Topic 10 Heart Failure Drugs

Question 1

Heart Failure Definitions ?

Answer 1

“Inability to effectively return all the blood volume it (the heart) receives to the critter’s circulation”
•“(The heart’s)…inability to deliver adequate oxygen to the critter’s body to maintain normal function and homeostasis”
•“The heart is unable to effectively provide
the critter’s tissues with necessary metabolites and remove metabolic wastes

Question 2

“The heart is unable to effectively provide

the critter’s tissues with necessary metabolites and remove metabolic wastes

Answer 2

Heart Failure

Question 3

What causes Heart Failure ?

Symptomatic definition

Answer 3

Symptomatic definition

-”A mismatch between right and left heart volume outputs”

Question 4

What causes Heart Failure ?

Cardio-centric definition

Answer 4

• “The heart’s impaired ability to adequately fill with &/or eject blood”
• Which sort of implies a dual causation

Question 5

Systolic HF - shows a decrease in what

Answer 5

Contractility and EF

Question 6

½ of the Systolic HF patients which tend to be what demographic?

Answer 6

“younger”

Question 7

“Batista Procedure”

Answer 7

used in Systolic HF patients

also called a reduction left ventriculoplasty

Question 8

Diastolic HF has a decrease it what?

Answer 8

Decrease CO and Ventricular Filling

Question 9

Diastolic HF patients tend to be what demographic?

Answer 9

Older

Question 10

Main HF causes ? (5)

Answer 10

1) Ischemia
2) Idiopathic
3) Viral
4) Immune-mediated
5) HTN

Question 11

Most common (~70%?) type of HF in
America

Answer 11

Ischemic

Question 12

Ischemic HF can contribute to what dysfunctions?

Answer 12

Can contribute to both systolic and diastolic

dysfunction

Question 13

What amount of HF are Idopathic?

Answer 13

1/3rd ish

Question 14

“Viral” is another term for ?

Answer 14

“idiopathic”

Question 15

Viruses errantly (going outside the proper area) take up residence in what kind of cells?

Answer 15

myocardial cells

Question 16

Viral HF creates what kind of cardiomyopathy?

Answer 16

Moderate/severe cardiomyopathy develops

Question 17

Type of HF that may require valvular surgery bc of new cardiac geometry?

Answer 17

Viral HF

Question 18

Acute myocardial infarctions (AMIs) may

expose what?

Answer 18

novel cardiac antigens affecting long-term prognosis of Immune mediated HF

Question 19

What forces contribute to the chronic

downhill HF slide? (2)

Answer 19

Renin Angiotensin Aldosteron System

SNS and PNS

Question 20

Why does the Heart remodel

Answer 20

Heart cells die and are replaced with

fibrotic tissues and remaining cells hypertrophy

Question 21

What are the Goals of Therapy for HF?

Answer 21

1) Improve/alleviate critter’s symptoms
2) Slow that “downhill slide” towards transplant/VAD/death
3) Improve survival ***Increase critter’s QALYs

Question 22

Six Classes of QALY-Improving Drugs

Answer 22

1) Positive Inotropes
2) Diuretics
3) Renin/Angiotensin Blockers
4) Primary Vasodilators
5) β-Blockers
6) Aldosterone Antagonists
7) Neprilysin Inhibitor (the future?)

Question 23

Types of Positive Inotropes ? (3)

Answer 23

• Cardiac Glycosides
• Catecholamines
• Bipyridines

Question 24

Digitalis

Answer 24

Digoxin

Cardiac Glycosides

Question 25

Digitalis (Digoxin) do what? Cardiac Glycoside

Answer 25

Positive Inotrope Negative Chronotrope Increased Baroreceptor sensitivity

Question 26

Digitalis (Digoxin) therapeutic window? Cardiac Glycoside

Answer 26

Narrow therapeutic window

Question 27

Cardiac Glycoside: Digitalis (Digoxin) side affect?

Answer 27

Arrhythmias, GI symptoms

Question 28

Do Cardiac Glycosides [Digitalis (Digoxin)] prolong life?

Answer 28

No evidence these drugs prolong life!

Question 29

Digitalis (Digoxin) blocks what?

Answer 29

Blocks Na⁺/K⁺-ATPase “The Sodium Pump” So the intracellular [ ] of Na increases, which decreases the Na/Ca exchanger so decreased extrusion into the EC space

Question 30

Catecholamines

Answer 30

Classic β-1 adrenergic receptor stimulants

Question 31

Catecholamine, β-1 adrenergic receptor stimulants? 4

Answer 31

Epinephrine Norepinephrine Dopamine Dobutamine

Question 32

Catecholamine, β-1 adrenergic receptor stimulants are powerful what?

Answer 32

Powerful positive inotropes and chronotropes

Question 33

PREFERRED DRUG FOR CARDIAC | ARREST

Answer 33

Epinephrine (Adrenaline)

Question 34

Epinephrine

Answer 34

Adrenaline β-1 adrenergic receptor stimulant

Question 35

Epinephrine (Adrenaline) good for what reactions?

Answer 35

Also handy for anaphylactic reactions

Question 36

A relatively non-specific catecholamine; acts | on dopaminergic receptors

Answer 36

Dopamine

Question 37

Dopamine does what ?

Answer 37

Improves cardiac function in heart failure. Also used for renal failure and shock Given by IV drip infusion

Question 38

Inamrinone | amrinone back in my day

Answer 38

Inocor Bipyridine

Question 39

Milrinone

Answer 39

Primacor -Referred to as “phosphodiesterase inhibitors” Bipyridine

Question 40

Bipyridines Increase what?

Answer 40

⬆️ intracellular levels of cAMP = ⬆️intracellular levels of Ca⁺⁺ = ⬆️myocardial contractility

Question 41

longer-term use of Bipyridines can result in?

Answer 41

results in significantly higher mortality than that seen in untreated patients

Question 42

Bipyridines are only used in what patients?

Answer 42

ONLY used in short-term (acute) HF patients | such as patients struggling to come off bypass

Question 43

First-line D.O.C.’s for heart failure?

Answer 43

Diuretics | particularly furosemide/lasix

Question 44

Ideal for those nasty “symptoms of excessive | venous pressure”

Answer 44

Diuretics

Question 45

Diuretics affect BP how?

Answer 45

Decrease plasma volume sooo -Decrease afterload and blood pressure -Decrease preload as well as edema Net affect is to decrease the heart’s workload and resulting myO₂cardial demand

Question 46

Renin-Angiotensin Converting Enzyme Blockers (Angiotensin-Converting Enzyme Inhibitors) are what drugs?

Answer 46

prils

Question 47

Renin-Angiotensin Converting Enzyme Blockers (Angiotensin-Converting Enzyme Inhibitors) - how do they work on BP

Answer 47

⬇️venous tone which in turn SVR. | * ⬇️preload & afterload

Question 48

D.O.C. at all stages of HF, particularly in patients with low EF

Answer 48

Renin-Angiotensin Converting Enzyme Blockers (Angiotensin-Converting Enzyme Inhibitors)

Question 49

Initiation of ACE-Inhibitor Rx after what event is widely considered a standard of care?

Answer 49

after AMIs

Question 50

Losartan

Answer 50

Cozaar ARB

Question 51

Losartan (Cozaar) is used as a replacement for what in intolerant patients?

Answer 51

ACE-Inhibitors

Question 52

What may be used with ACE-Inhibitors in decompensating patients?

Answer 52

Losartan (Cozaar)

Question 53

Dilation = ⬇️preload due to what?

Answer 53

⬇️preload due to ⬆️venous capacitance

Question 54

Dilation = does what SVR and afterload?

Answer 54

⬇️SVR and ⬇️afterload

Question 55

Frequently D.O.C. venous dilators for acute CHF episodes?

Answer 55

Nitrates

Question 56

Hydralazine

Answer 56

Apresoline

Question 57

Isosorbide dihy....

Answer 57

Isordil

Question 58

Critters intolerant of ACE-Inhibitors and Angiotensin Blockers &/or β-Blockers frequently respond to what two drugs?

Answer 58

Hydralazine (Apresoline) &/or Isosorbide (Isordil)

Question 59

β-Blockers contribute to what ? 2 things

Answer 59

``` Block chronic (and deadly) SNS stimulation which contributes to cardiomyocyte apoptosis and mitogenic remodeling ```

Question 60

Negative chronotrope do what to my0₂cardial needs?

Answer 60

⬇️my0₂cardial needs

Question 61

β-Blockers are what kind of chonotrope?

Answer 61

Negative chronotrope =⬇️my0₂cardial needs

Question 62

Metoprolol

Answer 62

(Lopressor, Toprol-XL) β-Blocker

Question 63

Carvedilol

Answer 63

(Coreg) β-Blocker

Question 64

Metoprolol (Lopressor) and Carvedilol (coreg) have been show to improve

Answer 64

long-term HF survivability

Question 65

What drugs are NOT for acute HF?

Answer 65

β-Blockers | Metoprolol (lopressor) and Carvedilol (Coreg)

Question 66

Spironolactone

Answer 66

(Aldactone) | -is a direct aldosterone antagonist (β-Blockers)

Question 67

Aldactone

Answer 67

Spironolactone, | a direct aldosterone antagonist (β-Blockers)

Question 68

Aldosterone Antagonists | Spironlactone (Aldactone) & Eplerenone (Inspra) help prevent what?

Answer 68

These help prevent salt~fluid retention, myocardial hypertrophy, and K⁺ (why?) *Improve long-term (long-term is relative when you have an EF~20%!) mortality post-MI

Question 69

Eplerenone

Answer 69

(Inspra) is a competitive aldosterone antagonist

Question 70

Inspra

Answer 70

Eplerenone is a competitive aldosterone

Question 71

LCZ696

Answer 71

An experimental drug combo showing great promise A 50/50 mix of Valsartan and Sacubitril

Question 72

Sacubitril is metabolized into a what?

Answer 72

neprilysin inhibitor

Question 73

ACC/AHA Stage: A | is what NYHA Class?

Answer 73

Prefailure

Question 74

ACC/AHA Stage: B | is what NYHA Class?

Answer 74

I (symptoms w/severe exercise)

Question 75

ACC/AHA Stage: C | is what NYHA Class?

Answer 75

II/III (symptoms w/marked or mild exercise)

Question 76

ACC/AHA Stage: D | is what NYHA Class?

Answer 76

IV (severe symptoms at rest)

Question 77

Morphine and its relatives are used in acute heart failure to reduce what?

Answer 77

Classically used in acute heart failure to reduce preload, heart rate, and afterload. •NO evidence it helps; substantial evidence it produces worse long-term outcomes

Question 78

Morphine and its relatives used in Chronic Heart Failure treatment does what?

Answer 78

Lowers respiratory rate which decreases cardiac workload –Decreases preload and afterload (some...a good reason to say why you’re giving morphine...) –EASES ANXIETY!