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HF Flashcards

1
Q

Heart responds to increase demands 3 ways?

A

Increase HR (chronotrope)

Increasing contraction force (inotrope)

Increase preload/afterload

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2
Q

Causes of Systolic HF (reduced ejection fraction)

A

Reduction in muscle mas

Dilated cardiomyopathies

Ventricular hypertrophy

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3
Q

Causes of diastolic HF (preserved ejection fraction)

A

Increased ventricular stiffness (e.g., hypertrophy, myocardial dz, MI)

Mitral/triscuspid valve stenosis

Pericardial dz

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4
Q

Neurohormones that contribute to/exacerbate ventricular hypertrophy/remodeling?

A

Angiotensin 2

Epi/norepi

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5
Q

What neurohormone would be elevated in response to stress/stretch of ventricles?

A

B-type natriuretic peptide (BNP)

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6
Q

Heart’s intrinsic ability to incraese its force of contraction and SV in response to an increase in venous return (prelaod)

A

Frank Starling Mechanism

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7
Q

Decreased cardiac output causes increased prelaod/afterload… ultimately activating/causing?

A

Activates SNS

Activates RAAS

Ventricular hypertrophy

(all increase CO but lead to further destruction of the heart)

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8
Q

HF w/ preserved EF aka?

A

Diastolic dsfx (restriction inventricular filling)

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9
Q

HF w/ reduced ejection fraction aka?

A

Systolic dsfx (decerased contractility)

(70% of HF causes)

(clots are commonly formed in the “leftover, stagnant” blood)

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10
Q

HFpEF?

HFrEF?

A

HFpEF > 50

HFrEF < 40

(41-49 is borderline and are apporached similarly to HFpEF)

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11
Q

HF signs?

A 
S3 gallop
Edema (pulmonary, peripheral = cardinal finding)
Rales
Elevated BNP
Extremities, cool/cyanotic

JVD

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12
Q

WHAT DO ALL PTS W/ HF GET?

A

ACEI

long term mgmt of chronic HF (rec’d use w/ b-blocker an diuretic)

(also pts w/ L ventricular hypertrophy w/o HF symptoms)

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13
Q

Considerations w/ ACEI usage?

A

SCr and BUN slightly increase (up to 20% acceptable)

BUT caution w/ renal artery stenosis

SO monitor K, SCr, and BUN at baseline/two weeks

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14
Q

Blocks angiotension2 at AT1 receptor, preventing vasoconstriction

Block aldosterone secretion

A

ARBs

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15
Q

ACEI for HF?

A

Captopril
Enalapril
Lisinopril

Perindopril
Ramipril
Trandolapril

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16
Q

ARBs for HF?

A

Candesartan
Losartan
Valsartan

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17
Q

Inhibits neprilysin thus allowing vasodilators that are otherwise degraded by nephrilysin to proliferate

A

Sacubitril

Note: it’s a prodrug and combined with Valsartan

aka ARNI

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18
Q

Rec’d in ALL pts w/ HFrEF (unless CI)

Consider even if asymptomatic…

Decrease in ventricular arrhythmias

And when combiend with ACEI -> decrease mortality, hospitalization

A

Beta blocker

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19
Q

Beta blocker HF considerations?

A

Class 2,3 (Stage B/C/D)

Stable pt w/ euvolemia and no recent decompensation

START THE DOSE LOW AND INCREASE q 2 WEEKS

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20
Q

Beta cautions/precautions?

A

DM - can mask hypoglycemia

Asthma - can block bronchodilation, exacerbating asthma

Disrupts lipid metabolism

Drug w/drawal may angina, MI, SUDDEN death in pts with ischemic heart dz

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21
Q

Beta blockers for HF?

A

Carvedilol (mixed alpha/beta blocker)
Metoprolol
Bisoprolol

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22
Q

Chronic heart failure w/ fluid overload, USE FIRST!

But, no mortality benefit

Decreases JVD, pulmonary congestion, peripheral edema

SHould be used w/ other drugs (adjunct)

A

Diuretics

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23
Q

Which diuretics have a ceiling effect?

A

Loops

Furosemide peaks at 160-200

24
Q

Thiazides at not effective at lower CrCl (<30)?

A

Thiazide/thiazide like

EXCEPT

Metalozone (can be used under 30)

25
Diuretics that eliminate catecholamine potentiation (decreasing BP) AND block direct fibrotic actions on the myocardium
Potassium sparing diuretics | Aldosterone contributes to cardiac hypertrophy -> so blocking it contributes to added benefit
26
What should be combined w/ ACEI/beta blockers for African American pts w/ NYHA Class 3,4 or HFrEF to reduce morbidity/mortality?
Hydralazine (BiDil)
27
Vasodilator (v>a) with a short half life that must be administered IV Tolerance rapidly develops
Nitroglycerin
28
Preferred agent for preload reduction in pts w/ pulmonary congestion?**
nitroglycerin
29
Used in ADHF (primarily in warm/wet) Ideal for pts w/ ischemic heart dz, MI, HTN following bypass
Nitroglycerin
30
DOC for most HTN emergencies Mixed/balanced aterial-venous vasodilator short half life/IV Warm/wet ADHF
Nitroprusside
31
Adverse effects include methemoglobinemia PVC tubing/bags may absorb...
nitroglycerin
32
Cyanide toxicity May increase ICP
nitroprusside
33
b-type natriuretic peptide -> vasodilation Suppresses RAAS Used for warm/wet ADHF
Nesiritide
34
Inotropic agents mostly used for ADHF Note that long term use of positive inotrope is not rec'd
Milrinone Dopamine Dobutamine (digoxin is also an inotrope but not limited to use in ADHF)
35
Cardiac glycoside that increases force of contractions (pos inotrope, sympathetic stimulant) that stimulates vagus nerve (parasympathetic effect) Improves symptoms BUT no effect on mortality
digoxin -- narrow therapeutic index
36
Digoxin is an add on therapy for other HF drugs. If starting digoxin/beta blocker at same time, whcih do you start first?
Beta blocker, duh
37
Monitoring parameters for digoxin? Antidote?
Monitor EKG, serum electrolytes, digoxin levels, BUN, Cr (narrow therapeutic index) Antidote = Digoxin Immune Fab (Digibind)
38
Dopamine usually avoided in ADHF, except?
when pt has significant systemic HOTN or cardiogenic shock w/ elevated ventricular filling pressures
39
beta blocker (w/ some alpha 1 effects) used in ADHF However, tachyphylaxis (decline in efficacy)
dobutamine
40
Positive inotrope Decreases SVP No direct adrenergic effect which is beneficial for pts using a beta blocker
milrinone
41
Brief linear run through of the drug(s) associated with each stage of HF (A-D)
A (risk but no structural dz/ssx): ACEI/ARB B (Structural heart dz but no ssx): ACEI/ARB + beta blocker C (symptomatic): >50 EF = ACEI/ARB + beta blocker + diuretic <40 EF = ACEI/ARB + beta blocker + diuretic(aldosterone antagonist) + consider digoxin/Bidil D: give 'em everything
42
Regarding CHF, which drugs have effects on mortality?
ACEI/ARBs Beta blockers Aldosterone antagonists Hydralazaine/isosorbide dinitate (for AAs) (long way of saying Diuretics/Digoxin = no effect on mortality)
43
provides an indirect estimate of L atrial pressure Normal range?
pulmonary cap wedge pressure normal 8-12, should be less than 18 for CHF "congestion = elevated PCWP"
44
volume of blood pumped by heart divided by BSA CHF optimal metric?
cardiac index (CO/BSA) CHF optimal > 2.2 "hypoperfusion = reduced CI"
45
Positive inotrope rimarily used in ADHF w/ cold/dry pt... Consider if receiving a b-blocker No direct chronotropic effects
Milrinone
46
Positive inotrope rimarily used in ADHF w/ cold/dry pt... Positive inotrope, b agonist
Dobutamine
47
Warm and wet get what drugs?
Diuretics and vasodilators Think = they're perfused but congested
48
Cold and dry patients get what drugs?
Inotropes and vasodilators Think = they're underperfused but not congested
49
Cold and wet (worst) patients get?
Inotropes and diuretics Think = they're underperfused and congested
50
Vasodilator primarily used in warm/wet Also ACS and HTN emergency Free radicals = NO = relaxes smooth muscle
Nitroglycerin
51
Vasodilator primarily used in warm/wet HTN emergency cyanide/thicyanate toxicity
Nitroprusside
52
Vasodilator primarily used in warm/wet Recombinant B-type natriuretic peptide
Nisiritide
53
Generally Non-DHP CCBs should be avoided in HFrEF, except for?
Amlodipine can be considered
54
Class 1,2 antiarrhythmics should be avoided in pts w/ HF... except for?
Amiodarone, dofetilide, sotalol
55
This drug is indicated for reduction of claudication/PVD ssx but has a black box warning (contraindicated) for pts w/ HF
Cilostazol

Pharm 2 (5 decks)

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