Exam 2 - Sowinski (CHF) Flashcards
(176 cards)
1
Q
2 types of CHF
A
HFrEF (systolic dysfunction) or HFpEF (diastolic dysfunction)
2
Q
definition of HFrEF:
A
HF symptoms with EF < 35 - 40%
3
Q
definition of HFpEF:
A
HF symptoms with EF > 50%
4
Q
main 4 compensatory responses
A
increased preload
vasoconstriction
tachycardia/increased contractility (SNS activation)
Ventricular hypertrophy/remodeling
5
Q
why is increased preload bad (aka what is its detrimental effect as part of compensation)
A
it causes pulmonary/systemic congestion and edema
6
Q
why is vasoconstriction bad (aka what is its detrimental effect as part of compensation)
A
increased afterload AND decreased SV AND
further activates compensatory responses
7
Q
why is tachycardia/increased contractility bad (aka what is its detrimental effect as part of compensation)
A
shortened diastolic filling time
ventricular arrhythmias
increased risk of myocardial cell death
8
Q
why is ventricular hypertrophy/remodeling bad (aka what is its detrimental effect as part of compensation)
A
diastolic/systolic function
Risk of myocardial cell death/ischemia
risk of arrhythmia/fibrosis
9
Q
3 main categories for drug-induced heart failue
A
Drugs that cause…
- Decreased contractility
- Direct Cardiac Toxins
- Na+/H2O retention
10
Q
What are some drugs that will may cause drug induced HF via decreased contractility
A
Beta blockers
CCBs (verap/diltiazem)
Antiarrhythmics
11
Q
What are some drugs that will may cause drug induced HF by being a direct cardiac toxin
A
Amphetamine/Cocaine/Ethanol
- nib drugs (Imatinib, Lapatinib, Sunitinib)
- rubin drugs
- zumab drugs
12
Q
What are some drugs that will may cause drug induced HF via Na+/H2O Retention
A
Glucocorticoids Androgens Estrogens NSAIDs/COX-2-Inhibitors Rosiglitazone/Pioglitazone Sodium Containing Drugs
13
Q
Classic HF Symptoms
A
- SOB and Chronic lack of Energy!!
- Swelling of feet/legs
- Difficultly sleeping due to breathing problems
- Swollen/tender abdomen w/ loss of appetite
- Cough with FROTHY sputum (??)
- Increased urination at night
- Confusion and/or impaired memory
14
Q
______ Ventricular failure is more related to signs/symptoms of Systemic venous congestion
A
RIGHT
15
Q
______ Ventricular failure is more related to signs/symptoms of pulmonary congestion
A
LEFT
16
Q
what are the symptoms of Left Ventricle Failure
A
since Left..pulmonary congestion happens….therefore.
- DOE
- Tachypnea
- Orthopnea
- Cough
- Hemoptysis
- PND (paroxysmal nocturnal dyspnea)
17
Q
what are signs of Left Ventricle Failure
A
Rales S3 gallop pulmonary edema pleural effusion Cheyne-Stokes Respiration
18
Q
what are the symptoms of right Ventricle Failure
A
since right..systemic venous congestion...aka lots of fluid overload Abdominal pain Anorexia nausea bloating constipation
19
Q
what are the signs of right Ventricle Failure
A
peripheral edema JVD (jugular venous distension) HJR (hepatojugular relfex) Hepatomegaly Ascites
20
Q
what is rales
A
when listening to lungs can hear fluid —- sounds like rattling
21
Q
what is orthopnea
A
having trouble breathing while laying down
22
Q
what is PND
A
Paroxysmal Nocturnal dyspnea
pt wakes up in middle of night and feels like they are drowning
23
Q
what is cardiomegaly
A
abnormal heart enlargement
24
Q
what is JVD
A
jugular venous distension
can see jugular vein pulsating
25
what are initial lab assessments done for HF
Hematology/Biochem (CBC, Serum electrolytes, BUN, CR, Thyroid function tests)
ECG (check for arrhythmias!!)
Chest X-Ray
BNP or NT-proBNP
26
what is a diagnostic value BNP in HF
> 100 pg/mL
27
what is a diagnostic value NT-proBNP in HF
> 300 pg/mL
28
How does NYHA classify HF patients
Classes I - IV and based on symptoms
| IV - is like hella bad/pt can't get out of bed without having symptoms
29
How does AHA classify HF pts
by STAGES A,B,C,D
A is at risk
D - is worst
30
AHA Classifications:
| What is Stage A
pt is at high risk of developing HF (ex: pt has HTN, CAD, DM, Dyslipidemia) NO symptoms
31
AHA Classifications:
| What is Stage B
pt has structural heart disease but NO signs/symptoms of HF
32
AHA Classifications:
| What is Stage C
current or prior HF symptoms with underlying struc. heart disease
33
AHA Classifications:
| What is Stage D
has advanced struc. heart disease and marked Sxs of HF
34
Definition of Asymptomatic rEF
No HF symptoms with EF < 40%
35
Definition of HFrEF
HF symptoms with EF < 40%
36
what classes/stages are known as Asymptomatic rEF
Stage B (AHA)
or
NYHA Funct. Class I
37
what classes/stages are known as HFrEF
Stage C/D (AHA)
or
NYHA Funct. Class II - IV
38
HF Pts: Sodium Intake Guidelines
2 - 3 gms/day (aka 4 - 6 gms of NaCl)
may have to do <2 g/day if severe HF
39
HF pts: Alcohol Intake Guidelines
if have HF due to EtOH -- then avoid completely
| if not EtOH induced --- NMT 2 drinks/day (men) or 1 drink/day (women)
40
HF Pts: when do you fluid restrict? how how do you fluid restrict?
```
if hyponatremia (Na < 130 mEq/L);
< 2 L/day
```
41
Managing HF:
| Reduce Intravascular Volume by using ______
diruetics
42
Managing HF:
| Increase myocardial contractility by using ______
positive inotropes
43
Managing HF:
| Decrease ventricular afterload by using _______
ACEIs and Vasodilators
44
Managing HF:
| Block Neurohormones by using what things?
```
Beta blockers
ACEIs
ARBs
Spironolactone
ARNIs
```
45
If Pt is Stage A HF --- how do you treat it?
Just Control Risk Factors
aka smoking cessation!!
treat any other diseases (DM, HTN, Dyslipidemia, CAD)
if PT has DM or coronary/cerebral, peripheral vascular disease then but them on an ACEI/ARB
46
If Pt is Stage B HF --- how do you treat it?
ACEI/ARB
and Beta-Blockers
(no diuretics because no symptoms)
47
If Pt is Stage C HF --- how do you treat it?
everyone is on ACEI/ARB, Beta blocker, and diuretic
48
T or F: Diuretics decrease hospitalization AND mortality
FALSE. reduces ONLY hospitalization
49
T or F: Even if HF pt does not have symptoms they should be on a diuretic
false! no symptoms = no diuretic
50
long term benefits of diuretics
reduce daily symptoms and improve quality to exercise
51
short term benefits of diuretics
reduce fluid retention by...
| decrease edema/pulmonary congestion/JVD
52
Diuretics:
| They reduce _____load AND reduce _______ pressure
PREload; cardiac filling
53
if a pt is fluid overloaded, diuretics should be used to reduce weight by ______ (how much?)
1 - 2 pounds/day
54
Patients need to report any weight gain of _______
3 - 5 lbs/week
55
____tension and (increase or decrease) SCr or BUN/Cr Ratio is indicative of volume depletion
HYPOtension
| INCREASE
56
What is a loop diuretic's "additional benefit"
they enhance release of renal prostaglandin
57
which loop diuretic has erratic bioavailability and which one could replace it
furosemide - erratic
| replace w/ torsemide
58
which thiazide diuretic is erratically absorbed
MTZ (metazolone)
59
initial dose of torsemide
10 - 20 mg QD
60
initial dose of furosemide
20 - 40 mg QD or BID
61
goal dose for furosemide
20 - 160 mg QD or BID
62
goal dose for torsemide
10 - 80 mg QD
63
which loop diuretic has the longest duration of action
Torsemide
64
Main ADEs of diuretics
Hypokalemia
Hypomagnesemia
Volume depletion
Decrease in renal function
65
Monitoring Parameters for Diuretics
```
Fluid intake/urinary output
Body weight
blood pressure
Serum Electrolytes (K+/Mg2+)
Renal function
S/Sx of systemic or pulmonary congestion (JVD etc..)
```
66
When using diuretics, K+ and Mg2+ can be low.... you should replace K+ if it is < _____ and replace Mg2+ if it is < ______
K: < 4
Mg: < 2
67
what drugs are known as neurohormonal blockers
```
ACEI/ARBs
Beta Blockers
ARNI
MRA (aldosterone antagonists! - mineralcorticoid receptor antag.)
ISDN/Hydralazine
```
68
what drug combo therapies have been proven to be most effective in HF (the chart about RCTs and the hazard ratio not crossing 1..)
- ARNI + BB + MRA
| - ACEI + BB + MRA
69
ACEI Mechanism:
| Bradykinin leads to vaso_____
dilation!
| why when ACEI prevents break down of bradykinin thats good....
70
Angiotensin II leads to vaso______
constriction
71
what are some reasons that a patient would be on a lower than normal ACEI dose
```
if CKD (CrCl < 30 mL/min)
Hypotension -- if symptomatic! (ok if low BP (to some extent...))
```
72
what are the 4 ACEIs used for HF
Lisinopril
Enalapril
Captopril
Ramipril
73
which ACEI for HF is once a day?
Lisinopril
74
which ACEI for HF is twice a day?
Ramipril and Enalapril
75
which ACEI for HF is three times a day?
captopril
76
For dosing of ACEI in HF:
| start low and double the dose how often?
every 2 weeks!!
| Q1 - 4 wks...
77
```
For dosing of ACEI in HF:
lower doses and more monitoring are required with...
SCr > ______
and/or
CrCl < _____
```
SCr > 3
| ClCr < 30
78
For dosing of ACEI in HF:
Use with caution if pt...
what 4 things
SBP < 80 mmHg
Volume Depleted
Serum K > 5
SCr > 3
79
Absolute contraindications for ACEI?
Pregnancy
Hx of Angioedema or Hypersensitivity
Bilateral Renal Artery Stenosis
Hx of well documented intolerance (dat cough)
80
ADEIs of ACEI
```
functional renal insufficency
hypotension
Hyperkalemia
skin rash
dysguesia (metallic taste in mouth)
Cough
Angioedema
```
81
Monitoring for ACEIs
| How to Monitor Renal Function and K+?
1) prior to therapy
2) 1 - 2 weeks after each increase in dose
3) 3- 6 mos intervals
82
T or F: It is ok to keep a patient on an ACEI even if their SCr has increased?
T and F.... it is ok unless the SCr increases more than 20%
83
Sacubitril/Valsartan is indicated for who?
HFrEF pts with NYHA Class II-IV
Must have K+ < 5.2
Must have eGFR > 30
84
ADEs of Sacubitril/Valsartan
just like ACEI/ARB...
Hypotension
Elevations in SCr and K+
(possibly rare) Angioedema
85
Contraindications for Sacubitril/Valsartan
within 36 hours of ACEI
if had angioedema with ACEI or ARB before
Pregnancy/Lactation
Severe Hepatic Liver impairment
known hypersensitivity to either ARB or ACEI
86
what are the 3 beta blockers that are ok to use in HF
carvedilol (regular or CR)
Metoprolol
Bisoprolol
87
Beta blockers are known to have what "special" property...
Reverse Remodeling! (genetic makeup changes)
88
2 pathways that beta blockers are beneficial for HF pts
Overall blocking cardiac NE.. but the 2 pathways are...
blocking Beta-AR pathway desensitization
AND
decreasing myocyte toxicity from NE
89
what patients should start a beta blocker
STABEL and EUVOLEMIC
90
if patient is in hospital for HF exacerbation--- when do you start a beta blocker (near beginning or end of stay?)
END!
| want them more stable before you start it...)
91
how do you titrate beta blockers
double the dose every 2 weeks and monitor closely!!
92
aim for the target dose of beta blockers with in ______ weeks or .....
8 - 12 weeks
OR
high of a dose as tolerated
93
initial dose for bisoprolol
1.25 mg QD
94
initial dose for Carvedilol (reg AND CR)
reg: 3.215 mg BID
CR: 10 mg QD
95
initial dose of Metoprolol XL
12.5 - 25 mg QD
96
goal HR for beta blockers in HF?
there isn't one!!
97
goal dose for bisoprolol
10 mg QD
98
goal dose for carvedilol (reg and CR)
reg: 25 mg BID
CR: 80 mg QD
99
goal dose of Metoprolol XL
200 mg QD
100
if patient is on a beta blocker and the start to experience...
Fluid retention/Worsening HF
What do you do?
don't stop drug...
| intensify diuretic therapy
101
if patient is on a beta blocker and the start to experience...
Bradycardia/Heart block
What do you do?
reduce beta blocker dose
| usually asymptomatic and do not need to treat though
102
if patient is on a beta blocker and the start to experience...
Hypotension
What do you do?
separate from ACEI to decrease risk
may reduce ACEI or diuretic dose to compensate
if also signs of hypoperfusion (aka low BP) - decrease the dose
103
benefits for Aldosterone Receptor Antagonists
- decrease K/Mg losses = protect against arrhythmia
decrease Na+ retention
Decrease sympathetic simulation
blocks direct fibrotic action on myocardium
104
Spironolactone or Eplerenone?
| is a substrate of CYP3A4
Eplerenone
105
Spironolactone or Eplerenone?
| has ADEs of gynecomastia, impotence, menstrual irregularities
Sprionolactone
106
For aldosterone antagonists, the CrCl cut offs are?
> 50
30 - 49
and < 30 - do not use
107
Spironolactone: if CrCl is > 50
what is initial dose
and maintenance
initial: 12.5 - 25 mg QD
Main: 25 mg QD
108
Spironolactone: if CrCl is 30 - 49
what is initial dose
and maintenance
initial: 12.5 mg QD or every other day
| 12. 5 - 25 mg QD
109
Spironolactone: if CrCl is < 30
what is initial dose
and maintenance
do not use under 30!!!!
110
Eplerenone: if CrCl is > 50
what is initial dose
and maintenance
initial: 25 mg QD
Main: 50 mg QD
111
Eplerenone: if CrCl is 30 - 49
what is initial dose
and maintenance
initial: 25 mg q other day
main: 25 mg QD
112
Eplerenone: if CrCl is < 30
what is initial dose
and maintenance
do not use!!
113
Avoid Aldosterone antagonists if....?
```
SCr > 2.5 (men) or > 2 (women)
or
CrCl < 30 mL/min
or
K+ > 5
or hx of severe hyperkalemia/recent worsening renal function
```
114
Monitoring of Aldosterone Antagonists:
| After any change, addition, diseases or acute illness that may affect K+? when to monitor again
3 days - 1 wk
115
```
Monitoring of Aldosterone Antagonists:
Normal monitoring (when no changes etc)
```
Q 3 mos
116
why is ISDN/Hydralazine of benefit?
reduces both preload AND after load because of hella vasodilation
(study to show efficacy in African American patients)
117
why is ISDN/Hydralazine problematic?
Side effects for dayz!
Reflex tachycardia, hypotension, HA, flushing...
lupus-like syndrome/fluid retention/myocardial ischemia
118
Hydralazine is a dilator of artieries or veins?
Arteries!
119
ISDN is a dilator of artieries or veins?
veins!
120
ISDN:
Initial
Target
Max dose
initial: 20 mg TID/QD
Target: 40 mg TID/QD
Max: 80 mg TID
121
Hydralazine:
Initial
Target
Max dose
Initial: 25 mg TID/QD
Target: 75 mg TID
Max dose: 100 mg TID
122
Ivabrandine is indicated for what pts?
- symptomatic HF
- EF < 35%
- in NSR (normal sinus rhythm)
- rHR >/= 70 in MAX TOLERATED beta blocker
123
Dosing for Ivabradine
start: 2.5 mg BID
adjust q 2 wks
Max: 7.5 mg BID
124
Adjusting dose for Ivabradine
| what are the HR cutoffs
> 60
50 - 60
< 50
125
Adjusting dose for Ivabradine
| pts HR is 60 BPM - what do you do?
increase dose by 2.5 mg (given BID)
| Max is 7.5 mg BID tho!
126
Adjusting dose for Ivabradine
| pts HR is in 50 - 60 range - what do you do?
maintain dose
127
Adjusting dose for Ivabradine
| pts HR is < 50 - what do you do?
decrease dose by 2.5 mg (BID)
| if already at 2.5, d/c the drug!
128
ADEs of Ivabradine
Fetal toxicity
A. Fib
Bradycardia/Conduction disturbances
129
Ivabradine - drug interactions?
it is a CYP3A substrate
| Ketoconazole, Diltiazem, Verapamil, grapefruit juice is concern!!
130
if a HF has persistent HTN (even with ACEI, beta blocker, and diuretic (for Sx) -- what do you give them
- ISDN/Hydralazine
OR
Amlodipine/Felodipine
131
if a HF has Concomitant Angina -- what do you give them
amlodipine/felodipine
132
T or F: Digoxin can reduce mortality
False! only reduces hospitalizations
133
Target goal of Serum Digoxin Concentrations
< 1
| 0.5 - 1 is acceptable range
134
T or F: do not do a loading dose of Digoxin in a pt with HF
True!!! (as long as they are in NSR (normal sinus rhythm) do NOT do a loading dose)
135
Dosing for Digoxin
0. 125 mg - .25 mg QD
| 0. 125 mg is normal dose to get into appropriate goal range of 0.5 - 0.9
136
What patients would more than likely get a lower dose of digoxin
> 70 y.o
decreased renal function
low weight
137
NON-CARDIAC ADEs of Digoxin:
- Anorexia, N/V
- Visual disturbances (halos, photophobia, altered color) (remember Van-Gogh crap)
- Fatigue, weakness, dizziness, confusion, psychosis
138
Cardiac ADEs of Digoxin
AV block
PVCs, VT, VF!!
Sinus Bradycardia
139
what is used to treat digoxin toxicity
digibind
140
what things may predispose someone to digoxin toxicity
```
Electrolyte disturbances (hypoK+/Mg2+, hyperCa2+)
older pt
Alkalosis
Hypoxia
Renal Dysfxn
Hypothyroidism
Drug interactions! (Verap and Amiod!!)
```
141
what electrolyte imbalances increase a pts risk for dig toxicity
hypokalemia
hypomagnesemia
hypercalcemia
142
T or F: all HF pts need to receive anti-platelet therapy
False!
| Should get it only if the have IHD, CAD, or ASCVD along with their HF
143
T or F: all HF pts need anti-coag therapy
false!!! (only if they have a reason to be on it... like A. Fib.)
144
Definition of ADHF
Acute Decompensated Heart Failue =
HF exacerbation =
pts with new or worsening HF signs/sx
145
Definition of Cardiogenic Shock:
Hypotension with Low CO
146
Definition of Hypotension
SBP < 90 mmHg
| MAP (mean arterial pressure) < 70 mmHG
147
T or F: ADHF includes both HFrEF and HFpEF
true!
148
ADHF is mainly of worsening HF cases or new cases?
worsening (~70%)
149
what are the 4 main reasons for why ADHF can happen
CV causes
Metabolic causes
Toxins/Drugs
Drug non-adherence/Dietary indiscretion
150
What are CV causes that can lead to ADHF
```
ischemia
arrhythmia
valvular disease
uncontrolled HTN
pulmonary embolism
progressive HF
```
151
what are metabolic causes that lead to ADHF
infection
anemia
thyroid disorders
renal insufficiency
152
what are some toxins/drugs that can lead to ADHF
negative inotropes, cardiotoxins, Na+/water retention
153
what is the main way that hospitals distinguish the SOB b/w Pulmonary embolism/pneumonia or heart failure
BNP and Nt-proBNP levels
154
what are the important "easy" things of a physical examination in ADHF that dictate treatment
warm/cold
and
dry/wet
155
For ADHF Classifications: What is subset I
warm/dry NORMAL
156
For ADHF Classifications: What is subset II
warm/wet - pulmonary congestion
157
For ADHF Classifications: What is subset III
cool/dry - hypoperfusion
158
For ADHF Classifications: What is subset IV
cool/wet
| pulmonary congestion AND hypoperfusion
159
For ADHF Classifications:
| Cardiac Index is a way to measure _______
contractility
160
For ADHF Classifications:
| PCWP is a way to measure
Pre-Load! or LV-End diastolic end pressure
161
For ADHF Classifications:
| Having a LOW PCWP means what?
there is PULMONARY CONGESTION (wet)
162
For ADHF Classifications:
| having a low cardiac index means what?
there is hypoperfusion (Cool)
163
if pt comes in and has ADHF..
| if they are Warm and Wet - what do you do?
IV diuretics!
| maybe a venous vasodilator - like morphine..
164
if pt comes in and has ADHF..
| if they are warm and dry - what do you do?
optimize chronic therapy
165
if pt comes in and has ADHF..
| if the pt is cold and dry what do you do?
have to look at PCWP:
if <15 - give IV fluids until PCWP reaches b/w 15 - 18
if < 15 and SBP is < 90 - give IV dopamine
if SBP is > 90 - IV inotrope or arterial vasodilator is good.
166
if pt comes in and has ADHF..
| if pt comes in Cold and wet - what do you do?
if SBP < 90 - IV dopamine
if SBP > 90: inotrope or arterial/venous vasodilator
167
Dosing Diuretics For Hospitalized Pts:
| Initial dose is done by IV.... how to pick a dose?
go with whatever they are taking at home!
*if furosemide 40 mg at home -- do 20 mg (b/c bioavailability is wack)
168
ways to overcome loop diuretic resistance?
```
Na+/Water restriction
increase dose (not just frequency)
do a continuous infusion
Add thiazide
```
169
what are vasodilators are mentioned for ADHF
```
Nitroprusside*
Nitroglycerin
Nesiritide
Morphine*
Enalaprilat
Hydralazine
```
170
what positive inotropes are mentioned for ADHF
Dobutamine, Milrinone, Dopamine
171
what is milrinones MOA
PDEI --- will increase cardiac indx
(since PDE inhibitor- good to use when pt is on beta blocker...effect wont be blunted by the beta blocker already present)
172
Dopamine's dosing leads to different effects... what are the different effects
Low Dose: renal vasculature dilator
Med. Dose: increase myocardial contractility/inotrope
High Dose: Aterial vasoconstriction - increase BP
173
When dopamine is at a low dose -- what is its effect
renal vasculature dilator
174
When dopamine is at a medium dose -- what is its effect
increase myocardial contractility/inotrope
175
When dopamine is at a high dose -- what is its effect
increase arterial vasoconstrition -- increase BP
176
if someone comes in for ADHF --- never been on diuretic but they need a diuretic - how do you dose it?
start with 40 mg IV --- see how they respond
good to check renal function too!
if they have shitty kidneys --- increase the dose!!
