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Flashcards in Heart Failure Deck (22)

Causes of systolic heart failure

Nonischemic cardiomyopathy: hypertension, valvular disease, excessive alcohol intake or illicit drug use, congenital heart defects, viral infections, diabetes, and cardio toxic drugs

Ischemic cardiomyopathy: myocardial damage such as that from a myocardial infarction


Drugs that cause or worsening heart failure

1. Chemotherapeutic agents
2. amphetamines
3. Anti-arrhythmic drugs: particularly class I (procainamide, quinidine, disopyramide, flecainide, and propafenone)
4. Itraconazole
5. NSAIDs: can cause renal dysfunction, fluid retention and worsen heart failure
6. Glucocorticoids can worsen heart failure
7. Triptan's are contraindicated with a history of CV disease or uncontrolled hypertension
8. TZD's particularly Avandia
9. Excessive alcohol
10. Calcium channel blockers in systolic failure


Signs and symptoms of heart failure

General: dyspnea at rest or on exertion, weakness/fatigue, SOB, reduction exercise capacity, LVH, increased BNP, increase NT – pro-BNP

Left sided heart failure: orthopnea, nocturnal dyspnea, Rales, S3 Gallup, ejection fraction less than 40%

Right sided heart failure: edema, SIGs, jugular venous distention, hepatojugular reflux, hepatomegaly


ACC/AHA staging system

A: at high risk for development of HF but without structural heart disease or symptoms

B: structural heart disease present but w/out signs or symptoms

C: structural heart disease with prior or current symptoms

D: advanced structural heart disease w/ symptoms of HF at rest despite maximal medical therapy


NYHA functional class

I: no limitations of physical activity. Ordinary physical activity does not call symptoms of heart failure

II: slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in symptoms

III: marked limitation of physical activity. Comfortable at rest but minimal exertion causes symptoms

IV: unable to carry out physical activity without symptoms of heart failure and symptoms at rest


Nonpharmacologic therapy

Very very important

1. Monitor and document weight daily
2.notify physician if symptoms worsen or weight increases
3. sodium restriction is reasonable for patients with symptomatic heart failure at less than 1500 mg per day
4. consider multivitamin due to dietary restriction and diuretics therapy
5. For later stages consider fluid restriction of 1.5 to 2 L per day
6. Exercise 30 minutes per day 3 to 5 days a week


OTC or alternative medicine

Avoid the use of ephedrine or pseudoephedrine products

Avoid NSAIDs including Cox two inhibitors

Hawthorne and CoEnzyme Q10 may improve heart failure symptoms based on a small study



1. Cornerstone is diuretic therapy to control fluid volume
2. Ace inhibitors and ARBs
3. Beta blockers


Loop diuretics

Causes increased excretion of water, sodium, chloride, magnesium, and calcium

Use: only for symptomatic control of congestion no survival benefit

Furosemide (Lasix), bumetanide, torsemide (Demadex), ethacrynic acid (edecrin)

40:1:20:50 mg equivalency

Warning: sulfa allergy

Side effects: hypokalemia, or the static hypotension, decreased electrolytes, increased Yorick acid, increase blood glucose and triglycerides and total cholesterol, photosensitivity, ototoxicity, tinnitus, vertigo, and hearing loss (ear side effects most associated with ethacrynic acid)

Furosemide IV:PO is 1:2


Ace inhibitors and ARBs in heart failure

Titrate the drug to target doses if possible when titrating doses do so to reduce symptoms not blood pressure

Some patients may be on an ace inhibitor and an ARB and some may be on an ace inhibitor and spironolactone but never put a patient on

ace inhibitors: enalapril (Vasotec), lisinopril (prinivil, zestril), quinapril (Accupril), Ramipril (Altace)

ARBs: losartan (Cozaar), valsartan (Diovan), candesartan (Atacand)


Beta blockers

Reduce morbidity and mortality in heart failure

Recommended in all heart failure patients especially those in functional class two through four

Only carvedilol, metoprolol succinate and bisoprolol are recommended in the guidelines

Target doses: bisoprolol 10 mg, metoprolol succinate 200 mg, carvedilol 80 mg

Considerations: do not withdraw abruptly and do not use if sinus bradycardia, second or third degree heart block, sick sinus syndrome, cardiogenic shock and in those with an active asthma exacerbation


Aldosterone receptor antagonist

Reduce morbidity and mortality

Should be added to any patients regimen w/out contraindications in functional class three or four

Drugs: Spironolactone (Aldactone), eplerenone (Inspra)

Blackbox warning: tumor risk with spironolactone

Contraindications: Renal impairment creatinine clearance less than 30, hyperkalemia

Warning: do not initiate therapy in patients with a potassium greater than five or a serum creatinine greater than 2 for females or 2.5 for males



Hydralazine is a direct arterial vasodilator which reduces afterload. Nitrates are venous vasodilators and reduce preload.

Shown to increase survival but not as much as with Ace inhibitors therefore this combination is used as an alternative therapy for patients you cannot tolerate a senators or ARB used you to pour renal function in Jadima or hyperkalemia

This combination may also be beneficial in black patients therefore the product by Dell, is indicated and self identified black patients with functional glass three or four heart failure who are symptomatic despite optimal therapy with Ace inhibitors and beta blockers

Drugs: isosorbide dinitrate/hydralazine (BiDil), hydralazine, isosorbide mononitrate (Monoket)


Isosorbide dinitrate/hydralazine

Contraindication: do not use with a PDE five inhibitor

Side effects: headache, dizziness, hypertension; rarely lupus like syndrome

Monitoring: heart rate, blood pressure, signs and symptoms of heart failure



Side effects: headache, reflex tachycardia, palpitations, anorexia; rarely lupus like syndrome

Monitoring: heart rate, blood pressure, Sarginson and heart failure


Isosorbide mononitrate (Monoket)

Contraindications: PDE five inhibitors

Side effects: headache, dizziness, lightheadedness, Flushing, hypertension, tachyphylaxis, syncope

Monitoring: heart rate, blood pressure, signs and symptoms of heart failure


Drug interactions with nitrates

Separate by 12 hours: avanafil

Separate by 24 hours: sildenafil or vardenafil

Separate by 48 hours: tadalafil



Positive Inotropic effect

Added to patient to remain symptomatic despite receiving standard therapy including and a senator and a beta blocker

No mortality or morbidity data that has been shown to improve symptoms come exercise tolerance and quality of life



toxicity: first signs of toxicity or nausea and vomiting, loss of appetite and bradycardia other signs include blurred vision, altered color perception, greenish yellow halos around lights are objects, abdominal pain, confusion or delirium, arrhythmia

Antidote: digifab

Those must be renally adjusted

Increased risk of toxicity with hypokalemia, hypomagnesemia, and hypercalcemia


Patient counseling for all heart failure patients

1. Monitor bodyweight daily in the morning before eating and after using the restroom

2. Limit foods high in sodium such as sauces, condiments, canned vegetables and soups, frozen dinners, deli meats

3. Avoid smoking, alcohol and illicit drug use

4. Stay compliant with all medications and be sure to ask about any over-the-counter medications particularly NSAIDs


Counseling on beta blockers and heart failure

1. Do not stop taking this medication unless your doctor tells you to do so

2. This medication can cover up some of the signs and symptoms of low blood sugar therefore make sure to test if instructed to do so


Coreg CR or carvedilol counseling

Take with food to help reduce dizziness by delaying absorption

Do not crush or chew the capsule; can be opened and beads sprinkled over a spoonful of applesauce or soft food


Digoxin counseling

Do not stop this medication without consulting a physician as it may worsen your condition

Avoid becoming dehydrated as it may increase your dose

Notice signs of overdose including nausea, vomiting, diarrhea, loss of appetite, vision changes, uneven heartbeats and feeling like you might pass out