Term
| what is the definition of cardiac function? |
|
Definition
| to maintain a continuous blood flow commensurate with the metabolic needs of tissues and organs |
|
|
Term
| what is the definition of heart failure? |
|
Definition
inability to maintain adequate blood flow to organs
OR
the ability to maintain cardiac function only at increased filling pressure of the heart (aka CHF) |
|
|
Term
| 2 categories of heart failure |
|
Definition
| systolic and diastolic failure |
|
|
Term
| what is seen in systolic heart failure? |
|
Definition
decreased contractile force of ventricle
ejection fraction < 40% |
|
|
Term
| what are causes of systolic heart failure? |
|
Definition
ischemic heart disease - most common
valvular heart disease
dilated cardiomyopathy |
|
|
Term
| which type of heart failure is more common? |
|
Definition
|
|
Term
| what is seen in diastolic heart failure? |
|
Definition
impaired ventricular relaxation filling with preserved contractility
ejection fraction > 60% |
|
|
Term
| cause of diastolic heart failure? |
|
Definition
| concentric left ventricular hypertrophy - requires a greater pressure to drive blood from atrium to ventricle |
|
|
Term
| which type of heart failure doesn't have great treatment? |
|
Definition
|
|
Term
|
Definition
no limitations
no symptoms with ordinary activity |
|
|
Term
|
Definition
slight limitation
comfortable at rest
symptoms with ordinary activity |
|
|
Term
|
Definition
marked limitation
comfortable at rest
symptoms with restricted activity |
|
|
Term
|
Definition
inability to carry on any activity
symptoms at rest |
|
|
Term
| how is heart failure classified and why is it important? |
|
Definition
classifications based on symptoms and abilities
important to tailor drug therapy and approach to treatment based on class |
|
|
Term
| general symptoms of heart failure |
|
Definition
dyspnea (SOB)
orthopnea
exercise intolerance |
|
|
Term
| mechanism of dyspnea (SOB) in heart failure |
|
Definition
| due to decreased pulmonary compliance from pulmonary vascular congestion/edema due to increased pressure in left heart |
|
|
Term
|
Definition
dyspnea at night when lying down
dyspnea when supine from interstitial to vascular ECF volume transfer |
|
|
Term
| what is the mechanism of exercise intolerance in heart failure? |
|
Definition
fatigue, weakness from decreased muscle and tissue perfusion
occur with greater degrees of heart failure |
|
|
Term
| what are the general signs of heart failure? |
|
Definition
edema
cardiac decompensation
gallop rhythm (S3)
systolic hypotension
cool extremities
altered sensorium |
|
|
Term
| increased interstitial volume due to increased pressures in the heart |
|
Definition
|
|
Term
|
Definition
pulmonary
peripheral (dependent) |
|
|
Term
| edema from left ventricle failure |
|
Definition
|
|
Term
| edema from right ventricle failure |
|
Definition
| peripheral (dependent) edema |
|
|
Term
| what is the most common cause of right sided heart failure? |
|
Definition
|
|
Term
| when do signs of heart failure show? |
|
Definition
| when a patient begins to decompensate - they can no longer maintain adequate perfusion for day to day functions |
|
|
Term
| what is a gallop rhythm (S3)? |
|
Definition
| extra heart sound indicating change in pressure relationships and the stiffness of the heart |
|
|
Term
| BP falls because heart can't generate enough forward force |
|
Definition
|
|
Term
| why do heart failure patients have cool extremities? |
|
Definition
| blood flow is directed to vital organs so extremities are cooler |
|
|
Term
| why do heart failure patients have altered sensorium? |
|
Definition
| brain is not getting as much blood flow so they can't think as well |
|
|
Term
| what are the 3 strategies for heart failure therapy? |
|
Definition
prevention - treat underlying cause
treat CHF syndrome
modify or prevent remodeling |
|
|
Term
| what are some underlying causes of heart failure that can be treated for prevention? |
|
Definition
HTN, diabetes, hyperlipidemia, valvular disease
treat with weight loss, diet, insulin, hypoglycemics, surgery |
|
|
Term
|
Definition
| combo of signs and symptoms that cause the patient to be impaired |
|
|
Term
|
Definition
reduce pre-load (amount of blood entering heart)
increase contractility
reduce afterload |
|
|
Term
| how do you reduce pre-load in treating CHF syndrome? |
|
Definition
reduce ECF volume or increase vascular compliance
diuretics |
|
|
Term
| how do you increase contractility in treating CHF syndrome? |
|
Definition
increase injection fraction
digitalis |
|
|
Term
| how do you reduce after-load in treating CHF syndrome? |
|
Definition
decrease vascular resistance
ACEI |
|
|
Term
| what are the 3 ways to prevent remodeling in treating heart failure? |
|
Definition
1. prevent hypertrophy - ACE Inhibitors
2. prevent fibrosis - aldosterone inhibitors
3. prevent apoptosis - beta blockers |
|
|
Term
| what does fibrosis do to the heart? |
|
Definition
| decreases compliance and filling of the heart |
|
|
Term
| how does apoptosis affect the heart? |
|
Definition
| leads to less contractile units |
|
|
Term
|
Definition
|
|
Term
| how is stroke volume determined? |
|
Definition
| left ventricle end diastolic volume (LVEDV) x ejection fraction (EF) |
|
|
Term
|
Definition
function of total ECF volume
determined by ventricular compliance, active atrial filling, ventricular filling time |
|
|
Term
| what determines ejection fraction? |
|
Definition
function of contractility
determined by muscle mass, energy supply, and ejection resistance |
|
|
Term
| main strategy of treating heart failure? |
|
Definition
|
|
Term
| final kick to fill ventricle with blood |
|
Definition
|
|
Term
| amount of time allotted to diastole as opposed to systole |
|
Definition
|
|
Term
|
Definition
|
|
Term
| how does decreased muscle mass effect contractility? |
|
Definition
| leads to decreased contractility |
|
|
Term
| strategies for acute therapy of heart failure syndrome? |
|
Definition
pre-load reduction
after-load reduction
contractility increase
rhythm control |
|
|
Term
| goal of acute therapy on pre-load |
|
Definition
| want to decrease total ECF volume and/or decrease fraction of blood returning to left ventricle |
|
|
Term
| goal of acute therapy on after-load |
|
Definition
| decrease arterial resistance through arterial vasodilation |
|
|
Term
| goal of acute therapy on contractility |
|
Definition
| increase contractile force of individual cardiomyocytes increase ejection fraction |
|
|
Term
| goal of acute therapy on rhythm |
|
Definition
| restore atrio-ventricular synchrony or reduce total rate to allow more time to maximize left ventricle filling and increase LVEDV |
|
|
Term
| what do diuretics accomplish in therapy of heart failure? |
|
Definition
pre-load reduction
ECF volume reduction |
|
|
Term
| classes of heart failure diuretics used to treat |
|
Definition
| NYHA class I-IV (all classes) |
|
|
Term
| what is the primary drug used for pre-load reduction? |
|
Definition
| diuretics to decrease entire ECF volume |
|
|
Term
| diuretic of choice for GFR > 50 ml/min |
|
Definition
|
|
Term
| diuretic used if edematous state or GFR < 50 ml/min |
|
Definition
| loop diuretic - furosemide |
|
|
Term
| when would you use furosemide instead of a thiazide? |
|
Definition
|
|
Term
| used as accessory drugs to reduce pre-load |
|
Definition
metolazone
K-sparing drugs |
|
|
Term
| used to complement loop diuretic if GFR < 50 ml/min; has distal action |
|
Definition
| metolazone - can get into kidney even when patient has low GFR |
|
|
Term
K sparing drugs
block aldosterone instead of K channel |
|
Definition
|
|
Term
|
Definition
| works in DCT by blocking K receptor |
|
|
Term
| side effects of spironolactone |
|
Definition
| 'promiscuous' - also occupies receptors for FSH/LH and leads to gynecomastia in males or menstrual irregularities in women |
|
|
Term
|
Definition
K sparing - accessory drug in pre-load reduction
helps decrease cardiac fibrosis and remodeling |
|
|
Term
| advantages of epleronone over spironolactone |
|
Definition
SPECIFIC effect on aldosterone receptors
side effects are less common |
|
|
Term
| disadvantage of epleronone vs. spironolactone |
|
Definition
| newer so much more expensive |
|
|
Term
| in what classes of heart failure can diet be used in pre-load reduction therapy? |
|
Definition
|
|
Term
| what dietary changes should be made in someone with heart failure? |
|
Definition
| low Na diet - 2 gm Na diet |
|
|
Term
| in which patients is digitalis indicated to increase contractility |
|
Definition
| NYHA class II/III-IV with pulmonary crackles |
|
|
Term
|
Definition
| benefits symptoms but not mortality |
|
|
Term
|
Definition
|
|
Term
|
Definition
| narrow therapeutic index - potential toxicity over entire therapeutic range |
|
|
Term
| what is the drug of choice to increase contractility? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| renal - accumulation in renal failure; must monitor levels in patients with decreased GFR and renal failure |
|
|
Term
|
Definition
| arrhythmia - increased in hypokalemia |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| hepatic - useful in renal failure |
|
|
Term
|
Definition
long-acting and prolong toxicity
not often used because of it's long acting effects and potential side effects |
|
|
Term
| in which patients are B-agonists used to increase contractility? |
|
Definition
NYHA class 4
or
acute decompensation in a hospitalized patient |
|
|
Term
| drug of choice B-agonist to increase contractility |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
little effect on increasing HR than do other B-adrenergic agents
no afterload increase |
|
|
Term
| dopamine use in heart failure |
|
Definition
| B-agonist used to increase contractility |
|
|
Term
|
Definition
|
|
Term
|
Definition
mixed DA/a/B effect
CO effect - at dominant B does (2-8 mcg/kg) |
|
|
Term
| in which patients are netriuretic peptides used to increase contractility |
|
Definition
| NYHA Class IV decompensated patients |
|
|
Term
| what is the natriuretic peptide used to increase contractility in class IV patients? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
ionotrophic and renal diuretic
+/- effect on symptoms
significant rate of hypotension |
|
|
Term
|
Definition
only acutely
not used very often |
|
|
Term
|
Definition
| cardiac phosphodiesterase inhibitor used to increase contractility |
|
|
Term
|
Definition
| mainly post cardiac surgery |
|
|
Term
|
Definition
+/- increase in mortality
arrhythmia |
|
|
Term
| what is the drug of choice for after-load reduction in NYHA class II-IV patients? |
|
Definition
| vasodilators - hydralazine |
|
|
Term
| in which patients is hydralazine (vasodilator) indicated to reduce after-load? |
|
Definition
|
|
Term
| hydralazine is used in combo with _____ to decrease _____ |
|
Definition
|
|
Term
| the combo of nitrate and hydralazine is highly beneficial to whom? |
|
Definition
|
|
Term
| B-blockers are indicated for use to reduce after-load in what type of heart failure patients? |
|
Definition
|
|
Term
| carvedilol and metoprolol use |
|
Definition
| B-blockers used in after-load reduction |
|
|
Term
| which drug is the best B-blocker for reducing after-load? |
|
Definition
|
|
Term
|
Definition
| a/B blocker - reduces after-load |
|
|
Term
|
Definition
B1 selective blocker
*reduces mortality |
|
|
Term
| what type of drugs are used in NYHA class I-II heart failure as adjunctive therapy? |
|
Definition
|
|
Term
| a-blocker used in NYHA class I-II patients |
|
Definition
|
|
Term
|
Definition
| not to be used as a primary durg |
|
|
Term
|
Definition
| decrease resistance in arterial tree - decreases after-load |
|
|
Term
| what type is the drug of choice for heart failure across all classes? |
|
Definition
|
|
Term
| what are the drugs of choice across spectrum for heart failure for after load reduction? |
|
Definition
|
|
Term
|
Definition
improve symptoms and patient functionality
*decreases mortality |
|
|
Term
|
Definition
| limited by hypotension and hyperkalemia |
|
|
Term
| first ACE I; not for once daily dosing |
|
Definition
|
|
Term
| first ACE I to show benefit in heart failure; twice daily dosing |
|
Definition
|
|
Term
| most popular generic ACE Is |
|
Definition
| lisinopril and fosinopril |
|
|
Term
| most advanced efficacy studies of ACE I |
|
Definition
|
|
Term
| in which patients are angiotensin receptor blockers (ARBs) indicated to reduce after-load? |
|
Definition
|
|
Term
| which ARBs may need twice daily dosing in heart failure? |
|
Definition
|
|
Term
| which ARBs need only daily dosing for heart failure? |
|
Definition
|
|
Term
| goal of rate control treatment of atrial fibrillation |
|
Definition
| induce AV conduction block and decrease ventricular rate |
|
|
Term
| drugs used in rate control of atrial fibrillation |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| non-dihydroperidine Ca channel blocker |
|
|
Term
|
Definition
|
|
Term
| major side effect of diltiazem |
|
Definition
|
|
Term
|
Definition
IV bolus
less predictable effect than diltiazem - causes AV block but not in all patients |
|
|
Term
|
Definition
| may increase conversion to sinus rhythm |
|
|
Term
| goal of rhythm conversion therapy in atrial fibrillation |
|
Definition
|
|
Term
| drug used for rhythm conversion in atrial fibrillation |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| slows heart - allows for increased diastolic filling without messing with atrial rhythm |
|
|
Term
| goal of rhythm conversion therapy in supra-ventricular tachycardia (SVT) |
|
Definition
|
|
Term
| drug used for rhythm conversion in SVT |
|
Definition
|
|
Term
|
Definition
IV bolus
repeated until effective |
|
|
Term
| 3 types of non-drug therapy for heart failure |
|
Definition
cardiac re-synchronization therapy (CRT)
intraventricular assist device
ventricular reduction surgery |
|
|
Term
| indications for cardiac resynchronization therapy |
|
Definition
| NYHA class III-IV patients who have wide QRS from intraventricular conduction delay and EF < 35% |
|
|
Term
| cardiac resynchronization therapy |
|
Definition
| biventricular pacer synchronized to patient's sinus rhythm |
|
|
Term
| cardiac resynchronization therapy outcome |
|
Definition
reduction in symptoms and NYHA classification
trend toward increased survival |
|
|
Term
| indications for intraventricular assist device |
|
Definition
| NYHA class IV > 90 days on optimal drug therapy |
|
|
Term
| outcomes for intraventricular assist device |
|
Definition
| prolonged survival but high complication rate |
|
|
Term
| indications for ventricular reduction surgery |
|
Definition
NYHA class IV
high risk of surgery |
|
|
Term
| ventricular reduction surgery effects |
|
Definition
| removes akinetic/dyskinetic ventricular wall to restore geometry of ventricle |
|
|
Term
| what drugs can be used for preventative therapy for heart failure? |
|
Definition
ACE I
B-blocker
aldosterone inhibitor |
|
|
Term
| when are ACE I indicated for preventative therapy? |
|
Definition
post MI
indicated in all patients lacking specific contraindication |
|
|
Term
| contraindications for ACE I post MI |
|
Definition
angioedema
hypotension
ARB may be substituted in these patients |
|
|
Term
|
Definition
| prevents remodeling to preserve left ventricular function |
|
|
Term
| when are B-blocker indicated for preventative therapy? |
|
Definition
post MI
indicated in all patients lacking specific contraindication |
|
|
Term
| contraindications for B-blocker post MI |
|
Definition
asthma/bronchospasm
claudication |
|
|
Term
| effect of B-blocker post MI |
|
Definition
prevents apoptosis and cell loss
reduces sudden death from arrhythmia in 1st year post-MI |
|
|
Term
| when is aldosterone indicated for preventative therapy? |
|
Definition
|
|
Term
| effect of aldosterone in preventative therapy? |
|
Definition
| reduces mortality and hospitalization when added to conventional therapy for NYHA class III-IV |
|
|
Term
| when is eplerenone indicated for preventative therapy? |
|
Definition
|
|
Term
| effect of eplerenone post MI |
|
Definition
| reduces mortality and symptomatic heart failure |
|
|
