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Flashcards in Heart Failure Pharmacology Deck (51)
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1

goals of HF treatment

prevent patients from ever getting symptomatic HF

focus on stage A and B HF for prevention

once symptomatic, prevent hospitalization

prevent progression to stage D HF

2

Stage A HF treatment

treat hypertension

encourage smoking cessation

treat lipid disorders

encourage regular exercise

discourage alcohol intake and illicit drug use

control metabolic syndrome

drugs: ACEI or ARB in appropritae patients

3

Stage B HF treatment

all measure under A

drugs: ACEI or ARB as well as beta-blockers in appropriate patients

4

Stage C HF treatment

all measures under stages A and B

dietary salt restriction

drugs for routine use: diuretics for fluid retention, ACEI, beta-blockers

drugs in selected patients: aldosterone antagonist, RBs, digitalis, hydralazine/nitrates

devices in selected patients: biventricular pacing, implantable defibrillators

5

Stage D HF treatment

appropriate measures under stages A, B, or C

decide on appropriate level of care

options are end-of-life care/hospice

extraordinary measures include heart transplant, chronic inotropes, permanent mechanical support, experimental surgery or drugs

6

symptoms of HF

low exercise capacity - decreased CO

dyspnea - pulmonary edema

orthopnea - increased venous return when supine

nocturia - increased venous return when supine

swelling, weight gain - salt and water retention

7

signs of HF

increased JVP - elevated RA pressure

rales - pulmonary edema

S3 - elevated LV filling pressures and stiff LV

hepatomegaly - systemic venous congestion

edema - transudation of fluid from capillaries

8

NYHA class I

no limitations of physical activity

9

NYHA II

slight limitation of activity

dyspnea and fatigue with moderate physical activity

10

NYHA III

marked limitation of activity

dyspnea with minimal activity

11

NYHA IV

severe limitation of activity

symptoms are present at rest

12

precipitating factors of HF

medication non-compliance

dietart indiscrtion

increased metabolic demands (fever, infection, anemia, tachycardia, hyperthyroidism, pregnancy)

increased circulating volume (increased preload)

increased afterload (uncontrolled systemic hypertension, pulmonary embolism)

reduced CO due to either reduced contractility or reduced stroke volume/abnormal heart rate

13

principles of HF treatment

identify underlying etiology

eliminate precipitating cause

ameliorate HF symptoms

modulate maladaptive neurohormonal response

improve long-term survival

14

steps to prevent heart failure

control blood pressure

control diabetes

control lipids

smoking cessation

weight control

early recognition and treatment of acute coronary syndromes

15

treatment of symptomatic HF

identify and treat the underlying etiology of HF

eliminate precipitating factors

ameliorate HF symptoms

modulate maladaptive neurohormonal response

improve long-term survival

16

treatment of heart failure with reduced EF (systolic HF)

improve Frank-Starling relationship in acute and asymptomatic patients

neurohormonal antagonists - reverse remodel and prolong life, pharmacogenomics is a possibility

devices to preevent sudden death

inotropic devices

heart replacement/support

17

treatment of heart failure with preserved EF (diastolic HF)

so far randomized controlled trials have been disappointing

find and treat underlying etiology

agggressively treat hypertension

coronary revascularization

if atrial fibrillation - control rate and/or convert to normal sinus rhyth

treat comorbidities

18

treatment of acute pulmonary edema in acute decompensated HF

LMNOP

L - loop diuretics, acutely venodilate and then natriuresis

M - morphine, venodilator to decrease sensation of dyspnea

N - nitrates, venodilator to increase pulmonary venous capacitance

O - oxygen, increased supply at a time when oxygen demand is high

P - positive pressure ventilation, improve oxygenation and decrease venous return, increases contractility

after acute stabilization, medicate underlying problem

19

hemodynamic goals for achieving symptom relief and stabilization in acute decompensated EF

reduce right and left heart filling pressures

reduce systemic vascular resistance

increase cardiac output

20

signs of congestion

orthopnea, increased JVP, rales, ascites, leg swelling

21

signs of poor perfusion

cool extremities, decreased BP, decreased pulse pressure, sleepy/obtunded, worsening renal function, decreased urine output

22

cold and wet

congested with poor perfusion

use vasodilators first and then inotropes

warm up and then diurese

23

cold and dry

no congestion but poor perfusion

end-stage HF vasodilators, inotropes

LVAD

heart transplant

24

warm and wet

congested but well-perfused

diurese and uptitrate HF meds

25

warm and dry

reconsider HF diagnosis

26

diuretics

most comonly used are secreted into the nephron via the proximal tubule (except aldosterone antagonists)

therefore doses need to be increased in patients with chronic kidney disease

categorized by site of action

27

types of diuretics

proximal tubule - acetazolamide, rarely used

thick ascending limb of loop of henle - loop diuretics

distal convoluted tubule - thiazide diuretics

collecting ducts - potassium-sparing diuretics

28

loop diuretics

improve symptoms but increase neurohormones

ex. furosemide, torsemide, bumetanide, ethycrinic acid (important, ototoxicity)

29

thiazide diuretics

HCTZ, chlorthalidone, chlorhiazide, metolazone

less potent than loop diuretics but can be very potent in combination

30

potassium sparing diuretics

triamterene and amiloride

rarely used

aldosterone-antagonists, improve mortality