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Flashcards in Heart Failure Deck (89):
1

T/F patients with heart failure all have volume overload

FALSE

why the term "heart failure" is actually preferred over CHF

2

volume coming into ventricles (end diastolic pressure)

preload

3

resistance - left ventricle must overcome to circulate load

afterload

4

percent of left ventricular blood ejected during each systolic contraction

ejection fraction (EF)

5

What is a normal EF?

60%

6

How is EF calculated?

stroke volume/end-diastolic volume

7

HFrEF

systolic dysfunction

(heart failure with reduced ejection fraction)

8

Disease that might lead to HFrEF

cardiomyopathies, CAD, valve diseases, arrhythmias

9

HFpEF

diastolic dysfunction

(heart failure with preserved ejection fraction)

10

Problem with HFpEF is _______ and problem with HFrEF is _________

1) filling (diastolic dysfn)

2) ejection (systolic dysfn)

11

Disease that might lead to HFpEF

chronic hypertension, aortic stenosis, cardiomyopathies (hypertrophic or restrictive)

12

What is the Frank-Starling mechanism?

the ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return

(i.e. incr. venous return to the heart --> incr. SV)

13

Symptoms of HF

FACES

Fatigue
Activity decrease
Cough (esp. supine)
Edema
Shortness of breath

14

What is the DIET approach to pt. w/ HF?

Diagnose
Initiate (drugs)
Educate (diet, lifestyle)
Titrate (adjust drugs)

15

What is EF in HFrEF?

= 40%

16

What is EF in HFpEF?

>/= 50%

17

Which type of HF has actually been studied in clinical trials?

Only HFrEF (systolic HF)

To date, efficacious therapies have not been identified for HFpEF (diastolic HF)

**HFpEF is a dx of exclusion

18

Stage A HF (ACC-AHA Classification)

High risk for HF, no SHD

HTN, CAD, DM, obesity, metabolic syndrome

19

Stage B HF (ACC-AHA Classification)

Asymptomatic HF, +SHD

previous MI, LVH, or low EF, asx valvular dz

20

Stage C HF (ACC-AHA Classification)

Symptomatic HF, +SHD

SOB, fatigue, reduced exercise tolerance

21

Stage D HF (ACC-AHA Classification)

Refractory end-stage HF, +SHD

sx at rest despite maximal medical therapy; recurrent hospitalizations

22

When would you use diuretics in HF?

symptomatic benefit in pt. w/ current or prior sx of HF and reduced LVEF who have evidence of fluid retention

should use used along with salt restriction

(in general should not be only therapy in stage C)

23

What is a ceiling dose?

eventually, if you keep pushing the dose, you don't get a greater benefit (this is when you would add another drug)

**Pt. with HF need higher doses of diuretics to get same response, and have diminished responses to ceiling doses

24

T/F, you cannot use thiazide and loop diuretics in combination

FALSE

esp. in pt. with HF that have diuretics resistance to loops, you may need to a thiazide in combo

25

What monitoring should be done in pt. on diuretics?

electrolytes (esp. potassium)

loop diuretics are more powerful than thiazides and must be used with caution to avoid dehydration

26

What is the key point to remember when tx pt. with diuretics?

SODIUM RESTRICTION!

if they aren't restricting sodium, the diuretics may not work b/c water will follow sodium

27

Nitroglycerine class

Nitrate - vasodilator

28

Nitroglycerine MOA (HF)

decreases preload

stimulates NO

29

Nitroglycerine indications (HF)

warm and wet acute decompensated HF (ADHF), ACS

30

Nitroglycerine adverse effects

hypotension, reflex tachycardia, HA, tachyphylaxis

31

Nitroprusside class

direct vasodilator

32

Nitroprusside MOA

decreases preload and afterload

stimulates NO

33

Nitroprusside indications

warm and wet acute decompensated HF (ADHF), alternative to inotropes in cold and wet ADHF

34

Nitroprusside adverse effects

hypotension or cyanide or thiocyanate toxicity

35

Nesiritide class

vasodilator, cardiac glycoside

36

Nesiritide MOA

decreases preload and afterload

37

Nesiritide indications

warm and wet acute decompensated HF (ADHF), alternative to inotropes

38

Nesiritide adverse effects

primarily hypotension (up to 1 hr), tachycardia

39

When would you Rx inotropes?

as a LAST resort w/ HF

they have a lot of serious s/e and should NEVER be used in an out-patient setting

40

What are the inotrope drugs talked about in class?

dobutamine (B1 agonist) and milrinone (PDE inhibitor --> incr CO)

41

ARNI

angiotensin receptor/neprilysin inhibitor

newest drug to hit the market and is going to replace ACEI

significantly decreases mortality rates

42

Which therapy combo has the highest reduction in mortality rates in HF pt?

BB + ACEI/ARB + ICD (implantable cardioverter-defibrillator)+ HF educations + anticoagulation for AF

43

When are ACEI indicated with HF?

Should be used in all pt. with a reduced EF to prevent HF

Recommended for all pt. with HFrEH

44

ACEI s/e

hypotensions, *cough*, renal effets, angioedema, teratogenic, hyperkalemia, rash and taste disturbance, transient incr. in serum creatinine

45

What do you need to monitor with on ACEI/ARB?

BP
BMP (electrolytes) w/in 1-2 wks

46

When is SCr concerning with ACEI/ARB tx?

a rise of >/= 0.5 needs evaluation

although expect a transient 20-30% incr in SCr after starting drugs

serum creatinine measures kidney fn

47

What do you need to remember when starting ACEI?

start SLOW

titrate every 2-4 wks toward target dose

48

T/F you cannot use ACEI and ARB together?

TRUE

it can be harmful to use them in combo

49

When would you use ARB is therapy?

- pt. with HFrEF who are ACEI intolerant
- reasonable as alternatives to ACEI as first line therapy in HFrEF
- pt. w/ a hx of MI and reduced EF, should be put on ACEI/ARB to prevent HR

50

How should you initiate ARB tx?

slowly

51

What is the recommendation for using ARB and ARNI in combo?

ARNI should NOT be administered concomitantly with ACE inhibitors or within 36 hr of the last dose of an ACEI

52

When are aldosterone antagonists recommended clinically?

- pt. with class II-IV HF who have LVEF = 35%
- pt. following an acute MI who have LVEF = 40% with sx of HF or DM

53

Which aldosterone antagonists are commonly used for HF?

Spironolactone/Eplerenone are "easy" drugs to prescribe for HF!!!

single dose once daily, no titration necessary

54

What are the cautions with aldosterone antagonists?

1) *significant* risk of hyperkalemia ( > 5%), needs close monitoring!!!
2) 10% risk of gynaecomastia w/ spironolactone (< 1% with eplerenone)

55

C/I to eplerenone

1) serum potassium > 5.5 mEq/L at initiation
2) creatinine clearance = 30 mL/min (can start at lower dose if CrCl 31-49 mL/min)
3) concomitant use of CYP3A4 inhibitors

56

C/I to spironolactone

1) serum potassium > 5 mEq/L at initiation
2) serum creatinine >2.5 mg/dL at initiation
3) renal insufficiency

57

Monitoring with aldosterone antagonists

1) titrate every 4-8 wks twd target dose
2) monitor BMP 3-7 days after start of therapy, the once monthly for 3 mo., then periodically as needed
(significant rights of hyperkalemia)

58

When should you use BB clinically in regards to HF?

1) in pt. w/ MI and reduced EF, use BB to prevent HF
2) in all pt. with reduced EF

(use of 1 of the 3 BB proven to reduce mortality is recommended for all stable pt)

59

What are the 3 BB proven to reduce mortality in pt. at risk for HF?

bisoprolol, carvedilol, and metoprolol succinate

60

What is a good alternative if pt. is hypotensive on carvedilol or cannot tolerate lower BP?

metoprolol succinate

**also good for pt. w/ Afib, COPD, asthma

61

adrenergic activation is lethal in __________

chronic HF

(why we use beta-blockers)

*pt. with highest NE levels have worst prognosis

62

BB C/I

1) cardiogenic shock
2) symptomatic bradycardia
3) 2nd/3rd degree heart block w/out pacemaker
4) severe reactive airway dz


*use w/ considerable caution in pt. w/ < 55 bpm or SBP < 80 mmHg
*NOT recommended in pt. with asthma with active bronchospasm

63

BB s/e

1) fatigue, weakness, lassitude
2) fluid retention
3) bradycardia
4) volume overload vs. COPD

64

Introducing BB to pt.

titrate every 2-4 wks toward target dose

may need to adjust diuretic dose

65

Monitoring with BB

BP, HR, HF sx, weights

66

Hydralazine class

arteriolar dilator

antioxidant (inhibits destruction of NO)

67

Isosorbide dinitrate (ISDN) class

venous dilator
large and small a. dilator

NO doner

68

BiDil

NO enhancer

**This is a combination drug that is a fixed dose of isosorbide dinitrate + hydralazine

69

Hydralazine s/e

hypotension, HA, tachycardia (less in HF), lupus like syndrome (+ANA)

70

Nitrates s/e

hypotension, HA, flushing, tolerance

71

Hydralazine, ISDN, BiDil are NOT recommended unless

pt. are unable to tolerate ACEI

72

When is Digoxin recommended?

HF with concurrent Afib

**controversy to use in normal rhythm (SE risk vs. benefit)

73

Digoxin MOA

unclear

-prob. NOT d/t positive inotropic effect
-likely benefits from neurohormonal inhibition

74

Target peak concentration (Cp) of Digoxin

0.5-0.8 ng/mL

75

T/F in clinical trials Digoxin use showed an increase rate of survival

FALSE

No survival benefit was seen at 4 yrs (although it did reduce symptomatic progression)

76

Clinical benefits seen from digoxin use

1) improved sx
2) improved exercise tolerance
3) improved QOL
4) decr. hospitalizations

***there is NO survival benefit

77

Digoxin s/e

CNS = HA, dizziness, halos, changes in yellow/green color perception

GI = anorexia, N/V, diarrhea, constipation

Cardiac = bradycardia (AV block), HR < 50, incr. PR interval

78

Risk factors for digoxin toxicity

renal insufficiency, hypokalemia/hyperkalemia, drug interactions

79

Digoxin interactions

See incr. serum concentration w/ amiodarone, erythromycin, itraconazole, omeprazole

See decr. serum concentrations w/ antacids, colestipol, laxatives

80

Which HF drugs should be considered in AA population?

hydralazine/ISDN

81

If EF < 35% despite optimized std therapy, consider

ICD

82

Tx protocol of HFpEF

1) tx physological factors (BP, HR, blood volume, ischemia)
2) tx dz known to cz HFpEF (HTN, CAD)
3) use of anticoagulation and anti-arrhythmic recommendations apply to all pt. w/ HF

**lack of randomized controlled trials

83

Hawthorn (Crataegus oxycantha) uses

CHF, angina, arrhythmias, hyperlipidemia, Buerger's dz

84

Hawthorn (Crataegus oxycantha) adverse effects

hypotension, palpitations, progression of HF

85

Crataegus oxycantha interactions

1) w/ BB, CCB, PDE-5 inhibitors, nitrates - decreases BP, dizziness, and/or light headedness
2) w/ antiplatelet/anticoagulants - incr. bleeding risk

86

Hypericum uses

depression, anxiety, sleep d/o, HIV

87

Hypericum s/e

arrhythmia and HTN

88

Hypericum interactions

w/ Digoxin, Statins, Verapamil, Warfarin, ARB, BB - decr. levels of drug

89

CAMs that may be mechanistically harmful in HF

aconite, ginseng, gossypol, gynura, licorice, lily of the valley, tetrandrine, yohimbine