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Flashcards in Heart Failure handout Deck (42):
1

Fill

Diastolic dysfunction

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Eject

Systolic dysfunction

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Definition of Heart Failure?

ACC/AHA defines heart failure as “a complex clinical syndrome that can result from any structural* or functional* cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

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Which side of the heart has the failure?

Left Sided:

Includes Diastolic

DysfunctionSystolic Dysfunction

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Description of Systolic Dysfunction?

ECHO:

EF < 40%****

Decrease contractility

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Causes of Systolic Dysfunction?

CAD

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Description of Diastolic Dysfunction?

Restriction in filling

ECHO: EF preserved

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Causes of Diastolic Dysfunction?

↑ ventricular stiffness

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Goals of Heart failure therapy?

Block the compensatory neurohormonal activation caused by ↓ CO↑ CO, ↓ afterload, and ↓ preload

Slow progression of cardiac dysfunctionImprove quality of life, ↓ hospitalizations

Decrease mortality/prevent premature death

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Enalapril:

Starting Dose

Target Dose

Starting Dose: 2.5 mg BID

Target Dose: 10 mg BID

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Lisinopril:

Starting Dose

Target Dose

Starting Dose: 5 mg daily


Target Dose:
20 mg (40mg) daily

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Special Dose Requirements?

START THE ACE-I, increase does irrespective of BP as long the patient can tolerate—NOT FOR BLOOD PRESSURE)

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Ace-I monitoring:

Serum creatinine, K+ and
BP 2 weeks after initiation and dose increase

Cough

Angioedema

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ACE-I: Contraindications

Hx of angioedema

Bilateral renal artery stenosis (RAS)

Pregnancy

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ARB : Benifits

↓ mortality in patients not taking ACE-I.

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Intolerant to ACE-Is: When to Use ARBs

Angioedema*

Cough


*The use of an ARB should not be D/C because of angioedema from the ACE. *

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Intolerant to ACE-Is: When NOT to use ARB?

!!!NOT!!!

Renal insufficiency

Hyperkalemia

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ARB medication: No dosing

Losartan

Valsartan

Candesartan

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ARB: Contraindication

Hx of angioedema

RAS

Pregnancy

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ARB: Monitoring

Serum creatinine, K+, and BP 2 weeks after initiation and dose increase

Angioedema

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β – Adrenergic Blockers:

Benefits

↓ mortality****

Everyone gets Beta blocker—the BACKBONE OF DRUGS ** Essentials

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β – Adrenergic Blockers:

Drug:

Starting Dose

Target Dose

Metoprolol succinate
Starting Dose
12.5 mg – 25 mg daily

Target Dose:
200 mg daily

Carvedilol
Staring Dose
3.125 mg BID

Target Dose
25 mg BID (wt 85 kg)

Bisoprolol (not uses in US)


"only approved for systolic"

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β – Adrenergic Blockers:

Dosing

Must be clinically asymptomatic, stable, and dry - (no fluid)***

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β – Adrenergic Blockers:

Monitoring

Monitoring: (monitor HF symptoms)

HR and BP
-Caution with marked bradycardia (< 90 mm Hg)

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β – Adrenergic Blockers:

When can't we use them if blood pressure is too low?

Systolic 90’s LEAVE IT ALONE!!!!

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β – Adrenergic Blockers:

When can't we use them if Heart rate is too low?

Increase Beta blocker over Ace : Hear Rate (different) –to low heart rate less than 60.

You may increase the dose of beta blocker if less than 60’s)
If the HR is in the 50’s

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Sinful Recommendation for β – Adrenergic Blockers:

Don’t increase two drugs at the same time: ACE and Beta Blocker

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What to check before increasing Beta Blocker?

Before increin: Renal Function, K+, cough, and BP (blood pressure—how low is too low ( Systolic 90’s LEAVE IT ALONE!!!!)

Do not have to wait to get target does for ACE or beta blocker –for the next visit

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The Randomized Cardiac Insufficiency Study (CIBIS III)

To assess whether a β – blocker as initial therapy in chronic heart failure is useful

In the intent-to-treat population, non-inferiority was met with bisoprolol as initial therapy compared to enalapril

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Use of β – Blockers and Concomitant Disease States:

Asthma!!

-β-blockers are recommended

Contraindicated in patients with asthma with active bronchospasm

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Use of β – Blockers and Concomitant Disease States:

Diabetes

β-blockers are recommended

Use with caution in patients with recurrent hypoglycemia

Heart Failure trumps all diseasing:
DM – masks, hypoglycemia

Masks tachycadia-- counsel

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Use of β – Blockers and Concomitant Disease States:

Chronic Obstructive Pulmonary Disease (COPD)

β-blockers are recommended

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Symptomatic Patients:

Loop Diuretics

When to use?

Should be given to all patients with current or prior HF and reduced LVEF who have evidence of fluid retention.

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Symptomatic Patients:

Loop Diuretics

Benefits?

↓ pulmonary congestion/JVD (fluid in lungs)

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Symptomatic Patients:

Loop Diuretics

Mortality

No effect on mortality*****WILL NOT SAVE YOU , only for symptoms

No effect on mortality*****WILL NOT SAVE YOU , only for symptoms

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Symptomatic Patients:
Loop Diuretics

MEDICATIONS

Furosemide
Bumetanide
Torsemide

Effective in compromised renal function
Get to know, the dose generally,

The NYAII symptomes does go back an forth.

Work when crcl is low or renal impairment.

<30Cr/min --Work

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Symptomatic Patients:
Loop Diuretics

Dosing

Determined based on clinical response

Titrate to achieve dry weight (ALWAYS BASED ON DRY WEIGHT)
-1 – 2 lbs of weight loss per day
-In an acute exacerbation: goal is to be 1 liter negative

May consider thiazide for diuretic resistance

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Symptomatic Patients:
Loop Diuretics

Monitoring

Signs of volume depletion

-Hypotension, dizziness, ↓ urine output, ↑ BUN/SCr (20-back off the dose)

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Loop Diuretics: Dosing Considerations

Hospital dosing in acute HF:

Use 40 mg IV as a single bolus dose

If patient is taking furosemide: double the first hospital dose

If PO: double the patient’s home dose

If IV: IV to PO conversion is 1:2 (i.e.e 10 mg IV =?

If the fluid retensiotn is reoccuring, that when we consider diuretics.

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Thiazide Diuretics:

Medication

Chlorthalidone
Hydrochlorothiazide *
Metolazone +


* ↓ effectiveness if CrCl < 30 mL/min

+ Can be used in compromised renal function

Thazides do not work in people who have compromised renal function,

CrCrl <30mL/min, the only one that works is METALAXONE
-more than 30 (any of them work)

-**Thiazide first 30mins prior to the LOOP***

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Aldosterone Antagonists

When to use:

Should be given to all symptomatic patients with NYHA class II-IV and who have LVEF < 35% taking ACE-I,
β – blocker, and diuretics (ALL THREE) than add Spirinolactone

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Aldosterone Antagonists

Benefits

↓ mortality