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Flashcards in Heart Failure Deck (166):
0

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

1

What causes HF?

HF is most commonly caused Reduced ability of the heart to eject blood, known AD low-output heart failure

2

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

3

What xterizes systolic dysfxn of HF?

Left ventricle ejection fraction < 40%

(HFrEF)

4

What xterizes diastolic dysfxn of HF?

Only mildly reduced (40-50%) or normal left ventricular ejection fraction

5

What sometimes xterizes low-output HF?

Both systolic and diastolic dysfunction

6

T/F? HF is one of the most important conditions to include lifestyle counseling and the requirements for strict medication adherence?

True

7

HF can be classified into 2 types based on underlying etiology. What are they?

Ischemic cardiomyopathy

Or

Non-ischemic cardiomyopathy

8

What does Ischemic cardiomyopathy result from?

From myocardial damage sustained during an acute myocardial infarction, resulting in loss of contractile function

9

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

10

What are the most common causes of HF in North America?

Ischemia heart dx (myocardial infarction)

And

HTN

11

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

12

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

13

What's stroke vol?

Amt of blood ejected from the left ventricle during 1 cardiac cycle

14

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

15

What's preload?

Volume of blood in the ventricle

16

What's afterload?

Resistance to forward flow in the arterial vessels

17

What's contractility?

How hard the ventricle squeezes during systole

18

What's cardiac index?

CO/BSA

19

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

20

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

21

What other compensation by the heart increases HR and contractility? (T4 augmenting CO)

Sympathetic (adrenergic) activation

22

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

23

Classic sx of "congestive" HF?

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

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