Drugs for Heart Failure - Kruse Flashcards Preview

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Flashcards in Drugs for Heart Failure - Kruse Deck (49):
1

Typical direct cause of heart failure

Decreased contractility of the myocardium --> insufficient oxygen supply to the body

2

Historically, drug therapy for heart failure has typically focused on what 2 end results?

But ____

- Volume overload (diuretics)
- Myocardial dysfunction/weakness (inotropic agents)

NOT ENOUGH to improve survival

3

Agents that act directly on _____ seem to be more valuable in the long run

Organs other than the heart that are involved in hemodynamic consequences of HF

4

Today, primary treatment for long term HF is aimed at doing what?

Mainly via altering what two compensatory systems?

Reducing preload and afterload
- RAAS
- Sympathetics

5

Common symptoms of all heart failure (5)

- Tachycardia
- Decreased exercise tolerance
- Shortness of breath
- Edema
- Cardiomegaly

6

Digoxin
- Drug class?
- Things to be cautious of when administering? (3)
- MoA?
- Results? (2)
- INDICATED WHEN?
- Toxicity?
- Cure?

- Cardiac glycoside
- Dose ∆ w/ renal problems, vasodilators, or sympathomimetics
- Inhibits Na/K ATPase of sarcolemma --> increased calcium build-up
- INCREASED CONTRACTILITY AND increased K+ efflux --> SHORTENED AP
- INDICATED in HF w/ S3 or A. FIB.
- Toxicity = ANY arrhythmia (next card)
- Give K+ (decrease K+ outflow) and antidigoxin fab Ab

7

Describe how arrhythmias can develop with digitalis toxicity

- Decreased atrial refractory period --> ectopic atrial contractions --> A. tach. --> A. fib
- Increased ventricular refractory period --> AV dissociation --> ectopic ventricular contractions --> V tach. --> V fib.

8

Classic EKG finding for digitalis toxicity

Downward "U-shaped" ST segment

9

"-rinone" - drug class?

Bipyridines - PDE3 inhibitors

10

MoA of bipyridines ("-rinone")

PDE3 inhibition --> increased cAMP --> increased Ca++ (contractility) and increased SM (vascular) dilation

11

End results of bipyridines (2)

- Increased contractility
- Decreased preload and afterload

12

Use of bipyridines

SHORT-TERM relief in HF

13

Toxicities of each of the bipyridines

Inamrinone - GI, arrhythmias, thrombocytopenia, liver enzymes
Milrinone - arrhythmias ONLY

14

A patient is on Inamrinone for short-term HF but is having complications with bleeding. Replacement drug?

Milrinone

15

Dobutamine
- MoA
- Direct result
- Overall result
- DOC for what?
- Side effects? (2)

- Beta-1 agonist
- AC --> cAMP --> PKA --> increased Ca++ (contractility)
- Increased stroke volume (cardiac output)
- DOC for SYSTOLIC DYSFUNCTION in HF
- S.E. = tachycardia, arrhythmias

16

Dopamine
- Used for what (in HF)?
- How?

- Raising BP in vasodilation circulatory collapse (sepsis, anaphylaxis)
- HIGH DOSE --> alpha-1 and beta-1 agonist --> peripheral vascular constriction and increased contractility

17

When should dopamine use be avoided? Why?

CAD patients - tachycardia (increased O2 demand) may provoke ischemia

18

Diuretic class shown to improve survival in advanced HF? Why?

Aldosterone antagonists - aldosterone causes myocardial and vascular fibrosis and remodeling, and baroreceptor dysfunction

19

Main aldosterone antagonists used

- Spironolactone
- Eplerenone

20

Antagonism of ____ from the RAAS system is a cornerstone for HF management

Angiotensin 2

21

Negative effects of angiotensin 2 in HF (6)

- Na/H20 retention
- Increased catecholamines (sympathetics)
- Arrhythmogenic
- Vascular hyperplasia
- Myocardial hypertrophy
- Myocyte death

22

Inhibiting Angiotensin 2 will do what? (multiple)

- Reduce preload
- Reduce afterload
- Decrease sympathetics
- Reduce aldosterone
- Reduce myocardial/vascular remodeling

23

Problem with loop diuretics in HF?

K+ wasting --> arrhythmias

24

Why are ACE inhibitors maybe even better than aldosterone inhibitors?

ACE inhibitors ALSO inhibit aldosterone secretion

25

Substance that directly slows myocardial and vascular remodeling by angiotensin 2

Bradykinin (increased w/ ACE inhibitors)

26

Which is better 1st: ACEI or ARB? Why?

ACEI - increased bradykinin --> slowed tissue remodeling

27

When to give an ARB?

Side effects from ACEI (cough, angioedema)

28

2 functions of vasodilators in HF

- Reduce preload (venous dilators)
- Reduce afterload (arteriolar dilators)

29

MoA of vasodilators

N.O. --> G.C. --> cGMP --> relaxation

30

Venodilator drugs

- Isosorbide
- Nitroglycerin

31

Adverse effects of venodilators

- Postural hypotension
- Tachycardia
- Headache

32

Arteriolar dilator drug

Hydralazine

33

Use of Hydralazine in HF

- Decrease afterload (BP), increased C.O.

34

How are vasodilators really used?

Veno and arteriolar TOGETHER

35

Hydralazine toxicity

- Tachycardia
- Fluid retention
- Lupus-like symptoms

36

Nitroprusside - MoA

Arteriolar AND venous dilator (via N.O.)

37

Nitroprusside - clinical use

- Acute cardiac decompensation
- HTN emergencies

38

3 beta blockers that reduce mortality in HF

- Bisoprolol (Beta-1)
- Carvedilol (Beta-1, Beta-2, and alpha-1)
- Metoprolol (Beta-1)

39

Results of beta blockers in HF

- Decreased myocardial remodeling
- Slight EF rise over time
- Decreased HR (oxygen demand, etc.)

40

How to safely remove sodium in HF?

- Loop diuretic + supplements
- K-sparing diuretics

41

Potassium levels are especially important when giving which drug?

Digoxin (Digitalis)

42

HF + edema...best first drug?

Diuretic

43

HF w/o edema...best first drug?

ACEI (or ARB)

44

How to know which vasodilator to use?

Based on patient symptoms

45

Patient w/ dyspnea, pulmonary congestion, high atrial diastolic volume (filling pressure)...

Which vasodilator to give?

Venous dilators (nitro, isosorbide)

46

How to administer beta blockers in HF?

LOW DOSES - prevent worsening of HF via too much sympathetic antagonism

47

Are effects of beta blockers in HF immediate?

NO, may take months

48

When is Digoxin given?

If ACEI and diuretics fail to control symptoms

49

11 steps to treating chronic HF

1. Control HTN, hyperlipidemia, DM, obesity
2. Reduce heart workload (rest)
3. Restrict Na, give diuretic
4. Restrict water (rare)
5. ACEI or ARB
6. Digoxin (S3 or A fib.)
7. Beta blocker (if stable; low dose)
8. Aldosterone antagonist
9. Vasodilator
10. Cardiac resynchronization
11. Cardiac transplant