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Heart Failure
Pharmacotherapy Exam 2
78
Pharmacology
Professional
03/25/2014

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Term
heart failure
Definition
heart cannot adequately provide circulatory support to meet the metabolic demands of the body
Term
stroke volume
Definition
volume of blood ejected from the ventricle during systole (single contraction)
Term
preload
Definition
volume of blood in the ventricle just prior to contraction
Term
afterload
Definition
tension/ resistance the left ventricle must overcome in order to empty and eject its SV
Term
contractility (inotropy)
Definition
force of contraction
Term
ejection fraction (EF)
Definition
% of blood pumped out of the LV with each contraction, normal range (50%-70%)
Term
cardiac output
Definition
volume of blood ejected from the LV per min, normal range 4-7 L/min
Term
decreased amount of blood/sodium sensed by stretch receptors in the blood vessels and barroreceptors
Definition
leads to decreased nerve firing causes relese of NE from CNS
Term
NE
Definition
causes increased HR (chronotropy) and release of renin from juxtaglomerular cells in kidney
Term
actions of AT2
Definition
stimulates secretion aldosterone, vasopressin, endothelin
Term
Norepi
Definition
down regulation of B1 receptors, shortened filling time, arrhythmias
Term
AT2
Definition
loss of flow mediated vasodilation
Term
endothelin
Definition
smooth muscle cells in vasclature hypertrophy, fibrotic changes
Term
aldosterone
Definition
apoptosis of endothelial cells, mechanical stress on heart from increased preload and afterload
Term
antidiuretic hormone
Definition
hyponatremia
Term
etiology of HF
Definition
ischemic, non-ischemic (HTN, obesity, DM, dilated cardiomyopathy), valvular heart disease
Term
non-ischemic etiology
Definition
more long-term disease process that causes HF
Term
signs and symptoms
Definition
dyspnea, fatigue, orthopnea, edema, paroxysmal nocturnal dyspnea (PND), pulmonar congestion
Term
diastolic HF
Definition
right sided; issue is with filling the heart, walls dont relax as much to allow blood to fill ventricle (peripheral edema)
Term
systolic HF
Definition
left sided; contractility issue, heart cannot pump blood out of ventricle (pulmonary edema)
Term
dilated cardiomyopathies
Definition
systolic (right sided) HF; LVEF <40%
Term
increased resistance to filling
Definition
diastolic HF
Term
S3 gallop
Definition
backflow of blood, blood swishing around in the heart
Term
JVD
Definition
jugular venous distension
Term
BNP
Definition
brain natriuretic peptide
Term
brain natriuretic peptide
Definition
protein released when there is left ventricular stretching
Term
hypothyroidism
Definition
masked by heart failure, check thyroid levels
Term
BNP > 100 pg/mL
Definition
86% pos predictive value
Term
BNP < 50 pg/mL
Definition
96% pos predictive value
Term
stage A and B
Definition
at risk of HF, A is no structural change, B is structural heart dx
Term
stage C and D
Definition
structural heart dx, stage D is refractory despite max treatment
Term
class I
Definition
no limitation of physical activity
Term
class II
Definition
slight limitation of physical activity
Term
class III
Definition
marked limitation of physical activity
Term
class IV
Definition
unable to carry on physical activity without symptoms of HF of symptoms at rest
Term
pharm management
Definition
ACE inhibs/ARBs, isosorbid dinitrate/hydralazine, BB, diuretics, aldosterone antagonists, inotropes, vasodilators
Term
ACE inhibitors
Definition
decreases preload and afterload *all pt's and specifically those with LVEF
Term
initiate ACE inhib
Definition
when PT is euvolemic
Term
lisinopril
Definition
2.5-5 mg initially titrate to 20 mg daily
Term
ARBs
Definition
use when ACE inhib are not tolerated
Term
combo of ARB and ACE inhib
Definition
not recommended due to hyperkalemia
Term
Isosorbide dinitrate and hydralazine
Definition
African Americans with NYHA class II-IV HF, already receiving an ACEI, BB, and diuretic therapy; can be substitute if ACEI/ARB are not indicated
Term
isosorbide dinitrate
Definition
contraindicated with PDE-5, TID dosing, stimulates nitric acid
Term
hydralazine
Definition
vasodilator, enhances nitrates, TID dosing, drug induced lupus
Term
Beta blockers
Definition
indicated for ALL HF patients, may increase dig levels, take with food
Term
must start slowly under supervision of cardiologist, can cause ADHF
Definition
beta blockers
Term
risk of causing bronchospasm with BB's
Definition
benefits outweigh risks for HF patients
Term
BB agents
Definition
carvedilol, metoprolol succinate, and bisoprolol
Term
coreg dosing
Definition
25 mg BID; 50 mg BID if >85 kg
Term
loop diuretic toxicity
Definition
ototoxicity with rapid IV administration
Term
loop diuretic
Definition
needs potassium supplementations
Term
max dose furosemide
Definition
600mg
Term
max dose torsemide
Definition
200 mg
Term
bumetanide max dose
Definition
10 mg
Term
ethacrynic acid max dose
Definition
200 mg
Term
thiazides ineffective
Definition
if GFR < 30
Term
thiazides
Definition
not used alone in HF
Term
thiazides used in combo with loops
Definition
in cases of ‘diuretic resistance’
Term
thiazide agents
Definition
metolazone (PO) or chlorothiazide (IV/PO)
Term
advise PTs to
Definition
keep a diary of daily weights, fluid intake and diuretic dose
Term
tell PT to advise doctor
Definition
when daily weight gain is over 2-3 days of 3-5lbs, or WT loss >2 lbs/day
Term
baseline weight
Definition
"dry weight," in which diuretic doses are adjusted
Term
net loss of water
Definition
500 mL to 1L/day
Term
split daily dose of diuretic
Definition
for max effect
Term
aldosterone antagonists
Definition
antagonizes effects of aldosterone secondary to AT2 buildup; cause gynecomastia and sexual dysfunction
Term
eplerenone
Definition
less side effects than other aldosterone antag like spironolactone
Term
digoxin
Definition
considered for PTs with LV systolic dysfunction (LVEF <40), who have S/Sx of HF while receiving first line care (ACEI, BBs, Diuretics)
Term
dig mechanism
Definition
Inhibits the Na-K ATPase pump; increase intracellular calcium
Term
recommended dig level
Definition
3 days after initiation
Term
therapeutic dig levels
Definition
HF patients: 0.5-0.9 ng/mL
Term
digibind is UNNECESSARY
Definition
unless a patient is experiencing significant conduction abnormalities; level alone is not an indicator
Term
dig interactions
Definition
p-glycoprotein inhibition (antiarrhythmic agents, azole antifungals, macrolides), and agents that cause hypokalemia (diuretics)
Term
dig should be
Definition
renal dose adjusted starting at > 60 mL/min
Term
parenteral inotropes
Definition
dobutamine and milrinone
Term
treatment of diastolic dysfunction
Definition
control tachycardia, HTN, reduce preload
Term
dietary sodium restriction
Definition
2-3 g or less per day
Term
fluid restriction
Definition
1.5-2 L/day
Term
drugs to avoid in HF
Definition
NSAIDs, antiarrhythmics (amiodarone, dofetilide--safe), CCB (verap and dilt-neg inotropic effects), thiazolididinediones (rosiglit and pioglit) and corticosteroids
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