Heart Failure Definition and Statistics
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Questions and Answers

What is the most common cause of right-ventricle heart failure?

  • Left-ventricle heart failure (correct)
  • Hypertension
  • Valvular heart disease
  • Coronary artery disease

    • Which of the following is the criteria for classifying heart failure with reduced ejection fraction (HFrEF)?

  • LVEF < 40% (correct)
  • LVEF between 41% and 49%
  • LVEF = 50%
  • LVEF > 40%

    • What characterizes the diastolic dysfunction in left-ventricle heart failure?

  • Reduced pumping force
  • Electrical conduction issues
  • Fluid accumulation in the lungs
  • Inadequate filling during diastole (correct)

    • Which term describes the heart failure classification with improved ejection fraction?

    <p>HFimpEF</p> Signup and view all the answers

    What is the primary goal of guideline-directed medical therapy (GDMT) in heart failure patients?

    <p>Improve mortality and clinical outcomes</p> Signup and view all the answers

    In a population of heart failure patients, which group is noted to have the highest age-adjusted mortality rates?

    <p>Non-Hispanic Black individuals</p> Signup and view all the answers

    What type of heart failure is characterized by reduced cardiac output relative to the needs of the body?

    <p>Left-ventricle heart failure</p> Signup and view all the answers

    How does age-adjusted HF mortality rates differ between rural and urban areas?

    <p>Higher in rural areas</p> Signup and view all the answers

    Which symptom is commonly associated with right-sided heart failure?

    <p>Peripheral edema</p> Signup and view all the answers

    In the context of left-sided heart failure, which of the following statements is accurate?

    <p>It can result in pulmonary hypertension.</p> Signup and view all the answers

    How does biventricular heart failure typically develop?

    <p>By left-sided heart failure leading to increased loads on the right side.</p> Signup and view all the answers

    What does ejection fraction indicate in heart failure patients?

    <p>The volume of blood pumped out of the heart with each contraction.</p> Signup and view all the answers

    Which classification reflects symptoms experienced at rest?

    <p>NYHA Class IV</p> Signup and view all the answers

    What is the primary characteristic that distinguishes heart failure with reduced ejection fraction (HFrEF) from preserved ejection fraction (HFpEF)?

    <p>Ejection fraction less than 40%</p> Signup and view all the answers

    Which of the following best describes the pathophysiological mechanism leading to systolic dysfunction in heart failure?

    <p>Myocardial damage leading to impaired contraction</p> Signup and view all the answers

    Which of the following medications is commonly known to exacerbate heart failure symptoms?

    <p>Nonsteroidal anti-inflammatory drugs (NSAIDs)</p> Signup and view all the answers

    What is the most appropriate first-line guideline-directed medical therapy (GDMT) for a patient diagnosed with HFrEF?

    <p>Beta-blockers</p> Signup and view all the answers

    Which classification system is primarily used to assess the severity of heart failure?

    <p>New York Heart Association (NYHA) classification</p> Signup and view all the answers

    In heart failure with preserved ejection fraction (HFpEF), what is a common underlying cause?

    <p>Hypertension-induced ventricular hypertrophy</p> Signup and view all the answers

    What is a key clinical feature of right heart failure?

    <p>Peripheral edema</p> Signup and view all the answers

    Which diagnostic criterion is essential for confirming a diagnosis of heart failure?

    <p>Increased B-type natriuretic peptide (BNP)</p> Signup and view all the answers

    What important role do diuretics play in the management of heart failure?

    <p>Reduce fluid overload</p> Signup and view all the answers

    Which of the following statements regarding heart failure classification is accurate?

    <p>HFmrEF is defined by an ejection fraction between 41% and 49%.</p> Signup and view all the answers

    Which of the following symptoms is primarily associated with right-sided ventricular failure?

    <p>Swelling of legs and hands</p> Signup and view all the answers

    What does a reduced ejection fraction primarily indicate in heart failure patients?

    <p>Dilated cardiomyopathy</p> Signup and view all the answers

    In guideline-directed medical therapy (GDMT) for heart failure, which medication category typically has a role as a positive inotrope?

    <p>Inotropes</p> Signup and view all the answers

    What defines New York Heart Association (NYHA) Class III heart failure?

    <p>Symptoms with minimal exertion that interfere with normal activities</p> Signup and view all the answers

    Which cause is most likely associated with heart failure with preserved ejection fraction (HFpEF)?

    <p>Ventricular hypertrophy</p> Signup and view all the answers

    Which of the following is not considered a negative inotropic medication in heart failure management?

    <p>ACE inhibitors</p> Signup and view all the answers

    In the classification of heart failure, what does 'HFrEF' stand for?

    <p>Heart Failure with Reduced Ejection Fraction</p> Signup and view all the answers

    Which of the following is a common sign of left-sided heart failure?

    <p>Orthopnea</p> Signup and view all the answers

    Which risk factor is considered a major cause of heart failure?

    <p>Hypertension</p> Signup and view all the answers

    Which of the following is associated with volume overload in heart failure?

    <p>Valvular regurgitation</p> Signup and view all the answers

    Which of the following is NOT a criterion for Stage B heart failure?

    <p>Presence of marked HF symptoms</p> Signup and view all the answers

    What is commonly assessed to determine reduced left ventricular systolic function?

    <p>Ejection fraction</p> Signup and view all the answers

    Which of the following interventions is targeted to individuals in Stage A heart failure?

    <p>Modify risk factors</p> Signup and view all the answers

    Which statement about the ACC/AHA stages of heart failure is true?

    <p>Advanced stages are associated with reduced survival rates</p> Signup and view all the answers

    What indicates the need for guideline-directed medical therapy in heart failure?

    <p>Current or previous symptoms of HF</p> Signup and view all the answers

    Which of the following is a sign that a patient may be progressing into Stage D heart failure?

    <p>Experiencing marked HF symptoms interfering with daily life</p> Signup and view all the answers

    Which condition is not classified as a structural heart disease risk factor for heart failure?

    <p>Acute coronary syndrome</p> Signup and view all the answers

    What does persistently elevated cardiac troponin indicate in the absence of competing diagnoses?

    <p>Structural heart disease</p> Signup and view all the answers

    Which of the following best represents the difference between Stage B and Stage C heart failure?

    <p>Stage C patients have current or previous symptoms of heart failure</p> Signup and view all the answers

    What effect does the activation of the sympathetic nervous system have on heart rate?

    <p>Increases heart rate by releasing catecholamines</p> Signup and view all the answers

    Which of the following factors most directly decreases heart rate in the body?

    <p>Stimulation of the vagus nerve</p> Signup and view all the answers

    What role do hormonal influences play in regulating heart rate?

    <p>Both increase and decrease heart rate based on circulating factors</p> Signup and view all the answers

    How do non-hormonal stimulants affect heart rate?

    <p>Only increase heart rate in a dose-dependent manner</p> Signup and view all the answers

    Which of the following accurately describes the parasympathetic effects on heart rate?

    <p>Reduces heart rate by acting through the vagus nerve</p> Signup and view all the answers

    What is the primary effect of the parasympathetic nervous system on heart rate?

    <p>Decreases heart rate through acetylcholine</p> Signup and view all the answers

    Which neurotransmitter is primarily responsible for the positive chronotropic effects of the sympathetic nervous system?

    <p>Norepinephrine</p> Signup and view all the answers

    Which physiological effect does caffeine primarily exert in the body?

    <p>Inhibits adenosine receptors</p> Signup and view all the answers

    During the fight or flight response, which system's activation leads to an increase in heart rate?

    <p>Sympathetic nervous system via epinephrine</p> Signup and view all the answers

    What is the main role of preload in determining stroke volume?

    <p>It enhances the stretch of cardiac muscle fibers.</p> Signup and view all the answers

    What role does thyroxine (T4) have in heart rate regulation?

    <p>Enhances heart rate sensitivity to catecholamines</p> Signup and view all the answers

    What is the effect of glucocorticoids on heart rate?

    <p>Increases heart rate sensitivity to catecholamines</p> Signup and view all the answers

    How does nicotine specifically affect the autonomic nervous system?

    <p>It stimulates the sympathetic nervous system.</p> Signup and view all the answers

    Which receptor subtype is primarily associated with the vasoconstrictive effects of the sympathetic nervous system?

    <p>Alpha-1 adrenergic receptors</p> Signup and view all the answers

    Which of the following correctly describes the Frank-Starling law of the heart?

    <p>Increased blood volume filling enhances contractile force.</p> Signup and view all the answers

    What effect does adenosine normally have on the body?

    <p>Encourages vasodilation and lowers heart rate.</p> Signup and view all the answers

    Which type of adrenergic receptor is primarily involved in increasing heart rate and contractility?

    <p>Beta-1 receptors</p> Signup and view all the answers

    Which factor is NOT considered a hormonal influence on heart rate?

    <p>Acetylcholine</p> Signup and view all the answers

    Which factor does NOT directly influence stroke volume?

    <p>Oxygen levels in the blood</p> Signup and view all the answers

    What is the relationship between muscle fiber stretch and contraction according to the Frank-Starling mechanism?

    <p>An optimal stretch increases contraction strength up to a certain point.</p> Signup and view all the answers

    Which of the following is primarily affected by the activity of the sympathetic nervous system?

    <p>Increased heart rate and enhanced myocardial contractility.</p> Signup and view all the answers

    In the context of stimulants, what common effect do both nicotine and caffeine have on heart function?

    <p>Both enhance sympathetic nervous system activity.</p> Signup and view all the answers

    What primarily regulates the heart rate during a stress response?

    <p>Sympathetic nervous system activation</p> Signup and view all the answers

    Which hormone is associated with increasing heart rate as part of the body's fight-or-flight response?

    <p>Epinephrine</p> Signup and view all the answers

    In the context of the autonomic nervous system, what effect does the parasympathetic nervous system have on heart rate?

    <p>It decreases heart rate.</p> Signup and view all the answers

    Which of the following non-hormonal stimulants is known to increase heart rate?

    <p>Caffeine</p> Signup and view all the answers

    What is the primary action of the sympathetic nervous system on cardiac function?

    <p>Increases heart rate and contractility</p> Signup and view all the answers

    Which of the following accurately describes the relationship between systemic vascular resistance and stroke volume in left ventricular dysfunction?

    <p>Increased systemic vascular resistance decreases stroke volume significantly.</p> Signup and view all the answers

    What effect does the renin-angiotensin-aldosterone system (RAAS) have on blood pressure and heart rate?

    <p>It increases blood pressure and can increase heart rate.</p> Signup and view all the answers

    What physiological change occurs in the heart as a result of prolonged sympathetic stimulation?

    <p>Ventricular dilation and hypertrophy</p> Signup and view all the answers

    Which factor most significantly influences heart rate variability among individuals?

    <p>Age</p> Signup and view all the answers

    What compensatory mechanism is activated to sustain cardiac output in the presence of heart muscle damage?

    <p>Cardiac remodeling</p> Signup and view all the answers

    Which of the following effects is primarily associated with sympathetic nervous system activation during heart failure?

    <p>Increased myocardial oxygen demand</p> Signup and view all the answers

    Which hormonal mechanism contributes to increased preload in heart failure patients?

    <p>Activation of the RAAS system</p> Signup and view all the answers

    In the context of heart failure, what is a detrimental consequence of ventricular hypertrophy?

    <p>Increased risk of diastolic dysfunction</p> Signup and view all the answers

    What is one of the primary roles of tachycardia in response to heart failure?

    <p>To maintain cardiac output</p> Signup and view all the answers

    Which of the following best describes a parasympathetic effect on heart function?

    <p>Decreased heart rate</p> Signup and view all the answers

    Which mechanism is responsible for increasing afterload during heart failure?

    <p>Increased systemic resistance</p> Signup and view all the answers

    In heart failure, increased heart rate can lead to which of the following adverse effects?

    <p>Increased myocardial oxygen consumption</p> Signup and view all the answers

    What negative impact does increased circulating catecholamines have in heart failure?

    <p>Increased myocardial cell death</p> Signup and view all the answers

    Which class of drugs modulates neurohormonal activation and targets the autonomic nervous system in heart failure treatment?

    <p>Beta-blockers</p> Signup and view all the answers

    Which of the following is a common effect of non-hormonal stimulants on heart rate?

    <p>Increased heart rate</p> Signup and view all the answers

    What is the impact of diuretics on patients with heart failure?

    <p>They primarily relieve symptoms of volume overload.</p> Signup and view all the answers

    What is the role of Hydralazine and Isosorbide Dinitrate (BiDil) in heart failure management?

    <p>They improve outcomes in selected heart failure patients.</p> Signup and view all the answers

    Which statement about Ivabradine in heart failure treatment is accurate?

    <p>It targets heart rate reduction without affecting myocardial contractility.</p> Signup and view all the answers

    Which guideline feature is crucial for managing patients with HFrEF?

    <p>Optimal use of ACE inhibitors to improve mortality rates.</p> Signup and view all the answers

    What is an important consideration for volume management in heart failure patients?

    <p>Volume status should be assessed using physical examination and weight.</p> Signup and view all the answers

    Which of the following treatments is not recommended in patients with HFrEF?

    <p>Non-DHP CCBs.</p> Signup and view all the answers

    In advanced heart failure patients, what is the benefit of restricting water intake?

    <p>Its effectiveness remains uncertain and should be evaluated carefully.</p> Signup and view all the answers

    Which patient profile warrants caution against using certain heart failure medications?

    <p>Patients with type 2 diabetes mellitus and cardiovascular risk.</p> Signup and view all the answers

    Which laboratory parameter is essential to evaluate at 1-2 weeks following dose changes in heart failure medication management?

    <p>Serum K+ levels</p> Signup and view all the answers

    Which statement correctly describes the guidelines for titration of ACE inhibitors in heart failure treatment?

    <p>Titration should be based on both the blood pressure response and renal function.</p> Signup and view all the answers

    Which of the following conditions should be approached with caution when initiating ACE inhibitors?

    <p>Preexisting hypotension or hyponatremia</p> Signup and view all the answers

    Which of the following is true about the timing of evaluations after starting ARNI therapy in heart failure patients?

    <p>Patients should be evaluated at 1-2 weeks and after any dose changes.</p> Signup and view all the answers

    What is the primary goal in managing hydration and volume in patients with heart failure?

    <p>Minimizing fluid retention to alleviate heart failure symptoms</p> Signup and view all the answers

    What is the recommended role of diuretics in patients with heart failure presenting fluid retention?

    <p>To relieve congestion and improve symptoms</p> Signup and view all the answers

    Which combination therapy has been established to reduce death and hospitalization in HFrEF, particularly in African American patients?

    <p>Hydralazine and Isosorbide Dinitrate</p> Signup and view all the answers

    What should be monitored in patients receiving diuretics for heart failure management?

    <p>Daily weights, blood pressure, and BMP levels including magnesium and calcium</p> Signup and view all the answers

    In patients with heart failure who are treated with loop diuretics, when is it appropriate to consider adding a thiazide diuretic?

    <p>Only if they do not respond to high-dose loop diuretics</p> Signup and view all the answers

    What is the primary benefit of using SGLT2 inhibitors like Dapagliflozin in patients with symptomatic chronic HFrEF?

    <p>To reduce hospitalization for heart failure and cardiovascular mortality</p> Signup and view all the answers

    Which of the following mechanisms of action is NOT typically associated with the use of diuretics in heart failure management?

    <p>Increasing systemic vascular resistance</p> Signup and view all the answers

    Which statement is accurate regarding the use of diuretics in patients with renal impairment?

    <p>Higher doses may be required to achieve desired effects</p> Signup and view all the answers

    What is a key aspect of hydration management in patients with congestive heart failure?

    <p>Balancing fluid intake and output to manage congestion</p> Signup and view all the answers

    What main issue does the use of thiazide diuretics in conjunction with loop diuretics aim to minimize?

    <p>Electrolyte abnormalities in patients unresponsive to loop diuretics</p> Signup and view all the answers

    Which diuretic is most commonly used and considered part of the first line of treatment in heart failure?

    <p>Hydrochlorothiazide (HCTZ)</p> Signup and view all the answers

    What should be monitored carefully before initiating spironolactone (Aldactone) in patients with HFrEF?

    <p>Potassium levels and renal function</p> Signup and view all the answers

    Which statement about the use of beta-blockers in HFrEF is true?

    <p>It is recommended to avoid discontinuation even if no symptom improvement is noticed for 2-3 months.</p> Signup and view all the answers

    Which class of medication is considered a cornerstone of guideline-directed medical therapy (GDMT) for HFrEF?

    <p>Mineralocorticoid receptor antagonists (MRAs)</p> Signup and view all the answers

    What is a critical component when titrating ARNI, ACEI, or ARB doses in HFrEF patients?

    <p>Monitoring based on renal function and potassium levels</p> Signup and view all the answers

    In patients with HFrEF and NYHA class II to IV symptoms, which is a requirement for recommended MRA treatment?

    <p>eGFR greater than 30 and serum potassium less than 5</p> Signup and view all the answers

    Which mechanism is NOT associated with the cardioprotective effects of SGLT2 inhibitors in patients with HFrEF?

    <p>Improved glucose metabolism</p> Signup and view all the answers

    What does the acronym HFrEF stand for in the context of heart failure?

    <p>Heart Failure with reduced ejection fraction</p> Signup and view all the answers

    What is the recommended action regarding hydration and diuretic management in HFrEF patients?

    <p>Regularly assess volume status and adjust diuretic dosing.</p> Signup and view all the answers

    Which treatment is indicated for patients experiencing clinical deterioration after abrupt withdrawal of beta-blockers?

    <p>Resume beta-blocker therapy gradually</p> Signup and view all the answers

    What should be done if a patient with HFrEF requires increased doses of ARNI, ACEI, or ARB?

    <p>Monitor potassium and renal function to ensure safety.</p> Signup and view all the answers

    Which adverse effect is associated specifically with the use of Bumetanide in heart failure management?

    <p>Hypokalemia</p> Signup and view all the answers

    In the context of heart failure treatment, which of the following is a contraindication for the use of Hydralazine?

    <p>Allergy to nitrates</p> Signup and view all the answers

    Which statement accurately describes Ivabradine's role in heart failure?

    <p>It reduces heart rate without affecting blood pressure.</p> Signup and view all the answers

    Which of the following is a key consideration when managing hydration and volume in heart failure patients?

    <p>Maintenance of fluid balance is paramount to prevent exacerbation.</p> Signup and view all the answers

    Which diuretic is often used in conjunction with loop diuretics for synergistic effects in heart failure?

    <p>Spironolactone</p> Signup and view all the answers

    For which of the following patient conditions is the combined use of Hydralazine and Isosorbide Dinitrate particularly indicated?

    <p>Heart failure in African-American patients</p> Signup and view all the answers

    Which pharmacological approach is recommended for controlling heart rate in patients with heart failure, particularly those with reduced ejection fraction?

    <p>Use of beta-blockers</p> Signup and view all the answers

    In clinical guidelines for HFrEF treatment, which medication class is considered first-line therapy?

    <p>ACE inhibitors</p> Signup and view all the answers

    Which is a common adverse effect of using diuretics in heart failure patients?

    <p>Acid-base imbalance</p> Signup and view all the answers

    What is the primary therapeutic goal of combining Hydralazine and Isosorbide Dinitrate in heart failure management?

    <p>To reduce afterload and improve myocardial oxygen delivery</p> Signup and view all the answers

    Which pharmacotherapy approach is most critical for managing adverse drug interactions in heart failure patients?

    <p>Identifying and monitoring specific drug interactions</p> Signup and view all the answers

    What is the best strategy to optimize pharmacotherapy for specific populations with heart failure?

    <p>Customizing plans based on unique patient factors</p> Signup and view all the answers

    Which of the following correctly outlines a fundamental mechanism of action for heart failure medications?

    <p>Decreasing vascular resistance to lower blood pressure</p> Signup and view all the answers

    When calculating medication doses for heart failure patients, which of the following factors is least relevant?

    <p>The brand name of the medication</p> Signup and view all the answers

    What principle should guide the design of treatment plans for individuals with heart failure?

    <p>Incorporating culturally relevant strategies tailored to individual needs</p> Signup and view all the answers

    Which parameter is crucial for monitoring the effectiveness of heart failure pharmacotherapy?

    <p>Clinical test results and symptom improvement</p> Signup and view all the answers

    Which of the following dietary supplements could pose risks in heart failure pharmacotherapy?

    <p>St. John's Wort, which can interact with medications</p> Signup and view all the answers

    What is a significant risk associated with using nonprescription drugs in heart failure management?

    <p>They may exacerbate existing conditions or interact negatively</p> Signup and view all the answers

    In assessing drug-induced heart failure, which medication category is most commonly implicated?

    <p>Non-steroidal anti-inflammatory drugs (NSAIDs)</p> Signup and view all the answers

    Which adverse effect is specifically associated with Aldosterone Antagonists like Spironolactone?

    <p>Gynecomastia</p> Signup and view all the answers

    What is a key consideration when initiating medication for patients with heart failure?

    <p>Monitor electrolytes during titration</p> Signup and view all the answers

    Which medication class combines the effects of ARBs and neprilysin inhibitors?

    <p>ARNIs</p> Signup and view all the answers

    What is a significant recommendation in recent heart failure management guidelines?

    <p>Focus on reducing hospitalizations</p> Signup and view all the answers

    Which of the following medications is not primarily indicated for patients with reduced ejection fraction?

    <p>Dapagliflozin</p> Signup and view all the answers

    Which adverse effect is common among Beta-blockers used in heart failure management?

    <p>Bradycardia</p> Signup and view all the answers

    What is the goal of regular follow-up appointments for heart failure patients?

    <p>To assess symptom improvement and vital signs</p> Signup and view all the answers

    Which is a potential consequence of not titrating medications for heart failure patients based on tolerance?

    <p>Increased risk of adverse effects</p> Signup and view all the answers

    What is an essential component of patient education regarding heart failure management?

    <p>Monitoring and recognizing symptoms for early intervention</p> Signup and view all the answers

    Study Notes

    Heart Failure Definition and Prevalence

    • Heart Failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in symptoms and/or signs corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.
    • Approximately 6.7 million Americans over 20 years of age have HF.
    • Prevalence is expected to rise to 8.5 million Americans by 2030.
    • Improved survival for comorbidities, such as coronary artery disease and hypertension, and use of device therapy have likely contributed to the increased incidence and prevalence of HF.
    • The lifetime risk of HF has increased to 24%, meaning approximately 1 in 4 persons will develop HF in their lifetime.

    Heart Failure Mortality Rates

    • HF mortality rates have been increasing since 2012.
    • HF is associated with a loss of 15 years of median survival for adults aged 65–90 years compared with the general US population.
    • Age-adjusted HF mortality rates are highest for non-Hispanic Black individuals.
    • Black, American Indian, and Alaska Native individuals with HF have the highest all-cause age-adjusted mortality compared with other racial and ethnic groups.
    • From 2010 to 2020, HF mortality rates have increased for Black women and men at a rate faster than any other racial or ethnic group, particularly for individuals below the age of 65.
    • Age-adjusted mortality rates (AAMRs) for HF have increased in the last decade with similar patterns of increase in women and men.
    • A greater relative annual increase in HF-related mortality rates has been noted for younger (35–64 years) compared with older (65–84 years) adults.
    • Rural areas demonstrate higher HF mortality rates for both younger and older age groups compared with urban areas.

    Prognosis of Heart Failure

    • Prognosis remains poor with a 5-year mortality rate of 50% or higher.
    • Prognosis is influenced by factors such as age, ejection fraction, renal function, natriuretic peptide concentrations, extent of CAD and symptom severity.
    • Sudden cardiac death occurs in about 40% of patients with HF.

    Types of Chronic Heart Failure

    • Right-ventricle heart failure (RHF): Most common cause is LHF, leading to blood backing up into the systemic veins causing swelling in the legs, hands, and liver.
    • Left-ventricle heart failure (LHF): Reduced cardiac output relative to the needs of the body, and blood backs up into the pulmonary veins leading to dyspnea, rales, orthopnea and more.
    • Reduced ejection fraction (HFrEF): “Pumping problem” caused by reduced contractile force of the ventricles.
    • Preserved ejection fraction (HFpEF): “Relaxation problem” caused by stiffening of the ventricles, preventing adequate filling during diastole.

    Heart Failure Staging

    • Stage A: Individuals with risk factors for HF but no structural heart disease or symptoms.
    • Stage B: Individuals with structural heart disease without symptoms of HF.
    • Stage C: Individuals with structural heart disease and symptoms of HF.
    • Stage D: Advanced HF with marked symptoms despite optimized GDMT.

    Risk Factors for Heart Failure

    • Hypertension: Major contributor to HFrEF and HFpEF.
    • Diabetes.
    • ASCVD (Atherosclerotic Cardiovascular Disease).
    • Obesity.
    • Exposure to cardiotoxic agents.
    • Genetic variant for cardiomyopathy: Hypertrophic cardiomyopathy (HCoM), Amyloid cardiomyopathy.
    • Family history of cardiomyopathy.

    Causes of Heart Failure

    • Heart Failure with Reduced Ejection Fraction (HFrEF)*

    • Coronary artery disease (eg, myocardial infarction or ischemia).

    • Dilated cardiomyopathies (eg, drug-induced, viral infections, postpartum).

    • Pressure overload (eg, systemic or pulmonary hypertension, or aortic valve or pulmonic valve stenosis).

    • Volume overload (eg, valvular regurgitation, shunts, high-output states).

    • Heart Failure with Preserved Ejection Fraction (HFpEF)*

    • Increased ventricular stiffness.

    • Ventricular hypertrophy (eg, hypertrophic cardiomyopathy, hypertension).

    • Infiltrative myocardial diseases (eg, amyloidosis, sarcoidosis, endomyocardial fibrosis).

    • Myocardial infarction or ischemia.

    • Mitral or tricuspid valve stenosis.

    • Pericardial disease (eg, pericarditis, pericardial tamponade).

    Medications that can Exacerbate Heart Failure

    • Negative inotropes.
    • Antiarrhythmics.
    • Beta-blockers.
    • Non-dihydropyridine calcium channel blockers.
    • Itraconazole.
    • Sodium and water retention medications: NSAIDS, TZDs (pioglitazone), glucocorticoids.
    • Cardiotoxic agents: Chemotherapy agents (doxorubicin, epirubicin, daunomycin, trastuzumab), ethanol, amphetamines, TNF alpha antagonists (etanercept, infliximab, adalimumab), dronedarone, saxagliptin, alogliptin.

    Clinical Presentation of Heart Failure

    • Classic Clinical Presentation*

    • Shortness of breath (dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea).

    • Fatigue.

    • Fluid overload: Pulmonary edema, lower extremity edema.

    • Intolerance of daily-life activities.

    • Signs and Symptoms*

    • Right-sided Ventricular Failure (Remember "Swelling")*

    • Swelling of legs/hands/liver.

    • Weight gain.

    • Pitting edema.

    • Large neck veins (jugular venous distention - JVD).

    • Lethargy.

    • Irregular heart rate.

    • Nocturia.

    • Girth (increased abdominal size/ascites).

    • Left-sided Ventricular Failure (Remember "Drowning")*

    • Dyspnea.

    • Rales (crackles).

    • Orthopnea.

    • Weakness.

    • Nocturnal dyspnea.

    • Increased heart rate.

    • Nagging cough.

    • Weight gain.

    • New York Heart Association (NYHA) Functional Class*

    • Class I: No limitation during ordinary activity.

    • Class II: Slight limitation by SOB and/or fatigue during moderate exertion/stress.

    • Class III: Symptoms with minimal exertion that interfere with normal daily activity.

    • Class IV: Symptoms at rest.

    Heart Failure Objectives

    • Define heart failure and distinguish between HFrEF and HFpEF.
    • Explain the pathophysiological mechanisms leading to heart failure and how they differ between systolic and diastolic dysfunction.
    • Describe the effects of guideline-directed medical therapy (GDMT) on components of the neurohormonal model.
    • Apply signs and symptoms, labs, diagnostic criteria, and staging criteria in patients with HFrEF.
    • Identify medications that can exacerbate heart failure.
    • Identify appropriate pharmacotherapeutic interventions for a patient with HFrEF, HFmrEF, and HFpEF based on current treatment guideline recommendations.

    Autonomic Nervous System

    • The autonomic nervous system regulates heart rate
    • The parasympathetic nervous system slows heart rate through the vagus nerve, releasing acetylcholine
    • The sympathetic nervous system increases heart rate by releasing norepinephrine and epinephrine.

    Sympathetic Nervous System Receptors

    • Alpha-2 receptors inhibit norepinephrine release
    • Beta-2 receptors facilitate norepinephrine release
    • Alpha-1 receptors cause vasoconstriction
    • Beta-1 receptors increase heart rate and contractility
    • Beta-2 receptors cause vasodilation and bronchodilation
    • Beta-3 receptors have negative inotropic effects and are present in lower concentrations in the heart

    Hormones Affecting Heart Rate

    • Thyroid hormones (T4 and T3) increase heart rate by enhancing sensitivity to catecholamines
    • Glucocorticoids (cortisol) indirectly increase heart rate by increasing sensitivity to catecholamines
    • Nicotine stimulates the sympathetic nervous system
    • Caffeine blocks adenosine receptors, which normally calm the central nervous system and slow heart rate.

    Stroke Volume

    • Stroke volume is the amount of blood pumped out of the heart with each beat
    • It’s determined by preload, contractility, and afterload
    • Preload is the stretch of cardiac muscle fibers at the end of diastole
    • Contractility is the force of contraction, independent of preload
    • Afterload is the resistance the heart overcomes to eject blood during systole

    Frank-Starling Law

    • The heart's stroke volume increases with increased end-diastolic volume (EDV)
    • Stretching the cardiac muscle fibers can enhance contractile force up to an optimal point
    • Overstretching can result in weak contractions and decreased stroke volume

    Compensatory Mechanisms in Heart Failure

    • Increased preload, achieved through sodium and water retention, helps maintain cardiac output through the Frank-Starling mechanism
    • Vasoconstriction helps maintain blood pressure despite reduced cardiac output, but increases myocardial oxygen demand
    • Tachycardia and increased contractility, triggered by the sympathetic nervous system, maintain cardiac output at the expense of increased myocardial oxygen demand and shortening diastolic filling time
    • Ventricular hypertrophy and remodeling can maintain cardiac output and reduce myocardial wall stress, but can lead to diastolic dysfunction, systolic dysfunction, increased arrhythmia risk, and fibrosis.

    Afterload

    • Represents the forces preventing blood ejection from the ventricle
    • In left ventricular dysfunction, there’s an inverse relationship between afterload and stroke volume
    • Afterload is clinically estimated by systemic vascular resistance, influenced by vasodilation and vasoconstriction
    • Relationship between stroke volume and systemic vascular resistance: In normal left ventricular function, increasing systemic vascular resistance has little effect on stroke volume. As left ventricular dysfunction increases, the negative, inverse relationship between stroke volume and systemic vascular resistance becomes more pronounced.

    Cardiac Output

    • Cardiac output is the volume of blood ejected per unit of time, calculated by multiplying heart rate by stroke volume
    • Average heart rate is 70 beats per minute
    • Average stroke volume is 70 ml per beat
    • Average cardiac output is 4900 ml per minute
    • Stroke volume is calculated by subtracting end systolic volume (ESV) from end diastolic volume (EDV)

    Phases of Heart Failure

    • Insult: Initial event or injury to the heart leading to structural changes and reduced contractility
    • Compensation: The heart compensates through the sympathetic nervous system and renin-angiotensin-aldosterone system (RAAS) to increase heart rate and blood volume, and through cardiac remodeling involving ventricular dilation and hypertrophy.
    • Decompensation: Compensatory mechanisms become maladaptive, leading to progressive worsening of left ventricular function with symptoms such as dyspnea, fatigue, and fluid retention.

    Entresto (Sacubitril/Valsartan)

    • Adverse effects include hypotension, hyperkalemia, increased serum creatinine, dizziness, and cough
    • Contraindications include previous angioedema due to angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), concomitant use of ACEI or use within the previous 36 hours, and concomitant use of aliskiren in patients with diabetes mellitus (DM)

    ACEIs

    • Common adverse effects: Hypotension, increased serum creatinine/blood urea nitrogen (BUN), hyperkalemia, and cough
    • Contraindications: Hypersensitivity and previous angioedema due to any ACEI

    ARBs

    • Common adverse effects: Hypotension, increased serum creatinine/BUN, hyperkalemia, and cough
    • Contraindications: Hypersensitivity and concomitant use with aliskiren in patients with DM

    Beta Blockers

    • Common adverse effects: Hypotension, first-degree heart block, edema, dizziness, abdominal pain/diarrhea, and bradycardia
    • Contraindications: Severe bradycardia, second or third-degree heart block in the absence of a pacemaker, cardiogenic shock, decompensated heart failure with reduced ejection fraction (HFrEF), sick sinus syndrome

    Mineralocorticoid Receptor Antagonists (MRA)

    • Spironolactone
      • Adverse effects include hyperkalemia, diarrhea, impaired renal function, dizziness, fatigue, and gynecomastia (long-term use)
      • Contraindications: Acute renal insufficiency, anuria, significant renal dysfunction
    • Eplerenone
      • Contraindications: Serum potassium > 5.5 at initiation, creatinine clearance (CrCl) < 30 ml/min, concomitant use of strong CYP3A4 inhibitors

    Sodium-glucose Cotransporter 2 (SGLT2) Inhibitors

    • Common adverse effects: Acute kidney injury, dyslipidemia, genital mycotic infection, hypoglycemia, ketoacidosis, urinary tract infection (UTI)
    • Contraindications: Type 1 diabetes mellitus (T1DM), pregnancy (2nd/3rd trimester), diabetic ketoacidosis (DKA), dialysis, volume depletion

    Loop Diuretics

    • Common adverse effects: Hypotension/dizziness, fluid loss, hypokalemia, hypocalcemia, hypomagnesemia, hyponatremia, hypochloremia, hyperuricemia, cramping/diarrhea, nephrotoxicity/ototoxicity
    • Contraindications: Hypersensitivity, anuria

    Thiazide Diuretics

    • Metolazone
      • Common adverse effects: Hypotension, dizziness, gout attacks, hypercalcemia, increased BUN
      • Contraindications: Hypersensitivity, anuria, hydrochlorothiazide (HCTZ): CrCl ≤ 10 ml/min
    • HCTZ
      • Used in combination with loop diuretics

    Vasodilators

    • Hydralazine
      • Common adverse effects: Hypotension, headache, dizziness, asthenia, nausea
      • Contraindications: Allergy to nitrates, phosphodiesterase type 5 inhibitor (PDE5i), riociguat
    • Isosorbide dinitrate
    • BiDil

    Ivabradine (HCN Blocker)

    • Common adverse effects: Bradycardia, atrial fibrillation, phosphenes, blurred vision
    • Contraindications: Acute decompensated HFrEF, blood pressure (BP) < 90/50 mmHg, sick sinus syndrome, sinoatrial block or third-degree atrioventricular (AV) block without a functioning demand pacemaker, resting heart rate (HR) < 60 bpm prior to treatment, severe hepatic impairment, pacemaker dependence, concomitant use with strong CYP3A4 inhibitors

    Soluble guanylate cyclase (sGC) Stimulator

    • Common adverse effects: Symptomatic hypotension, syncope, anemia
    • Contraindications: Pregnancy and breastfeeding

    Digoxin

    • Common adverse effects: Arrhythmias, heart block, nausea/vomiting, diarrhea, anorexia, visual changes, headache, gynecomastia (long-term use), confusion
    • Contraindications: Hypersensitivity, ventricular fibrillation

    Monitoring Parameters for Vasodilators

    • Evaluate blood pressure, renal function (BUN, SCr), and serum potassium every 1-2 weeks and following dose changes
    • Ensure an ACEI washout period of 36 hours
    • Titrate to target dose depending on the patient

    ACEI Therapy

    • 1-2 week evaluation of blood pressure, renal function (BUN, SCr), and serum potassium
    • Caution with preexisting hypotension, hyponatremia, DM, concurrent potassium supplements, or azotemia
    • Titrate to target dose depending on the patient
    • Some ACEI is better than no ACEI

    ARB Therapy

    • 1-2 week evaluation of blood pressure, renal function (BUN, SCr), and serum potassium
    • Caution with preexisting hypotension, hyponatremia, DM, concurrent potassium supplements, or azotemia
    • Titrate to target dose depending on the patient
    • Studies: CHARM (Candesartan), OPTIMAAL (Losartan), Val-HeFT (Valsartan)

    ARNI, ACEI, ARB Recommendations

    • Entresto is the preferred therapy for patients eligible for ARNI therapy
    • If a patient is not eligible for ARNI, then they should receive an ACEI or ARB
    • If a patient is not able to tolerate an ACEI or ARB, then they should be switched to the other class of drug

    Beta Blocker Therapy

    • Approved agents: Bisoprolol (CIBIS II), Metoprolol Succinate (MERIT-HF), Carvedilol (CARVEDILOL HEART FAILURE)
    • Titrate dose every 1-2 weeks as tolerated
    • Use HR and BP to guide dosage changes
    • Titrate to target dose depending on the patient
    • May need to decrease ARNI, ACEI, ARB dose while up-titrating beta-blockers
    • Start ARNI, ACEI/ARB before starting beta-blockers
    • Fluid retention or worsening of heart failure is not a reason to permanently withdraw beta-blocker therapy
    • Staggering vasoactive medications may help reduce hypotension

    Beta Blocker Actions

    • Antiarrhythmic effects
    • Prevention/reversal of ventricular remodeling
    • Decreased myocyte death from catecholamine-induced necrosis or apoptosis
    • Improved left ventricular (LV) systolic function
    • Decreased myocardial oxygen consumption (MVO2) by decreasing HR and LV wall stress
    • Inhibition of plasma renin release

    Heart Failure Pharmacotherapy

    • Pathophysiology and Mechanisms of Disease:

      • Heart failure occurs when the heart cannot pump blood effectively, leading to reduced cardiac output and systemic congestion.
      • This can be caused by various factors, including coronary artery disease, hypertension, cardiomyopathy, and valvular heart disease.
      • The goal of pharmacotherapy is to improve cardiac function, reduce symptoms, and enhance quality of life.

    • Nonprescription Drug Therapies and Dietary Supplements:

      • Risks:
        • Many over-the-counter medications and supplements can interact with heart failure medications, potentially worsening symptoms.
        • Some supplements can contain substances that can affect heart rate, blood pressure, and fluid balance.
      • Benefits:
        • Some supplements, like omega-3 fatty acids, may have beneficial effects on heart health but should be discussed with a healthcare professional.

    Special Populations

    • Unique considerations for special populations:
      • Older adults: May have more comorbidities increasing the risk of drug interactions and adverse effects.
      • Patients with renal impairment: May require dose adjustments due to altered drug elimination.
      • Patients with hepatic impairment: May experience increased drug levels due to reduced metabolism.

    Drug Interactions

    • Pertinent drug interactions:
      • ACE inhibitors and potassium-sparing diuretics: Potential for hyperkalemia.
      • Beta-blockers and non-dihydropyridine calcium channel blockers: Potential for bradycardia and hypotension.
      • Digoxin and amiodarone: Increased risk of digoxin toxicity.

    Drug-Induced Heart Failure

    • Medications implicated in drug-induced heart failure:
      • Nonsteroidal anti-inflammatory drugs (NSAIDs)
      • Certain chemotherapy agents
      • Some anti-arrhythmics

    Foundational Drug Knowledge

    • Pharmacokinetic and pharmacodynamic principles: Understanding drug absorption, distribution, metabolism, and excretion is crucial for personalized dosing and management.
    • Common heart failure medications:
      • Diuretics: Reduce fluid overload, improve symptoms, and improve cardiac function.
      • ACE inhibitors and angiotensin II receptor blockers (ARBs): Reduce blood pressure and prevent remodeling of the heart.
      • Beta-blockers: Reduce heart rate, improve cardiac function, and reduce mortality.
      • Digoxin: Increases cardiac contractility and slows heart rate.
      • Aldosterone antagonists: Reduce fluid retention and prevent cardiac remodeling.

    Dosage Considerations

    • Calculating appropriate medication doses:
      • Doses are individualized based on patient factors like weight, age, renal and hepatic function, and comorbidities.
      • Close monitoring of blood pressure, heart rate, electrolytes, and renal function is crucial.

    Monitoring Parameters

    • Monitoring parameters:
      • Blood pressure: Evaluate response to antihypertensive therapy.
      • Heart rate: Assess for bradycardia or tachycardia, especially with beta-blockers and digoxin.
      • Electrolytes: Monitor for hypokalemia, hypomagnesemia, and hyperkalemia, particularly with diuretics and ACE inhibitors.
      • Renal function: Assess for renal impairment, especially with diuretics and ACE inhibitors.

    Patient-Centered Care

    • Pharmacists' Patient Care Process:
      • Collect relevant patient information.
      • Assess medication therapy and identify potential problems.
      • Plan a medication regimen tailored to the patient's needs.
      • Implement the plan and provide patient education.
      • Monitor the patient's response to therapy and adjust the plan as needed.
    • Culturally relevant treatment plans: Consider patient beliefs, cultural preferences, and socioeconomic factors when developing treatment plans.

    Clinical Tests

    • Interpreting clinical test results:
      • Echocardiogram: Evaluates cardiac function, size, and structure.
      • Electrocardiogram (ECG): Assesses heart rhythm and electrical activity.
      • Chest X-ray: Identifies pulmonary congestion and enlargement of the heart.
      • Blood tests: Monitor kidney function, electrolytes, and other biomarkers.

    Wellness and Disease Prevention

    • Wellness and disease prevention strategies:
      • Lifestyle modifications: Healthy diet, regular exercise, smoking cessation, weight management.
      • Early detection and treatment of risk factors: Hypertension, diabetes, hyperlipidemia, and coronary artery disease.

    Clinical Practice Guidelines

    • Integrating clinical practice guidelines into patient care decisions:
      • American College of Cardiology (ACC) and American Heart Association (AHA) guidelines: Provide evidence-based recommendations for the pharmacological management of heart failure.

    Medication Classes for Heart Failure

    • ACE Inhibitors are a first-line treatment for heart failure with reduced ejection fraction (HFrEF), examples include Lisinopril and Enalapril.
    • ARBs (Angiotensin II Receptor Blockers) are alternatives for patients who are intolerant to ACE inhibitors, examples include Losartan and Valsartan.
    • Beta-blockers are crucial for HFrEF management as they decrease mortality and hospitalization rates, examples include Carvedilol and Metoprolol succinate.
    • Aldosterone Antagonists are used for patients with HFrEF and signs of fluid retention, examples include Spironolactone and Eplerenone.
    • SGLT2 Inhibitors are a newer class for both HFrEF and preserved ejection fraction (HFpEF), examples include Dapagliflozin and Empagliflozin.
    • Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) combine the benefits of ARBs and neprilysin inhibitors, example: Sacubitril/valsartan.

    Adverse Effects of Heart Failure Medications

    • ACE Inhibitors can cause dry cough, hypotension, hyperkalemia, and renal impairment.
    • ARBs can cause hypotension and hyperkalemia.
    • Beta-blockers can cause fatigue, bradycardia, hypotension, and exacerbation of asthma or COPD.
    • Aldosterone Antagonists can cause hyperkalemia, renal dysfunction, and gynecomastia (Spironolactone).
    • SGLT2 Inhibitors can cause genital infections, dehydration, and hypotension.
    • ARNIs can cause hypotension, hyperkalemia, renal impairment, and cough.

    Guideline Updates for Heart Failure

    • Organizations like the American Heart Association (AHA) and the Heart Failure Society of America (HFSA) regularly update heart failure guidelines.
    • Recent recommendations emphasize early initiation of therapy in symptomatic patients and combination therapy for high-risk patients.
    • The focus is on reducing hospitalizations and improving quality of life.

    Dosing Strategies for Heart Failure Medication

    • Start with low doses of medications and titrate based on tolerance and therapeutic goals.
    • Monitor blood pressure, renal function, and electrolytes during titration.
    • Dosing should be individualized based on patient response and comorbid conditions.
    • Consider initiating medications in combination for some patients.

    Patient Monitoring for Heart Failure

    • Regular follow-up appointments are necessary to monitor symptom improvement (fatigue, dyspnea), blood pressure and heart rate, kidney function (eGFR) and serum potassium levels.
    • Monitoring for signs of worsening heart failure (edema, weight gain) is also important.
    • Patient education is critical for recognizing symptoms that warrant early intervention.

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    Related Documents

    Heart Failure 1 Fall 2024 PDF
    Heart Failure Pathophysiology PDF
    Winston's Heart Failure PDF

    Description

    This quiz covers the definition, prevalence, and mortality rates associated with heart failure (HF). Learn about the rising statistics and implications of HF in the American population, including the expected increase in prevalence by 2030. Test your knowledge on this critical medical condition.

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