Heart Failure

CO = SV x HR Clinical Diagnosis Signs and symptoms Dyspnea at rest Weakness/fatigue SOB Jugular venous distention Edema S3 Gallop Increased BNP o Normal is < 100pg/mL EF fraction falls below 40% - Systolic dysfunction EF fraction above 40% - Diastolic dysfunction

Long standing Hypothyroidism has been linked to causing Heart Failure TNF blockers are typically avoided in patients with heart failure Methotrexate is the agent of choice in patients who suffer from Heart failure along with Rheumatoid Arthritis Acetozolamide is a Carbonic Anhyrdrous Inhibitor Which results In a reduction of bicarbonate

Non-Pharmacologic Therapy
Limit Sodium to <2gms a day with HF o <1.5g if pt also has HTN Monitor Body Weight Daily in the morning before eating and after voiding Fish oils may decrease mortality o 1gm q day Avoid products with ephedrine Avoid NSAIDS Stop smoking and alcohol Pneumococcal Vaccine and annual influenza recommended Reduce BMI < 30 Exercise 30mins/day x 3-5 days

CO = SV x HR Cardiac Index (CI) = CO/BSA

Drugs that cause or worsen Heart Failure

Chemotherapeutic agents o Anthracyclines and derivatives Doxorubicin Daunorubicin o Trastuzumab Herceptin o Imatinib Gleevec o Docetaxol Taxotere Amphetamines Intraconazole Negative inotropic drugs o Verapamil and Diltiazem Anti-arhythmic drugs o Class I antiarrhythmic agents Mexiletine Tocainide Procainamide Quinidine Disopyramide Flecainide Propafenone o Lower risk with Amiodarone and Dofetilide Fenfluramine Pondimin Dexfenfluramine Redux Egot derivatives o Ergotamine Ergostat o Dihydroergotamine Migranal o Methysergide Sansert Immunomodulators o Interferons o Etanecept o TNF-bockers o Rituximab NSAIDS Triptans Thiazolidinediones Excessive alcohol

Two Cornerstone drug classes

Beta blockers Work by blocking the effects of NE and Epi

Ace Inhibitors Work by decreasing the effects of Angiotension II Agents thathave been shown to have a positive impact on mortality Beta Blockers o Bisoprolol Zebeta o Metoprolol Toprol XL o Carvedilol - Coreg, Coreg CR Take with food 2D6 substrate Non-Selective Beta and Alpha blocker Titrate up to 25mg BID Max dose for < 85kg = 25mg BID Max Dose for > 85kg = 50mg BID Ace Inhibitors o Lisionpril Target dose 20mg daily ARBs decrease mortalilty only if not on ace inhibitor CAD o Candesartan Atacand o Losartan Cozaar o Valsartan Diovan Aldosterone antagonists decrease mortalilty 1st second line agent o Spironolactone Aldactone Non-selecive blocking both androgen and progesterone Titrate to 25mg/day o Eplerenone Inspra Selective blocking Contraindications K >5 CrCl < 30mL/min Pts on Diltaziem and Verapramil DC if K reaches 5.5 Monitor potassium 3 and 7 days after starting Hydralazine(afterload) and Nitrate(preload) combos does decrease mortalilty o Good in black patients o Good if Ace and Arb can not be used o Can cause LUPUS o No Concurrent PDE-5 inhibitors Loop Diuretics are used in patients with congestive heart failure Lithium should not be given with diuretics Risk of OTOTOXICITY with Aminoglycosides Have been shown to also increase Triglycerides and total cholesterol

Digoxin Does not decrease mortality Range o 0.5-.09 ng/mL Decrease by 25% when converting from PO to IV Signs of Toxicity o Loss of Appetite o Naustea and Vomiting o Bradycardia o Yellow Halos vision o Confusion o Increased PR interval o Adjust with renal disfunction o Hypokalemia < 3.5 increases risk of Digoxin toxicity o Hypercalcemia can increase risk of Digoxin toxicity Antidote o Digibind or DigiFab Acute Decompensated Heart Failure treatment Contraindicated with BP <90 Nitroglycerin NTG o Cannot be in a PVC bag o Contraindicated with increased intracranial pressure and PDE-5 Nesiritide Natrecor o May increase SCr Nitroprusside Nipride o Need to protect infusion bag from light o Any change in color indicates degradation and do not use o Can cause cyanide/thiocyanate toxicity Monitor PH of pt to determine 1. B 2. D 3. C 4. A 5. E 6. A 7. A 8. B 9. E 10. A 11. E 12. A 13. B 14. A

15. E 16. C 17. D 18. B 19. E 20. A 21. A 22. A 23. B 24. C 25.