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40 Cards in this Set
- Front
- Back
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Heart Failure
Overview |
-variety of cardiac disorders
-impair ability of ventricle to fill / eject blood -heart unable to pump blood to meet metabolic demands of body |
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Heart Failure
Classification |
New York Heart Association Functional Classification
American College of Cardiology / American Heart Association |
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New York Heart Association Functional Classification
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-widely used many years
-reflects severity of SX based on subjective provider assessment -doesn't recognize preventive measures or progressive nature |
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American College of Cardiology / American Heart Association
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-most recent guidelines
-recognizes both evolution and progression of dz -objectively ID's pts and links to specific treatments |
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New York Heart Association Functional Classification
Functional Classes I - V |
I - no SX during physical activity
II - SX during physical activity III - SX during regular activity IV - SX present at rest SX = fatigue, dyspnea, palpitations, angina |
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American College of Cardiology / American Heart Association
Stages A - D |
A - pts at risk (HTN, CAD, DM)
B - pts with structural dz but no SX (post MI, LVH, impaired LV f(n)) C - pts with structural dz with SX or aSX and being treated for HF D - advanced structural dz, marked SX despite treatment, hospitalized |
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Heart Failure
Clinical Presentation (primary) |
dyspnea and fatigue - may limit exercise tolerance
fluid retention - may lead to pulmonary and peripheral edema |
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Heart Failure
Clinical Presentation (other) |
-paroxysmal (sudden violent onset) nocturnal dyspnea (diff breathing)
-orthopnea (diff breathing while lying) -tachypnea, cough, nocturia ascites (fluid in abdomen) |
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Heart Failure
Pathophysiology |
-Results from any disorder that impairs heart's systolic (pumping ability) or diastolic (cardiac relaxation) functions
-both -> DEC CO-> act'n compens. mechanisms to improve CO |
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Heart Failure
Pathophysiology (Compensatory Mechanisms due to ↑ Cardiac Output) |
↑ CO
→ ↑ (ATII, NE, aldosterone, proinflammatory cytokines, vasopressin) → ↑ (Na + H2O retention, vasoconst., tachycardia, and ventricular hypertrophy and remodeling) BB, ACEi, Aldosterone Antag. → ↓ mortality and slow progression |
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Heart Failure
Specific Causes |
- CAD in 65% of pts with LV systolic dysfunction.
-Others=nonischemic cardiomyopathy (due to HTN, thyroid dz, or valvular dz). Most of these pts have EF<40%. - 20-50% have normal LVS f(n) and HF secondary to diastolic dysfunction. Mainly seen in elderly. |
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Drugs that can precipitate or worsen HF
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Drugs with (-) ionotropic effects:
- antiarrhythmics: disopyramide, flecainide, propafenone - BBs - CCBs: verapamil and diltiazem - oral antifungals: itraconazole, terbinifine |
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Drugs that can precipitate or worsen HF
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Cardiotoxic drugs:
doxorubicin daunorubicin cyclophosphamide alcohol |
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Drugs that can precipitate or worsen HF
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Drugs → Na and H2O retention
- NSAIDs (also can ↓ efficacy and ↑ toxicity of diuretics and ACEi) - glucocorticoids - rosi and pioglitazone |
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Diagnostic Criteria of HF
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- no single test (based on PE and SX)
- B-type natriuretic peptide (BNP) can differentiate HF from other causes of dyspnea (COPD, asthma, infection) - in HF have ↑ BNP -echocardiogram (most useful) showing VEf < 40% |
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Ejection Fraction
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- Ejection fraction (Ef) is the fraction of the end-diastolic volume that is ejected with each beat
- stroke volume (SV) divided by end-diastolic volume (EDV) - Healthy Ef > 55% |
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Treatment Principles and Goals of HF
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- ↑ QOL
- ↓ SX - ↓ hospitalizations for exacerbations - slow progression - improve survival |
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Heart Failure
Drug Tx (stage C aka Outpt Tx) ↑ ← → ↓ |
routine management with 3 drugs:
1. diuretic (use potent loop > thiazide) 2. ACEi 3. BB - Selected pts - digoxin, aldosterone antagonists, hydralazine / isosorbide dinitrate |
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Heart Failure
ADEs - loops |
Loops
↓K, ↓Mg, hypotension, ↓renal f(n) overdiuresis - cramps, dizziness, excessive thirst, weakness, confusion photosensitivity |
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Heart Failure
Drug - Drug, DZ interactions |
Furosemide - food ↓s bioavailability so take on empty stomach
Torsemide - food has no effect NSAIDs may ↓ diuretic effect K+ supplementation likely not required when pt on ACEi, ARB, or aldosterone antag. |
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Heart Failure
ACEi - indication, MOA, hemodynamics |
ACEi - all pts with HF due to LVS dysf(n) unless ci
↓ AT II and aldosterone, ↑ [bradykinin] (a vasodilator) ↑ CO ↓ left ventricular filling pressures, SVR, BP, HR |
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Heart Failure
ACEi - ADEs |
Hypotension
dizziness renal insufficiency cough - due to bradykinin angioedema hyperkalemia rash taste disturbances |
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Heart Failure
ACEi - Drug - Drug, Dz interactions |
Captopril - take on empty stomach
Preg. Cat - C 1st, D 2nd, 3rd trimester (can kill fetus) NSAIDS - ↑ risk for renal insufficiency, limit hemodynamic effects of ACEis Cyclosporin and tacrolimus may ↑ risk of nephrotoxicity and hyperkalemia |
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Heart Failure
ARB - indication, MOA |
ARBs - candesartan or valsartan approved in pts who don't tolerate ACEis
block AT 1 - receptor; do not affect bradykinin |
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Heart Failure
ARB - ADEs |
Hypotension
Dizziness Renal insufficiency Hyperkalemia |
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Heart Failure
ARB - Drug - Drug, Dz interactions |
USE K supp and K - sparing diuratics with caution (same w/ACEi)
Diuretics: ↑ risk of hypotention (same w/ACEi) Preg. Cat - C 1st, D 2nd, 3rd trimester (can kill fetus) |
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Heart Failure
BB - indication |
all pts with HF due to LVS dysf(n) unless ci
BB used to be contraindicated b/c of (-) ionotropic effets but...shown to improve sx, hemodynamics, and survival 3 BB approved: metroprolol succinate, bisoprolol, carvedilol |
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Heart Failure
BB - MOA |
antagonize the increase in sympathetic activity that causes HF progression
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Heart Failure
BB - ADE |
fluid retention and worsening HF
Fatigue Bradycardia and heart block Hypotention Abrupt w/d → HTN, tachycardia, or myocardial ischemia |
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Heart Failure
BB - Drug - Drug, Dz interactions |
amiodarone and Non-DHP CCB:
- ↑ risk of bradycardia, hypotension, heart block Quinidine, fluoxetine, paroxetine (inhibitors of CP450 2D6): - inhibit metab of metoprolol and carvedilol → ↑ effects Opthalmic BBs ↑ risk of hb, bradycardia, and hypotention ↑ bronchioconstrictionin asthma or COPD ↑ blood glucose in DM |
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Heart Failure
Aldosterone Antags. - indications ↑ ← → ↓ |
↓ aldosterone is not maintained with long-term treatment of ACEis and ARBs
spironolactone and eplerenone → ↓death and hospitalization add ald antags in pts with moderately severe to severe SX of HF and ↓ LVEf that can be monitored closely for renal f(n) and serum K+ |
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Heart Failure
Aldosterone Antags. - ADE |
hyperkalemia
gynecomastia (spironolactone) irregular menses |
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Heart Failure
Aldosterone Antags. - Drug-Drug,Dz |
ACEi, ARBs, NSAIDS → ↑ risk of ↑ K+
elderly and pts with DM ↑ risk of ↑ K+ |
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Heart Failure
digoxin - indications, MOA |
improves SX but not mortality
inhibits Na/K ATPase pump → + ionotropic effect (via ↑ Ca+) ↓ sympathetic outflow |
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Heart Failure
digoxin - ADE |
Major AEs involve 3 systems:
1. Cardiovascular: arrhythmias, bradycardia, and heart block (HB) 2. GI: anorexia, abdominal pain, N/V 3. Neuro: visual disturbances, disorientation, confusion, fatigue >2ng/mL → toxicity or even lower in elderly and pts w/↓ K+ or Mg++ |
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Heart Failure
digoxin - Drug - Drug, Dz |
TONS of Drug-drug interactions, may not be worth memorizing, but ??
digoxin clearance ↓d in pts with renal insufficiency no loading dose needed in HF |
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Heart Failure
hydralazine-isosorbide nitrate |
ACEi superior to hyd/iso
used in pts who cannot tolerate ACEi or ARB (drug intolerance, hypotension, or renal insufficiency) adding hydral/iso to standard background Tx (ACEi or ARB, BB, diuretic, digoxin) → ↓ mortality by 40% in Blacks BiDil (isosorbideditrate/hydralazine) |
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Advanced Heart Failure Treatment
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admitted to hospital for aggressive treatment with IV diuretics, vasodilators, or + inotropic drugs
Approach to treatment depends on pts hemodynamic profile 1. warm and dry - no treatment 2. warm and wet - goal = ↓ volume overload and congestive sx (IV loop) 3. cold and dry - rule out volume depletion from over diuresis 4. cold and wet - improve CO 1st (vasodilators or + inotropes) before removing excess volume |
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Vasodilators
+ inotropes |
vasodilators
- nitroprusside (Nipride) - nitroglycerine (NitroBid or NitroStat) - Nesiritide (Natrecor) Inotropes - dopamine (Intropin) - dobutamine (Dobutrex) - milrinone (Primacor) |
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Heart Failure Nondrug TX
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intra-aortic balloon pump
Left ventricular assist devices Biventricular pacing Implantable cardioverter-defibrillator (ICD) Cardiac Transplantation |
