Term
| What is the difference between systolic and diastolic HF? |
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Definition
-Systolic - most common, defect in contractility. See a decreased ejection fraction of <40
- Diastolic - Defect in relaxation - restriction in filling but normal EF. Can be caused by mitral/tricuspid stenosis, hypertrophy |
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Term
| What are symptoms of left sided heart failure and why? |
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Definition
Left side is fed from the lungs. As it fails due to stenosis, and MI, or myopathy/HTN, blood/fluid backs up into the lungs --> fatigue, congestion, edema
Increased LVEDV and preload, decreased SV |
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Term
| What are symptoms of right sided heart failure and why? |
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Definition
| Usually caused by the left side failing or COPD/pulmonary valve problems, blood backs up into the systemic circuit leading to venous congestion |
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Term
| What is F-S law and how does it relate to HF? |
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Definition
| As a heart stretches to increase contractility, heart will return to normal function for a time but lose it's ability to compensate. Leads to further dmg of myocardium |
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Term
| What is the Law of Laplace and how does it relate to ventricular hypertrophy? |
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Definition
| An increased wall thickness will decrease tension, but the muscle operates at lower inotropy |
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Term
| As CO decreases in HF, what peripheral mechanisms activate? |
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Definition
- SNS - increased HR --> increased SV
- RAAS - increase volume/CO
- ADH - promotes water retention
- ANP/BNP - released in times of stress, tries to counteract RAAS |
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Term
| What factors can lead to heart failure? |
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Definition
- An increase in metabolic demands such as infection or hyperthyroidism
- Increased volume/preload due to sodium, water, or renal failure
- Increased afterload due to HTN
- Impaired inotropy due to drugs or ischemia
- Non-compliance in meds |
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Term
| What compensatory mechanisms are targets for interventions? |
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Definition
- Increased workload --> decr activity
- Increased preload --> decr salt/fluid, use loop diuretics and Aldactone
- Increased Afterload - use vasodilators and AceI/ARBs
- Decreased contractility - use positive inotropes
- Increased SNS - use beta blockers |
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Term
| What medications contribute to HF? |
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Definition
- Non-DHP CCBs - NEVER use them in a HF patient
- NSAIDS
- TZDs - Actos and avandia |
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Term
| What are the most common S/S of HF? |
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Definition
SOB and fatigue, s3 gallop, pitting edema, JVD and enlarged heart.
Orthopnea - needs pillows to sleep at night, sign of congestion |
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Term
| What are the ACC/AHA stages for HF? |
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Definition
A - At risk but no evidence - HTN, DM, atherosclerotic disease
B - Evidence of disease but no symptoms: EF < 40%
C - EF < 40% and symptoms visible
D - Symptoms persist despite maximum therapy, ADHF
** Cannot go up and down functional classes |
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Term
| What are the NYHA classifications for HF? |
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Definition
- Class 1 - Asymptomatic
- Class 2 - slight limitation, no symptoms at rest
- Class 3 - Marked limitation, comfortable only at rest
- Class 4 - Must be at complete rest for any relief
** May move between catagories |
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Term
| What are the goals of treatment at Stage A HF? |
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Definition
- Risk factor control - stop smoking, treat HTN, DM2, lipids
- Every patient at risk for Heart Failure receives an Ace Inhibitor (or ARB) even when asymptomatic |
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Term
| In stage B HF, what is the goal of therapy? |
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Definition
If EF < 40% OR patient has an MI:
Initiate appropriate beta blocker therapy. Therapy must be STOPPED if bronchospasms, severe depression, or ADHF.
For Lethargy and bradycardia, reduce dose. |
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Term
| In Stage C of HF what becomes the goal of therapy? |
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Definition
| - Fluid overload : Add loop diuretic --> if no improvement, add Spironolactone --> If no improvement, add Bidil or Digoxin |
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Term
| When should Spironolactone or Eplerenone be used in HF patients? What are the doses? |
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Definition
In stage C, when initial diuresis fails. Spironolactone 12.5 mg QD, max 25 mg BID. Better than Eplerenone according to RALES study.
K must be < 5 and SCr < 2.5/2
Use Eplerenone 25 mg only in post-MI patients |
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Term
| When are Hydralazine/ISDN and Digoxin used in HF patients? |
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Definition
In stage C:
- Bidil - for persistent symptoms in African American patients in place of or in addition to AceI (VHeft study)
- Digoxin - as last line therapy, only to reduce hospitalizations, must stay withing a plasma conc of 0.5 - 1 ng/ml. Watch for Dig toxicity - halos |
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Term
| What drugs should be avoided in Stage C HF? |
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Definition
- Class 1 and 2 antiarrhythmics
- Non-DHP CCBs ALWAYS
- NSAIDs
- Corticosteroids, amphetamines, Minoxidil
- Diabetes meds: TZDs and Metformin
- Do not use triple combo of AceI + ARB + Spironolactone, 2 is fine |
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Term
| What counseling points are important in HF patients? |
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Definition
Limit water and salt intake to 2 L/ 2 G.
Get flu and pneumonia vaccine
Weigh daily, get ins/outs |
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Term
| Which AceI are appropriate for HF therapy and their doses? |
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Definition
- Enalapril/Vasotec - Start at 5 mg BID, titrate to 10 mg BID
- Lisinopril/Prinivil - Start at 5 mg QD, titrate to 40 mg daily
- Ramipril/Altace - Start at 2.5 mg QD, titrate to 5 BID
Monitor BP, K, SCr |
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Term
| Which Beta Blockers are appropriate for HF therapy and what are their doses? |
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Definition
- Bisoprolol/Zebeta - start at 1.25 mg qd, titrate to 10 mg daily
- Metoprolol XL only - start at 12.5 mg qd, titrate to 200 mg QD
- Carvedilol/Coreg - Start at 3.125 mg BID, titrate to 25 mg BID.
Titrate every 2 weeks |
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Term
| What are the Doses and goals for diuretic therapy in HF patients? |
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Definition
Use loop diuretics. Most common is Lasix starting 20-40 mg QD to BID w/ a max of 600 mg.
May also use Bumetanide or Torsemide
If additional diuresis is needed --> Metolazone 2.5-5 mg QD - BID with loop. |
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Term
| What ARBs are indicated for HF and what are their doses? |
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Definition
- Candesartan/Atacand 4-8 mg QD, max 32 mg QD
- Valsartan/Diovan 20-40 mg BID, max 160 mg BID
- Losartan/Cozaar 25-50 mg, max 50-100 mg |
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Term
| When should HF patients receive anticoagulation? |
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Definition
| When they also have: AFib, prior VTE, stasis from bed rest. Give warfarin with an INR goal of 2-3 |
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Term
| How is diastolic HF treated? |
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Definition
| Treated exactly the same, except non-DHP CCB can be used |
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Term
| How do medications compare to CHF devices? |
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Definition
| Several drugs, including anti-arrhythmics, worsen mortality. Devices have positive life saving results. |
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Term
| What is an ICD and how does in work? |
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Definition
For arrhythmias, senses Vtach and shocks back into normal sinus rhythm.
Patient must by post-MI, have HF, have limitation in activity, an expectation of survival, or have HF and an arrhythmia
Drugs increase or decrease Defib threshold, several of them anti-arrhythmics
- Want concomitant beta blocker therapy |
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Term
| When is ventricular dyssynchrony and how is it treated? |
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Definition
Ventricles do not contract at the same time due to a bundle block
Biventricular device synchronizes heart.
Eligible for CRT if: EF < 35% and sinus rhythm, and NYHA 3 or 4, and cardiac dyssynchrony |
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Term
| What pharmacological management is there of ICD and CRT? |
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Definition
- do not want anticoagulated -- bridge therapy for 5 days, restart right after surgery
- Continue ASA only if patient is moderate to high risk for a CV event
- Antibiotic before implant, no antibiotic after |
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Term
| What are VADs, and in who are they used? |
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Definition
| Risk assessed through INTERMACS. Hooks up a continuous flow, requires battery pack. Has long term complications |
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Term
| What is the criteria and benefits of heart transplant? |
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Definition
For Class D HF, Recurrent arrhythmia, dependence on Inotropes, cardiogenic shock
Lots of contraindications - age, cancer, smoking, BMI, DM2
Avg survival is 13 years |
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