5b Heart Failure ✅.pdf

Prevent the onset of clinical symptoms or reduce them Prevent or reduce hospitalizations Treatment of chronic HF What are they? Slow the progression Improve QOL, and Prolong survival. Low intensity Physical Activity? smoking? Non-Ph. Intervention Aerobic exercise Reduction Immunization: daily w...

Prevent the onset of clinical symptoms or reduce them Prevent or reduce hospitalizations Treatment of chronic HF What are they? Slow the progression Improve QOL, and Prolong survival. Low intensity Physical Activity? smoking? Non-Ph. Intervention Aerobic exercise Reduction Immunization: daily weight: influenza and pneumococcal infections What are the two infection? ↑ 1.4 kg in a single day or 2.3 kg in week What is the goal? What are the dietary modifications Sodium: < 3 g / day Fluid restriction: < 2 L / day Treatment of risk factors and consider ACEI/ARB Stage A ACE inhibitors or ARBs and βblockers. Stage B Add Diuretics with ACEI/ARB and BB, angiotensin receptor neprilysin inhibitor [ARNI] and aldosterone RA Stages: In African American - Hydralazine and isosorbide dinitrate Stage C In GDMT (Guideline-directed medical therapies)digoxin and ivabradine Mechanical support, transplantation, and IV vasoactive therapies Stage D Furosemide, Torsemide, bumetanide Loop Diuretics Dose 3-4 times higher in CrCl < 20ml/min. HCTZ, Chlorthalidone, Metolazone Thiazide diuretics Spironolactone, Triamterene, Amiloride Potassium sparing diuretics volume overload Pharmacological diuretics What are the Benefits: sodium overload Preload Electrolyteabnormalities Hyperuricemia Hypovolemia,hypotension,renal dysfunction What are the Adverse effects: Activation of neurohormonal system Captopril Enalapril Lisinopril Quinapril Drug list: *Fosinopril *Trandolapril *Perindopril Inhibit production of what? Angiotensin II Blocks RAA system: Bradykinin degradation ACE inhibitors Inhibit the degradation of what? ↑ PG secretion & nitric oxide production What happens as well? Improve survival in CHF patients: Delay onset & progression of HF in pts with asymptomatic LV dysfunction What does it delay? It lowers the … ? Cardiac remodelling Undergoes both hepatic and renal elimination Last 3 drugs : By reducing the load on the heart How to do they help? ARNI(Angiotensinreceptornepril ysininhibitor) Neutral endopeptidase breaks down natriuretic peptides, substance P, bradykinin, and angiotensin II Neprilysin: ↑ circulating natriuretic peptide levels What does it increase? Sacubitril / Valsartan : Diuretics & ACE-i Reduce death or hospitalization for HF by 20% cmpared to enalapril What does it reduce? Any CI? with ACE-I : A gap of 36 hours Any AE? Angioedema What does it lower? ↓ preload - by venous vasodilation Nitrate: And more selective to what? Veins Hydralazine & Isosorbide Dinitrate : ↓ afterload by direct arterial smooth muscle relaxation What does it lower? Pharmacological treatment More selective to what? Arteries Nitrate tolerance Hydralazine: Heart Failure Reduce the development of what? Thrombic headache , pumping feeling , due to vaso-d. Cause: What happens when glutathione is depleted? Nitrate stop working Notes: 8 hr drug free interval Metoprolol Eg: Carvedilol may be the only medication that shows substantial improvement in LV function They are the main stay in treatment on CHF B-blockers ⬇ Any CI ? Improve survival Severe decompensated heart failure (3 & 4 degree) Any adverse effects? Bradycardia, heart block, hypotension, worsening HF Bronchospasm If heart rate reach what number we should stop? BP, HR, ECG, 60 bpm Signs and symptoms of worsening HF Need monitoring for what? Blood glucose Aldosterone antagonist, Ksparing diuretic CHF: Aldosterone inappropriately elevated Mobilizes edema fluid in heart failure (4-5 %) Hypokalemia that are induced by loop diuretics What does it prevent ? Spironolactone: Prolongs life in CHF patients Check k+ levels every what when stabilized? Every 3 months And when starting? Every 3 days What does it inhibit? Inhibit the Na+/K+ pump What does it increase? Vagotonic effect Arrhythmogenic effect (electrophysiological effects) What an effect does it give? GI and CNS adverse effects, brady- and tachyarrhythmias List the adverse effects? Electrolytes: potassium and magnesium, BUN, creatinine Cardiac Glycosides: digoxin What to monitor? HR, ECG, serum digoxin concentration 1st degree heart block, ectopic beats Reduce dose: Atropine: Treatment of Digitalis Toxicity: (symptomatic relief) AV heart block and bradycardia supraventricular arrhythmia , aka: tachycardia Propranolol: KCl: increased automaticity Fab (Digoxin) antibodies: (antidote) Lower sinus HR without affecting BP or contractility What does it lower? Any d/i ? Other drugs: Ivabradine CYP3A4 inhibitors Bradycardia, hypertension, atrial fibrillation Any AE ? Luminous phenomena (phosphenes)- bright halos or colored bright lights Indicated in patient what what? LVEF ≤ 35% (0.35), NYHA II and III, in normal sinus rhythm. IndicatedinpatientswithHFrEF: HFrEF are at increased risk of what? Other drugs: Antiplatelets & Anticoagulants if severe toxic serum concentration; acute toxicity thromboembolic events A risk happening when traveling for long hours in the air Explain Deep Vein Thrombosis (DVT) Any solution? Aspirin only in HF patients with what ? Take aspirin IHD or embolic stroke. Warfarin and non–vitamin K oral anticoagulants (NOACs) – HF with what? atrial fibrillation Correct the underlying precipitating factor and relieve patient symptoms Desired therapeutic outcome : Improve or normalize hemodynamics Educate the patient Oral agents : BBs, ACE inhibitors or ARBs (also ARNI), and MRAs ↓ preload by functional vasodilation within 5 to 15 minutes What does it decrease? Loop Diuretics ↑ sodium and water excretion Subsequently increase what? Failure to achieve a negative net fluid balance of at least 500 mL or greater Diuretics: Diuretics resistance Overcome by: > frequency, (20 mg TID - up to 80mg)> dose, > sequential blockage of sodium > combination of Loop and thiazide Add vasodilator or iontropes perfusion to the kidneys Rapid ↓ in arterial tone, resulting in a ↓ in SVR Decrease what? Nitroglycerin Treatment for Acute HF: To enhance what? Effect on preload & afterload? decrease in preload, decrease in afterload significant venous and arterial vasodilation, Vasodilators: Nitroprusside Effect? Nesiritide rapid onset of action and metabolism reduces PCWP, right atrial pressure, and SVR Reduce 3 things? Inotrope of choice for AHF = increase FOC Agonist on β1- and β2-receptors, less on α1-receptors Dobutamine: = increase FOC & decrease … ??? … As Monotherapy reserved with systolic BP > 90 mm Hg. With vasopressors in patients with lower systolic BP Ionotropic agents: When spleen and kidney blood need to be increased When to use it? Pharmacologic Treatment for AHF with low systolic BP and cardiogenic shock. Dopamine: < 3 mcg/kg/min: stimulates renal D1 receptors vasodilation. 10 mcg/kg/min: chronotropic and α1mediated vasoconstriction = increase heart rate Milrinone and amrinone (or inamrinone) Phosphodiesterase-III Inhibitors: Positive inotropic: ↑ SV and CO, Milrinone (inodilator) : firstchoice = vasoconstriction of heart Vasodilating: > on venous capacitance vessels and pulmonary vascular beds. = vasodilation of periphery use where inotropic support is needed. Milrinone: Reduced doses in renal insufficiency. Intra-aortic balloon counterpulsation (IABC) Short term use intra-aortic balloon pumps(IABPs) Synchronized with cardiac cycle When the balloon inflate & deflate? Percutaneous Mechanical Circulatory Support Devices: Impella: Inflate = diastole Deflate = systole pumps blood from – LV into the aorta Tandem Heart: takes blood from what? Left atrium and return it into the femoral artery Advtg? can be used in patients with LV thrombus Impella & TandemHearta: Both Provide continuous blood flow Which means? Not with cardiac cycle For longer duration ⬇