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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
What is the New Approach classification of heart failure?
- A: high risk for developing HF
- B: asymptomatic
- C: symptomatic
- D: refractory end-stage HF
What are the causes of systolic failure (dilated cardiopyopathy)?
What are the causes of diastolic failure (hypertrophic cardiomyopathy)?
- low O2low energy
What are the sx of poor perfusion?
- high BUN/creatinine ratio
- cold extremities
- decreased urine output
- 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
What are the sx of CHF?
- fluid overload
- high BNP
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
What is the vicious cycle of aldosterone on CHF?
- Na+ and water retention =
- increased preload and pulmonary edema =
- vasoconstriction =
- increased afterload =
- decreased CO =
- decreased perfusion =
- more RAAS stimulation
also stimulates the SNS which causes even more
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
What is the best parameter to monitor for CHF?
- 1kg = 1L of water loss
- goal is 1L/d net loss
- 700mL insensible loss (respiration, perspiration)
What is the best way to dose diuretics for CHF?
- Nike rule......just do it!
- 20-40mg for 1-2h then
- 80mg for 1-2h then
- be a wimp, keep it low if at all d/t possible decrease in CO
What is the relationship between loops and thiazides in CHF?
- thiazides are better until kidney fx declines
- loops are better as kidney fx declines
What are the SE of diuretics?
- increased BUN/Cr ratio
- decreased K+decreasing hydration status
What are the SE of thiazides?
- Glucose increase
- Lipids increase
- Uric acid increase
- Urea increase
- Calcium increase
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
What are the SE of ACE inhibitors?
- increased BUN/Cr
- increased potassium (d/t increased Na+)
- cough (dry, non-productive)
What is the diffence in ACEI dosing between CHF and HTN?
- lower dose is better - don't want to make pressure too low
- high dose is better because pressure is too high
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
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)
What are the SE of nitrates and hydralazine?
- Pill Overload Syndrome (POS)
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
What should be monitored for digoxin tx?
- urine output
- mental status
- exercise capacity
What are the SE of digoxin?
- low potassium will increase dig toxicity
- mental status change
- low pulse/ECG
What are the uses of BBL in CHF?
- decreased mortality!
- do not use unless fluid stable
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
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
What are the SE of spironolactone?
What is the use of BNP levels in CHF?
- good for diffentiating cause of SOB
- not good for progress check
What are the clinical sx of CHF fluid overload?
DOE (dyspnea on exertion)orthopnea/Peroxismal nocturnal dyspnea (SOB upon laying down)
What is the treatment for diastolic HF?
- NO GOOD WAY
- ACEI (just because it can't hurt)
What are some inappropriate drugs for CHF pts?
- NSAIDS (Na+ retention)
- estrogens (Na+ retention)
- corticosteroids (Na+ retention)
- non-DHP CCBs (in systolic HF)
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)
What are the mandatory drugs for CHF?
- BBL (once fluid stable)
- diuretic (most likely)
What would you like to do?
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