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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
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What is the New Approach classification of heart failure?
- A: high risk for developing HF
- B: asymptomatic
- C: symptomatic
- D: refractory end-stage HF
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What are the causes of systolic failure (dilated cardiopyopathy)?
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What are the causes of diastolic failure (hypertrophic cardiomyopathy)?
- HTN
- genetic
- low O2low energy
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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
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What are the sx of CHF?
- fluid overload
- hypoperfusion
- high BNP
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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
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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
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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
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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)
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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
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What is the relationship between loops and thiazides in CHF?
- thiazides are better until kidney fx declines
- loops are better as kidney fx declines
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What are the SE of diuretics?
- increased BUN/Cr ratio
- decreased K+decreasing hydration status
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What are the SE of thiazides?
- Glucose increase
- Lipids increase
- Uric acid increase
- Urea increase
- Calcium increase
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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
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What are the SE of ACE inhibitors?
- increased BUN/Cr
- increased potassium (d/t increased Na+)
- hypotension
- cough (dry, non-productive)
- angioedema
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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
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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
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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)
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What are the SE of nitrates and hydralazine?
- Pill Overload Syndrome (POS)
- HA
- nausea
- hypotension
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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
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What should be monitored for digoxin tx?
- urine output
- mental status
- exercise capacity
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What are the SE of digoxin?
- low potassium will increase dig toxicity
- mental status change
- low pulse/ECG
- nausea
- vomiting
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What are the uses of BBL in CHF?
- decreased mortality!
- do not use unless fluid stable
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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
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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
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What are the SE of spironolactone?
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What is the use of BNP levels in CHF?
- good for diffentiating cause of SOB
- not good for progress check
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What are the clinical sx of CHF fluid overload?
DOE (dyspnea on exertion)orthopnea/Peroxismal nocturnal dyspnea (SOB upon laying down)
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What is the treatment for diastolic HF?
- NO GOOD WAY
- diuretic
- ACEI (just because it can't hurt)
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What are some inappropriate drugs for CHF pts?
- NSAIDS (Na+ retention)
- estrogens (Na+ retention)
- corticosteroids (Na+ retention)
- non-DHP CCBs (in systolic HF)
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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)
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What are the mandatory drugs for CHF?
- ACEI
- BBL (once fluid stable)
- diuretic (most likely)
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