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heart failure
| Question | Answer |
|---|---|
| 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
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