1. What is the New York classification of heart failure?
    • Class I: asymptomatic
    • Class II: sx upon excessive exertion
    • Class III: sx upon normal activity of daily living
    • Class IV: arrest
  2. What is the New Approach classification of heart failure?
    • A: high risk for developing HF
    • B: asymptomatic
    • C: symptomatic
    • D: refractory end-stage HF
  3. What are the causes of systolic failure (dilated cardiopyopathy)?
    • genetic
    • virus
    • CAD
    • HTN
  4. What are the causes of diastolic failure (hypertrophic cardiomyopathy)?
    • HTN
    • genetic
    • low O2
    • low energy
  5. What are the sx of poor perfusion?
    • high BUN/creatinine ratio
    • cold extremities
    • decreased urine output
    • fatigue
    • confusion
    • pulmonary edema (L side failure)
    • peripheral edema and JVD (R side failure)
    • high ADH = low Na+ lab value = poor perfusion is stimulating the ADH despite low Na+ and osmolality
  6. What are the sx of CHF?
    • fluid overload
    • hypoperfusion
    • high BNP
  7. What is BNP?
    • B Natriuretic Peptide - stimulated by stretch of the atria and ventricles and causes Na+ and water excretion.
    • kind of a counter-regulatory hormone to aldosterone
  8. What is the vicious cycle of aldosterone on CHF?
    • Na+ and water retention =
    • increased preload and pulmonary edema =
    • strain

    • vasoconstriction =
    • increased afterload =
    • decreased CO =
    • decreased perfusion =
    • more RAAS stimulation

    Angiotensin also stimulates the SNS which causes even more vasoconstriction
  9. How does the body compensate for low CO in CHF?
    • poor perfusion stimulates RAAS
    • Angiotensin stimulates SNS (+) inotrope effect to increase CO
    • aldosterone causes Na+ and water retention which increases preload, which increases CO
    • the vicious cycle means that eventually it will overstimulate and cause decreased CO
  10. What is the best parameter to monitor for CHF?
    • weight!
    • 1kg = 1L of water loss
    • goal is 1L/d net loss
    • 700mL insensible loss (respiration, perspiration)
  11. What is the best way to dose diuretics for CHF?
    • short-term:
    • Nike rule......just do it!
    • 20-40mg for 1-2h then
    • 80mg for 1-2h then
    • 160mg
    • long-term:
    • be a wimp, keep it low if at all d/t possible decrease in CO
  12. What is the relationship between loops and thiazides in CHF?
    • thiazides are better until kidney fx declines
    • loops are better as kidney fx declines
  13. What are the SE of diuretics?
    • increased BUN/Cr ratio
    • decreased K+
    • decreasing hydration status
  14. What are the SE of thiazides?
    • Glucose increase
    • Lipids increase
    • Uric acid increase
    • Urea increase
    • Calcium increase
  15. What are the effects of ACE inhibitors on CHF?
    • decreased preload d/t venous dilation = decreased fluid overload
    • increased artery dilation
    • increased output but decreased pressure = kidney fx worse initially
    • breathing improved
    • increased exercise capacity
    • mental status improved
    • decreased BP
  16. What are the SE of ACE inhibitors?
    • increased BUN/Cr
    • increased potassium (d/t increased Na+)
    • hypotension
    • cough (dry, non-productive)
    • angioedema
  17. What is the diffence in ACEI dosing between CHF and HTN?
    • CHF:
    • lower dose is better - don't want to make pressure too low
    • HTN:
    • high dose is better because pressure is too high
  18. How are ARBs useful in HF?
    • in place of ACEI - DO NOT add to an ACEI!
    • DO NOT add to a BBL - increased mortality
    • better outlook for angioedema and cough - no effect on bradykinin
  19. How are Nitrates and Hydralazine used in CHF?
    • nitrates decrease preload (dilate arteries)
    • hydralazine decreases afterload (dilate veins)
    • less mortality benefit than ACEI
    • more sx benefit than ACEI
    • less renal impairment (no dilation of efferent arterioles)
  20. What are the SE of nitrates and hydralazine?
    • Pill Overload Syndrome (POS)
    • HA
    • nausea
    • hypotension
  21. What is digoxin's role in CHF?
    • flogging the heart (pos inotrope)
    • decreased HR
    • probably diuretic effect
    • LAST thing to add, no benefit for CHF, but some decreased SE
    • FORBIDDEN in diastolic dysfunction
  22. What should be monitored for digoxin tx?
    • urine output
    • mental status
    • exercise capacity
  23. What are the SE of digoxin?
    • low potassium will increase dig toxicity
    • mental status change
    • low pulse/ECG
    • nausea
    • vomiting
  24. What are the uses of BBL in CHF?
    • decreased mortality!
    • do not use unless fluid stable
  25. What should you do if pt is on a BBL and becomes fluid unstable?
    add a diuretic, if that doesn't work, decrease BBL dose 50% until stable
  26. What is the use of spironolactone in CHF?
    • decrease mortality!
    • not sure if it has benefit when added to ACEI
    • great for hypokalemic CHF pts instead of K+ supplementation
  27. What are the SE of spironolactone?
    • hyperkalemia
    • gynecomastia
  28. What is the use of BNP levels in CHF?
    • good for diffentiating cause of SOB
    • not good for progress check
  29. What are the clinical sx of CHF fluid overload?
    DOE (dyspnea on exertion)orthopnea/Peroxismal nocturnal dyspnea (SOB upon laying down)
  30. What is the treatment for diastolic HF?
    • diuretic
    • ACEI (just because it can't hurt)
  31. What are some inappropriate drugs for CHF pts?
    • NSAIDS (Na+ retention)
    • estrogens (Na+ retention)
    • corticosteroids (Na+ retention)
    • non-DHP CCBs (in systolic HF)
  32. What is the pharmacist's role in CHF?
    • weights daily (3-5lbs increase = call physician)
    • poke ankles
    • ensure labs (esp. K+)
    • teach to take their pulse
    • get rid of NSAIDs
    • salt police
    • cough syrup patrol
    • appropriate drugs (ACEI, BBL, diuretic)
  33. What are the mandatory drugs for CHF?
    • ACEI
    • BBL (once fluid stable)
    • diuretic (most likely)
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