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heart failure

heart failure structural or funtional disorder imparing the ability of ventricles to fill or eject
have heart failure in US 5 million
new cases of HF per year 550,000
die each year from HF 300,000
systolic dysfxn EF <40% or S3 heart sounds
what causes systolic dysfxn ischemia, aortic stenosis, dilated L, poor LV fxn
distolic dysfxn restricted LV filling
characteristics of diastolic dysfxn thick LV, stiff LV
drug induced heart failure diltiazem, verapamil (inhibition of contractility)
proarrhythmic effects class 1a and class 1c
plasma volume expansion nsaids, steroids, estrogens, high Na antibiotics, TZDs
who do you not use glidazones in class III and class IV patients
system of heart remodeling renin - anangiotensin - aldosterone
preload increasing exacerbates heart failure (more in heart less pumping out)
afterload incresing exacerbates workload of heart (ex)atherosclerosis)
naturetic peptides cardias neurohormones with beneficial physiology effects
ANP secreted by atria when stretched
BNP secreted by ventricles (pro-peptide cleaved into active form)
heart failure naturetic peptide NT-pro BNP (from BNP)
BNP t1/2 = 20 minutes not standardized 100pg/ml< x >500pg/ml
NT-pro BNP t1/2 = 120 minutes standardized age >50 >900pg/ml age <50 >450pg/ml
stage 1 heart failure high risk for heart failure (HTN, CAD, DM, Fam hx of card myop) NYHA-asymptomaic
stage 2 heart failure asymptomatic, structural heart disease (prev MI, LVSD, assym vulvular disease) NYHA-symptomatin on moderate exertion
stage 3 heart failure prior or current symptoms of heart failure (known structural heart disease, SOB, fatigue, red. exercise tollerence) NYHA-symptomatic on minimal exertion
stage 4 heart failure refreactory end-stage heart failure (marked symptons at rest, max therapy) NYHA-symptomatic at rest
FACES counseling fatigue, activities limited, chest congestion, edema or ankle swelling, SOB
standard heart failure meds (ABCDs) ACE inhibitors, Beta Blockers, Check doses, Diuretics
ACE inhibitors should be on, reduce mortality work on pre and afterloads
consensus trial 1987 27% reduction in stage IV mortality
SOLVD trial 1991 16% reduction in stage II-III mortality on pts. taking diuretics, digoxin
side effects of ACE inhibitors hypotension, hyperkalemia, renal insuficiency, angioedema, cough
ACE inhibitors contraindications bilateral renal artery stenosis, Hx of angioedema, pregnancy
ACEi monitoring parameters serum K, renal fxn, blood pressure (1-2 weeks after initiation)
long term/outpatient ACEi lisinopril, ramipril (better compliance 1 po qd)
short term/tollerance of ACEis captopril (in hospital)
beta blockers block effects of NE on heart, dec. preload, dec. myocardial o2 demand, dec. hospitalization for worsening, dec. mortality
titration of beta blockers MUST BE CLINICALLY STABLE, ASYMPTOMATIC, DRY failure of this leads to negative outcomes for HF patients must titrate slowly (double dose q2weeks)
metoprolol tartrate not approved for HF patients
loop diuretics remove excess fluid, dec. preload, improves symptoms in HF NO EFFECT ON MORTALITY
usage of loop diuretics all pts. with fluid retention
bumetanide bioavailability 80-90%
furosemide bioavailability 60%
torsemide bioavailability 90%
ethacrynic acid bioavailability 100%
AHF furosemide dosing w/o previous therapy use inital dose w/ previous therapy double po dose or use same IV dose further dosing based on clinical response
diuretic resistance consider IV 5mg/hr and inc. prn add thiazide diuretic for synergy
diuretic monitoring parameters symptom relief, urine output, I/O goal (-)1L per day until dry weight achieved, electrolytes, volume depletion
diuretic pt. education compliance, Na intake, qd am bid am + afternoon, check weight, dehydration signs
digoxin no effect on mortality but beneficial in HF
textbook theraputic digoxin range 0.8-2ng/ml
heart failure digoxin range 0.5-1ng/ml
when to use digoxin used early to prevent symptoms in pts. not at target doses of BB or ACEi delayed use unti pt is on adequate doses of BB and ACEi
digoxin side effects GI, fatigue, blurry vision/halos, prolonged PR interval, AV block, atrial tachycardia/fibralation, ventricular arrhythmias
digoxin monitoring parameters serum dig concentrations, heart rate, EKG, BUN/creatinine, signs of dig toxicity, low serum K levels can enhance dig tox.
when to check dig levels loading dose - after 8 hours no loading dose - 5 to 7 days (steady state)
checking when digoxin at full distribution IV - 6 hours after dose given PO - 8 hours after dose given (if checked before distribution phase complete levels will be falsely high)
prevent digoxin toxicity amiodarone, erythromycin, verapamil, diltiazem, antacids, cholestyramine, metamucil
digoxin pt. education compliance, if dose missed DO NOT DOUBLE, signs of dig tox., inform all pts. MDs that the patient is on digoxin
ARBs dec. pre/afterloads, improve exercise tollerance reduce mortality in pts. not taking ACEIs
when to use ARBs in ACEI intolerant patients NOT 1st line or if pt. is already on a BB and ACEI
ARB side effects hypotention, renal insufficiency, hyperkalemia, angioedema
ARBs in angioedema? evaluate pts. risk/benefit and see which outweighs which
spironolactone HF benefits dc. preload, reduces aldosterone escape, decreases K reduces mortality
spironolactone trial 1999 30% reduction in all mortality 35% reduction in hospitalization for HF
when to use spironolactone ONLY if symptoms after ACEIs, BBs, diuretics and digoxin SeCr <2.5mg/dl serum K ,5.0mmol/L
spironolactone side effects gynecomastia (interchange with eplerenone(inspra)), hyperkalemia
hydralazine arteriolar vasodilator = dec. afterload
isosorbide dinitrate venodilator = dec. preload
when to use hydralazine/ISDN in pts. not taking ACEIs
A-HEFT trial 1050 class III-IV blacks had 43% reduction in mortality on Bidil
when to use bidil blacks on ACE/BBs already ACE and ARB intolerant patients
bidil limitations tolerance of both agents high doses QID compliance
bidil side effects GI upset, headache, hypotension, tachycardia, flushing, orthostasis
bidil monitoring parameters HR, BP, side effects(headache), compliance
Created by: lex86