heart failure (pharmacology)

heart failure

complex clinical syndrome that can result from any structural or functional cardiovascular disorder causing systemic perforation inadequate to meet the body's metabolic demand without excessively increasing left ventricular filling pressures

left ventricular ejection fraction

the volume of blood % pumped with each ventricular contraction

SV = (LV end-diastolic volume) - (LV end-systolic volume)

formula for stroke volume in relation to left ventricular volume

LVEF = SV/(LV end-diastolic volume) x 100

formula for LVEF

50-70%

normal LVEF in an adult

systolic dysfunction (HFrEF)

reduced LVEF = _________

decreased ejection fraction due to enlarged ventricles

systolic dysfunction results in....

lower amount of blood being ejected due to stiff ventricles (hypertrophy); ejection fraction stays the same, but the amount is lower

diastolic dysfunction results in...

hyper/hypotension, SOB

common symptoms of acute heart failure

airway management (keep patient upright, oxygen therapy, intubation/full ventilatory support)

main mode of treatment for acute heart failure

Non-Invasive Positive Pressure Ventilation (NIPPV)

BIPAP and CPAP apply pressure to the lungs to open up the alveoli and improve ventilation and oxygenation

BiPAP (bilevel positive airway pressure)

Mask that ventilates either by facial or nasal mask with inspiratory pressure is higher and expiratory pressure is lower; tries to keep alveoli open, forces air and fluid to cross alveolar membrane and back into the cardiovascular system --> gets fluid out!

CPAP (continuous positive airway pressure)

a device that is commonly used to regulate breathing during sleep as a treatment for sleep apnea

Diuretics

medications administered to increase urine secretion in order to rid the body of excess water and salt

aortic stenosis

use caution in using diuretics in patients with...

IV

preferred mode of administration for diuretics

loop diuretics

drugs that act in the ascending limb of loop of henle by clocking the reabsorption of Na+/K+/Cl-

block reabsorption of Na+/Cl-/K+ into the bloodstream from the ascending loop of henle

loop diuretic MOA

increased Na+, K+, Cl- excretion; profound diuretic action (water follows solutes)

effects of loop diuretics

Furosemide (Lasix), Bumetanide (Bumex), Torsemide (Demadex)

loop diuretic medications

volume depletion, hyponatremia, hypokalemia, hypochloremia, hypocalcemia, hypomagnesemia, hyperuricemia, hyperglycemia, hypotension, ototoxicity

adverse effects of loop diuretics

vasodilator therapy

medications that correct elevated filling pressures and/or left ventricular afterload

nitroglycerine, nitroprusside, nicardipine

vasodilator therapy agents

2-3

when managing acute heart failure, one must not have more than _______ grams of sodium daily.

1.5-2

when managing acute heart failure, one must not have more than _______ L of fluid daily.

manage associated/contributing conditions (hypertension), lifestyle modifications, pharmacologic therapy, device therapy, cardiac rehabilitation, serial assessments

key ways to manage chronic heart failure

increased after load/ventricular remodeling

hypertension can caused what issues that can exacerbate heart failure?

beta blockers, ace inhibitors, ARBs, hydralazine, calcium channel blockers (dihydropyridine), loop diuretics

preferred agents to treat hypertension in someone with chronic heart failure

smoking cessation, weight management, sodium/fluid restriction, restrict ETOH/illicit drugs, daily weight monitoring

lifestyle modifications that help manage chronic heart failure

so that they can make sure they are not retaining fluid/exacerbating their heart failure

why should one with chronic heart failure check their weight every day?

volume status, kidney function

in patients with chronic heart failure, dosing of diuretics will depend on _________ and _________.

asymptomatic/symptomatic left ventricular dysfunction

ACE inhibitors are imperative in patients with what condition(s)?

low

ACE inhibitors are began at _____ doses

cough

ARBs are given to patients that are ACE inhibitor intolerant due to...

beta blockers can actually make heart failure symptoms worse, since they won't let the pump work harder/squeeze faster; can be bad b/c they can decrease CO (Too relaxed)

why should one be careful in their use of beta blockers for heart failure?

inotropic therapy (do not give BB to those who required this recently)

dopamine/epinephrine

cariogenic shock

results when an inefficient heart cannot sustain adequate circulation

very low

when starting a pt on a beta blocker, start doses...

Cavedilol, Metoprolol, Bisoprolol

go to beta blockers for one with CHF

Carvedilol

beta-blocker with alpha-blocking activity

Metoprolol

beta blocker that is cardiac specific

resistant edema, reduction/cessation

_______ or more severe decompensation may require dose ______ or ______ of beta blockers

ACEI

in pts with CHF, are ACEI or beta blockers given first?

ACE inhibitors, as they provide rapid hemodynamic benefit and will not exacerbate HF in the short term

in CHF patients, _______ are given first because...

Spironolactone

potassium sparing diuretic that is used in addition to ACEI/ARB and BB

a beta blocker, an ACEI, and a diuretic

almost all CHF patients will be on...

increase any of the 3 or add something in to help

what is the next step in CHF treatment if pharmacologic therapy is not getting patient to their goal

ACEI/ARB and BB

Spironolactone is used in addition to...

adjuvant

Spironolactone is an ______ drug

potassium (remove potassium supplementation) and renal function

one should carefully monitor what in a patient on Spironolactone?

potassium

Spironolactone is a ________-sparing diuretic

competes with aldosterone for receptor sites in the distal renal tubules, increasing NaCl and water excretion while conserving potassium and hydrogen ions

Spironolactone MOA

treatment post MI

off label use for Spironolactone

gynecomastia, renal failure, dizziness, hepatotoxicity, hyperkalemia

side effects of Spironolactone

hyperkalemia, renal failure/anuria, Addison disease, hypersensitivity/anaphylaxisis

contraindications for Spironolactone

Digoxin

Antiarrhythmic/cardiac misc drug that is used in addition to ACEI/ARB, BB, and diuretic; adjutant drug

works on rhythm system of the hear, and helps heart SQUEEZE MORE EFFECTIVELY

function(s) of Digoxin

fatigue, dyspnea, and exercise intolerance

Digoxin is used to control symptoms such as...

to control the ventricular rate

how is digoxin used in patients with A-fib

Anti-arrhythmic/cardiac misc

Digoxin classification

inhibition of sodium/potassium ATPase pump in myocardial cells results in a transient increase of intracellular sodium, which in turn promotes calcium influx via the sodium-calcium exchange pump leading to increased contractility (SQUEEZE MORE EFFECTIVELY)

Digoxin MOA in heart failure

direct suppression of the AV node condition to increase effective refractory period and decrease conduction velocity - positive inotropic effect, enhanced vagal tone, and decreased ventricular rate to fast atrial arrhythmias

Digoxin MOA in supraventricular arrhythmias

bradycardia/heart block; ventricular arrhythmias; N/V; dizziness (esp. with toxicity); rash, laryngeal edema

Digoxin side effects

ventricular arrhythmias, hypersensitivity/anaphylaxis

contraindications for Digoxin

implantable cardioverter defibrillator (ICD)

an implanted, battery-operated device with rate-sensing leads; the device monitors cardiac impulses and initiates an electrical stimulus as needed to stop ventricular fibrillation or tachycardia; used for primary or secondary prevention of sudden cardiac death

internal-defibrillators

all ______ are pacemakers, but not all pacemakers are ________

sudden cardiac death

ICD is used for primary or secondary prevention of...

cardiac resynchronization therapy (CRT)

biventricular pacing used to correct desynchronization in the ventricles which would therefore increase cardiac output

sinus rhythm, reduced LVEF, prolonged QRS duration

CRT improves symptoms and survival in what kinds of patients?

Cardiac Rehabilitation

An intervention program designed to help heart patients achieve their optimal physical, medical, psychological, social, emotional, vocational, and economic status after the diagnosis of heart disease or a heart attack; beneficial effects of exercise are seen with high or low levels of training, and are apparent as early as three weeks after training.

advanced arrhythmias, other limitations to exercise, advanced HF

what are some contraindications to cardiac rehabilitation

Serial Assessment

continuing evaluation to meet changing needs; assesses status, response to therapy, and potential need for changes in management

ability to perform activities of daily living, volume status and weight, current use of alcohol, tobacco, illicit drugs, alternative therapies, and chemotherapy drugs, diet and sodium intake

what is assessed during a serial assessment

get an updated ECHO

if there are changes in a pt with CHF's treatment/status, what should you do?

annual influenza vaccine, pneumococcal vaccination

important preventative care in patients with CHF

these illnesses can exacerbate HF

why is it important for CHF pts to get their annual influenza vaccine and pneumococcal vaccination?

Heart failure with reduced ejection fraction

HFrEF; heart failure associated with systolic dysfunction and reduced myocardial contractility; ejection fraction is ≤ 40%.

Heart failure with improved ejection fraction

HFimpEF, previous LVEF ≤ 40%. and now with LVEF >40%

Heart failure with Mildly reduced ejection fraction

HFmrEF; LVEF 41-49% and/or evidence of increased LV filling pressures

Heart failure with preserved ejection fraction

HFpEF; LVEF >50% and evidence of increased LV filling pressures; "diastolic dysfunction"

volume overload (peripheral/pulmonary edema)

we use the term "congestive heart failure" when the patient shows signs of...

CAD/ischemic cardiomyopathy, diabetes, LVH, hypertension, valvular heart disease, family history, cardiotoxic agents, obesity, smoking

major risks for HF

left heart failure

the left side of the heart is weakened and results in reduced ability for the heart to pump blood into the body.

Right heart failure

the right side of the heart is weakened and results in fluid in your veins, causing swelling in the legs, ankles, and liver.

pulmonary edema (fluid backs up to lungs and causes crackles; no gas exchange)

LHF leads to....

swelling in other parts of the body --> ankles, sacrum; congestion of liver; jugular dissension

RHF leads to...

LHF

the most common cause of RHF is...

dyspnea (orthopnea, DOE, paroxysmal nocturnal dyspnea), edema/volume overload (pulmonary edema (crackles/spiutum), peripheral edema, jugular vein distention), abdominal distention, weakness/fatigue

presentation of a pt in heart failure

tachycardia, narrow pulse pressure, hyper/hypotension, diaphoresis, pale skin, precordial palpitation, displacement of the apex, parasternal lifting, S3 heart sound, P2 heart sound

physical exam findings on a pt with HF

S3 heart sound

Increased ventricular filling pressure (e.g., mitral regurgitation, HF), common in dilated ventricles

P2 heart sound

Pulmonic closure that occurs slightly before pulmonic closure; pulmonary insufficiency

see changes in those with systolic dysfunction; can see cause of HF (previous MI, ischemic changes, arrhythmia, signs of LVH)

purpose of an EKG on an HF pt

anemia can exacerbate HF

why do you get a CBC for a person with suspected HF?

hyponatremia is seen in HF (Na+ low --> too much water)

why do you get a serum electrolytes count for a person with suspected HF?

renal insufficiency can contribute/be caused by HF

why do you get a BUN/Creatinine for a person with suspected HF?

their LFTs would be elevated due to liver congestion

why do you get liver function tests for a person with suspected HF?

hyper/hypothyroidism can precipitate HF

why do you test TSH levels in a person with suspected HF?

Troponin

heart muscle protein released into circulation after myocardial injury

it may be elevated in acute HF, AMI can precipitate HF

why do you test for troponin levels in the blood in a pt with HF?

BNP (brain natriuretic peptide)

natriuretic hormone released primarily from the heart, particularly the ventricles (they pump it out when they're strained); measurement for this is suggested in the evaluation of pts with suspected HF when the diagnosis is uncertain