Heart Failure

Question 1

Define Heart Failure

Answer 1

-clinical syndrome or condition caused by heart’s inability to generate enough cardia output to meet body’s metabolic demands

Question 2

Pathophysiology (Signs and Sxs) of HF

Answer 2

• intravascular and interstitial volume overload: SOB, rales, edema
• manifestations of inadequate tissue perfusion (fatigue, poor exercise tolerance)

Question 3

5 Year Mortality Rate HF

Answer 3

> 50%

Question 4

Causes of HF

Answer 4

• coronary artery disease
• HTN
• idiopathic dilated cardiomyopathy

Question 5

Preload

Answer 5

amount of venous return to heart

Question 6

Afterload

Answer 6

resistance against which the ventricle must pump

Question 7

Contractility

Answer 7

force of contraction

Question 8

What effect do positive inotrope medications have on contractility?

Answer 8

positive inotropes increase contractility

Question 9

Sxs of Heart Failure

Answer 9

• dyspnea, orthopnea, SOB, PND, exercise intolerance, tachypnea
• cough
• fatigue, weakness, lethargy
• nocturia, polyuria
• hemoptysis
• abdominal pain, anorexia, nausea, bloating, ascites

Question 10

Signs of Heart Failure

Answer 10

• rales, S3 gallop
• pleural effusion
• tachycardia
• cardiomegaly
• peripheral edema
• JVD
• hepatojugular reflex, hepatomegaly

Question 11

Lab Tests for HF

Answer 11

• BNP > 100 pg/mL
• EKG
• SCr
• CBC
• CXR
• echocardiogram

Question 12

Stage A HF

Answer 12

• pts at high risk of developing HF but w/o structural heart dz or sxs of HF
• eg pts w/ HTN, DM, obesity, metabolic syndrome, atherosclerotic dz

Question 13

Stage B HF

Answer 13

• pts with structural heart dz but w/o signs or sxs of HF

- eg pts w/ previous MI, LVH, low EF

Question 14

Stage C HF

Answer 14

• pts with structural heart dz with current or prior sxs of HF
• eg pts w/ known structural heart dz and SOB, fatigue, reduced exercise tolerance

Question 15

Stage D HF

Answer 15

• pts with refractory HF requiring specialized interventions

- eg pts with marked sxs at rest despite maximal medical therapy

Question 16

NY Functional Class I

Answer 16

-pts w/ cardiac dz but w/o limitations of physical activity

Question 17

NY Functional Class II

Answer 17

-pts with cardiac dz that results in slight limitations of physical activity (ordinary activity results in fatigue, palpitation, dyspnea and angina)

Question 18

NY Functional Class III

Answer 18

-pts with cardiac dz that results in marked limitation of physical activity

Question 19

NY Functional Class IV

Answer 19

-pts with cardiac dz that results in an inability to carry on physical activity without discomfort

Question 20

Drugs that May Precipitate/Exacerbate HF

Answer 20

• negative inotropic effect (anti-arrhythmics, BB, CCB, terbinafine)
• cardiotoxic: doxorubicin, daunomycin, imatinib, ethanol, amphetamines
• Na and water retention: NSAIDs, COX2 inhibitors, glucocorticoids, androgens, estrogens, salicylates (ASA)

Question 21

Treatment Principles for HF

Answer 21

• optimize preload
• reduce afterload
• increase contractility

Question 22

ACE-I Effect on Ventricular Workload

Answer 22

-decrease preload and afterload

Question 23

ACE-I Benefits for HF

Answer 23

• reduce morbidity and mortality
• reduce hospitalizations in HFrEF
• slow dz progression: decrease or prevent ventricular remodeling

Question 24

ACE-I Recommended for which HF Pts?

Answer 24

• all pts with reduced EF to prevent HF

- all pts with HFrEF unless CI (2/3 tri preg, angioedema, renal artery stenosis, hyperkalemia)

Question 25

Beta Blockers that Are Used in HF

Answer 25

-carvedilol, metoprolol, bisoprolol

Question 26

BBs Effect on Ventricular Workload

Answer 26

-decrease preload and afterload; decrease HR and antiarrhythmic

Question 27

Benefits of BBs in HF

Answer 27

- reduce morbidity and mortality - reduce hospitalizations - cause "reverse modeling" of L ventricle; return heart to more normal size, shape, function

Question 28

BBs Recommended for which HF Pts?

Answer 28

- all pts with reduced EF to prevent HF | - all STABLE pts with HF unless CI (eg asthma)

Question 29

How should pharm therapy be initiated with BB for HF?

Answer 29

- start at low doses | - titrate slowly up to target dose and monitor closely

Question 30

Monitoring for BB for HF

Answer 30

- BP - HR - fluid status

Question 31

Aldosterone Antagonists MOA

Answer 31

-decrease sodium retention

Question 32

Aldosterone Antagonists Effect on Ventricular Workload

Answer 32

decrease preload

Question 33

Aldosterone Antagonists Benefits in HF

Answer 33

- reduce morbidity and mortality | - reduce hospitalizations

Question 34

Aldosterone Antagonists Recommended for which HF Pts?

Answer 34

- patients with NYHA class II-IV who have LVEF < 35% | - pts after acute MI with LVEF <40% w/ sxs of HF or DM

Question 35

Aldosterone Antagonists Monitoring

Answer 35

- BP - K+ - renal function (baseline, 3 days, 1 week, qmonth x3 for spironolactone)

Question 36

Diuretics Effect on Ventricular Workload

Answer 36

-decrease preload

Question 37

Diuretics Benefit in HF

Answer 37

-relieve congestive sxs (systemic edema)

Question 38

Diuretics Recommended in which HF Pts? | Also say which diuretic for mild, mod, severe

Answer 38

-pts with HFrEF with fluid retention +mild overload = thiazide +moderate = loop +severe = IV furosemide

Question 39

Diuretics Monitoring

Answer 39

- BP | - serum K+

Question 40

ARBs MOA

Answer 40

- block angiotensin II receptor, but do not affect bradykinin - effect is vasodilation and inhibition of ventricular remodeling

Question 41

ARBs Recommended for which HF Pts?

Answer 41

- pts w/ HFrEF who are ACE-I intolerant - alternative to ACE-I as first line therapy in HFrEF - consider in persistently symptomatic pts with HFrEF on guideline directed med therapy

Question 42

Hydralazine/Isosorbide MOA

Answer 42

- hydralazine: direct acting vasodilator = decrease SVR, increase SV and CO - nitrates: venodilation = decreased preload, may inhibit ventricular remodeling

Question 43

Hydralazine/Isosorbide Recommended for Which HF Pts?

Answer 43

- African Americans with NYHA class III-IV HFrEF | - pts with HFrEF who cannot have ACE-I or ARBs

Question 44

Hydralazine/Isosorbide AEs

Answer 44

- HA - palpitations - nasal congestion

Question 45

Digoxin MOA

Answer 45

-positive inotrope = increase contractility

Question 46

Digoxin Benefits in HF

Answer 46

- antiarrhythmic for pts with afib | - alleviates sxs and improves clinical status in pts with HFrEF (decrease hospitalizations)

Question 47

When should dig be used in HF pts?

Answer 47

-add for pts who remain symptomatic despite optimized tx

Question 48

Signs of Digoxin Toxicity

Answer 48

- anorexia - N/V/D - tiredness, weakness - decrease HR - yellow/green halo vision - confusion, HA

Question 49

Digoxin Drug Interactions

Answer 49

- verapamil - captopril - diuretics - amiodarone, dronedarone - clarithromycin, erythromycin

Question 50

Managing Decompensated HF

Answer 50

- hospitalize - IV loop diuretic for pts w/ sig fluid overload - IV dobutamine to increase renal blood flow and diuresis - if symptomatic HoTN is absent, IV NTG, nitroprusside or nesiritide may be considered

Question 51

B-type Natriuretic Peptide Indication

Answer 51

-IV tx of pts with acutely decompensated HF with dyspnea at rest or with minimal activity

Question 52

B-type Natriuretic Peptide MOA

Answer 52

- smooth muscle relaxation - dilates veins and arteries - dose dependent decrease in wedge pressure and systemic arterial pressure

Question 53

B-type Natriuretic Peptide Half Life

Answer 53

18 minutes

Question 54

B-type Natriuretic Peptide Elimination

Answer 54

- cell surface clearance receptors - proteolytic cleavage - renal filtration - clearance proportional to body weight

Question 55

B-type Natriuretic Peptide Monitoring

Answer 55

-monitor BP and decrease dose if HoTN develops