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Which type of heart failure is characterized by an ejection fraction of less than 40%?
Which type of heart failure is characterized by an ejection fraction of less than 40%?
Which factor is primarily responsible for the majority of cases of heart failure?
Which factor is primarily responsible for the majority of cases of heart failure?
What is one of the defined goals of heart failure therapy?
What is one of the defined goals of heart failure therapy?
Which of the following is considered a neurohormonal blocking agent used in heart failure treatment?
Which of the following is considered a neurohormonal blocking agent used in heart failure treatment?
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What role do ACE inhibitors and ARBs play in heart failure management?
What role do ACE inhibitors and ARBs play in heart failure management?
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Which non-pharmacological therapy is aimed at managing fluid retention in heart failure patients?
Which non-pharmacological therapy is aimed at managing fluid retention in heart failure patients?
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What is a significant risk factor that should be modified in heart failure therapy?
What is a significant risk factor that should be modified in heart failure therapy?
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Which drug class is primarily focused on blocking compensatory neurohormonal activation?
Which drug class is primarily focused on blocking compensatory neurohormonal activation?
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What is a key indication for the use of digoxin?
What is a key indication for the use of digoxin?
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Which of the following conditions is digoxin NOT indicated for?
Which of the following conditions is digoxin NOT indicated for?
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What is a potential adverse effect of digoxin toxicity?
What is a potential adverse effect of digoxin toxicity?
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Which electrolyte disturbance could predispose a patient to digoxin toxicity?
Which electrolyte disturbance could predispose a patient to digoxin toxicity?
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What drug interaction should be considered when prescribing digoxin?
What drug interaction should be considered when prescribing digoxin?
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What is the primary effect of β-adrenergic agonists like dobutamine?
What is the primary effect of β-adrenergic agonists like dobutamine?
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In cases of digoxin toxicity, which treatment may be necessary?
In cases of digoxin toxicity, which treatment may be necessary?
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What effect do antacids have on digoxin therapy?
What effect do antacids have on digoxin therapy?
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What does heart failure primarily impair in the heart's function?
What does heart failure primarily impair in the heart's function?
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What is the normal range for left ventricular ejection fraction (LVEF)?
What is the normal range for left ventricular ejection fraction (LVEF)?
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Which mechanism is NOT considered a compensatory mechanism in heart failure?
Which mechanism is NOT considered a compensatory mechanism in heart failure?
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Which of the following is a primary etiology of ischemic heart failure?
Which of the following is a primary etiology of ischemic heart failure?
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What aspect of stroke volume directly affects cardiac output (CO)?
What aspect of stroke volume directly affects cardiac output (CO)?
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What is indicated by a left ventricular ejection fraction (LVEF) of less than 30%?
What is indicated by a left ventricular ejection fraction (LVEF) of less than 30%?
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Which hormone is primarily released as a result of the activation of the renin-angiotensin-aldosterone system (RAAS)?
Which hormone is primarily released as a result of the activation of the renin-angiotensin-aldosterone system (RAAS)?
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What term has replaced 'Congestive Heart Failure' in modern terminology?
What term has replaced 'Congestive Heart Failure' in modern terminology?
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What is a primary effect of diuretics on heart failure patients?
What is a primary effect of diuretics on heart failure patients?
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Which loop diuretic is NOT mentioned as commonly used in heart failure?
Which loop diuretic is NOT mentioned as commonly used in heart failure?
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What is the expected weight loss goal per day when titrating diuretics for volume overload?
What is the expected weight loss goal per day when titrating diuretics for volume overload?
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After reaching a euvolemic state, how should diuretics be managed?
After reaching a euvolemic state, how should diuretics be managed?
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Which of the following describes digoxin's effect on heart rate?
Which of the following describes digoxin's effect on heart rate?
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Which classification of agents does digoxin belong to?
Which classification of agents does digoxin belong to?
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What is the primary reason digoxin is prescribed to heart failure patients?
What is the primary reason digoxin is prescribed to heart failure patients?
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What effect does digoxin have on sympathetic and vagal activity?
What effect does digoxin have on sympathetic and vagal activity?
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What is a contraindication for using aldosterone antagonists like Spironolactone and Eplerenone?
What is a contraindication for using aldosterone antagonists like Spironolactone and Eplerenone?
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Which of the following outcomes is NOT improved by the use of β-blockers in patients with systolic heart failure?
Which of the following outcomes is NOT improved by the use of β-blockers in patients with systolic heart failure?
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Which of the following is a recommended approach for dosing β-blockers in heart failure?
Which of the following is a recommended approach for dosing β-blockers in heart failure?
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What effect do aldosterone antagonists have on cardiac tissue?
What effect do aldosterone antagonists have on cardiac tissue?
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Which of the following β-blockers is considered a non-selective antagonist?
Which of the following β-blockers is considered a non-selective antagonist?
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What is one of the primary benefits of using aldosterone antagonists in heart failure management?
What is one of the primary benefits of using aldosterone antagonists in heart failure management?
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What condition must be present for β-blockers to be prescribed in heart failure treatment?
What condition must be present for β-blockers to be prescribed in heart failure treatment?
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What is one mechanism by which β-blockers improve heart failure outcomes?
What is one mechanism by which β-blockers improve heart failure outcomes?
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What is a significant adverse effect associated with the long-term use of Milrinone?
What is a significant adverse effect associated with the long-term use of Milrinone?
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What is the main therapeutic effect of nitrates in heart failure management?
What is the main therapeutic effect of nitrates in heart failure management?
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What defines the use of Hydralazine in chronic heart failure management?
What defines the use of Hydralazine in chronic heart failure management?
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What population may benefit from the combination therapy of Hydralazine and Isosorbide Dinitrate?
What population may benefit from the combination therapy of Hydralazine and Isosorbide Dinitrate?
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What physiological mechanism does Ivabradine utilize in heart failure treatment?
What physiological mechanism does Ivabradine utilize in heart failure treatment?
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In which situation is Dobutamine commonly indicated for use?
In which situation is Dobutamine commonly indicated for use?
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What is a critical concern associated with the use of Phosphodiesterase Inhibitors like Milrinone?
What is a critical concern associated with the use of Phosphodiesterase Inhibitors like Milrinone?
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What outcome is associated with the use of Isosorbide Dinitrate in heart failure therapy?
What outcome is associated with the use of Isosorbide Dinitrate in heart failure therapy?
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Study Notes
Heart Failure
- Heart failure (HF) is a complex clinical syndrome arising from structural or functional cardiac disorders.
- These disorders impair the ventricle's ability to fill or eject blood, failing to meet the body's metabolic demands.
- Chronic heart failure (CHF) term replaced the term Congestive Heart Failure.
- Acute heart failure is an acute decompensation of a patient with a history of chronic heart failure or new onset HF symptoms.
- Ejection fraction (EF) represents the percentage of blood ejected by the ventricle in each cardiac cycle relative to its end-diastolic volume.
- A normal LVEF ranges from 50% to 70%.
- Mild dysfunction is an LVEF of 40% to 49%.
- Moderate dysfunction is an LVEF of 30% to 39%.
- Severe dysfunction is an LVEF less than 30%.
- Heart failure can be ischemic (70% secondary to CAD) or non-ischemic (HTN, valvular disorders, thyroid diseases, cardiotoxins, viral illness).
Intended Learning Outcomes
- Define heart failure and its underlying causes
- Describe factors affecting cardiac output
- Differentiate between systolic and diastolic heart failure
- Identify the signs and symptoms of heart failure
- Characterize different pharmacological classes used for HF management, including their mechanisms of action and side effects
Pathophysiology of Heart Failure
- Factors controlling cardiac output (CO) include heart rate (HR), stroke volume (SV), preload, and afterload. These are influenced by adrenergic nerve activity and circulating catecholamines.
- Increased preload, due to hypervolemia or regurgitation of cardiac valves, can impair contractility.
- Also, increased afterload from hypertension or vasoconstriction intensifies cardiac workload.
- Compensatory mechanisms occur to maintain CO, including activation of the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS).
- RAAS activation leads to increased peripheral resistance (afterload) and water/sodium retention (preload), which further impairs cardiac function.
- These mechanisms trigger a vicious cycle of neurohormonal activation and worsen HF progression.
Compensatory Mechanisms
- Activation of SNS leads to increased heart rate and contractility.
- RAAS activation leads to fluid retention and increased afterload.
- Cardiac hypertrophy and remodeling are adaptive responses to chronic stress, potentially leading to decreased contractility and impaired diastolic function over time.
Counter-Regulatory Hormones (Natriuretic Peptides)
- Natriuretic peptides (NPs) such as ANP and BNP are released in response to increased cardiac chamber wall stretch.
- ANPs and BNP lead to natriuresis by reducing sodium reabsorption, improving blood pressure and filtration.
- Higher concentrations of NPs correlate with more severe HF.
Types of Heart Failure
- HFrEF (<40%): Heart failure with reduced ejection fraction (systolic HF), results from reduced contraction of the left ventricle.
- HFpEF (>50%): Heart failure with preserved ejection fraction (diastolic HF), results from stiffening and impaired relaxation of the left ventricle, preventing adequate filling.
- Coronary artery diseases are the most important cause of HFrEF.
- Hypertention is responsible for 60-90% of cases of HFpEF.
Clinical Picture
- Right-sided heart failure (cor pulmonale) can be secondary to chronic pulmonary problems. Symptoms include fatigue, edema in dependent areas (legs, ankles), enlarged liver and spleen, and ascites.
- Left-sided heart failure symptoms include paroxysmal nocturnal dyspnea, cough, crackles, wheezes, and orthopnea.
Goals of Therapy
- Modifying or controlling risk factors (e.g., hypertension, obesity, diabetes, coronary artery disease).
- Eliminating or minimizing HF symptoms.
- Reducing morbidity and mortality.
- Slowing the progression of worsening cardiac function
- Preventing or minimizing sodium and water retention.
Non-Pharmacological Therapy
- Sodium restriction
- Fluid restriction
- Smoking cessation
- Weight reduction in obese patients
- Supervised physical activity
- Control of hypertension (goal: 130/80 mmHg)
- Screen and treat for other conditions (diabetes, coronary artery disease)
- Assess for depression
Drug Classes for Heart Failure
- Neurohormonal Blocking Agents: ACE inhibitors, ARBs, aldosterone antagonists, β-blockers, and ARNIs. These aim to reduce the detrimental effects of the neurohormonal systems.
- Inotropic Agents: Digoxin, dopamine, dobutamine, and Milrinone. These improve cardiac contractility, helping the heart pump more blood (increasing cardiac output, or CO).
- Vaso- and Venodilators: Hydralazine, isosorbide dinitrate and other nitrates. These aim to reduce preload (venodilation) or afterload (vasodilation).
- If Channel Blocker: Ivabradine, which selectively decreases heart rate without affecting other functions.
1- Neurohormonal Blocking Agents (ACEIs and ARBs)
- Inhibit the renin-angiotensin-aldosterone system (RAAS).
- Reduce afterload and preload, improving cardiac function.
- Slow disease progression and reduce mortality.
- Adverse effects include cough, angioedema, hypotension, and hyperkalemia.
2- Aldosterone Antagonists
- Counteract the negative effects of aldosterone on the heart.
- Reduce cardiac remodeling and improve survival in patients with reduced ejection fraction.
- Limited use in other HF types.
- Careful monitoring is needed due to potential hyperkalemia.
3- β-Blockers
- Control symptoms and improve cardiac function by reducing heart rate, decreasing cardiac workload, and reducing the effects of catecholamines on the heart.
- Reduce mortality in systolic HF.
- These should be added to therapy very slowly to avoid exacerbating HF and should be used in conjunction with diuretics in patients with fluid retention.
3- Angiotensin Receptor-Neprilysin Inhibitor (ARNI): Sacubitril/valsartan
- Improves survival and clinical symptoms in HFrEF.
- An ARNI should replace an ACE inhibitor or ARB.
Contraindications and Side Effects of Drugs in HF Treatment
- History of angioedema to ACE inhibitors or ARBs.
- Concomitant use of ACE inhibitors with Aliskiren.
- Pregnancy and/or Hyperkalemia should be carefully considered.
4- Diuretics
- Relieve acute symptoms of congestion (e.g., dyspnea).
- Improve euvolemia (reduce fluid overload).
- Do not improve long-term mortality in HF.
- Loop diuretics are widely used, initially, in acute or chronic volume overload.
5- Inotropic Agents (Digoxin)
- Increase cardiac contractility and thus increase cardiac output (CO).
- Reduce sympathetic activity and increase vagal tone.
- Should be used with caution, especially in patients with electrolyte imbalances (e.g., hypokalemia).
- Potential adverse effects include arrhythmias, nausea, vomiting, and visual disturbances.
6- Vaso- and Venodilators
- Reduce preload and/or afterload.
- Useful in long-term HF management; or in acute settings when used intravenously.
- Hydralazine and isosorbide dinitrate combination therapy can improve survival in patients with HF, especially in those of African descent.
7- If Channel Blocker (Ivabradine)
- Selectively reduces heart rate without affecting other functions.
- Can provide improvement in symptoms, particularly in HFrEF.
Cardiac Hypertrophy and Remodeling
- Adaptive response to chronic hemodynamic stress.
- Increased muscle mass and structural changes
- Long-term adverse affect on cardiac function.
- Contributes to worsening HF progression.
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Description
This quiz covers the complexities of heart failure, including its definitions, types, and measurement through ejection fraction. Understand chronic and acute heart failure, as well as the underlying cardiac disorders that contribute to this condition. Test your knowledge on key concepts related to heart function and health.
