Flashcards in Heart Failure Deck (166):
What's heart failure (HF)?
HF is a syndrome where the heart is not able to supply sufficient blood flow (or cardiac output) to meet the metabolic needs of the body
What causes HF?
HF is most commonly caused Reduced ability of the heart to eject blood, known AD low-output heart failure
Types of heart failure?
HF with Reduced ejection fraction (HFrEF)/Systolic dysfunction - impaired ability of LEFT ventricle to EJECT blood
HF with preserved ejection fraction (HFpEF)/ Diastolic dysfunction - impaired ability of LEFT ventricle to FILL with blood
What xterizes systolic dysfxn of HF?
Left ventricle ejection fraction < 40%
What xterizes diastolic dysfxn of HF?
Only mildly reduced (40-50%) or normal left ventricular ejection fraction
What sometimes xterizes low-output HF?
Both systolic and diastolic dysfunction
T/F? HF is one of the most important conditions to include lifestyle counseling and the requirements for strict medication adherence?
HF can be classified into 2 types based on underlying etiology. What are they?
What does Ischemic cardiomyopathy result from?
From myocardial damage sustained during an acute myocardial infarction, resulting in loss of contractile function
What does Non-Ischemic cardiomyopathy encompass?
A variety of conditions that ultimately increase the workload of cardiomyocytes, accelerating cell death and lead to a thin-walled dilated left ventricle with reduced contractile function
What are the most common causes of HF in North America?
Ischemia heart dx (myocardial infarction)
List drugs that cause or worsen HF
Chemotherapeutic agents (Doxorubicin, (Adriamycin, Doxil))
Amphetamines and other sympathomimetics
Routine use of CCBs in systolic HF
Anti-arrhythmic drugs (lower risk with amiodarone and Dofetilide). Avoid class I drugs entirely
Avoid Itraconazole for non-life threatening inf such as Onychomycosis
Immunomodulators, including interferons, TNF inhibitors, rituximab etc
NSAIDs, including the selective COX-2 inhibitor Celecoxib (Celebrex)
Glucocorticoids can worsen HF
Triptan migraine drugs
Thiazolidinediones, esp, Rosiglitazone (Avandia) and Pioglitazone (Actos)
Excessive alcohol use
Heart valve dx can be cause by: fenfluramine (Pondimin), dexfenfluramine (Redux), ergot derivative including ergot (Ergostat), dihydroergotamine (Migranal), methysergide (Sansert) and others
What's cardiac output? (CO)
Vol of blood (in L) pumped by the heat in 1 min
It's a fxn of HR and stroke vol.
CO = HR x SV
What's stroke vol?
Amt of blood ejected from the left ventricle during 1 cardiac cycle
What determines stroke volume?
SV is determined by vol of blood in ventricle (preload), the resistance to forward flow in arterial vessels (afterload), and how hard the ventricle squeezes during systole (contractility)
T4, SV is determine by preload, afterload and contractility
Volume of blood in the ventricle
Resistance to forward flow in the arterial vessels
How hard the ventricle squeezes during systole
What's cardiac index?
HF is a progressive syndrome, what does that mean?
Regardless of the initial etiology of myocardial damage, over time left ventricular systolic fxn will continue to decline
T4 initial damage to heart => reduction in CO
One of the ways the heart tries to compensate during HF is by activating RAAS? Implication of this?
Results in vasoconstriction, which helps maintain BP and perfusion to vital organs
What other compensation by the heart increases HR and contractility? (T4 augmenting CO)
Sympathetic (adrenergic) activation
While the RAAS activation in HF is useful (maintains BP and adequate perfusion), what's not so good abt it?
Na and water retention => edema
Excess fluid causes body to be congested and the classic sx of "congestive" HF is seen
Classic sx of "congestive" HF?
General s/sx of HF?
Dyspnea at rest or on exertion
Shortness of breath
Reduction in exercise capacity
Increased BNP (B-type Natriuretic Peptide): normal < 100 pg/ml
Increased NT-proBNP (N-terminal pro B-type Natriuretic Peptide) normal < 300 pg/ml
S/sx of left-sided HF?
Paroxysmal nocturnal dyspnea (PND) or nocturnal cough
EF < 40%
S/sx of right-sided HF?
Jugular venous distention (JVD)
Hepatojugular reflux (HJR)
What're gen the results of sx in HF?
Either congestion behind the failing ventricle
Hypoperfusion due to reduced cardiac output
What's the use of the staging system of HF?
Help practitioners optimize mgt of pts in order to slow the development of sx in asymptomatic pts (stages A and B) or slow the progression of syndrome (stages C and D)
Whats another type of classification system used in HF?
New York Heart Association functional class (NYHA)
Important prognostic indicator for HF pts
What's the equivalent of ACC/AHA Staging System A to NYHA functional class?
No corresponding category
What's the equivalent of ACC/AHA Staging System B to NYHA functional class?
NYHA functional class I
What's the equivalent of ACC/AHA Staging System C to NYHA functional class?
NYHA functional class I, II, III
What's the equivalent of ACC/AHA Staging System D to NYHA functional class?
NYHA functional class IV
Characteristics of ACC/AHA Staging System A?
At high risk for dev HF, but w/o structural HD or sx of HF (ie, pts with HTN, CHD, DM, obesity, metabolic syndrome
Characteristics of ACC/AHA Staging System B?
Structural heart dx present but w/o s/sx of HF (ie, LVH, low EF, valvular dx, previous MI)
Which stages of ACC/AHA Staging System is included in clinical diagnosis of HF?
C and D
Characteristics of ACC/AHA Staging System C?
Structural HD + prior/ current sx of HF (ie, pts with known structural HD, SOB and fatigue, reduced exercise tolerance
Characteristics of ACC/AHA Staging System D?
Advanced structural HD + sx of HF at rest despite maximal medical therapy (Refractory HF requiring specialized interventions)
Characteristics of NYHA Functional Class I?
No limitations of physical activity
Ordinary physician activity doesn't cause sx of HF
Characteristics of NYHA Functional Class II?
Slight limitation of physical activity
Comfortable at rest, but ordinary physical activity results in sx of HF
Characteristics of NYHA Functional Class III?
Marked limitation of physical activity
Comfortable at rest, but minimal exertion (bathing, dressing) causes sx of HF
Characteristics of NYHA Functional Class IV?
Unable to carry on any physical w/o sx of HF
HF at rest
Non-pharmacologic therapy for HF?
Monitor and document body weight DAILY
Notify provider of HF sx worsens or when weight increases (3 lbs in 1 day or >= 5 lbs in 1week)
Sodium restriction is reasonable for pts with symptomatic HF @
< 1500 mg/d
Fluid restrictions (1.5-2 L/D), esp stage D pts
BMI < 30 preferred
Exercise 30 mins/day, 3-5 days a wk as tolerated
What's the appropriate sodium restriction for HF pts?
< 1500 mg/d
What OTC med is reasonable to be used as adjunctive therapy in pts with NYHA class II - IV to reduce mortality and CV hospitalizations?
Omega-3 polyunsaturated fatty acid (PUFA)
What meds should be avoided in HF?
Products contains ephedra (ma huang) or ephedrine
NSAIDs, including COX-2 inhibitors (due to risk of renal insufficiency and fluid retention)
What alt med has shown promise in HF?
Hawthorn and coenzyme Q10
What meds are the cornerstones of HF therapy?
Diuretics to control fluid volume
Angiotensin antagonist (ACE-I or ARBs)
Beta blockers (to delay the progression of cardiac dysfunction and improve survival)
These combo should be used in everyone with HF, who doesn't have a CI or intolerance to their use
Which of the cornerstones of HF therapy improves survival rate?
What type of diuretic is more commonly used in HF?
MOA of loop diuretics?
They block Na and Cl reabsorption in the THICK ASCENDING LIMB OF LOOP OF HENLE =>
Increased excretion of water, Na, Cl, Mg and Ca
What's excreted by loop diuretics in HF?
Whys the lowest effective dose of loop used in HF?
They haven't been shown to alter the survival of HF pts
List loop diuretics used in HF?
Ethacrynic Acid (Edecrin)
Whats the brand name of Furosemide (loop used in HF)?
Whats the oral loop dose equivalency of Furosemide (Lasix)?
Whats the oral loop dose equivalency of Bumetanide?
Whats the oral loop dose equivalency of Torsemide (Dermadex)?
Whats the oral loop dose equivalency of Ethacrynic acid (Edecrin)?
What's warning associated with loops use?
Which loop is the sulfa allergy warning not applicable to?
Ethacrynic acid (Edecrin)
SEs of loop?
Decreased Na, Mg, Cl, Ca (different than thiazides which increase Ca)
Hyperuricemia (increased uric acid)
Increased TGs, TC
Ototoxicity (more with Ethacrynic acid), including hearing loss, tinnitus and vertigo
Monitoring for loops?
Hearing with high doses of rapid IV admin
Renal fxn (SCr, BUN)
Fluid status (in's and out's, weight)
Which loops are light-sensitive (stored in Amber bottles)?
IV furosemide and Bumetanide
What's the furosemide IV to PO ratio?
(Furosemide 20mg IV = Furosemide 40mg PO)
Diuretics and lithium?
May decrease lithium renal clearance and increase risk of lithium toxicity
MOA of ACE-I?
Block conversion of angiotensin I to angiotensin II by inhibiting the ACE
MOA of ARBs?
They block angiotensin II receptor AT1, which is responsible for vasoconstriction, aldosterone stimulating and re-modeling effects of angiotensin II
Is triple combo of ACE-I/ARB/aldosterone receptor antagonist recommended? Why/why not?
Not recommended due to elevated risk of hyperkalemia and increased incidence of renal insufficiency
List ACE-I agents
Lisinopril (Prinivil, Zestril)
What's the brand name of Enalapril (ACE-I)?
What's the brand name of Lisinopril (ACE-I)?
What's the brand name of Quinapril (ACE-I)?
What's the brand name of Ramipril (ACE-I)?
Howz Captopril (Capoten) taken?
1 hr B4 meals
Black box warning of ACE-I?
D/c as soon as pregnancy is detected
CI to ACE-I use?
Bilateral renal artery stenosis
SEs to ACE-I and ARBs use?
Cough (not for ARB, only ACE-I SE)
Angioedema (d/c drug immediately and drug is then CI)
Which ACE-I has more SEs? What are they?
Monitoring parameters of ACE-I and ARBs?
S/sx of HF
List ARBs agents
Which of the ARBs has shown benefit in clinical trials but no FDA indication for use in HF?
What's the brand name of Losartan (ARB)?
What's the brand name of Valsartan (ARB)?
Black box warning, CI, SEs, Monitoring Parameters same as ACE?
Same as ACE-I
Which electrolyte is typically increased in ACE-I and ARBs use?
MOA of bb in HF?
Bb antagonize the effects of catecholamines, esp norepinephrine
Both BB and ACE-I/ARBs reduce mortality and morbidity, but what's the difference btw them?
BB don't have a class effect, only Carvedilol, Metoprolol Succinate ext-release and Bisoprolol
ACE-I/ARBs have a class effect
List BB used in HF?
Metoprolol Succinate extended-release
Which BB should be absolutely avoided?
BB with intrinsic sympathomimetic activity (ISA)
List the selective BB used in HF
Metoprolol Succinate ext-release (Toprol XL)
What's the brand name of Metoprolol Succinate ext-release (selective BB)?
List non-selective BB used in HF
Carvedilol (Coreg, Coreg CR)
What's the brand name of Carvedilol (non-selective BB)?
SE of selective BB (Bisoprolol and Toprol XL)?
Monitoring of selective BB (Bisoprolol and Toprol XL)?
BP (titrate Q 2 wks, reduce dose if HR < 55 BPM)
S/Sx of HF
How do u d/c BB?
Are IV doses of selective BB (Bisoprolol and Toprol XL) equivalent to oral doses?
IV doses are NOT equivalent to PO doses (IV is usually lower)
How do u take Carvedilol (Coreg, Coreg CR) - no selective BB?
Take Carvedilol - all forms -'with food
Which DM sx are NOT masked by BB?
Which ARAs is non-selective?
Which ARAs is selective? Benefits?
Doesn't exhibit endocrine SE
MOA of ARAs?
They compete with aldosterone at receptor sites in DISTAL CONVOLUTED TUBULE and COLLECTING DUCTS
When ARAs used in pts with HF?
Standard therapy in pts who have progressed to NYHA class III or IV
What's the brand name of Spironolactone (ARAs)?
CI of Aldosterone Receptor Antagonists (ARAs)?
Renal impairment (CrCl < 30mL/min)
SEs of ARAs?
Gynecomastia and breast tenderness (Spironolactone)
Which SE is unique to Spironolactone?
Gynecomastia and breast tenderness
Monitoring of ARAs?
Check K B4 starting and freq thereafter
S/Sx of HF
How do u minimize risk of hyperkalemia in pts treated with aldosterone blockers?
Higher risk if reduced renal fxn (CI if CrCl < 30ml/min)
Don't start if K > 5 mEq/L
Use low doses, start low
Don't use NSAIDs concurrently
Counsel pt about increased risk of dehydration (due to vomiting, diarrhea or reduced fluid intake)
A direct vasodilator which reduces afterload
Nitrates are venous vasodilators and reduce preload
What's the role of Hydralazine/Nitrate (combo) in HF?
Alternative therapy for pts who can't tolerate ACE-I or ARBs
Standard therapy in black pts with class III or IV
What's the brand name of Hydralazine/Nitrate (combo) in HF?
What's the brand name of Isosorbide mononitrate in HF?
CI to using BiDil (Isosorbide dinitrate/hydralazine), Hydralazine, Monoket (Isosorbide mononitrate)?
CI with PDE-5 inhibitors
SE to using BiDil (Isosorbide dinitrate/hydralazine)?
Rare lupus-like syndrome
Monitoring of BiDil (Isosorbide dinitrate/hydralazine), Hydralazine, Monoket (Isosorbide mononitrate)?
S/Sx of HF
SE unique to Hydralazine? (Gen. SE include headache, rare lupus-like syndrome)
SE of Monoket (Isosorbide mononitrate)?
Tachyphylaxis (need 10-12 hr nitrate free interval)
MOA of Digoxin?
Inhibits the Na/K ATPase pump => positive INOTROPIC effect (increased in CO)
Exerts a parasympathetic effect which provides a negative CHRONOTROPIC effect (decreased HR)
Role of digoxin?
Added in pts who remain symptomatic despite receiving standard therapy, including ACE-I and BB.
Effects of digoxin in HF?
Shown to improve sx, exercise tolerance and QOL
Shown to reduce hospitalizations for HF
But, doesn't improve survival of HF pts
What should be considered b4 dosing digoxin?
Pts renal fxn
T4, lower dose for renal insufficiency, smaller, older, female
What's the brand name of Digoxin?
Usual dose of digoxin in HF?
LD not used in HF
Therapeutic range for digoxin in HF?
0.5-0.9 ng/ml (higher range for A.Fib)
What's the antidote for Digoxin?
What increases the risk of digoxin toxicity?
Hypokalemia (K < 3.5 mEq/L)
Why's potassium oral supplementation necessary in HF?
Bcuz many HF drugs waste K
What's the most commonly used potassium oral supplementation in HF?
Potassium chloride (KCl)
When should K levels be checked?
Any change in diuretic, ACE-I, ARBs or ARAs dose
When a pt's renal fxn changes
What deficiency aggravates hypokalemia? What should be done?
Mg deficiency aggravates hypokalemia
Check Mg levels and correct prior to correcting K levels
What's the usual range of K? Exception?
In pts using Digoxin: 4-5 mEq/L
Do all pts require K supplement?
No! Some, esp those in class I and II, are able to get their K from food e.g.
Banana, potatoes, orange juice, beans, dark leafy greens, apricots, peaches, avocados, white mushrooms and some varieties of fish
What's the brand name of Potassium chloride?
K-Tab, Klor-Com, Klor-Con M10; M15; M20, Micro-K; 10 etc
How should Micro-K capsules be used?
Capsules may be opened and contents sprinkled on a spoonful of applesauce or pudding and immediately swallowed w/o chewing
How should Klor-Con, K-Tab be used?
Swallow whole, don't crush, cut, chew, or suck on tablet
How should Kor-Con M be used?
Swallow whole, don't crush, chew or suck on tablet
Tablet may be cut in half and swallowed separately or dissolve the whole tab in 4 oz of water - drink immediately
What's acute decompensated HF?
When pts experience episodes of worsening sx such as sudden wt gain, inability to lie flat w/o becoming SOB, decreasing functionality (eg, unable to perform their daily routine), increasing SOB and fatigue.
What does most ADHF pts present with?
When should BB be stopped in ADHF?
When hypotension or hypoperfusion is present
Howz congestion treated in ADHF?
Diuretics and possibly IV vasodilators
What's the inotrope of choice in HF pts with SBP < 90 mmHg?
How long should HF be on dopamine?
Inotropes (dopamine) are ass with worse outcomes and should be d/c once pt is stabilized
List vasodilators used in ADHF?
What must be monitored if ADHF pt is on vasodilators (NTG, nitroprusside and nesiritide)?
BP must be monitored closely
Howz NTG effective in ADHF?
It's more of a venous VD, esp at low doses; it's effective as an arterial VD at higher doses (doses should be titrated up)
In what cases is NTG preferred? Duration of tx?
In ADHF + active myocardial ischemia or uncontrolled HTN
Effectiveness may be limited after 2-3 days
An equal arterial and venous VD at all doses
Effect of Nitroprusside metabolism?
Results in the formation of Thiocyanate and Cyanide (both of which can cause toxicity)
When's Nitroprusside preferred in ADHF?
In pts with uncontrolled HTN, but renal and hepatic fxn must be monitored closely
Recombinant B-type natriuretic peptide
Effect of Nesiritide (Natrecor)?
Both arterial and venous VD
What's the brand name of Nesiritide (VD used in ADHF)?
What's the brand name of Nitroprusside (VD used in ADHF)?
SE of Nesiritide (Natrecor)?
Monitoring of Nesiritide (Natrecor) and NTG?
CI to NTG and Nitroprusside (Nitropress) use?
SBP < 90mmHg
CI with PDE-5 inh
Increased intracranial pressure
Monitoring of Nitroprusside (Nitropress)?
SEs of Nitroprusside (Nitropress)?
Thiocyanate/cyanide toxicity (esp, in renal and hepatic impairment)
Storage of Nitroprusside (Nitropress)?
Need to protect infusion bag from light (cover with opaque material or aluminum foil)
What's indicates degradation of Nitroprusside (Nitropress) to cyanide?
A blue color solution
T4 don't use
What's the target dose of Carvedilol (Coreg) in HF?
IR: 25 mg bid
50 mg bid (if pt > 85kg)
CR: 80mg daily.