Term
| heart failure is measured clinically with __ __. |
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Definition
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Term
| formula for ejection fraction: |
|
Definition
ejection fraction = [(SV)/(EDV)]x100
OR
ejection fraction= (EDV-ESV)/(EDV) all times 100 |
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Term
| normal ejection fraction: |
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Definition
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Term
| SO PROBLEM WITH EJECTION FRACTION IS THAT IS MISLEADING B/C CAN STILL GET NORMAL EJECTION FRACTION WITH HEART FAILUR, YOU REALLY NEED TO KNOW STROKE VOLUME BUT ITS TOO HARD TO GET |
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Definition
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|
Term
systolic heart failure= enlarged heart= post MI, high EDV but can't pump it all out
diastolic heart failure= chronic HTN= thick heart muscle, limited ventricular lumen, so EDV is small |
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Definition
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Term
| 2 ways to improve heart failure: |
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Definition
- make the heart better by allowing it to beat stronger
- decrease symptoms |
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Term
| Standard of care for treating heart failure b/c make the heart a better pump: |
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Definition
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Term
| If patient cannot tolerate ACE inhibitors, try an ___. |
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Definition
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Term
| After starting ACE-I or ARB for heart failure, then start a __ __. |
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Definition
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Term
| Then after ACE-I/ARB, and beta blocker, then add a __ like ___. |
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Definition
| - diuretic like furosemide (lasix) |
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Term
| primary cause of CHF in United States: |
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Definition
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|
Term
| primary cause of CHF in world: |
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Definition
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Term
| ACE-I/ARBs and Beta blockers are first line drugs to __ __ in heart failure patients. |
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Definition
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Term
| ACE INHIBITORS AND BETA BLOCKERS MOST I MPORATANT DRUGS FOR HEART FAILUURE. |
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Definition
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Term
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Definition
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Term
| Any ACE-I will work in heart failure. List some. |
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Definition
- Captopril
- Enalapril
- Lisinopril
- Ramipril |
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Term
| They really bad side effect of ACE-I: |
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Definition
- angioedema
(also cause cough, but the bad threatening side effect is angioedema) |
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Term
| Angiotensin receptor blockers (ARBs) all end in: |
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Definition
|
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Term
| Only approved ARBs for CHF (2): |
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Definition
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Term
| Beta blockers for HF (3): |
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Definition
- Carvedilol (Barron's favorite)
- Metoprolol succinate
- Bisoprolol (only approved in Europe) |
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Term
| You want to give HF patient metoprolol, do you give them metoprolol tartrate or metoprolol succinate? |
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Definition
METOPROLOL SUCCINATE FOR HF
- tartrate will not improve function
It sucks to have heart failure, so use metoprolol succinate. |
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Term
| Drugs that improve survival in heart failure include: |
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Definition
- ACE-I
- ARBs
- Beta blockers
- potassium sparing diuretics (spironolactone and eplerenone) |
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Term
| potassium sparing diuretics like __ and ___ improve __ in HF patients. |
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Definition
- spiranolactone
- eplerenone
- improve survival |
|
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Term
| what order should you start HF drugs in? |
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Definition
1. ACE-I/ARB
2. Beta- blocker
3. Potassium sparing diuretics
KNOW THIS ORDER
allow each drug to stabilize before adding next drug |
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Term
| African Americans respond better to ___ __ plus ___ than to spiranolactone and eplerenone. |
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Definition
| - Isosorbide dinitrate plus hydralazine |
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Term
| drugs that improve symptoms only in heart failure: |
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Definition
- Furosemide
- Bumetanide
- Torsemide
- Digoxin |
|
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Term
| potassium sparing diuretics improve ___ while loop diuretics only improve ___. |
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Definition
- improve survival
- only improve symptoms |
|
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Term
| When use isosorbide dinitrate and hydralazine for HF in African Americans, you don't have to use __ or __ b/c African Americans aren't as responsive to these. |
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Definition
| - don't have to use ACE-I or ARBs |
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Term
| Thiazides are NOT included in normal SOC for HF, instead loops and potassium sparing diuretics are. |
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Definition
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Term
| what is the difference b/w CHF and HF? |
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Definition
| - Heart Failure is a syndrome, not a single disease: structural/functional defects and diminished blood flow or tissue oxygenation in HF |
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Term
Heart disease and MI> systolic heart failure> enlarged myocardial and thin walls
Diastolic heart failure due to hypertension> thick myocardium small ventrical space, muscle bound
With both types of heart failure the problem is stroke volume, not delivering enough blood flow or oxygen |
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Definition
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Term
| The NYHA Classifies heart failure into __ different classes based on ___. All __ of these classes have an ejection fraction of __ or less. |
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Definition
- 4
- symptoms
- 40% or less |
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Term
|
Definition
| - asymptomatic cardiac disease |
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Term
|
Definition
- SOB with ordinary activity
- class example was SOB after 2 flights of stairs |
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|
Term
|
Definition
- SOB with minimal activity
- class example was SOB after one flight of stairs |
|
|
Term
|
Definition
- SOB at rest
- class example was SOB looking at stairs
- most of these patients are on oxygen |
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Term
| Heart failure is defined as ejection fraction of __ or less. |
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Definition
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Term
| The American College of Cardiology organizes heart failure into __ based on ___ ___. |
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Definition
- stages
- structural changes |
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|
Term
| What are the 4 stages the American College of Cardiology uses to classify HF? |
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Definition
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Term
| Stage A has a __ __ for developing HF as evidenced by __, __, ___ __, or a __ __ of ___. |
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Definition
- high risk
- hypertension
- CAD (coronary artery disease)
- Diabetes Mellitus
- family history of cardiomyopathy |
|
|
Term
| Stage B is __ ___ with a ___ __, __ __ ___/___, and __ __ __. |
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Definition
- Asymptomatic HF
- previous MI
- LV systolic dysfunction/LVH
- asymptomatic valvular disease |
|
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Term
| Stage C is __ __ where there is __ __ __ __, __ and __, and reduced __ __. |
|
Definition
- symptomatic HF
- known structural heart disease
- SOB and fatigue
- reduced exercise tolerance |
|
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Term
| Stage D is __ ___ __ where there are __ __ at __ despite maximal medical therapy. These are the patients that are __ ___. |
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Definition
- Refractory end-stage HF
- marked symptoms at rests
- recurrently hospitalized |
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Term
| Correlation of classes vs stages: |
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Definition
- Stage A is pre-HF
- so classes 1-4 only correlate with stages B,C, and D
- so class 1 aligns with stage B
- and both classes II and III align with stage C
- class IV aligns with stage D
so stage A does NOT align with a class!
see slide 17 of HF lecture for chart illustrating this |
|
|
Term
|
Definition
Ischemic disease/MI
Hypertension
Cardiomyopathy
Genetic disorders
Valvular abnormalities
Infection
Alcohol
Arrhythmias
Hyperthyroidism
Anemia |
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Term
| When considering HF, consider which side of the heart is affected. __ is more common. __ may occur due to __ sided MI or __ __. |
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Definition
- left is more common
- right may occur due to right sided MI or pulmonary HTN |
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Term
| Also when considering HF, need to know which heart function is affected. With left sided heart failure there is __ __ and __ __ due to a __ left ventricle. With right sided heart failure, there is __ __ and left ventricular ___, so ejection fraction is usually __ but stroke volume is ___. |
|
Definition
left sided> decreased contraction and decreased ejection fraction due to dilated left ventricle
- right sided> decreased relaxation> decreased left ventricular filling> normal ejection fraction, decreased SV |
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|
Term
| Congestive heart failure symptoms: |
|
Definition
- fatigue
- activities limited
- chest congestion
- edema/swelling
- shortness of breath
remember FACES |
|
|
Term
| possible signs/symptoms of HF: |
|
Definition
DOE, fatigue
Orthopnea
JVD, enlarged liver
Nocturnal cough or DOE
Bilateral crackles at lung bases
Lower extremity edema
S3 and/or S4 gallop |
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Term
32 y/o AA male presents with progressive DOE over the past 3 weeks - unable to walk one flight of stairs without resting. He also complains of severe weight gain over this time period (>15 lbs), feeling bloated, and unable to sleep because he feels like he stops breathing.
No PMH/meds
PE: HR 110s, BP 115/75
JVD to jaw, pitting edema
What meds do you start him on first? |
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Definition
| - ACE-I, probably Lisinopril |
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Term
| Can you start a HF patient on a beta blocker while they still have symptoms? |
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Definition
NO, ABSOLUTELY NOT, THEY WILL DIE.
- have to start loop diuretic first and get all the edema off before you start the beta blocker
- this is b/c with all the extra fluid on them, sympathetics is what is keeping the heart going, so if you block beta they would crash |
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Term
| what studies do you want to order for HF patient? |
|
Definition
- chest x-ray
- EKG
- CBC
- transthoracic ECHO
- LFTs
- Chem
- TSH
- lipids
- baseline BNP |
|
|
Term
| An EKG can check for __ __, __ __, and __ __. |
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Definition
- rhythm disturbance
- structural changes
- previous MI |
|
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Term
| chest x-ray will check for __ __. |
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Definition
|
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Term
| ECHO will check for __ vs. __ __ and __ __. |
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Definition
- systolic vs. diastolic HF
- structural abnormalities |
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Term
| TSH should be checked b/c hyper and hypothyroidism can lead to ___. |
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Definition
|
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Term
| CBC should be checked b/c __ leads to __ __ HF. |
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Definition
| - anemia leads to high output HF |
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Term
| Renal function should be checked with HF patient b/c __ reduces ___. |
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Definition
|
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Term
| Liver fx should be checked with HF b/c HF causes __ __. |
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Definition
| - HF causes hepatic congestion |
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Term
| Electrolytes should be checked with HF b/c __ __ and __ __ can cause lyte disturbances. |
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Definition
| - volume overload and diuretic use |
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Term
| Iron panel should be checked in some patients with heart failure to check for ___. |
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Definition
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Term
| A coronary angiogram should be done on patients with __ __ on __. |
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Definition
|
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Term
| A biopsy should be done on patients with ___ __ and __ __ not due to ischemic disease. |
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Definition
| - heart failure and dilated cardiomyopathy not due to ischemia |
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Term
| BNP is B-type natriuretic peptide that comes from the __ of the __. When there is excess fluid, the heart stretches and releases __ which goes to __ and causes you to __. |
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Definition
- atria of the heart
- BNP
- kidneys
- pee |
|
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Term
| A few words about diuretics in HF: |
|
Definition
Mainstay of symptomatic treatment
No clinical trials on mortality effects
Thiazide diuretics OK in mild HF
Most HF patients will eventually require loop diuretics
Trick: balancing hypervolemia reduction vs. renal function, electrolytes, hemodynamic stability |
|
|
Term
| The loop diuretics (furosemide, torsemide, bumetanide) cause profound __ by inhibiting the ____ ___ in the __ _ __. This works at very low glomeruluar filtration rates. |
|
Definition
- profound diuresis
- inhibiting the Na-K-2Cl symporter in the loop of henle |
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Term
The volume problems are addressed, Mr. Jones is still experiencing shortness of breath and edema but both are markedly improved.
What is the next step? |
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Definition
|
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Term
| ACE-I are first line tmt for HF and are beneficial across all classes of HF. They reduce the risk of developing __ in at __ patients (like those that are 55 and older with previous MI, vascular disease, or DM). Start __ and titrate. There is __ specific goal for dosing. |
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Definition
- reduce risk of developing HF in at risk patients
- low
- no |
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Term
| In clinical trials ACEI are great. |
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Definition
|
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Term
| Even before you start ACE-I, treat the edema symptoms first with a loop. |
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Definition
|
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Term
| ACE-I adverse drug interactions: |
|
Definition
- Angioedema (big bad one)
- Renal impairement
- Renal failure
- Hyperkalemia
- Dry cough (not a big deal but switch them to ARB if they get this) |
|
|
Term
| ACE-I drug-drug interactions: |
|
Definition
- NSAIDs (fluid retention, acute renal failure)
- potassium supplements
- potassium sparing diuretics |
|
|
Term
| ___ plays a key role in organ damage in HF. In HF ___ puts fibrotic material in the heart causing it to change shape and be less effective. ___ prevent these structural changes of the heart. |
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Definition
- Angiotensin-II
- angiotensin-II
- ACE-inhibitors |
|
|
Term
| Angiotension II causes bad structural changes in heart, kidneys, and vasculature, ACE-I prevent this. |
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Definition
|
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Term
| Beta blockers were historically contraindicated, but now they are strongly indicated once HF pt has controlled volume status. Class effect only with ___ or __ __. Start low and titrate to max tolerated. |
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Definition
| - Carvedilol or Metoprolol succinate |
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Term
| when titrating beta blocker up watch for toxicity symptoms such as: |
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Definition
| - fatigue and low heart rate |
|
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Term
| CARMEN trial is the first trial comparing __ __ monotherapy compared to __ __ monotherapy. They found that beta blockers are good enough and are a good alternative to ACE-I intolerant patients, but __ is still the best. |
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Definition
- beta blocker
- ACE-I
- combination |
|
|
Term
| ARBs selectively block the __ __, __ _ receptor. |
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Definition
|
|
Term
| ARBs are recommended for routine administration to symptomatic and asymptomatic patients with LVEF less than or equal to 40% who are intolerant to ACE-I for reasons OTHER THAN ___ or __ __. |
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Definition
hyperkalemia
renal insuffienciency |
|
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Term
| you can also use an ACE-I ARB combo if need to. |
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Definition
|
|
Term
| Candesartan added to background therapy (ACE-I and ARB) – resulted in statistically significant reduction in CV mortality and HF hospitalization |
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Definition
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|
Term
| ___ antagonists are recommended for patients on standard therapy, including diuretics, who have class __ HF due to LV systolic dysfunction (LVEF less than or equal to 35%). |
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Definition
Aldosterone antagonists
class IV or class III previously class IV |
|
|
Term
| aldosterone should be considered for the following patients: |
|
Definition
| - patients post-MI with clinical HF or DM and LVEF less than 40, who are on standard ACE-I or ARB therapy |
|
|
Term
| Spiranolactone is used in __ _ and __ _ HF. Eplerenone is used in __ __ heart failure. |
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Definition
spiranolactone> class III and class IV HF
eplerenone> post-MI HF |
|
|
Term
| Aldosterone antagonists are not recommended when: |
|
Definition
- creatinine is greater than 2.5mg/dL or when clearance is less than 30mL/min
- serum potassium greater than 5mmol/L
- therapy includes potassium sparing diuretics |
|
|
Term
| Aldosterone antagonists cannot be used with __ __ ___. |
|
Definition
| potassium sparing diuretics |
|
|
Term
| With Aldosterone Antagonists, potassium should be measured at ___, then at __ __, __ __, and then every __ __. |
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Definition
- baseline
- 1 week
- 1 month
- every 3 months |
|
|
Term
| Supplemental potassium is not recommended unless potassium is less than 4 mmol/L when patients are on aldosterone antagonists. |
|
Definition
|
|
Term
African American Heart Failure trial: Isosorbide dinitrate and hydralazine added to standard therapy in black males
showed 43% decrease in mortality when compared to placebo. |
|
Definition
|
|
Term
| A combo of hydralazine and isosorbide dinitrate is recommended as part of standard therapy in addition to beta blockers and ACE-I for AA with ___ __ __ ___. |
|
Definition
| - left ventricular systolic dysfunction |
|
|
Term
Mr. Jones was discharged last week in NYHA class II heart failure, but comes back to the ED with abdominal distension and after gaining 20 lbs with an increase in fatigue and SOB – he’s having trouble walking up one flight of stairs.
BP 95/52 HR 58 Cr 1.5 K+ 3.9
What happened?
Which meds should we hold?
Should we change anything else? |
|
Definition
| Probalby had bad response to diuretic. The diuretic (furosemide) has not been working well, so try torsemide or bumetinide= have better bioavailability. |
|
|
Term
| DIGOXIN DOES NOT IMPROVE SURVIVAL JUST KEEPS YOU OUT OF HOSPITAL. |
|
Definition
|
|
Term
|
Definition
Limited role in HF
Does not improve mortality in mild to moderate HF
Can reduce hospitalization in poorly controlled CHF patients
Narrow therapeutic window (0.125-0.250 mg daily)
Watch for digoxin toxicity |
|
|
Term
| Mr. Jones comes back still doing horribly, admitted to hospital, what do you do now? |
|
Definition
| - recombinant human B-type natriuretic peptide (BNP) |
|
|
Term
| recombinant human BNP helps to get extra fluid off early on in the __ __. |
|
Definition
|
|
Term
NATRECOR® (nesiritide) is the recombinant form of endogenously produced hBNP, a cardiac hormone secreted largely by the cardiac ventricles in response to pressure and volume overload.1–8 The structure of nesiritide is identical to that of naturally occurring BNP.1,2,6,8
BNP binds NPR-A and increases cGMP production intracellularly.3,4
Nesiritide is cleared from the circulation via 3 routes: receptor-mediated endocytosis, proteolytic degradation by NEP, and renal filtration of intact peptide.3,7–9
Dialysis patients usually do not have significantly elevated BNP levels if they do not have LV dysfunction or LVH.10 |
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Definition
|
|
Term
| The hemodynamic effects of NATRECOR® are characterized by balanced venous and arterial dilation, resulting in decreased preload and afterload as assessed by reductions in pulmonary capillary wedge pressure (PCWP), right arterial pressure (RAP), pulmonary pressures, and systemic vascular resistance (SVR). Cardiac index (CI) also increases secondary to afterload reduction in a dose dependent manner. Unlike vasodilators, however, vasodilatory effects of nesiritide are accompanied by no significant increase in heart rate. |
|
Definition
|
|
Term
REMEMBER SPIRANOLACTONE ONLY FOR CLASS III OR IV HF.
EPLERENONE IS FOR POST-MI HF. |
|
Definition
|
|
Term
| Ventricular remodeling, which can occur as a consequence of myocardial damage suffered during an acute MI or as a gradual consequence of untreated hypertension, coronary artery disease, and other disease states, leads to myocardial hypertrophy and dilation. One of the mechanisms by which ACE-inhibitors, ARBs, beta-blockers and aldosterone antagonists appear to improve mortality is through reversal of the ventricular remodeling that occurs with different forms of heart failure. |
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Definition
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|
