Heart Failure Flashcards by K W

Symptoms of L-sided HF

dyspnea, fatigue, edema, and specifically for L: PULMONARY CONGESTION

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Most common causes of L-sided HF

general: MI, atherosclerotic heart ds, hypertensive changes, valve ds, dilated cardiomyopathy, congenital heart ds. Most common: MYOCARDIAL ISCHEMIA due to coronary artery ds, followed by HTN

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Symptoms of R-sided HF

dyspnea, fatigue, edema, and specifically for R: PERIPHERAL EDEMA

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Most common causes of R-sided HF

general: MI, atherosclerotic heart ds, hypertensive changes, valve ds, dilated cardiomyopathy, congenital heart ds. Most common: MYOCARDIAL ISCHEMIA due to coronary artery ds, followed by HTN

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Compensatory effects of HF

3 major responses: Increase sympathetic activity, activate RAS (renin-angiotensin system), myocardial hypertrophy

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Two Pathways of SNS stimulation during HF

Stimulation of B-adrenergic receptors; alpha 1-adrenergic stimulation

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Effects of alpha 1-adrenergic stimulation in HF

produces vasoconstriction that enhances venous return, Increase cardiac preload and afterload.

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Effects of B-adrenergic stimulation in HF

Stimulation of B-adrenergic receptors in heart Increase HR, Increase force of contraction

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Adverse Effects of SNS Stimulation as a Compensatory Measure in HF

Increase work-load of heart (which causes further decline in cardiac function)

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Mechanism of Renin-Angiotensin System Activation due to HF

Decrease in CO leads to Decrease renal blood flow that triggers release of renin to both: Increase formation of angiotensin II (vasoconstrictor that Increase peripheral resistance); and release aldosterone

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Effects of Renin-Angiotensin System Activation in HF

Release of aldosterone promotes retention of Na & water thus Increase blood vol and amount of blood returned to heart

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Adverse Effects of Renin-Angiotensin System Activation in HF

edema because of Increase venous pressure due to inability of heart to pump extra vol

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Effects of Myocardial Hypertrophy in HF

Myocardial Hypertrophy: heart Increase size via: chambers dilate; initial stretching leads to more forceful, stronger contraction, but excessive elongation of fibers and thus weaker contractions (ultimately Decrease ejection ability - systolic failure); a

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Compensated HF

compensatory mechanisms (myocardial hypertrophy, RAS activation, SNS stimulation0 are restoring ADEQUATE CARDIAC OUTPUT

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Decompensated HF

mechanisms eventually Increase overall workload on heart and lead to furhter decline in cardiac functio; compensatory mechanisms FAIL TO MAINTAIN ADEQUATE CO

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Drug classes used to treat HF

Inhibitors of renin-angiotensin-aldosterone system (RAAS); β-blockers; diuretics; inotropic agents; direct vasodilators; aldosterone antagonists

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Types of RAAS Inhibitors

ACE inhibitors; Angiotensin-Receptor Blockers (ARBs)

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Indications for ACEIs

MONOTHERAPY (pts with mild DOE and no apparent signs of vol overload); ASYMPTOMATIC PTS WITH EJECTION FRACTION <35% (left ventricular dysfunction); PTS WITH RECENT MI; all stages LEFT VENTRICULAR FAILURE with or w/o symptoms

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Indications for ARBs

Angiotensis-Receptor Blockers (ARBs): HTN, SUBSTITUTES FOR ACEI (esp. when ACEI associated with cough &/or angioedema)

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Indications for B-Blockers

Unless BB therapy contraindicated, BB should be used in management of HF

Indications for Loop Diuretics

provide relief of volume overload symptoms (dyspnea and peripheral edema)

Primary Inotropic Drug

Digoxin

Indications for Direct Vasodilators

Add on therapy

Aldosterone Antagonists

Spironolactone; eplerenone

Indications for Aldosterone Antagonists

aldosterone antagonists: spironolactone: reserved for most severe HF cases; eplerenone: REDUCES MORTALITY in L VT SYSTOLIC DYSFUNCTION, HF AFTER ACUTE MI

Which B-blockers are indicated for HF

CARVEDILOL (COREG) - non-selective B-blockade, also alpha -blockade. METOPROLOL (LOPRESSOR); Long-Acting variant (Toprol)- B1 selective (cardioselective), immediate or extended release

When B-blockers are indicated for HF

used for structural heart ds, no symptoms in selected pts with ACEI; structural heart ds with previous or current symptoms in all pts with ACEI

3 Stages of HF

Stage A: High Risk, No Symptoms Stage B: Structure HD, No Symptoms Stage C: Structure HD, previous or current symptoms

Treatment Regimen for Stage A HF (Lowest Level)

Risk-factor reduction; patient education

Treatment Regimen for Stage A (2nd tier) HF

Treat HTN, DM, dyslipidemia; ACEIs or ARBs in SOME patients

Treatment Regimen for Stage B HF

ACEIs or ARBs in ALL patients; B-blocker in selected patients

Treatment Regimen for Stage C HF

ACEIs and B-Blockers in ALL patients

Treatment Regimen for Stage C HF (Highest Level)

ACEIs and B-Blockers in ALL patients; dietary Na+ restriction; diuretics & digoxin

Use of digoxin

1. increase cardiac contractility 2. improve ejection fraction 3. lower diastolic volume, 4. improved circulation

MoA of digoxin

promotes calcium entry into the cell and causees retention of calcium in the cell

Indication for digoxin

in severe left ventricular systolic dysfunction - after initiation of a ACE inhibitor and diuretic

Half-life of digoxin

36 hours (very long)

Side effects of digoxin

GI effects: anorexia (due to N/V), N/V; CNS effects: headache, fatigue, confusion, blurred vision, alteration of color perception and halos

Use of spironolactone

direct antagonist of aldosterone

MoA of spironolactone

prevents salt retention, myocardial hypertrophy and hypokalemia due to elevated aldosterone levels and angiotensin II stimulation and reduced hepatic clearence

Indication for for spironolactone

Reserved for the most severe heart failure cases

Half-life of spironolactone (active metabolites)

14-22 hr

Side effects of spironolactone

GI disturbances, lethargy and confusion, gynecomastia;progestational and antiandrogenic adverse effects due to its nonspecific binding to various steroid receptors

Use of eplerone

competitive antagonist of aldosterone

MoA of eplerone

lower incidence of endocrine related side effects because of reduced affinity for glucocorticoid, andogen and progesterone receptors

Indications for eplerone

left ventricular systolic dysfunction and heart failure after acute myocardial infarction

Half-life of eplerone

4-6 hr

Side effects of eplerone

Reduced compared to spironolactone

Treatment for overt HF

loop diuretics are initated first to provide relief of volume overload; then an ACE inhibitor or ARB is induced; third, beta blockers are started after the patient is stable on ACE and finally digoxin is added if needed (symptoms remain)