Heart Failure Flashcards by Rebecca Evatt

What is afterload?

the pressure in the arteries the heart has to pump against to eject blood out

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What is preload?

the pressure in the venous system that is needed to fill the heart with blood (venous return)

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What is systole?

contraction of the heart

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What is diastole?

relaxation of the heart, when the heart fills with blood

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Negative Chronotrope

decrease in HR

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Positive inotrope

increase in FOC

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Negative dromotrope

decrease in the speed of conduction through the AV node

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inability of the heart to deliver oxygenated blood sufficient to meet the needs of the body

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What factors contribute to the maintenance of MAP and CO?

An increase in contractility, systemic vascular resistance (SVR) and
blood volume

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How does the body compensate when a person has heart failure. Specify myocardial vs. peripheral mechanisms.

Myocardial —Remodeling of the heart

Peripheral —(+) RAAS, (+) SNS

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What are 3 things that persistent release of NE can do to the body?

ß-1 down regulation
Direct myocardial TOXICITY
Pro-arrhythmic effects

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What are the three types of cardiomyopathy?

Dilated
Hypertrophic
Restrictive

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stretched myocardium

thin, flexible myocardial walls

Dilated cardiomyopathy

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when the heart muscle becomes too THICK (internal ventricular chamber is smaller and filling vol is decreased) There isn’t enough blood to pump out

Hypertrophic cardiomyopathy

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STIFFENING of the myocardium (changes functionality of heart, hard to see structure changes)

restrictive cardiomyopathy

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Which type of cardiomyopathy causes SHF?

Dilated cardiomyopathy

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What are risk factors that can worsen HF?

HTN
Smoking
CAD
Race: Blacks (greater chance of hospitalizations with HF, equal mortality to whites)

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What are 3 classes of drugs that can worsen HF?

Negative inotropes
cardiotoxins
plasma volume expanders

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What are 3 drug classes that can be classified as Negative inotropes?

BB
Non-DHP CCBs
some antiarrthymics

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What are 3 drugs or classes of drugs that can be classified as cardiotoxins?

cocaine
chemo agents (ex.anthracyclines)
excessive alcohol

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What are 6 drug classes that are classified as plasma volume expanders?

NSAIDs
Vasodilators
Na+ containing agents
Steroids
Licorice
TZDs (for DM)

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What are the signs and symptoms of Left-sided HF?

Symptoms:
SOB & cough
dyspnea on exertion (DOE)
orthopnea
paroxysmal nocturnal dyspnea (PND)
Signs: 
S3/S4 heart sounds
Rales
cardiomegaly

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What are the signs and symptoms of Right-sided HF?

Symptoms:
weight gain
swelling
abdominal distension
Signs:
edema/ascites
JVD
HJR
hepatomegaly

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What is bilateral HF?

when the pt has both right and left-sided HF

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What do you need to differentiate between diastolic and systolic HF?

What must a pt's BNP be to be diagnosed with HF?

> 100 pcg/mL

What must a pt's NT-pro BNP be to be diagnosed with HF?

> 300-400 pcg/mL

If a pts EF is ≤ 40% that pt has _______.

HFrEF

If a pts EF is ≥ 50% that pt has _______.

HFpEF

If a pt has an EF between 41-49% they are considered to have ______.

borderline HFpEF

``` Which of the following is the most useful in acute decompensated HF? A. BNP B. Cardiac troponin C. Chest x-ray D. MRI ```

Describe Stage A HF.

pt has risk factors no HF symptoms no heart damage

Describe Stage B HF.

``` No symptoms heart damage (ex. MI) ```

Describe Stage C HF.

Symptoms + Heart damage

Describe Stage D HF.

Refractory HF

Describe Class I HF

physical activity does not cause HF symptoms | Can dance as much as they want

Describe Class II HF

No symptoms with normal activity but cannot go as far as long as when perfectly healthy

Describe Class III HF

comfortable at rest, but has HF symptoms when walking or moving around

Describe Class IV HF

has HF symptoms even at rest

What is appropriate non-drug therapy for HF patients?

``` correct underlying causes patient education on self-care and adherence Na+ restriction: 1.5-3 g/day (~2-3 tsp) Fluid restriction: 1-2 L/day Exercise/physical activity ```

GDMT

guideline directed medication therapy

Our lectures on Heart failure is centered on: A. Circulatory collapse/hypovolemia B. Volume Overload C. Chronic Myocardial Failure D. High output—thyrotoxicosis, anemia, sepsis

What test can you run to determine ejection fraction? A. chest X-ray B. comprehensive 2-D echocardiogram with Dopplar C. MRI D. radionuclide ventriculography

``` Which of the following helps you determine if a person has left-sided HF? A. Anorexia B. Tachycardia C. Diaphoresis D. Orthopnea E. Swelling ```

SOB

shortness of breath (L)

DOE

dyspnea on exertion (L)

Obtundation

less than full alertness (nonspecific)

Jugular venous distension (JVD):

when blood pools in the jugular vein on the neck (R)

Cardiomegaly

enlarged heart (L)

Diaphoresis

intense sweating (nonspecific)

Paroxysmal Nocturnal Dyspnea (PND)

SOB or coughing while asleep

Rales

crackly sounds in the lungs (indicative of fluid build up in the lungs) (L)

Hepatomegaly

enlarged liver (R)

Hepatic jugular reflux (HJR):

when you push on the liver of a person with hepatomegaly blood pools in their neck (R)

S3 sounds in Left HF are usually associated with ___________ while, S4 sounds are usually associated with ________. A. SHF, DHF B. DHF, SHF

Explain the treatment options associated with the ACC/AHA stages of HF.

A: lifestyle management of risk factors B: an ACEI or BB may be appropriate for people with other diseases C: put on an ACEI & BB D: Heart transplant if a candidate

What are 2 characteristics of dilated cardiomyopathies?

1. decreased contractility | 2. increased afterload

What are some reasons the heart may have decreased contractility that may lead to a dilated cardiomyopathy?

``` ischemia MI ethanol drugs idiopathic (we don’t know) ```

What are some causes of a thickened myocardium that may lead to a hypertrophic cardiomyopathy —> DHF?

``` HTN DM valvualar heart disease CAD A fib ```

``` What is the most common cause of a restrictive cardiomyopathy? A. Alchohol B. Amyloidosis C. valvular heart disease D. DM ```

``` Which of the following indicates a pt has HFrEF? A. EF = 33% B. EF = 45% C. EF = 55% D. NT proBNP = 515 pcg/mL ```

``` RG is a 67 yo male who has recently had an MI and is presenting to clinic for follow up. He says he feels “great” denying any edema or SOB. Which ACC/AHA stage best describes RG? A. A B. B C. C D. D ```

Which of the following is characterized by problems with relaxation and filling? A. Diastolic dysfunction B. Systolic dysfunction

What are 3 compensatory mechanisms that occur when CO is decreased?

1. remodeling 2. (+) SNS 3. (+) RAAS

How do you treat stage A HF?

heart healthy lifestyle and appropriate therapy for risk factors

``` [SATA] All patients with a reduced ejection fraction need to be on? A. ACE Inhibitor B. BB C. Non-DHP CCBs D. Statins ```

A, B

``` . [SATA] All patients with a previous MI should be on _______ to prevent HF. A. ACE Inhibitor B. BB C. Non-DHP CCBs D. Statins ```

A, D

``` Which of the following should your patient NOT be on if they have SHF? A. ACE Inhibitor B. BB C. Non-DHP CCBs D. Statins ```

``` [SATA] All patients with Stage C HFrEF MUST be on: A. ACE Inhibitor B. BB C. Diuretic D. Aldosterone Antagonist ```

A, B

[SATA] Which of the following are reasons why you would give and ARB instead of an ACEI? A. intolerant to ACEI B. doctor thinks it is best C. combined with an ACEI in very symptomatic pts D. ACEI + Aldosterone Antag + ARB in very symptomatic pts

A, B, C

``` Which of the following are recommended as add-on therapy in HF class pts who have LVEF ≤ 35%? A. ACE Inhibitor B. BB C. Diuretic D. Aldosterone Antagonist ```

Why would you use a loop diuretic in HF patients?

volume overload

_____ should be used in all stable HF patients to decrease mortality.

When would you give an aldosterone antagonist to post-acute MI patients with symptoms of HF or who also have DM?

when their EF ≤40%

``` [SATA] Which of the following can be beneficial in HF patients that are persistently symptomatic and are already on GDMT (ACEI + BB + (Aldosterone Antagonist) + (Loop))? A. Statin B. Bidil C. Digoxin D. Warfarin ```

B,C

Why would you give an anticoagulant to a HF pt?

Pts with A fib or prior VTE or cardioembolic risk factors

Why would you give someone with risks of HF or actual HF a statin?

if they have dyslipidemia | to prevent HF in post- MI pts

``` [SATA]Which of the following is a correct starting dose for HF? A. Lisinopril 2.5 BID B. Enalapril 20 mg BID C. Bisoprolol 1.25 mg daily D. Metoprolol 12.5 mg daily ```

A, C, D

``` Which of the following is a correct maximum dose for HF? A. Lisinopril 20 mg daily B. Enalapril 40 mg BID C. Bisoprolol 1.25 mg daily D. Metoprolol 200 mg daily ```

What is the treatment goal for systolic HF?

To reach the MAXIMUM dose with ACEI & BB that you can possibly give them to treat HF

``` How do ACEI effect the following? _____ preload _____ afterload _____ mortality _____ HF symptoms _____ digoxin levels ```

``` How do ACEI effect the following? preload (decrease) afterload (decrease) mortality (decrease) HF symptoms (improve) digoxin levels (increase) ```

What should you monitor when your pt is on an ACEI?

1. K+ 2. bp 3. renal function

What is CI with ACE inhibitors?

bilateral renal artery stenosis | pregnancy

Which trial proved that ARBs can be beneficial in HF patients?

CHARM trial

What is the MOA of ARBs?

bind to the ATII1 and prevent Ang II from binding to it

``` Which of the following do ARBs not block? A. Aldosterone release B. SNS activation C. cell growth and fibrosis D. Vasodilation ```

D (they block VC and cause VD)

``` Which of the following is NOT a correct starting dose? A. Candesartan 32 mg daily B. Valsartan 20 mg C. Bidil 1 tab TID D. Lisinopril 5 mg BID ```

Why would you start a patient on Bidil?

if they are not tolerating an ACEI/ARB | as add on therapy for an AA with HF

What is the dose for hydralazine and ISDN in one tablet of Bidil?

hydralazine 37.5 mg + ISDN 20 mg

When can you give a BB to a Class IV HF patient?

if they are clinically stable

``` [SATA] Which of the following should you titrate up in HF patients? A. ACEI B. ARBs C. BB D. Bidil ```

A, B, C

``` [SATA] Which of the following are ß-1 selective? A. Carvedilol B. Metoprolol Succinate C. Bisoprolol D. Nebivolol ```

B,C,D

Name some other effects of Carvedilol other than beta blocking.

CCB, antioxidant activity, anti proliferative activity

What are 2 drugs that interact with carvedilol and do they increase or decrease carvedilol concentrations?

fluconazole & amiodarone (increase)

What patients should you NOT give Carvedilol to and why?

Asthmatics & COPD patients (carvedilol blocks ß-1 and ß-2 receptors which causes bronchoconstriction and can induce asthma attacks and make it harder to breathe)

When should you counsel your patent to take Coreg CR?

in the morning with food

Can you crush Coreg CR?

NO, swallow the whole capsule, do not crush chew or take in divided doses.

Can you take Coreg CR and drink alcohol on game day?

separate Coreg CR from alcohol (including cough syrup and mouth wash) by 2 hours

``` Which of the following is an effect of Nebivolol? A. alpha-adrenergic receptor antagonist B. nitric oxide mediated VD effects C. calcium channel antagonist D. ß-2 receptor antagonist ```

If you gave Nebivolol to treat HF, when it enters the guidelines, what dose could you start them on and what would be the max dose to give your patient?

start at 1.25 mg daily, and increase by 2.5 mg q 1-2 weeks | Max: 10 mg daily

Name the 2 aldosterone antagonists you can give HF pts for add on therapy.

spirinolactone and eplerenone

``` What trial was the landmark trial for spirinolactone in HF treatment? A. CHARM B. RALES C. EPHESUS D. FIELDS ```

``` What trial was the landmark trial for eplerenone in HF treatment? A. CHARM B. RALES C. EPHESUS D. FIELDS ```

What should you monitor when a pt is on an aldosterone antagonist?

K+

What is the correct initial dose of spirinolactone and eplerenone in HF pts?

25-50 mg po QD

What is the max dose for spironolactone in HF pts?

25 mg QD or BID

What is the max dose for eplerenone in HF pts?

50 mg QD

What do diuretics do to each of the following? ______ preload ______ signs and symptoms of congestion

preload (decrease) | signs and symptoms of congestion (decrease)

What should you monitor for patients on a Loop diuretic?

K+, weight loss

What are the ADRs of loop diuretics?

ototoxicity, electrolyte disturbances

Which one is better in a renal insufficient patient? A. Metazolone B. HCTZ

What trial said that Digoxin decreased hospitalizations and improved quality of life in pts with HF?

DIG trial

What should you monitor for in HF pts on Digoxin?

``` Efficacy: improvement of symptoms Toxicity: GI—N/V, anorexia, wt loss Cardiac—arrhythmias Misc—vision changes (yellow and green halos) ```

What should you monitor for efficacy in A fib pts on digoxin

rate control (HR)

What are ways you cant treat digoxin toxicity?

``` Stop giving the drug Treat arrhythmias if present Give K+ if hypokalemic Give cholestyramine (to bind digoxin and decrease half-life) Digoxin antibodies (Digibind) ```

``` [SATA] Which of the following decrease the BA or serum levels of digoxin? A. Amiodarone B. St. John’s Wort C. Cholestyramine D. NSAIDs E. Non-DHP CCBs ```

B, C

``` [SATA] Which of the following increase the BA or serum levels of digoxin? A. Amiodarone B. St. John’s Wort C. Cholestyramine D. NSAIDs E. Non-DHP CCBs ```

A, D, E

``` [SATA] Which of the following have a less serious increase in BA or serum levels of digoxin? A. Amiodarone B. NSAIDS C. BBs D. K+ sparing diuretics E. Atorvastatin F. Non-DHP CCBs ```

B, C, D, E

What is the daily dose for digoxin?

0.125 mg daily

What is the therapeutic range for digoxin in treating HF?

~0.5-0.9 ng/mL (drawn atleast 6 hours after dose & about 6 days after first dose)

Is digoxin effective at doses higher than 0.9 ng/mL?

for A fib, yes up to 2 ng/mL | for HF, NO

``` [SATA] Which of the following are IV inotropes that are used to treat cardiac shock or acute decompensated HF pts? A. Dobutamine B. Amrinone C. Amiodarone D. Dopamine ```

A, B, D

If a pt needs something for pain or headaches which pain reliever would you recommend for a HF pt?

Tylenol

What is Stage D HF also called?

Advanced HF, end-stage HF, refractory HF

How should you treat a pt with Stage D HF?

inotrope infusion heart transplant if a candidate hospice

What are the 3 ultimate goals in HF patients?

1. Prolong life 2. control symptoms 3. preserve of increases quality of life

What are the clinical goals in HFpEF?

1. control bp 2. control HF 3. choose meds based on other disease states

When would you give a HFpEF patient a BB or ACEI or ARB?

if they also have HTN

What must the HR be above to start a pt on a BB?

60-70 bpm

Heart Failure Flashcards

(129 cards)