Heart Failure Flashcards
0
Q
What causes HF?
A
HF is most commonly caused Reduced ability of the heart to eject blood, known AD low-output heart failure
1
Q
What’s heart failure (HF)?
A
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
2
Q
Types of heart failure?
A
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
3
Q
What xterizes systolic dysfxn of HF?
A
Left ventricle ejection fraction < 40%
HFrEF
4
Q
What xterizes diastolic dysfxn of HF?
A
Only mildly reduced (40-50%) or normal left ventricular ejection fraction
5
Q
What sometimes xterizes low-output HF?
A
Both systolic and diastolic dysfunction
6
Q
T/F? HF is one of the most important conditions to include lifestyle counseling and the requirements for strict medication adherence?
A
True
7
Q
HF can be classified into 2 types based on underlying etiology. What are they?
A
Ischemic cardiomyopathy
Or
Non-ischemic cardiomyopathy
8
Q
What does Ischemic cardiomyopathy result from?
A
From myocardial damage sustained during an acute myocardial infarction, resulting in loss of contractile function
9
Q
What does Non-Ischemic cardiomyopathy encompass?
A
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
10
Q
What are the most common causes of HF in North America?
A
Ischemia heart dx (myocardial infarction)
And
HTN
11
Q
List drugs that cause or worsen HF
A
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
12
Q
What’s cardiac output? (CO)
A
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
13
Q
What’s stroke vol?
A
Amt of blood ejected from the left ventricle during 1 cardiac cycle
14
Q
What determines stroke volume?
A
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
15
Q
What’s preload?
A
Volume of blood in the ventricle
16
Q
What’s afterload?
A
Resistance to forward flow in the arterial vessels
17
Q
What’s contractility?
A
How hard the ventricle squeezes during systole
18
Q
What’s cardiac index?
A
CO/BSA
19
Q
HF is a progressive syndrome, what does that mean?
A
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
20
Q
One of the ways the heart tries to compensate during HF is by activating RAAS? Implication of this?
A
Results in vasoconstriction, which helps maintain BP and perfusion to vital organs
21
Q
What other compensation by the heart increases HR and contractility? (T4 augmenting CO)
A
Sympathetic (adrenergic) activation
22
Q
While the RAAS activation in HF is useful (maintains BP and adequate perfusion), what’s not so good abt it?
A
Na and water retention => edema
Excess fluid causes body to be congested and the classic sx of “congestive” HF is seen
23
Q
Classic sx of “congestive” HF?
A
Dyspnea (SOB)
Fatigue
Peripheral edema
24
General s/sx of HF?
Dyspnea at rest or on exertion
Weakness/fatigue
Shortness of breath
Reduction in exercise capacity
LVH
Increased BNP (B-type Natriuretic Peptide): normal < 100 pg/ml
Increased NT-proBNP (N-terminal pro B-type Natriuretic Peptide) normal < 300 pg/ml
25
S/sx of left-sided HF?
SOB PE
S3 gallop
Orthoptera
Bibasilar rales
Paroxysmal nocturnal dyspnea (PND) or nocturnal cough
EF < 40%
26
S/sx of right-sided HF?
A JEHH
Ascites
Jugular venous distention (JVD)
Edema
Hepatojugular reflux (HJR)
Hepatomegaly
27
What're gen the results of sx in HF?
Either congestion behind the failing ventricle
Or
Hypoperfusion due to reduced cardiac output
28
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)
29
Whats another type of classification system used in HF?
New York Heart Association functional class (NYHA)
Important prognostic indicator for HF pts
30
What's the equivalent of ACC/AHA Staging System A to NYHA functional class?
No corresponding category
31
What's the equivalent of ACC/AHA Staging System B to NYHA functional class?
NYHA functional class I
32
What's the equivalent of ACC/AHA Staging System C to NYHA functional class?
NYHA functional class I, II, III
33
What's the equivalent of ACC/AHA Staging System D to NYHA functional class?
NYHA functional class IV
34
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
35
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)
36
Which stages of ACC/AHA Staging System is included in clinical diagnosis of HF?
C and D
37
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
38
Characteristics of ACC/AHA Staging System D?
Advanced structural HD + sx of HF at rest despite maximal medical therapy (Refractory HF requiring specialized interventions)
39
Characteristics of NYHA Functional Class I?
No limitations of physical activity
Ordinary physician activity doesn't cause sx of HF
40
Characteristics of NYHA Functional Class II?
Slight limitation of physical activity
Comfortable at rest, but ordinary physical activity results in sx of HF
41
Characteristics of NYHA Functional Class III?
Marked limitation of physical activity
Comfortable at rest, but minimal exertion (bathing, dressing) causes sx of HF
42
Characteristics of NYHA Functional Class IV?
Unable to carry on any physical w/o sx of HF
OR
HF at rest
43
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
Daily MVTE
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
44
What's the appropriate sodium restriction for HF pts?
< 1500 mg/d
45
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)
46
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)
47
What alt med has shown promise in HF?
Hawthorn and coenzyme Q10
48
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
49
Which of the cornerstones of HF therapy improves survival rate?
Beta blockers
50
What type of diuretic is more commonly used in HF?
Loop diuretics
51
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
52
What's excreted by loop diuretics in HF?
Water
Sodium
Chloride
Magnesium
Calcium
53
Whys the lowest effective dose of loop used in HF?
They haven't been shown to alter the survival of HF pts
54
List loop diuretics used in HF?
Furosemide (Lasix)
Bumetanide
Torsemide (Demadex)
Ethacrynic Acid (Edecrin)
55
Whats the brand name of Furosemide (loop used in HF)?
Lasix
56
Whats the oral loop dose equivalency of Furosemide (Lasix)?
40mg
57
Whats the oral loop dose equivalency of Bumetanide?
1mg
58
Whats the oral loop dose equivalency of Torsemide (Dermadex)?
20mg
59
Whats the oral loop dose equivalency of Ethacrynic acid (Edecrin)?
50mg
60
What's warning associated with loops use?
Sulfa allergy
61
Which loop is the sulfa allergy warning not applicable to?
Ethacrynic acid (Edecrin)
62
SEs of loop?
Hypokalemia
Orthostatic hypotension
Decreased Na, Mg, Cl, Ca (different than thiazides which increase Ca)
Metabolic alkalosis
Hyperuricemia (increased uric acid)
Hyperglycemia
Increased TGs, TC
Photosensitivity
Ototoxicity (more with Ethacrynic acid), including hearing loss, tinnitus and vertigo
63
Monitoring for loops?
BH REF
BP
Hearing with high doses of rapid IV admin
Renal fxn (SCr, BUN)
Electrolytes
Fluid status (in's and out's, weight)
64
Which loops are light-sensitive (stored in Amber bottles)?
IV furosemide and Bumetanide
65
What's the furosemide IV to PO ratio?
1:2
| Furosemide 20mg IV = Furosemide 40mg PO
66
Diuretics and lithium?
May decrease lithium renal clearance and increase risk of lithium toxicity
67
MOA of ACE-I?
Block conversion of angiotensin I to angiotensin II by inhibiting the ACE
68
MOA of ARBs?
They block angiotensin II receptor AT1, which is responsible for vasoconstriction, aldosterone stimulating and re-modeling effects of angiotensin II
69
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
70
List ACE-I agents
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril
Lisinopril (Prinivil, Zestril)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)
71
What's the brand name of Enalapril (ACE-I)?
Vasotec
72
What's the brand name of Lisinopril (ACE-I)?
Prinivil
Zestril
73
What's the brand name of Quinapril (ACE-I)?
Accupril
74
What's the brand name of Ramipril (ACE-I)?
Altace
75
Howz Captopril (Capoten) taken?
1 hr B4 meals
76
Black box warning of ACE-I?
D/c as soon as pregnancy is detected
77
CI to ACE-I use?
Angioedema
Bilateral renal artery stenosis
78
SEs to ACE-I and ARBs use?
Cough (not for ARB, only ACE-I SE)
Hyperkalemia
Angioedema (d/c drug immediately and drug is then CI)
Hypotension
79
Which ACE-I has more SEs? What are they?
Captopril (Capoten)
Taste perversion
Rash
80
Monitoring parameters of ACE-I and ARBs?
BP
Potassium
Renal fxn
S/sx of HF
81
List ARBs agents
Candesartan (Atacand)
Losartan (Cozaar)
Valsartan (Diovan)
82
Which of the ARBs has shown benefit in clinical trials but no FDA indication for use in HF?
Lossrtan (Cozaar)
83
What's the brand name of Losartan (ARB)?
Cozaar
84
What's the brand name of Valsartan (ARB)?
Diovan
85
Black box warning, CI, SEs, Monitoring Parameters same as ACE?
Same as ACE-I
86
Which electrolyte is typically increased in ACE-I and ARBs use?
Potassium (Hyperkalemia)
87
MOA of bb in HF?
Bb antagonize the effects of catecholamines, esp norepinephrine
88
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
89
List BB used in HF?
Carvedilol
Metoprolol Succinate extended-release
Bisoprolol
90
Which BB should be absolutely avoided?
BB with intrinsic sympathomimetic activity (ISA)
91
List the selective BB used in HF
Bisoprolol (Zebeta)
Metoprolol Succinate ext-release (Toprol XL)
92
What's the brand name of Metoprolol Succinate ext-release (selective BB)?
Toprol XL
93
List non-selective BB used in HF
Carvedilol (Coreg, Coreg CR)
94
What's the brand name of Carvedilol (non-selective BB)?
Coreg
95
SE of selective BB (Bisoprolol and Toprol XL)?
Reduced HR
Hypotension
Fatigue
Dizziness
96
Monitoring of selective BB (Bisoprolol and Toprol XL)?
HR
BP (titrate Q 2 wks, reduce dose if HR < 55 BPM)
S/Sx of HF
97
How do u d/c BB?
Must taper
98
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)
99
How do u take Carvedilol (Coreg, Coreg CR) - no selective BB?
Take Carvedilol - all forms -'with food
100
Which DM sx are NOT masked by BB?
Sweating (Diaphoresis)
And
Hunger
101
Which ARAs is non-selective?
Spironolactone
102
Which ARAs is selective? Benefits?
Eplerenone
Doesn't exhibit endocrine SE
103
MOA of ARAs?
They compete with aldosterone at receptor sites in DISTAL CONVOLUTED TUBULE and COLLECTING DUCTS
104
When ARAs used in pts with HF?
Standard therapy in pts who have progressed to NYHA class III or IV
105
What's the brand name of Spironolactone (ARAs)?
Aldactone
106
CI of Aldosterone Receptor Antagonists (ARAs)?
Renal impairment (CrCl < 30mL/min)
Hyperkalemia
107
SEs of ARAs?
Hyperkalemia
Increased SCr
Gynecomastia and breast tenderness (Spironolactone)
108
Which SE is unique to Spironolactone?
Gynecomastia and breast tenderness
109
Monitoring of ARAs?
Check K B4 starting and freq thereafter
BP
SCr/BUN
S/Sx of HF
110
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
Monitor freq
Counsel pt about increased risk of dehydration (due to vomiting, diarrhea or reduced fluid intake)
111
What's Hydralazine?
A direct vasodilator which reduces afterload
112
What's Nitrates?
Nitrates are venous vasodilators and reduce preload
113
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
114
What's the brand name of Hydralazine/Nitrate (combo) in HF?
BiDil
115
What's the brand name of Isosorbide mononitrate in HF?
Monoket
116
CI to using BiDil (Isosorbide dinitrate/hydralazine), Hydralazine, Monoket (Isosorbide mononitrate)?
CI with PDE-5 inhibitors
117
SE to using BiDil (Isosorbide dinitrate/hydralazine)?
Headache
Dizziness
Hypotension
Rare lupus-like syndrome
118
Monitoring of BiDil (Isosorbide dinitrate/hydralazine), Hydralazine, Monoket (Isosorbide mononitrate)?
HR
BP
S/Sx of HF
119
SE unique to Hydralazine? (Gen. SE include headache, rare lupus-like syndrome)
RAP
Reflux tachycardia
Anorexia
Palpitations
120
SE of Monoket (Isosorbide mononitrate)?
Headache
Dizziness/ Lightheadedness
Flushing
Hypotension
Tachyphylaxis (need 10-12 hr nitrate free interval)
Syncope
121
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)
122
Role of digoxin?
Added in pts who remain symptomatic despite receiving standard therapy, including ACE-I and BB.
123
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
124
What should be considered b4 dosing digoxin?
Pts renal fxn
Body size
Age
Gender
T4, lower dose for renal insufficiency, smaller, older, female
125
What's the brand name of Digoxin?
Lanoxin
126
Usual dose of digoxin in HF?
0.125-0.25mg daily
LD not used in HF
127
Therapeutic range for digoxin in HF?
0.5-0.9 ng/ml (higher range for A.Fib)
128
What's the antidote for Digoxin?
DigiFab
129
What increases the risk of digoxin toxicity?
Hypokalemia (K < 3.5 mEq/L)
Hypomagnesemia
Hypercalcemia
130
Why's potassium oral supplementation necessary in HF?
Bcuz many HF drugs waste K
131
What's the most commonly used potassium oral supplementation in HF?
Potassium chloride (KCl)
132
When should K levels be checked?
Baseline
Any change in diuretic, ACE-I, ARBs or ARAs dose
When a pt's renal fxn changes
133
What deficiency aggravates hypokalemia? What should be done?
Mg deficiency aggravates hypokalemia
Check Mg levels and correct prior to correcting K levels
134
What's the usual range of K? Exception?
3.5-5 mEq/L
In pts using Digoxin: 4-5 mEq/L
135
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
136
What's the brand name of Potassium chloride?
K-Tab, Klor-Com, Klor-Con M10; M15; M20, Micro-K; 10 etc
137
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
138
How should Klor-Con, K-Tab be used?
Swallow whole, don't crush, cut, chew, or suck on tablet
139
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
140
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.
141
What does most ADHF pts present with?
Worsening congestion
142
When should BB be stopped in ADHF?
When hypotension or hypoperfusion is present
143
Howz congestion treated in ADHF?
Diuretics and possibly IV vasodilators
144
What's the inotrope of choice in HF pts with SBP < 90 mmHg?
Dopamine
145
How long should HF be on dopamine?
Inotropes (dopamine) are ass with worse outcomes and should be d/c once pt is stabilized
146
List vasodilators used in ADHF?
Nitroglycerin
Nitroprusside
Nesiritide
147
What must be monitored if ADHF pt is on vasodilators (NTG, nitroprusside and nesiritide)?
BP must be monitored closely
148
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)
149
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
150
What's Nitroprusside?
An equal arterial and venous VD at all doses
151
Effect of Nitroprusside metabolism?
Results in the formation of Thiocyanate and Cyanide (both of which can cause toxicity)
152
When's Nitroprusside preferred in ADHF?
In pts with uncontrolled HTN, but renal and hepatic fxn must be monitored closely
153
What's Nesiritide?
Recombinant B-type natriuretic peptide
154
Effect of Nesiritide (Natrecor)?
Both arterial and venous VD
155
What's the brand name of Nesiritide (VD used in ADHF)?
Natrecor
156
What's the brand name of Nitroprusside (VD used in ADHF)?
Nitropress
157
SE of Nesiritide (Natrecor)?
Hypotension
SCr
158
Monitoring of Nesiritide (Natrecor) and NTG?
BP
SCr
BUN
Urine output
159
CI to NTG and Nitroprusside (Nitropress) use?
SBP < 90mmHg
CI with PDE-5 inh
Increased intracranial pressure
160
Monitoring of Nitroprusside (Nitropress)?
BP
HR
BUN
Urine output
Thiocyanate/cyanide toxicity
Acid-base status
161
SEs of Nitroprusside (Nitropress)?
Hypotension
Headache
Tachycardia
Thiocyanate/cyanide toxicity (esp, in renal and hepatic impairment)
162
Storage of Nitroprusside (Nitropress)?
Need to protect infusion bag from light (cover with opaque material or aluminum foil)
163
What's indicates degradation of Nitroprusside (Nitropress) to cyanide?
A blue color solution
T4 don't use
164
What's the target dose of Carvedilol (Coreg) in HF?
IR: 25 mg bid
Or
50 mg bid (if pt > 85kg)
CR: 80mg daily.
165
What's the brand name of Eplerenone?
Inspra
