Term
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Definition
inadequate ability of heart to pump enough blood to meet metabolic demands of body;
Clinical syndrome resulting from structural or functional cardiac disorder that impairs ability of ventricles to fill with (diastolic dysfunction) or eject blood (systolic dysfunction);
Systolic HF: LVEF <40%; |
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Term
| Systolic Dysfunction (decreased contractility) |
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Definition
reduced ventricular contraction --> decreases CO;
most common form;
reduced EF (LVEF <40%);
right-sided HF: systemic congestion;
left-sided HF: pulmonary symptoms;
Caused by:
- decreased muscle mass (post MI);
- dilated cardiomyopathy;
- ventricular hypertrophy: pressure overload, volume overload; |
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Term
| Diastolic Dysfunction (restricted ventricular filling) |
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Definition
reduced ventricular filling --> decreases CO;
- ventricular hypertropy --> thick, stiff walls do not relax to accomodate filling, occurs following long-standing HTN or ischemia;
Caused by:
- increased ventricular stiffness;
- ventricular hypertrophy (pressure, volume overload);
- infiltrative myocardial diseases;
- mitral or tricuspid valve stenosis;
- pericardial dx (pericarditis, pericardial tamponade) |
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Term
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Definition
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Term
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Definition
| volume of blood ejected during systole; dependent on preload, afterload, and contractility |
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Term
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Definition
LV end diastolic volume;
- measure of ventricular filling pressures;
- controlled by venous return & atrial contraction; |
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Term
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Definition
resistance to ventricular ejection;
- measured clinically as systemic vascular resistance (SVR);
- controlled by ejection impedance, wall tension, & regional wall geometry; |
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Term
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Definition
| influenced by cardiac muscle fiber shortening and tension and circulating catecholamines |
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Term
| Frank-Starling Mechanism (Analogy: spring) |
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Definition
| increased atrial contraction --> increased stretch of cardiomyocyte sarcomeres --> increased # of cross-bridges in actin/myosin myofilaments --> increased force of contraction |
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Term
| Increased Preload (Na/H2O Retntion) |
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Definition
Pros (Beneficial Effects):
- optimize SV via Frank-Starling mechanism --> increased Preload --> increased SV;
CONS (Detrimental Effects):
- pulmonary congestion;
- systemic congestion;
- edema;
- increased MVO2 |
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Term
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Definition
PROS (Beneficial Effects):
- conserve blood supply to vital organs;
- decreased perfusion of periphery;
- maintain BP;
CONS (Detrimental Effects):
- increase MVO2;
- increase Afterload;
- decrease SV;
- activates compensatory mechanisms |
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Term
| tachycardia & increase contractility (via sympathetic nervous system) |
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Definition
PROS (Beneficial Effects):
- maintain CO;
CONS (Detrimental Effects):
- increase MVO2;
- shorten diastolic filling time;
- downregulation of Beta-1-receptors & decreased receptor sensitivity;
- ventricular arrhythmias;
- myocardial cell death; |
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Term
| Ventricular Hypertrophy & Remodeling |
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Definition
PROS (Beneficial Effects):
- maintain CO;
- decrease myocardial wall stress;
- decrease MVO2;
CONS (Detrimental Effects):
- diastolic dysfunction;
- systolic dysfunction;
- increased risk of myocardial ischemia;
- increased risk of arrhythmia |
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Term
| Precipitating & Exacerbating Factors in HF |
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Definition
Cardiac:
- MI, arrhythmia, endocarditis, uncontrolled HTN, valvular disorders, pulmonary embolism;
Metabolic:
- anemia, hyperthyroidism, infection, pregnancy, worsening renal function;
Patient-Related:
- non-adherence (dietary, fluids, meds), cardiotoxin use (cocaine, EtOH, amphetamines), OTC medications (NSAIDS) |
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Term
| Drugs that cause Negative Inotropic Effects related to HF |
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Definition
antiarrhythmics;
CCBs - especially non-dihydropyridines;
beta-blockers;
itraconazole;
terbinafine; |
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Term
| Drugs that are Cardiotoxins that cause HF |
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Definition
doxorubicin;
daunomycin;
cyclophosphamide;
EtOH;
amphetamines (cocaine); |
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Term
| Drugs that cause Na & H2O Retention related to HF |
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Definition
NSAIDs & COX-2 inhibitors;
ASA & salicylates;
thiazolidinediones (Actos, etc.);
Na-containing drugs: carbenicillin, ticarcillin;
glucocorticoids;
estrogen;
androgens |
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Term
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Definition
| dyspnea (on exertion); orthopnea (when lying flat); shortness of breath; paroxysmal nocturnal dyspnea; exercise intolerance; tachypnea; cough; fatigue; nocturia; polyuria; hemoptysis; abdominal pain; anorexia; nausea; bloating; ascites; mental status changes; weakness; lethargy; |
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Term
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Definition
| pulmonary rales; pulmonary edema; S3 gallop; pleural effusion; Cheyne-Stokes respiration; tachycardia; cardiomegaly; peripheral edema; pedal edema; jugular venous distention; hepatojugular reflex; hepatomegaly; cyanosis; pallor or cool extremities; |
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Term
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Definition
| symptoms of congestion: lower extremity swelling, GI bloating, anorexia, fatigue |
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Term
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Definition
| pulmonary symptoms: rails, crackles, dyspnea, orthopnea |
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Term
| Lab Tests for Diagnosing HF |
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Definition
BNP: >100 pg/mL;
NT-proBNP: >300 pg/mL;
ECG: normal or acute changes in ST-T waves;
CBC: rule out anemia;
Chest X-ray: cardiac enlargment, pulmonary edema, pleural effusion;
Echocardiogram: LV size, valve fcn, wall motion abnormalities, EF;
Weight: determine fluid gain/loss |
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Term
| Stage A (ACC/AHA), no comparable class in NYHA |
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Definition
high risk of developing HF; no identified structural or functional abnormalities & never shows S/sx of HF;
Ex: HTN, CAD, DM, hx of EtOH abuse, cardiotoxic drug therapy, hx of rheumatic fever, family hx of CMP |
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Term
| Stage B (ACC/AHA), Class I (Mild, NYHA) |
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Definition
Stage:
- developed structural heart dx but have never shown S/sx of HF
Ex: LV hypertrophy, asymptomatic valvular heart dx, previous MI;
Class:
- no limitation of physical activity; |
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Term
| Stage C (ACC/AHA), Class II (Mild, NYHA) |
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Definition
Stage:
- current or prior sx of HF associated w/ underlying structural heart dx;
Ex: dyspnea, fatigue due to LV systolic dysfunction;
Class:
- slight limitation of physical activity, comfortable at rest but ORDINARY physical activity results in fatigue, palpitation, dyspnea; |
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Term
| Stage C (ACC/AHA), Class III (Moderate, NYHA) |
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Definition
Stage:
- current or prior sx of HF associated w/ underlying structural heart dx;
Ex: dyspnea, fatigue due to LV systolic dysfunction;
Class:
- marked limitation of physical activity, comfortable at rest bu LESS THAN ORDINARY physical activity causes fatigue, palpitation, dyspnea |
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Term
| Stage D (ACC/AHA), Class IV (Severe, NYHA) |
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Definition
Stage:
- advanced structural heart dx & marked sx of HF at rest despite max medical therapy, require specialized interventions;
EX: freq. hospitalizations, mechanical circulatory assist device, hospice;
Class:
- unable to carry out any physical activity without discomfort, sx of cardiac insufficiency at rest; |
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Term
| Goals of Therapy for HF (NO CURE!!!) |
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Definition
increase quality of life;
relieve or decrease sx (increase exercise tolerance, prevent/minimize hospitalizations for HF);
slow progression;
decrease mortality; |
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Term
| Non-Pharm management of HF |
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Definition
1) dietary modification: sodium restriction (MAX 2 g/day), fluid restriction (2 L/day);
2) Risk Factor Reduction: smoking cessation, managing hyperlipidemia & HTN, immunizations, physical activity as tolerated, weight reduction if overweight;
3) Education: monitor sx, dietary & med adherence, exercise, EtOH avoidance/moderation; |
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Term
Stage A HF Therapy Options
- Pts with: HTN, athersclerosis, DM, metabolic syndrome |
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Definition
Therapy Goals:
- tx HTN (diet, ACE-I/ARB or diuretic);
- smoking cessation;
- tx lipid disorders (diet, statins);
- encourage regular exercise;
- discourage EtOH intake, illicit drug use;
- control metabolic syndromes;
DRUG THERAPY:
- ACE-I or ARB in appropriate pts for vascular dx or DM |
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Term
| Stage B HF Therapy Options - Pts w/: previous MI, LV remodeling, asymptomatic valvular dx; |
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Definition
Therapy Goals:
- Tx HTN, high lipids, smoking cessation, exercise, diet mods;
Drugs:
- ACEI or ARB in appropriate pts;
- beta-blockers in appropriate pts;
DEVICES:
- implantable defibrillators |
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Term
| Stage C HF Therapy Options - Pts w/: known structural heart dx & SOB, fatigue, reduced exercise tolerance |
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Definition
Therapy Goals:
- Tx HTN, smoking, lipid disorders, regular exercise, EtOH use, illicit drug use, metabolic syndrome;
- dietary salt restriction;
- Drugs for routine use: diuretic (fluid retention), ACE-I, & beta-blocker;
Drugs in Selected Pts:
- aldosterone antagonist
- ARBs;
- digitalis;
- hydralazine/nitrates;
Devices in Selected Pts:
- biventricular pacing;
- implantable defibrillators; |
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Term
| Stage D HF Therapy Options - Pts w/ marked sx at rest despite max therapy |
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Definition
Therapy Goals:
- - Tx HTN, smoking, lipid disorders, regular exercise, EtOH use, illicit drug use, metabolic syndrome;
- dietary salt restriction;
- Drugs for routine use: diuretic (fluid retention), ACE-I, & beta-blocker;
Drugs in Selected Pts:
- aldosterone antagonist
- ARBs;
- digitalis;
- hydralazine/nitrates;
Devices in Selected Pts:
- biventricular pacing;
- implantable defibrillators;
- Decision re: appropriate level of care;
OPTIONS:
- compassionate end-of-life care/hospice;
- extraordinary measures: heart transplant, chronic inotropes, permanent mechanical support, experimental surgery or drugs; |
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Term
| Diuretics (primarily loop diuretics) |
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Definition
Place in Therapy:
symptomatic pts to relieve acute sx of congestion & maintain euvolemia;
Symptom control, NO impact on mortality |
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Term
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Definition
Place in Therapy:
- Stages B-D;
- slow dx progression, improve survival (decreases mortality);
- decreases hospitalizations, improved symptoms;
Start at low dose & titrate slowly;
Consider in Stage A if compelling indication (CKD, DM, HTN) |
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Term
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Definition
Place in Therapy:
- Stages B-D;
- slow dx progression, improve survival (decreases mortality);
- decreases hospitalizations, improved symptoms;
Start at low dose & titrate slowly;
Consider in pts intolerant to ACE-Is;
Consider in Stage A if compelling indication (CKD, DM, HTN) |
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Term
| Hydralazine & Isosorbide Dinitrate |
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Definition
Place in Therapy:
- Stages B-D;
- decreased mortality & hospitalizations in African-American pts;
- consider if intolerant to ACE-I or ARB or C/I'd
- add-on in African American HF tx |
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Term
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Definition
Place in Therapy:
- Stages B-D;
- slows dx progression & improves survival (decreased mortality);
- improves symptoms over long-term;
- DO NOT initiate in ACUTE exacerbation; |
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Term
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Definition
Place in Therapy:
- Stages C-D;
- slows dx progression & improves survival (decreases mortality);
- risk of hyperkalemia |
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Term
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Definition
Place in Therapy:
- pts w/ Afib;
- Pts w/ symptoms despite optimal HF regiment (ACE-I or ARB, beta-blocker, & diuretic);
- keep serum levels <1 ng/mL |
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Term
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Definition
thiazide diuretic used for symptomatic relief to decrease acute congestion & maintain euvolemia; no mortality benefit;
Dose: 12.5-25 mg PO daily
NOT used as monotherapy, DON'T use if CrCl <30 ml/min;
Indications: edema, dyspnea, rales, JVD, hepatomegaly, pulmonary edema, +HJR; |
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Term
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Definition
thiazide diuretic used for symptomatic relief to decrease acute congestion & maintain euvolemia; no mortality benefit;
Initial Dose: 2.5-5 mg PO daily
MAX Dose: 10 mg PO daily;
NOT used as monotherapy;
MAINTAINS activity in RENAL INSUFFICIENCY, use in conjunction w/ LOOP diuretic if additional diuresis needed;
Indications: edema, dyspnea, rales, JVD, hepatomegaly, pulmonary edema, +HJR; |
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Term
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Definition
loop diuretic used for symptomatic relief to decrease acute congestion & maintain euvolemia; primary diuretic used in tx of HF;
Dose: 20-160 mg/day, dosed BID;
MAX dose: 80-160 mg/day;
Use if CrCl <30 ml/min;
Indications: edema, dyspnea, rales, JVD, hepatomegaly, pulmonary edema, +HJR; |
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Term
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Definition
loop diuretic used for symptomatic relief to decrease acute congestion & maintain euvolemia; primary diuretic used in tx of HF;
Dose: 0.5-4 mg/day;
MAX dose: 1-2 mg/day;
Use if CrCl <30 ml/min;
Indications: edema, dyspnea, rales, JVD, hepatomegaly, pulmonary edema, +HJR; |
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Term
| ADRs & Monitoring Parameters of Diuretics |
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Definition
ADRs:
- hypokalemia, hypomagnesemia, hyponatremia, hypochloridemia, hyperuricemia, hypotension, ototoxicity, renal insufficiency if overdiuresis;
Monitor:
- BMP (SCr, electrolytes [K]), Mg, uric acid;
- Diuretic Response: weight, edema, JVD, I/O;
- BP, orthostatic changes; |
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Term
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Definition
ACE-I;
Initial Dose:
- 2.5 - 5 mg BID;
Target Dose:
- 10 mg BID; |
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Term
| lisinopril (Zestril, Prinivil) |
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Definition
ACE-I;
Initial Dose:
- 2.5-5 mg daily;
Target Dose:
- 20-40 mg daily; |
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Term
|
Definition
ACE-I;
Initial dose:
- 1.25 - 2.5 mg daily;
Target Dose:
- 10 mg daily or 5 mg BID; |
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Term
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Definition
ARB;
Initial Dose:
- 25-50 mg daily;
Target Dose:
- 50-100 mg daily |
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Term
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Definition
ARB;
Initial Dose:
- 20-40 mg BID;
Target Dose:
- 160 mg BID; |
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Term
| spironolactone (Aldactone) |
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Definition
aldosterone antagonist;
Initial Dose:
- 12.5-25 mg daily;
Target Dose:
- 25 mg BID; |
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Term
| carvedilol (Coreg, Coreg CR) |
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Definition
nonselective Beta-blocker (beta-1 & beta-2);
Initial Dose:
- 3.125 mg BID;
Target Dose:
25 mg BID, if >85 kg then 50 mg BID; |
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Term
| metoprolol succinate (Toprol XL) |
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Definition
beta-1 selective Beta-blocker;
Initial Dose:
- 12.5-25 mg daily;
Target Dose:
- 200 mg daily; |
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Term
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Definition
vasodilator - decreases Afterload through direct arterial smooth muscle relaxation - reduces nitrate tolerance;
Effects:
- improved symptoms & increased survival, particularly in African Americans;
Indications: pts intolerant to ACE-I or ARB therapy, add-on therapy for African Americans in addition to standard ACE-I or ARB + Beta-blocker;
Initial Dose:
- 10 mg QID;
Target Dose:
- 75 mg QID;
Practical Applications:
- start low & titrate up
- HA & Hypotension limit use;
C/I's: phosphodiesterase inhibitors;
ADRs:
- GI upset, HA, hypotension, dizziness;
Monitor: HF sx, BP, hypotension, HR, adverse effects |
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Term
| isosorbide dinitrate (Isordil) |
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Definition
nitrate - decreases Preload through venous vasodilation;
Effects:
- improved symptoms & increased survival, particularly in African Americans;
Indications: pts intolerant to ACE-I or ARB therapy, add-on therapy for African Americans in addition to standard ACE-I or ARB + Beta-blocker;
Initial Dose:
- 10 mg QID;
Target Dose:
- 40 mg QID;
Practical Applications:
- start low & titrate up
- maintain nitrate free interval;
- HA & Hypotension limit use;
C/I's: phosphodiesterase inhibitors;
ADRs:
- GI upset, HA, hypotension, dizziness;
Monitor: HF sx, BP, hypotension, HR, adverse effects |
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Term
| hydralazine + isosorbide dinitrate (BiDil) |
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Definition
combination nitrate + vasodilator;
Pill: 37.5 mg/20 mg;
Initial Dose:
- 1 tab TID;
Max Dose: 2 tabs TID |
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Term
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Definition
MoA in HF:
- neurohormonal attenuation to reduce compensatory remodeling in HF;
Effects:
- decreases hospitalizations;
- DOES NOT decrease mortality;
- increased mortality with serum conc. >1.2 ng/mL;
Indications:
- use in pts w/ systolic dysfunction (LVEF <40%) w/ S/sx of HF while on standard therapy (ACEI/ARB + beta-blocker);
- consider use in Afib for rate control in pts w/ HF/
- Maintain serum levels <1 ng/mL;
Dose:
- 0.125-0.25 mg PO daily, adjust for renal function;
- Check serum levels 6-8 hrs after dose (if suspecting toxicity) |
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Term
| ACE-Is - lisinopril (Zestril, Prinivil), ramipril (Altace), enalapril (Vasotec) |
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Definition
MoA: decreases neurohormonal activity (blocks Ang I to Ang II), decreases Preload & Afterload, decreases sympathetic activation;
Effects: improves sx, reduces remodeling/progression, reduces hospitalizations, improves survival (decreases mortality);
Indication:
- recommended for symptomatic & asymptomatic Pts w/ LVEF <40%;
Practical Application:
- pts w/ HF have high renin status --> start w/ very low doses;
- increase dose to target dose if well tolerated (don't do at expense of using other beneficial drugs);
C/Is:
- bilateral renal artery stenosis, pregnancy, angioedema, SCr >3.0 or K >5.5;
Adverse Effects:
- hyperkalemia, cough, angioedema;
Monitoring Parameters:
- BP, BMP (SCr, electrolytes [K]), cough, angioedema |
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Term
| ARBs - valsartan (Diovan), losartan (Cozaar) |
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Definition
MoA: blocks Ang II mediated vasoconstriction, aldosterone release, and remodeling;
Effects: improves sx, reduces remodeling/progression, reduces hospitalizations, improves survival (decreases mortality);
Indications:
- 2nd line to ACE-Is
- recommended for symptomatic & asymptomatic pts w/ LVEF <40% who are INTOLERANT to ACE-Is;
- considered as initial therapy (instead of ACE-Is) for pts w/ HF post-MI or chronic HF and systolic dysfunction |
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Term
| Beta-blockers - carvedilol (Coreg), metoprolol XL (Toprol XL) |
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Definition
MoA in HF:
- inhibition of SNS blocks neurohormonal remodeling --> upregulation of beta-receptors, improves ventricular shape, decreases end-diastolic & end-systolic volume; antiarrhythmic effects; decreased myocyte death;
Effects:
- improve EF & sx;
- improve survival (decreases mortality);
- decreases hospitalizations;
Indications:
- recommended for pts w/ HF (LVEF <40%) who are CLINICALLY STABLE (no S/sx) --> add to standard therapy (ACE-I or ARB);
Practical Applicatoin:
- start at low doses, titrate q2 wks;
- avoid abrupt D/C;
- pts may feel worse before feeling better;
C/I's:
- recommended to STILL USE in relative C/I's (DM, COPD, PVD);
- do not use if active bronchospasm;
- avoid if HR <55 or SBP <80;
ADRs:
- hypotension, bradycardia, bronchospasm;
Monitoring Parameters:
- HF sx, BP: hypotension, HR |
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Term
| Aldosterone Antagonists - spironolactone (Aldactone), eplerenone (Inspra) |
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Definition
MoA in HF:
- blocks effects of aldosterone in neurohormonal pathway;
- mild diuretic effect (K-sparing);
Effects:
- improves survival (decreases mortality) in pts w/ NYHA Class III-IV HF;
- decreased hospitalizations;
Indications:
- pts w/ NYHA Class III-IV HF (ACC/AHA Stage C & D);
Practical Application:
- added to standard therapy w/ ACE-Is/ARB & beta-blocker in certain pt populations;
- Adjust for CrCl <50 ml/min;
- avoid NSAIDs and COX-2 inhibitors;
- HOLD during diarrhea;
C/Is: SCr >2.5, CrCl <30 ml/min, K >5.0;
ADRs:
- HYPERKALEMIA, gynecomastia, breast tenderness & menstrual irregularities;
Monitoring Parameters:
- BP, BMP (SCr, electrolytes [K]), gynecomastia; |
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Term
|
Definition
non-specific (fatigue, HA);
GI distress: N/V, anorexia, abdominal pain;
CNS: confusion, delirium, psychosis;
Visual changes: blurred vision, changes in color perception, yellow halo;
Arrhythmias: bradycardia, heart block, PVC, ventricular tachycardia/fibrillation; |
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Term
| non-dihydropyridine CCBs (diltiazem, verapamil) |
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Definition
| AVOID in systolic HF since neg. inotropic effects may worsen HF; |
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Term
| dihydropyridine CCBs (amlodipine, felodipine) |
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Definition
no mortality benefit or harm;
- safe in pts w/ LV dysfunctions since they do not decrease contractility;
- may be used as add-on to standard therapy if needed for hypertensive control; |
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Term
|
Definition
antiplatelet therapy recommended in pts w/ ischemic etiology (hx of MI);
may blunt effect of ACEI/ARBs - use low dose daily (81 mg); |
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Term
|
Definition
anticoagulant used in pts w/ evidence of mural thrombus;
- used in some pts w/ poor LV function to prevent mural thrombus |
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Term
| Diastolic Dysfunction/Diastolic HF |
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Definition
preserved LV function (EF 40-60%);
ventricular relaxation & filling is root of problem;
Treatment:
- correct underlying etiology (control HTN, maintain NSR);
- diuretics & ACE-I/ARBs standard therapy for congestive sx;
- beta-blockers & CCBs --> decrease HR & improve ventricular relaxation (non-dihydropyridine CCBs may be beneficiail) |
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