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PHARM 344 Cardio > Lecture 15-18 Heart Failure > Flashcards

Lecture 15-18 Heart Failure Flashcards

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1
Q

What is heart failure

A

Complex clinical syndrome

Any structural or functional disorder that impairs ventricular filling or ejection of blood

Results in decrease cardiac output

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2
Q

Most common cause of mortality rate in HF

A

Progressive pump failure

Sudden cardiac death

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3
Q

Pathophysiology in heart failure

A

Myocardial dysfunction: left ventricular, LowSV, Low CO, Low BP

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4
Q

Important equation for heart failure

A

BP = CO x SVR

CO= Cardiac out
SVR: Systemic vascular resistance

CO = SV x HR

SV= Stroke volume (amount of blood heart pumps with every beat)

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5
Q

Stroke volume is affected by 3 factors

A
  1. Pre load ( end diastolic volume)
  2. Afterload ( resistance to LV ejection)
  3. Contractility (inherent strength of contraction of LV myocytes)
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6
Q

Definite pre load and after load

A

Pre load: volume of blood in the ventricles at end of diastole)

After load: pressure required to push blood into the arteries)

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7
Q

Define stroke volume

A

Volume of blood ejected by the left ventricles with each beat

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8
Q

(T/F) Increasing after load will increase stoke volume

A

False

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9
Q

Frank starling curve

Normal
Mild
Severe LV dysfunction

A

Normal- more filling, greater force

Mild- moderate LV dysfunction: more filling, no more force

Severe LV dysfunction: more filling, less force

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10
Q

Acute compensatory mechanisms aims to maintain:

A

BP and CO

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11
Q

risk factors for Heart failure

A

IHD
Hypertension
Valvular disease
Atrial fibrillation
Diabetes
Heavy alcohol or substance use
Chemotherapy or radiation therapy
Family hx of cardiomyopathy
Smoking
Hyperlipidemia

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12
Q

Exacerbating factors of HF

A

ACS
Uncontrolled hypertension
AF and other arrhythmias
Additional cardiac disease
Acute infections
Non adherence to medication regimen
Anemia

Hypo or hyperthyroidism
Medications that increase sodium retention (NSAIDS)
Medications with negative intropic effect

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13
Q

Medications that can cause or worsen HF

Many of them

A

Medications that can cause fluid retention

Medication that can decrease cardiac output

Oral meds with high sodium content

Medications with miscellaneous mechanisms of cardiotoxicity

Oncology drugs

LICORICE, NSAID (DOSE DEPENDANT)**

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14
Q

Natriuretic peptides in heart failure: Counter regulation

A

Should not be used independent of signs, symptoms and other diagnostic info

Gold standard biomarkers in HF
- B-type natriuretic peptide (BNP)
-NTproBNP (N terminal pro-hormone BNP)

Elevated plasma concentrations can be used to in:

  • diagnosis
  • prognosis
    -risk stratification
  • monitor heart failure
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15
Q

Echocardiogram

Gives info on…..

Quality is dependent on

A

Size and shape of heart
Pumping capacity (ejection fraction)
Structures
Pressure estimates

Dependent on type of echocardiogram, who is conducting, reading results and patient anatomy + comorbidities

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16
Q

What is a normal left ventricular ejection fraction (LVEF)

A

Normal = 50-70%

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17
Q

Universally definition and classification of heart failure

Stage C

Stage D

A

HF (Stage C) = patient with current or prior symptoms and or/signs of HF caused by a structural and/or functional cardiac abnormality

Advanced HF (Stage D) = severe symptoms and/or signs of HF at rest, recurrent hospitalization despite GDMT, refractory or intolerant to GDMT, requiring advanced therapies transplantation, mechanical circulatory support, or palliative care

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18
Q

Typical features, patient profile for HFrEF

A

Younger male post MI

Clinical features: AF, CAD, Diabetes, hypertension,

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19
Q

Typical patient profile for HFpEF

A

Older female

Clinical features: AF, CAD, CKD, Diabetes, HTN

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20
Q

Signs and symptoms of right heart failure

A

Congestion of peripheral tissues:

  • dependent edema and ascites
  • liver congestions
  • GI tract congestions
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21
Q

Signs and symptoms of left heart failure

A

Decreased cardiac output:
- activity intolerance and signs of decreased tissue perfusion

Pulmonary congestion:
- impaired gas exchange
- pulmonary edema

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22
Q

HF non pharmacological management

A

Restrict dietary sodium (2-3 grams/day)
Restrict fluid intake ( 2L a day)
Monitor body weight
Excercise
Alcohol
Smoking
Vaccines

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23
Q

Daily weights

A

Those prone to fluid retention or difficult to control fluid retention

More than 2 lbs in 24hrs or 5lbs in 1 week = fluid retention

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24
Q

Most commonly used Loop diuretics and what do they do

A
  • Furosemide, bumetanide, ethacrynic acid
  • blocks sodium potassium chloride cotransporter

Increases Na excretion
Increase K excretion
Increase Cl excretion

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25
Diuretic, indication, considerations, Baseline
Indication: volume overload Considerations: volume status, renal function, electrolytes, urate/gout, sulfa allergy Baseline: volume assessment (HF symptoms,weight), labs for K,SCr,Urea
26
Diuretic monitoring Symptoms Vitals/exams Labs Drug intx
Symptoms: Hypervolemic, dyspnea, orthopnea, PND, hypovolemia Vitals/exams: BP, HR, daily weights, ascites, JVP Labs: SCr, urea, decrease in K, Mg, Ca, Na Drug intx: digoxin toxicity if hypokalemia occurs, lithium toxicity - reduced lithium clearance
27
Diuretic monitoring
Caution with over-diuretics ( low cardiac output, renal perfusion, symptoms of volume depletion) Caution with increasing serum creatinine Symptoms improve in 1-2 hours Symptom resolution dependent on degree of fluid retention
28
Diuretic monitoring Volume depletion Euvolemic Volume overload
volume depletion: reduce or hold diuretic for 2-3 days Euvolemic: consider stepwise reduction in diuretic dose or frequency Volume overload: increase dose by 25-50% depending on prior response and scenario
29
Metolazone Mechanism Indication Dose Adverse effects
Thiazide like diuretic with long duration of action Most common adjunct added in diuretic resistance, based on experience, Small RCTs and case series Inpatient: 5-20mg/d Outpatient: 2.5-10 daily for q2days Adverse effects: volume depletion, renal function, hyponatremia, hypokalemia
30
HF pharmacotherapy HFrEF
ACEi, ARB or ARNI Beta blocker MRA SGLT2i (Flozin) Ivabradine Digoxin Hydralazine-nitrate Intravenous iron Vericiguat
31
HF pharmacotherapy HFmrEF
ACEi, ARB or ARNI Beta blocker MRA SGLT2i
32
HF pharmacotherapy HFpEF
ARB or ARNI MRA? SGLT2i( Flozin) GLP-1RA
33
Before starting an ACEi/ARB/ARNI Indication Contraindications Baseline Drug intx
All patients with HFrEF Previous angioedema, severe aortic stenosis, bilateral renal artery stenosis, pregnancy, systolic BP <90mm Hg Serum pottasium > 5.2 mmol/l BP,labs, cough, if on ARNI: assess fluid status Lithium: increase in lithium levels Increase pottasium: k sparing diuretics, potassium supplements
34
Entresto (Sacubitril/valsartan) doses
24mg/26mg 49mg/51mg 97mg/103mg
35
Converting to ARNI from ACEi and ARB
ACEi: stop ACEi, wait at least 36 hrs after last dose ARB: stop ARB, no washout period necessary
36
ACEi/ARB/ARNI adverse effects and monitoring Vitals H&N RESP Renal
Vitals: hypotension, monitor BP H&N: Angioedema, monitor for symptoms RESP: Dry cough, monitor for symptoms Renal: Hyperkalemia, Monitor labs K, SCr
37
Key counseling points in ACE/ARB/ARNI
Lightheadedness is common initially, but often improves over 1-2 weeks Dry cough usually occurs in first few weeks, but may occur after taking ACEi for years
38
Before starting a beta-blocker Indication Absolute contraindications Relative contraindications Baseline Drug intx
All patients with HFrEF Cardiogenic shock Decompensated heart failure Wolff-Parkinson’s-white syndrome 1st degree Atrioventricular block Systolic BP <100mmhg Raynaud’s disease Severe peripheral arterial disease Volume assessment ) HF symptoms, weight, physical exam) Non DHP CCB = lower HR Digoxin + Amiodarone = Lower Heart rate
39
Beta blocker dosing and outpatient titrations Initial dose Target dose Mean daily dose achieved in HFrEF RCT
Bisoprolol: Initial: 1.25mg daily Target: 10mg daily Achieved: 8.6mg Carvedilol: Initial: 3.125mg Target: 25 mg bid (<85kg), 50mg BID (>85kg) Achieved: 37mg
40
Beta blocker adverse effects Vitals CV RESP ENDO
Vitals: hypotension, bradycardia CV: fatigue, claudication, acute worsening HF RESP: bronchspasm ENDO: Sexual dysfunction
41
Key counseling points on Beta blockers
Fatigue is symptoms of both HF and Beta blockers Start low and go slow Do not stop beta blocker abruptly
42
Before starting an MRA Indications Contraindications Baseline Drug intx
Indications: All patients with HFrEF Contraindications: eGFR <30, K>5.2 mmol/l, severe hepatic impairment Baseline: BP, Labs: K, eGFR Drug intx: increase digoxin levels (spironolactone), eplerenone 3A4 substrate, NSAIDS, Potassium supplements
43
MRA dosing and titrations Initial dose Target Mean daily dose achieved in HFrEF RCT
Spironolactone: Initial dose: 12.5-25mg daily Target dose: 25-50mg daily Mean daily dose: 26mg Eplerenone Initial dose: 12.5-25mg Target: 50mg daily Mean daily dose: 42.6mg
44
MRA adverse Effects Vitals Renal ENDO
Vitals : Hypotension’s Renal: Hyperkalemia (K > 5.5mmol/l ENDO: gyneomastia/mastodynia erectile dysfunction
45
MRA key counselling points
This is not being used as a diuretic in this scenario, make sure patients know which medication is their diuretics Warn males about gynecomastia and there is alternative if this occurs
46
Before starting a Flozin Indication Absolute contraindications Caution Baseline
Indication: HFrEF Absolute contraindication: type 1 diabetes, prior diabetic ketoacidosis, chronic Limb ishcemia Caution: using insulin/ sulfonylurea : may need to adjust. Using diuretic: assess volume status Baseline: volume status, BP, Labs
47
Flozin dosing and titrations Initial Target dose Mean daily dose achieved in HFrEF RCT
Dapagliflozin Initial: 10mg daily Target: 10mg daily Mean daily: 9,8mg Empafliflozin: Initial: 10mg daily Target: 10mg daily
48
Flozin adverse effect vitals CVS RENAL GU ENDO
Vitals: Hypotension CVS: hypovolemia Renal: Acute eGFR GU: genital my optic infection ENDO: Euglycemic ketoacidosis
49
T/F Flozins acutely decrease eGFR ( usually <10%)
True
50
ACEi/ARB/ARNI and Flozins and renal function
ACEi and ARB dilate the efferent arteriole = decreases intraglomerular pressure Flozin may also constrict the afferent arteriole and dilate the efferent arteriole, further decreasing intraglomerular pressure But if combined with lower afferent arteriole flow, can reduce kidney perfusion and lower eGFR If SCr high/eGFR low >30% 1. Stop NSAID 2. Correct hypovolemia 3. Lower ACEi/ARB/ARNI/SGLT2i dose
51
Flozin key counseling points
Sick day management is key Genital mycotic infections , can be prevented with good genital hygiene
52
HFrEF pharmacotherapy sequencing what’s the right order ??
Order determined by: Acuity, co-morbidities, ADE profile, Financial considerations, patient preference Traditional sequence: ARNi, BB, MRA, SGLT2i
53
Withdrawal of HFrEF pharmacotherapy
Generally should be avoided Most causes of HFrEF, LVEF improvement is remission, not cure Exceptions : cardiomyopathies from reversible cause: if NYHA 1 + normal LVEF/LV volumes + control of etiology
54
Canadian guideline on recommendation for Digoxin
Considered in patients with HFrEF and atrial fibrillation, with poor control of ventricular rate and or persistent symptoms despite optimally tolerated beta blocker therapy, or when beta lower are not tolerated in the setting of chronic HF, new onset HF or HF hospitalization
55
Before starting digoxin and dosing Indication Absolute contraindication Caution Baseline Dose
HFrEF with 1 persistent symptoms despite optimized GDMT or (2) AF with suboptimal rate control Wolff Parkinson’s white syndrome, 2nd or 3rd degree AV block, sick sinus syndrome K<3.5mmol/l, eGFR <30 HR,labs, (K,eGFR) Starting: 62.5-125mcg po daily depending on renal function. Max 250mcg po daily
56
Digoxin safety and monitoring Vitals Gen Renal
Vitals: bradycardia, monitoring EKG If HR <50 Gen : Toxicity, monitor signs and symptoms, altered level of consciousness, psychosis, visual disturbances, Hyperkalemia, Severe N/V/D Renal: SCr, K, hypokalemia potentiates digoxin toxicity, digoxin can cause Hyperkalemia
57
Cardiac resynchronization therapy
Dyssynchronous ventricular contraction impairs cardiac function Biventricular pacemaker: improves symptoms, survival, EF, and reduce hospitalization Indications: NYHA-FC II-IV, EF <35%, QRS> 130 msec, LBBB, despite optimal medical therapy
58
Implantable cardioverter defibrillator (ICD)
Sudden cardiac death is a common mode of death in HF Monitors rhythm, paces or delivers electrical shock Indications: primary prevention - non ishemic: NYHA II-III; EF< 35% 3 mos post med optimization
59
HFpEF and HFmrEF pharmacotherapy bottom line for guidelines and evidence
The 3 major HF guidelines differ in their recommendations for HFpEF and HFmrEF HFpEF: only SGLT2i clearly reduce HF hospitalizations, but dont reduce death HFmrEF: SGLT2i and MRA reduce HF hospitilizations, ARBs less likely reduce Hospitilizations, role of ARNI and beta blockers, nothing seems to reduce death
60
All patients with HFrEF unless contraindicated should be on…
ARNI,ACEi,ARB Beta blocker MRA Flozin
61
What are the S&S of HF?
Right HF: congestion of peripheral tissues ⇒⇒⇒ dependent edema and ascites, GI tract congestion ⇒ anorexia, GI distress, weight loss liver congestion ⇒ signs related to impaired liver fxn Left HF: decreased CO ⇒ activity intolerance and signs of decreased tissue perfusion pulmonary congestion ⇒⇒ impaired gas exchange ⇒ cyanosis and signs of hypoxia pulmonary edema ⇒ orthopnea, cough with frothy sputum, paroxysmal nocturnal dyspnea
62
How should dyspnea be evaluated in HF?
Step 1: establish baseline activities, think daily activities ⇒ ex. sighing, dressing, bathing, housework, walking, walking uphill/upstairs, strenuous work, aerobic exercise Step 2: establish a timeline
63
What symptoms should be assessed in HF patients?
dyspnea, orthopnea, PND (paroxysmal nocturnal dyspnea), general fatigue
64
What is paroxysmal nocturnal dyspnea (PND)?
sensation of SOB that suddenly awakes a pt often after 1-2 hours of sleep usually relieved in upright position after 10+ min, may be associated with coughing and wheezing beware of snoring or sleep apnea
65
How does orthopnea and PND actually occur (MOA)?
pt lies flat ⇒ redistribution of blood from periphery to heart - heart overwhelmed, chamber pressure increase, pressure increase transmitted back into pulmonary circulation ⇒ pulmonary congestion - alveoli surrounded by interstitial fluid leading to decreased lung compliance ⇒ receptors triggered, CNS activated - orthopnea, CND
66
What is the NYHA classification?
used to class HF ⇒ Class I: no limitation of activity, normal activity doesn't cause sx ex. carry objects >/= 80 lbs, shovel snow, play basketball, jog/walk 5 miles/hr Class II: slight limitation, comfortable at rest ex. sex without stopping, rake, play golf, walk 4 miles/hr Class III: marked limitation, comfortable at rest ex. mop floors, push lawnmower, shower and dress, walk 2.5 miles/hr Class IV: severe limitation, sx present at rest ex. cannot perform any activities previously states
67
How is lung edema in HF assessed?
may be causing dyspnea, cough, cyanosis Cardiac: signs of fluid overload ⇒ sx - SOB, PND, orthopnea, cough Percussion - fluid in lungs, pleural effusion, 'dullness' Auscultation - crackles, bubbly, rhochi (coarse rattle)
68
How is abdominal edema in HF assessed?
S&S - bloating, fullness, early satiety increased girth gaining weight over short period of time - not eating but still gaining evaluate GI for other reasons of bloating, etc before cardiac: signs of fluid overload ⇒ hepatomegaly - percussion of liver border, abnormal > 3 cm below R subcostal border, palpation ascites - fluid wave, shifting dullness, bulging flanks
69
How is peripheral edema in HF assessed?
↔Legs: bilateral, pitting, doesn't resolve overnight, shoes too tight or don't fit, onset of swelling associated with other CV sx Steps: use thumb to firmly press for 5 sec over bony prominence ⇒ start behind ankle, move over dorsum, then shins ⇒ rate severity and note distribution ⇒ evaluate skin: tight, shiny, erythematous = acute edema dry, scaly, hyperpigmented = chronic edema
70
What is jugular venous pressure (JVP) in HF, how is it measured and what causes its increase?
assessed via the right internal jugular vein, reflects pressure in right atrium, excellent reflector of fx of the right heart, volume status soft, undulating pulsation, rarely palpable, pulsation eliminated by soft pressure, double vs single waveform (a or v-wave) Measured: measured from sternal angle (30 degrees) to highest point of the pulse, normally is < 4cm Causes: hypervolemia/fluid overload, right ventricular dysfunction, pericardial disease, tricuspid valve disease, obstruction of superior vena cava
71
What are the different cardiac auscultation sounds, what do they represent, when do they occur, location where they are best heard, and how to listen to them?
S1: represents MV and TV closure, LV movement occurs during beginning of systole heard best at apex/mitral area (5th ICS) listen with diaphragm (lying/sitting) S2: represents AV and PV closure occurs during end of systole heard best at aortic area (USRB 2nd ICS) listen with diaphragm (lying/sitting) S3: represents rapid ventricular filling occurs during early diastole heard best at apex/mitral area (left, 5th ICS), xiphoid process/left LSB (right) listen with bell (left lateral lying) S4: represents 'atrial kick' (atrial systole) occurs during late diastole heard best at apex/mitral area (left, 5th ICS), xiphoid process/left LSB (right) listen with bell (left lateral lying)
72
What heart sounds have extra significance in HF?
S3: ventricular gallop, associated with HFrEF + fluid overload - will result with euvolemia, may be normal in children/young adults with HF S4: aka atrial gallop, associated with long standing HTN, HFpEF

PHARM 344 Cardio (17 decks)

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