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Flashcards in Treatment of Heart Failure Deck (19):
1

HF definition

Clinical syndrome or condition caused by the heart's inability to generate a sufficient CO to meet metabolic demands of the body, characterized by: 

  • signs and sxs of intravascular and interstitial volume overload (SOB, rales, edema)
  • Manifestations of inadequate tissue perfusion (Fatigue, poor exercise tolerance)

 

2

Etiology of HF 

MC--Coronary Artery Disease 

HTN 

Idiopathic dilated cardiomyopathy

Alcohol Abuse 

3

Ventricular Workload Determinants

Preload

Afterload

Contractility 

Heart Rate 

(think Frank Starling Curve)

4

Compensatory responses that are detrimental in HF

Increase preload through Na and water retention 

Vasoconstriction (will eventually increase afterload, decrease SV)

Tachycardia and increased contractility due to SNS activitation (shortens diastolic filling time, precipitation of ventricular arrhythmias)

Ventricular hypertrophy and remodeling 

5

Stages of Heart Failure

Stage A 

  • Pt at high risk of developin gHF but without structural heart diseae or sx of HF
  • i.e. pts with HTN, atherosclerotic disease, DM, obesity, metabolic syndrome, cardiotoxins, or FHx

Stage B

  • Pts iwth structural HD, but no signs or sx of HF
  • Pts with previous MI, LV remodeling including LVH/low EF, asymptomatic valvular heart dz

Stage C 

  • Patients with structural heart disease with current or prior sx of HF 
  • Patients with known structural heart disease and SOB and fatigue, reduced exercise tolerance 

Stage D 

  • Pts with refractory HF requiring specialized interventions 
  • pts with marked sx at rest despite maximal medical therapy (i.e. can't be safely discharged from hospital w/o specialized measures

6

New York Heart Association Functional Classification 

Class I: With cardiac disease, but no limitations

Class II: pts iwth cardiac disease with slight limitaitons. Ordinary activity results in sxs 

Class III: Marked limitation, but still comfortable at rest. Less than ordinary activity is sx'tic

Class IV: Inability to carry out physical activity, sxs present even at rest

7

Drugs that may precipitate or exacerbate HF 

Negative Inotropic Effect

Antiarrhythmics 

Beta Blockers

CCB

8

Drugs that may precipitate or exacerbate HF

Cardiotoxic and Sodium and Water

Cardiotoxic--chemo agents, EtOH, amphetamines

NSAIDS

Glucocorticoids

Androgens, estrogens 

Drugs with high sodium content

9

Treatment principles of HF

optimize preload

reduce afterload

increase contractility 

10

ACEI in HF

Dec preload, Dec afterload

Recommended for all pts 

Can be useful to prevent HF with high risk 

11

Beta Blockers in HF 

For all stable pts 

"reverse remodeling"

12

Diuretics in HF

Mild overload--thiazide

Moderate overload--loop 

Severe--IV furosemide 

13

Digoxin in HF

Inc myocardial contractility 

Antiarrhythmic for pts with A fib 

Add digoxin for pts who remain symptomatic despite optimal ACEI (or ARB), BB, and diuretic 

Be aware of toxicity and drug interactions

14

Other HF Therapies 

Spironolactone (Adolsterone Antagonist)

Angiotension II Receptor Blockers (ARBs)

Hydralazine/Isosorbide (dec nitrate tolerance)

15

Therapy Recommendations for Stage A

  • ACEI or ARB to prevent HF in pts at high risk (Hx of atherosclerotic vascular dz, DM, or HTN with CV RFs)
  • Tx HTN and dyslipidemia 
  • Control metabolic syndrome
  • Encourage exercise, smoking cessation 
  • Discourage smoking and drugs

16

Therapy Recommendations for Stage B

  • All measures in Stage A 
  • BB in all pts with h/o MI with reduced EF and no HF sxs
  • ACEI in pts with reduced EF (+/- MI)
  • BB and ACEI in all pts with h/o MI regardless of EF or presence of HF 

17

Therapy Recommendations for Stage C

  • All measures in Stages A & B
  • ACEI in all pts 
  • BB in all stable pts 
  • Avoid drugs that adversely effect HF (NSAIDs, antiarrhythmics, CCBs)
  • DIuretics and salt restriction 
  • In selected pts:
    • aldosterone antgonists-severe sx w monitoring
    • ARBs 
    • Digoxin- tx sxs
    • Hydralazine/nitrates
  • Devices:
    • Biventricular pacing 
    • Implantable defibrillators 

18

Therapy Recommendations for Stage D

  • Consider approrpiate level of care
  • Hospice 
  • Heart transplant
  • Permanent mechanical support (LVAD)
  • Chronic inotropes
  • Experimental surgery or drugs

19

Treating Diastolic HF

Improve ventricular filling

Control both systolic and diastolic HTN 

Control HR--BB, CCB so not tachycardic 

Optimize blood volume with diuretics