective for B1 and B2 blockade, no ancillary properties (met, as, bis)
Third: Selective or non-selective with ancillary (car and nep) properties.


Appropriate Patients for Therapy

Mild to severe symptoms of HF, LVEF <40%, receiving Rx with ACEI and diuretic, any age and either sex, CAD or nonischemic dilated cardiomyopathy. Diabetic and Non-Diabetic. COPD without reactive airway disease.


Neprilysin (LCZ696)

Action similar to Kinase II. Inhibits neprilysin from breaking down natriuretic peptides. Even better than ACEI.



Can Tx HTN with BB, ACEI, and ARBs. ARBs might be considered to decrease hospitalizations in HFpEF.


Digoxin Patient Considerations

Sinus rhythm or atrial fibrillation with HF despite ACEI, ARBs, BB,and diuretics. Patients who have symptoms of HF!



Beneficial in pts with HFrEF, unless contraindicated, to decrease hospitalizations for HF. No role in HFpEF.


Inotropic Therapy

Dobutamine: B1 agonist to increase contractility, slight peripheral vasodilation.
Milronone: PDE inhibitor, augments myocyte Ca2+ utilization,moderate peripheral vasodilation.
Indications: ADHF short-term management- Cold and Wet. To relieve symptoms and end-organ function, <90 systolic pressue, symptomatic hypotension despite adequate filling pressures, unresponsive to, or intolerant of intravenous dilators.



endogenous precursor of NE- exerts its effect by directly stimulating adrenergic receptors, as well as, release noepi from nerve terminals.


Aortic Stenosis

Crescendo-descrendo systolic ejection murmur. LV >> aortic pressure during systole. Loudest at hear base; radiates to carotids. Pulsus parvus et tardus. Syncope, angina, and dyspnea on exertion.



Holosystolic, high-pitched "blowing murmur". Mitral- loudestat apex and radiates towards axilla. MR is often due to ischemic heart disease, LV dilatation.


Mitral Valve Prolapse

Late systolic crescendo murmur with midsystolic click (due to sudden tensing of chordae tendinae). Loudest just before S2. Usually benign. Can be caused by myxomatous degeneration.


Ventricular Septal Defect

Holosystolic, harsh sounding murmur. Loudest at tricuspid area.


Aortic Regurgitation

High-pitched blowing early diastolic descrendo murmur. Long dyastolic murmur and signs of hyperdynamic pulse. when severe and chronic. Aortic root dilation, bicuspid, endocarditis, RF. Progresses to HF.


Mitral Stenosis

Follows opening snap. Delayed rumbling late diastolic murmur. LA >> LV pressure. Can lead to LA dilatation.


Loop Diuretics

Furosemide, torsemide, bumetanide (High loops). Thiazide (low loops). Acts on ascending limb (K+ wasting), Inhibits NaCl transport. po/iv if congested. High loops 25-30% of filtered Na+ reabsorbed. Use spironolactone to enhance diuresis and ameliorate potassium wasting. Hyperuricemia. Sulfa allergy.


Aldosterone Antagonists

Spironolactone (also a hormone receptor) and eplerone. Use because ACEI/ ARB aldosterone block is incomplete.