Term
| Systolic dysfxn summary (3) |
|
Definition
Fills fine, can't pump
Venous congestion causing pulm. and peripheral edema
Dec. EF, SV |
|
|
Term
| Symptoms of forward failure = dec. SV (4) |
|
Definition
Hypotension
Tachycardia
Fatigue
Dec. ability to exercise |
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|
Term
| Symptoms of backward failure = congestion (3) |
|
Definition
Dyspnea
Pulmonary and peripheral edema
Right heart failure |
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Term
| Renal hypoperfusion causes... |
|
Definition
Retention of salt, water thus inc. ECF
Exacerbates forward and backward failure |
|
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Term
| How does the kidney maintain GFR in the face of hypoperfusion? |
|
Definition
Afferent arteriole dilates until it can't dilate any more
AngII (preferentially) constricts efferent arteriole |
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|
Term
| What's the new idea about the etiology of heart failure? |
|
Definition
| Systolic heart failure causes neurohormonal activation which causes volume overload and cardiac remodeling |
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Term
| Inc. release of NE in the face of hypovolemia causes...(5) |
|
Definition
Constriction of resistance arterioles to inc. TPR and thus BP
Constricts veins to inc. venous return
Enhanced cardiac contractility
Renin secretion
ADH effect in PT |
|
|
Term
| Why do dec. venous capacitance and inc. contractility not necessarily help ameliorate hypovolemia? |
|
Definition
| Blood volume is already low, so we're not returning much to the heart, and it still doesn't have much to pump |
|
|
Term
| The net effect of NE, AngII, aldosterone, and ADH are... |
|
Definition
| Isotonic volume expansion |
|
|
Term
| Summary of NE/AngII, RAAS effects on hemorrhage |
|
Definition
Short term: NE/AngII maintain BP
Long term: RAAS restores blood volume |
|
|
Term
| AngII stimulates mitogenesis and causes... |
|
Definition
Remodeling:
Hypertrophy of myocytes
Inc. deposition of fibrillary collagen in ECM = fibrosis causing stiffness |
|
|
Term
| How does aldosterone contribute to remodeling? |
|
Definition
| Causes deposition of fibrillar collagen in ECM, causes ventricular muscle to stiffen |
|
|
Term
| The CHF inc. in preload and TPR causes...(2) |
|
Definition
Ventricular dilation and wall stress = pressure overload
Stimulates collagen synthesis in ECM |
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|
Term
| The Starling mechanism ___ in a CHF patient |
|
Definition
|
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Term
| Describe the effects of inc. preload/contractility/afterload on SV in a normal heart |
|
Definition
Inc. preload = inc. SV
Inc. contractility = inc. SV
Inc. afterload = nc on SV b/c the Starling mech allows for maintenance of SV in the face of inc. afterload |
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|
Term
| Describe the effects of inc. preload/contractility/afterload on SV in a systolic CHF heart |
|
Definition
Inc. preload = dec. SV
Inc. contractility = inc. SV
Inc. afterload = super dec. SV |
|
|
Term
| How do diuretics and VD/inotropic agents work regarding the Starling curve? |
|
Definition
Diuretics dec. LV-EDV = dec. preload = shift the curve to the left
VD/inotropic agents = inc. SV = shift the curve upward |
|
|
Term
| Strategies that improve CHF symptoms (4) |
|
Definition
Dec. preload w/ diuretics or nitrate VD
Dec. afterload w/ arteriolar VD
Dec. preload and afterload w/ ACEI balanced VD
Inc. contractility w/ inotropes |
|
|
Term
| Strategies that reverse cardiac remodeling and inc. longevity in CHF |
|
Definition
| Block cardiac AngII, aldosterone, adrenergic receptors |
|
|
Term
| Furosemide, nitrate VD: summary of effects on systolic CHF |
|
Definition
Dec. congestive symptoms
Doesn't inc. SV
Doesn't reverse cardiac remodeling or inc. longevity |
|
|
Term
| Spironolactone, eplerenone: MOA, effect |
|
Definition
Blocks aldosterone R in DT
Inc. excretion of Na, Cl, H2O, HCO3
Dec. excretion of K
Dec. collagen turnover in ECM of ventricles and thus prevents/reverses the cardiac remodeling caused by aldosterone |
|
|
Term
| Spironolactone, eplerenone: S/E |
|
Definition
Dose-related hyperkalemea
Be careful w/ severe renal insufficiency esp. if also taking ACEI
CHF patients have inc. symp. activity and dec. renal perfusion = renin secretion
AngII maintains GFR by constricting the efferent arteriole
ACEI block the effects of AngII and so actually impairs renal fxn in some patients
(Captopril is okay, though, b/c it has a short t1/2)
Small doses of spironolactone can do the job and usually not cause hyperkalemia as long as the S-Cr < 2.5 mg/dL
Spironolactone, but not eplerenone, is a partial agonist at androgen/estrogen/ progesterone receptors causing gynecomastia, azoospermia, breast pain, menstrual irregularitiy |
|
|
Term
|
Definition
Must dose bid/tid b/c short t1/2
Filtered, secreted into PT via organic acid transport system (oral or IV)
Activity not affected by pH
Rapid diuresis of short duration Effective if GFR <25 ml/min |
|
|
Term
|
Definition
Inhibit NaK2Cl symporter in medullary/cortical loop of Henle
Dec. reabsorption of NaCl, Ca, Mg
Huge natriuresis (and subsequent inability to make a dilute or concentrated urine b/c no osmotic gradient)
Stim renal synthesis of PG in kidney, spills into circulation, causes dilation of veins causing immediate dec. in RA pressure
Inhibit NaK2Cl symporter in macula densa
Block TG feedback and immediate inc. GFR and inc. renin secretion (subsequent AngII inc. causes secondary hyperaldosteronism)
Inc. Na delivery to DT, inc. flow, and secondary hyperaldosteronism cause inc. K secretion (administered KCl can correct the hyperaldosteronism-induced metabolic alkalosis)
Furosemide can inhibit CA in large doses and thus inhibit Na reabsorption in PT |
|
|
Term
|
Definition
Secondary hyperaldosteronism
Hypokalemia hypochloremic metabolic acidosis from excess loss of NaCl and KCl = give w/ K-sparing diuretic like spironolactone! |
|
|
Term
| ACEI, ARBs: summary of effects on CHF (6) |
|
Definition
Balanced VD!
Dec. congestive symptoms
Inc. SV and EF = get rid of forward failure
Reverse cardiac remodeling (and hypertrophy) and inc. longevity
Dec. hospitalization and mortality
Improve fxl status and quality of life |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
Dec. ECF = dec. venous return = dec. preload = dec. LV filling pressure
Alleviates congestive/backward failure symptoms
Still on the same Starling curve, though, so SV may not inc.
Doesn't improve survival! |
|
|
Term
| How does balanced VD work? (6) |
|
Definition
Venodilation dec. venous return = dec. preload, so LV-EDV and LA pressure dec.
Arteriolar dilation dec. afterload = dec. TPR, which allows for an inc. in SV and EF
The inc. SV also contributes to the dec. LV-EDV and LA pressure
The inc. SV + dec. LV-EDV also dec. LV wall stress and pulmonary congestion
RBF inc. more than does GFR, so FF dec. causing diuresis
MAP and HR don't change! |
|
|
Term
| With ACEI, you need to monitor...(2) |
|
Definition
Plasma K
Serum Cr
Especially if renal fxn is poor |
|
|
Term
| Why would you use an ACEI post MI? |
|
Definition
| Dec. incidence of CHF and death |
|
|
Term
| Why would you use an ARB vs an ACEI? |
|
Definition
Use ARBs if the pt develops a dry cough while taking the ACEI
ARBs cause nearly the same hemodynamic changes as ACEI |
|
|
Term
| What other drugs besides ACEI and ARB can cause balanced VD? |
|
Definition
Nitrate venodilator + arterial VD like hydralazine
Though prolonged treatment w/ hydralazine can cause an SLE-ish syndrome in slow acetylators |
|
|
Term
| ACEI are also used to treat ___ in addition to CHF |
|
Definition
| HTN, but you use lower doses to treat this |
|
|
Term
| Spironolactone, eplerenone: summary of effects on systolic CHF (4) |
|
Definition
Dec. backward failure and inc. ventricular compliance and filling
Inhibit cardiac collagen synthesis Reverse cardiac remodeling and inc. longevity
Improve survival! |
|
|
Term
| B-blockers: summary of effects on CHF (2) |
|
Definition
(Dec. HR and prevents exercise-tachycardia = longer diastole = dec. ventricular pressure and better filling)
Reverse cardiac remodeling and inc. longevity
Inc. SV and EF |
|
|
Term
|
Definition
Block B1, B2, a1 adrenoR
Block excessive symp. stimulation = prevent/reverse remodeling of myocardium
Prevent ventricular dysrhythmias = dec. sudden death
Anti-anginal |
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|
Term
|
Definition
|
|
Term
| Carvedilol: indications, S/E |
|
Definition
NYHA II, III CHF and EF < 35% patients already taking an ACEI and diuretics (possibly digoxin)
Patient should be w/in 2-3 lbs of dry weight, meaning not volume-expanded
"Start low, go slow"
Patient will feel worse at first due to the B-blockade causing dec. EF, but this will eventually inc. above baseline and the patient will feel fine |
|
|
Term
| Carvedilol: dosing, effects |
|
Definition
Use the largest dose tolerated (benefits are dose-related!)
Dec. death from LV failure by 50% |
|
|
Term
|
Definition
| Prevents exacerbations of CHF |
|
|
Term
| Digoxin: summary of effects on CHF (3) |
|
Definition
Inc. SV and EF and thus dec. pulmonary congestion
Marginally inc. longevity
Don't reverse cardiac remodeling! |
|
|
Term
| Digoxin: effects (good and bad) |
|
Definition
Direct positive inotropic effect (good)
Indirect enhancement of vagal tone (good)
Direct enhancement of dysrhythmia (bad) |
|
|
Term
|
Definition
CHF pt w/ systolic dysfxn + ACEI + diuretic and still symptomatic
CHF pt w/ atrial fib (the enhanced vagal tone controls ventricular HR in the face of high atrial rate) |
|
|
Term
| Digoxin: pharmacokinetics (4) |
|
Definition
Miniscule therapeutic window
t1/2 24-48 hrs
Stored in skeletal muscle so dose based on lean body mass
Excreted unchanged, clearance proportional to GFR |
|
|
Term
| Digoxin: drug-drug interactions (4) |
|
Definition
Antacids, cholestyramine, colestipol dec. digoxin absorption from GI
Spironolactone dec. clearance of digoxin
Hypokalemic drugs (furosemide, HCTZ) potentiate adverse effects of digoxin
Verapamil, diltiazem, B-blockers enhance the bradycardia and AV block caused by digoxin |
|
|
Term
|
Definition
Inc. vagal tone causing sinus bradycardia, AV block
PACs, PVCs
These cardiac S/E are ppt by hypokalemia, hypomagnesemia, hypercalcemia
Anorexia, nausea, yellow-green vision |
|
|
Term
|
Definition
|
|
Term
| If the rates of active/passive LV relaxation don't inc. during exercise in diastolic dysfxn... |
|
Definition
| The Starling mechanism can't be used to inc. CO b/c diastolic relaxation doesn't speed up w/ HR and ventricular stiffness prevents inc. preload from inc. LV EDV = SV doesn't inc. |
|
|
Term
| Diastolic dysfxn can be prevented by...(3) |
|
Definition
Treating HTN to prevent/reverse LVH
Treating CAD-induced ischemia w/ antianginals, antilipemics, or CABG
Valve replacement for AS |
|
|
Term
| Patients w/ systolic dysfxn always have... |
|
Definition
|
|
Term
| Diastolic dysfxn therapy is aimed at... |
|
Definition
| Inc. ability of LV to relax and fill at a normal pressure |
|
|
Term
| Diagnosing systolic vs. diastolic dysfxn |
|
Definition
Doppler distinguishes diastolic dysfxn!
E and A waves (transmitral inflow velocity) are abnormal |
|
|
Term
| Diastolic dysfxn: hallmarks (2) |
|
Definition
Pulmonary congestion causing dyspnea
Dec. exercise tolerance even though EF > 50% |
|
|
Term
| Ventricular stiffness is caused by ___ and results in ___ of the active and passive phases of diastolic relaxation |
|
Definition
Deposition of fibrillar collagen in the heart ECM
Impairment |
|
|
Term
| If ventricular compliance is decreased, it requires ___ filling pressure. |
|
Definition
|
|
Term
| In diastolic dysfxn, EDV is ___ despite ___ |
|
Definition
Abnormally high
Volume is normal |
|
|
Term
| Treatment of diastolic dysfxn: summary (5) |
|
Definition
Dec. pulmonary venous pressure at rest and during exercise = relieve symptoms
Reverse LVH = inc. ventricular compliance and filling
Block cardiac aldosteroneR = reverse remodeling = inc. ventricular compliance and filling
Dec. HR to prolong diastole = allow for better filling
Prevent myocardial ischemia, b/c ischemia makes the wall stiffer |
|
|
Term
| Notes about using diuretics in diastolic dysfxn |
|
Definition
Small doses are necessary to prevent hypotension and fatigue
Too much results in dec. blood volume = dec. preload = dec. CO |
|
|
Term
|
Definition
|
|
Term
| Furosemide is used mainly in pt w/ ___ dysfxn |
|
Definition
Systolic
Used w/ care in diastolic |
|
|
Term
| Symptoms of cardiogenic shock (4) |
|
Definition
Hypotension
Tachycadia
Hypoperfusion = cold, clammy skin, dec. urine output, altered mental status
PEd |
|
|
Term
| Non-pharm methods to inc. CO in cardiogenic shock |
|
Definition
Intra-aortic balloon pump
Ventricular assist device |
|
|
Term
| Treatment of PEd due to cardiogenic shock (and what's used to treat MI) |
|
Definition
Morphine
Oxygen
NTG
Furosemide |
|
|
Term
| Isosorbide dinitrate + hydralazine: MOA |
|
Definition
Balanced VD!
Hydralazine VD arterioles, nitrate VD venules |
|
|
Term
|
Definition
SBP <70 + shock: IV NE
SBP 70-100 + shock: IV DA
SBP 70-100 no shock: IV dobutamine |
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