Heart Failure

Question 1

an impairment of the contraction of left ventricle such that stoke volume (SV) is reduced for any given end-diastolic volume (EDV) or filling pressure.

Answer 1

Systolic Dysfunction

Question 2

what is a normal ejection fraction?

Answer 2

Normal: 50 - 70%

Question 3

Heart failure with preserved left ventricular systolic function (or EF)

Answer 3

Diastolic dysfunction

Question 4

left ventricular end-diastolic pressure (LVEDP)

Answer 4

Preload

Question 5

systemic vascular

resistance (SVR)

Answer 5

Afterload

Question 6

What are 2 toxic responses to NE release?

Answer 6

Arrhythmias

Apoptosis

Question 7

Patient prevents with SOB, DOE, orthopnea, cough, PND, fatigue and weakness, memory loss and confusion, anorexia
Signs: tachy, rales, diaphoresis, S3 and S4 gallops

Answer 7

LVF

Question 8

patient presents with : weight gain, transient ankle swelling, abdominal distention, anorexia, nausea
Signs: JVD. Edema, hepatomegaly, ascites, (+) hepatojugular reflux

Answer 8

RVF

Question 9

HF class with no limitations to physical activity

Answer 9

NYHA class 1

Question 10

slight limitation of activity, ordinary activity results in symptoms

Answer 10

NYHA class II

Question 11

marked limitation of activity; less than ordinary activity results in symptoms

Answer 11

NYHA class III

Question 12

unable to carry on any physical activity without discomfort; symptoms at rest

Answer 12

NYHA class IV

Question 13

what class if the best for CHF procedure/ therapy?

Answer 13

Class I

Question 14

CHF guidelines for conditions where there is conflicting evidence and/or divergence of opinions about the usefulness/ efficacy or performing the procedure/ therapy.

Answer 14

Class II

Question 15

what level is if the data was derived from multiple randomized clinical trial

Answer 15

Level A

Question 16

what level is when data were derived from a single randomized trial?

Answer 16

Level B

Question 17

What level is the consensus opinion of experts was primary source of recommendation.

Answer 17

Level C

Question 18

As GFR decreases, what diuretics don’t work as well?

Answer 18

thiazide only use if GFR >30 ml/lmin

Question 19

what should you monitor with diuretics.

Answer 19

Monitor K+, Mg2+, BUN, SCr

Question 20

what class id digitlais?

Answer 20

Class IIa

Question 21

what is digoxin used for?

Answer 21

patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalization for HF

Question 22

hemodynamic effects of digoxin

Answer 22

Increased CO
Decreased PCWP
Increased LVEF

Question 23

what does digoxin help stop?

Answer 23

Neurohomonal effects that the body is trying to do to compensate that actually harm the body

Question 24

Electrophysiological effects of Digoxin

Answer 24

slowing of sinus rate of SA node

slowed conduction of AV node

Question 25

when are ionotropic effects of digoxin seen?

Answer 25

low concentrations. Inhibits ATPase pump which incrases intracellular calcium so increased contractility

Question 26

who does digoxin seem to work better in?

Answer 26

Men

Question 27

what is a big potential problem with digoxin?

Answer 27

hypokalemia

Question 28

what drugs decrease digoxin clearance?

Answer 28

Amiodarone and quinidine (so decrease digoxin dose by 1/2)

Question 29

other drug interaction with digoxin (can decrease digoxin clearnace)

Answer 29

Diltiazem, verapamil, Abx, azole antifungals, propafenone decrease digoxin clearance furosemide

Question 30

Symptoms of digoxin toxicity

Answer 30

Ventricular arrhythmias heart block anorexia, N/V

Question 31

Tx of digoxin toxicity

Answer 31

Give digoxin Immune Fab (digibind) binds with digoxin and excreted via kidneys

Question 32

Everyone with current or prior symptoms of heart failure and reduced LVEF should be taking what?

Answer 32

ACEI

Question 33

what to monitor w/ ACEI

Answer 33

SrCr Potassium BP cough (bradykinnin)

Question 34

what drug may interfere w/ the efficacy of an ACEI

Answer 34

aspirin; patients should stick to lowest dose (both are recommended for HF)

Question 35

signs of intolerance to ACEI

Answer 35

Cough (more common in Chinese) angioedema (higher AA) increase in SrCr

Question 36

Alternative for ACEI

Answer 36

``` Class I(a) ARBs Class II(c) Combo of isosorbide dinitrate & hydralazine ```

Question 37

Beta Blockers used for heart failure

Answer 37

Bisoprolol Carvedilol Metoprolol

Question 38

Contraindications for BB

Answer 38

symptomatic brady > 1st degree Heart block (unless have pacemaker) evidence of fluid overload or recent requirement for IV inotropic agents

Question 39

Monitoring with BBs

Answer 39

HR, BP, weight

Question 40

when should you consider holding dose or changing reigmen for BB

Answer 40

HPOTN bradycardia worsening symptoms

Question 41

Effects of aldosterone in CHF

Answer 41

``` NA and H20 retention increased plasma fluid volume elevated BP myocardial and vascular fibrosis excretion of K+ and Mg++ elevated ANP parasympathetic inhibition ```

Question 42

In patients with moderate to severe symptoms of heart failure, what should be added to drug regimen?

Answer 42

Aldosterone antagonist (spirolactone, eplerenone)

Question 43

what do a patient need to have before starting on aldosterone antagonist

Answer 43

SCr <5.0 | moderate to severe CHF

Question 44

what do you need to monitor w/ aldosterone antagonists

Answer 44

K+ and renal function (BUN/ SCr) at 1 week and monthly for first 3 months

Question 45

When may you combine ACEi and ARB

Answer 45

``` heart failure (recommended as Class IIb) Use in patients who are persistently symptomatic with reduced LVEF ```

Question 46

should you combine ACEI, ARB, and aldosterone antagonist in CHF?

Answer 46

No, should be combining ACEI + aldosterone antagonist

Question 47

what can you add if a patient has reduced LVEF who is already taking an ACEI and BB for symptomatic HF and who have persistent symptoms.

Answer 47

Nitrates and hydralazine

Question 48

In africans amercians with NYHA class III or IV HF what can be added along with an ACEI and BB?

Answer 48

isosorbide dinitrate and hydralazine

Question 49

ASA has been proven to reduce risk of CV events in who?

Answer 49

patients without CHF (not proven in those with CHF)

Question 50

who are anticoagulants reserved for?

Answer 50

Afib or previous transient ischemic episode

Question 51

Medications to avoid in CHF

Answer 51

antiarrhythmics (except amiodarone and dofetilide) CCB (except amlodipine) NSAIDs (except low dose ASA w/ ischemic patient)

Question 52

If a patient is asymptomatic, LV dysfunction EF <40%

Answer 52

ACEI or ARBs | BB

Question 53

What do you add for symptomatic CHF NYHA II

Answer 53

``` ACEI or ARB BB Diuretics Digoxin Devices ```

Question 54

What do you add fro CHF NYHA III

Answer 54

``` Spironolactone ISDN/HYD ARBs or ACEI (or both) BB Diuretics ```

Question 55

Symptomatic CHF NYHA IV

Answer 55

``` Inotropes LV assist devices transplantation hospice may stop beta blockers ```

Question 56

Causes of acute decompensation of HF

Answer 56

``` Medical- don't take meds nutrition undertreatment progression of dz acute MI ```

Question 57

3 compensatory mechanisms of HF

Answer 57

increased sympathetic activation fluid retention myocardial dilation and hypertrophy

Question 58

way to monitor HF and for dx

Answer 58

pulmonary artery catheterization

Question 59

If the patient is warm and dry and has no signs of CHF what stage are they?

Answer 59

Stage I

Question 60

If a patient is "warm and wet" and will have S3 and rales, what stage are they?

Answer 60

Stage II

Question 61

If a patient is "cold and dry", has low perfusion and can go into hypovolemic shock what stage are they?

Answer 61

Stage III

Question 62

It a patient is cold and wet what are they probably experiencing?

Answer 62

Cardiogenic shock, stage IV

Question 63

If adaptive mechanisms fail to maintain cardiac output, what stage is a patient in?

Answer 63

decompensated

Question 64

3 treatment options for ADHF

Answer 64

Diuretics vasodilators inotropes (augment contractility)

Question 65

what are used to reduce pulmonary and systemic congestion in a decompensated patient

Answer 65

loop diuretic (furosemide) give IV (large doses) and may need continuous infusion

Question 66

what can happen with over diuresis

Answer 66

reduce CO | must monitor ins and outs

Question 67

Positive inotropes that help with ADHF

Answer 67

Beta adrenergic agonists (Dobutamine- agonist at beta 1 and 2 and alpha 1) increases CO and vasodilation (+ inotropy)

Question 68

what should you monitor with dobutamine

Answer 68

arrhythmias vitals, urine output monitor vitals to look for response

Question 69

How does dopamine in ADHF at medium doses

Answer 69

beta 1 effects which increases CO and some milke alpha 1 which increases SVR

Question 70

what can too high of doses of dopamine cause

Answer 70

INcrease vasoconstriction which isn't beneficial in ADHF

Question 71

Increase intracellular cAMP which increases intracellular calcium which increases contractility and cardiac output

Answer 71

Hosphodiesterase inhibitors | milrinone (need loading dose)

Question 72

what are some other inotroeps used in ADHF

Answer 72

epinephrine (Beta 1 and 2 and alpha 1 agonist) norepinephrine(Beta 1 and 2 and alpha 1 agonist) isoproterenol (beta 1 and beta 2 agonist- increase CO and decrease SVR)

Question 73

what drugs can lead to arrhythmias (inotropes)

Answer 73

Dobutamine | Milrinone

Question 74

how are inotropes given

Answer 74

give for a short time period to get patient back to compensation status

Question 75

what are some venodilators used in ADHF

Answer 75

nitroprusside and nitroglycerin morphine nesiritide

Question 76

what venodilator is preferred when CO is not severely compromised or when other inotropic agents are administered

Answer 76

nitroglycerin

Question 77

what venodilator is also an arterial vasodilator and is preferred in patients with an increased SVR. also has a thiocyanate toxicity

Answer 77

Nitroprusside

Question 78

venodilator that reduces preload and heart rate. Typically used in early stage of tx particularly is patient has associated anxiety, restlessness and dyspnea

Answer 78

Morphine

Question 79

Vasodilator that is a Recombinant B-type natriuretic peptide Increases intracellular cGMP which leads to smooth muscle relaxation Promotes vasodilation, natriuresis, and diuresis Reduces PCWP, SVR, and increase CO

Answer 79

Nesiritide

Question 80

is there a risk of arrhythmias with nesiritide

Answer 80

No

Question 81

can you add BB with nesiritide

Answer 81

Yes (can't add it with inotropes though)

Question 82

ADR of nesiritide

Answer 82

Worsening in renal function compared to other meds

Question 83

what should nesiritide be limited to?

Answer 83

patients presenting to hospital w/ ADHF and dyspnea at rest

Question 84

If a patient is cold and dry what is your therapaeutic goals and tx

Answer 84

Increase CO | give fluids +/- inotropes and mechanical assistance

Question 85

should you give fluids in "cold and wet" and "warm and wet" patients presentations

Answer 85

No

Question 86

If a patient is cold and wel with a low BP what do you give?

Answer 86

IV inotropes + IV diuretics + mechanical assistant

Question 87

If a patient is warm and wet what is your goal and tx

Answer 87

Relieve congestion | Tx- IV diuretics +/- nitrates or nesiritide

Question 88

Anticoags used for patients in decompensation phase

Answer 88

heparin | LMWH (enoxaparin)