Management of Heart Failure- CardioRush

Lidocaine CRI, address any underlying issues
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Lidocaine CRI, address any underlying issues
What would be the first line of treatment for this arrhythmia?
Image: Lidocaine CRI, address any underlying issues
Radiographic evidence on 2 views, elevated NT proBNP, jugular distention with ascites, echo compatible with heart disease
What are the top 4 ways that diagnosis with CHF is confirmed?
Dilated hepatic veins on US, history of cough, cardiac gallop, cardiomegaly on rads, pulmonary crackles, sinus tachycardia, slow CRT, weak arterial pulses
What tests or findings are supportive of diagnosing CHF, but not definitive?
SNS activation, RAAS, renal Na and water retention, ANP
What are the the main neurohormonal contributors to development of CHF with heart disease?
Pimobendan
What is the only positive inotrope drug that has been shown to improve CHF?
No clear positive study for use
What is the evidence for use of beta blockers in CHF in vet patients?
No data for support
What is the evidence for use of digoxin in CHF in vet patients?
Some positive studies supporting use
What is the evidence for use of ACE inhibitors in CHF in vet patients?
False (no data, but it clearly helps with pulmonary edema on emergency presentation so it has continued to be used)
True or false: there are many published studies showing that use of furosemide in vet patients with CHF improves outcome
Sudden death from arrhythmia, thromboembolic disease, refractory or acute recurrence of CHF, elected euthanasia
What are some examples of common causes of death in cats and dogs with CHF?
Poor QOL, recurrent CHF, anorexia/weakness, poor prognosis from DVMWhat are some reasons owners elect to euthanize in animals with CHF?TrueTrue or false: Generally, owners would rather have a shorter time with an animal with excellent QOL than a longer time with poor QOLFurosemide, pimobendan, ACE inhibitors, spironolactoneWhat are some of the first line drugs we use when initially treating CHF?Antiarrhythmics, sildenafil, beta blockers, Na nitroprusside, dobutamine, digoxin, nitroglycerineIf the first line drugs for treatment of CHF don't work, what are some additional drugs that can be added on?Runs of VPCs and V tach, absent P waves indicates underlying A fibWhat are the ECG findings?Na restricted diet, exercise limitationWhat are some lifestyle changes that can be instituted in dogs with CHF in addition to drug therapy?Loop diuretic at ascending limb of LOH, interferes with Cl resorption through Na/K/2Cl cotransporter, water followsWhat is the MOA of furosemide?Wide dose range and high ceiling, rapid onset of actionWhat are the characteristics of dosing furosemide?Pulmonary edema, pleural effusion, ascitesWhat are the indications for furosemide use?FurosemideWhat is the most used diuretic in vet med?Dehydration, azotemia, hypokalemia, chloremia, or natremia, metabolic alkalosisWhat are potential side effects of furosemide?DeafnessWhat is a potential risk of giving furosemide too quickly IV?ACE inhibitorsWhat drug type is furosemide almost always paired with to control and treat CHF?Blocks intrarenal compensation for reduced blood flow and vasoconstriction of efferent arteriole due to RAASWhat is the MOA of ACE inhibitors?Diuretics cause volume depletion and reduced renal blood flow, ACE inhibitors prevent kidney compensationHow does use of furosemide and ACE inhibitors together cause or worsen azotemia?Stop furosemide for a day and continue ACE inhibitor, add back furosemide on lower doseIf an animal is on furosemide and an ACE inhibitor and presents with azotemia, what should you do?False (depends on the situation and severity of signs)True or false: the dose and frequency that is chosen for furosemide is always the same in animals with CHFFalse (no difference found in humans between bolus and CRI treatment)True or false: Furosemide is best given as a CRI instead of a bolus to treat emergency presentation of CHFCa sensitizer by blocking PDE3, positive inotrope and vasodilatorWhat is the MOA of pimobendan?OralWhat is the only form of pimobendan available in the US?Dogs with CHF due to valve disease or DCM (used off label in cats)What is the approved use of pimobendan?False (has been shown to improve survival in DCM and valvular disease in dogs, especially once CHF is present)True or false: Pimobendan has been shown to improve the survival time of dogs with CHF from only DCMRarely diarrhea, tachycardia or arrhythmiaWhat are the side effects of pimobendan?False (was shown to delay the onset of CHF in Dobermans with DCM as well as other breeds with underlying heart disease)True or false: use of pimobendan before the onset of CHF is not recommendedFew clinical reports, anecdotal info onlyWhy is the safety and efficacy of pimobenan in cats unclear?CHF from DCM, RCM, UCM, only in HCM without obstructive physiologyWhat are some indications for possibly using pimobendan in cats?Digoxin (also available are digitoxin and ouabain)What is the most common formulation of digitalis in vet med?Positive inotrope, vagomimetic/decrease SNS output, improve baroreceptor functionWhat are the main effects of digoxin?Blocks Na/K ATPase pumpWhat is the MOA of digoxin that causes it to be a positive inotrope?Slows HR, slows AV conduction, antiarrhythmicWhat is the effect of digoxin due to its vagomimetic MOA?Withhold at least 1 day due to long half life, start at lower doseHow is digoxin restarted after toxicity from too high a dose?Higher side effect rateWhy don't we tend to give digoxin IV in small animals?Slowed HR, prolonged PR interval (first degree AV block common), shortened QT, AV junctional rhythms, ventricular arrhythmiasWhat are the changes that can be seen on ECG with digoxin use?False (findings overlap, can't completely rely on ECG to determine toxicity occurring)True or false: there are separate ECG findings when there is normal digoxin effect vs. when there is toxicityTreat CHF, SVTsWhat are the main indications for use of digoxin?Positive inotropic effects increase CO and renal flow to improve diuresisHow is digoxin used in treatment of CHF?Sinus tachycardia, SVT, a fibWhat type of supraventricular arrhythmias can digoxin be used to treat?A fibWhat is the main arrhythmia that digoxin is used to treat?Anorexia, lethargy, depression, vomiting, diarrhea, cardiac arrhythmiasWhat are signs of digoxin intoxication?First degree AV blockWhat is the arrhythmia?False (Narrow therapeutic index, toxic range very close to therapeutic range)True or false: Digoxin has a wide therapeutic index, making it safe to use at a range of dosesRenal insufficiency, low K or Mg, reduced skeletal mass, older age, dosing without considering ascites, interaction with quinidine, verapamilWhat predisposes digoxin intoxication?8 hoursHow long after administration of digoxin do we measure serum levels to check for toxicity?Advanced CHF not controlled by ACE inhibitors, pimobendan, or diureticsWhen do we usually add digoxin to CHF treatment?TrueTrue or false: an indication for use of digoxin is in dogs that experience syncope with valvular disease, since it improves baroreceptor functionDiltiazem, Amlodipine (verapamil, nifedipine)What are examples of class IV (Ca channel blockers) antiarrhythmic drugs?AmlodipineWhat class IV antiarrhythmic is used in treatment of systemic hypertension?SVT, a fib, HCMWhat are examples of situations that diltiazem is used?Excessive negative chronotropism, negative inotropism, excessive vasodilationWhat are some potential side effects seen with class IV antiarrhythmic drugs (usually from too high a dose)?Not all of it, enough to relieve diaphragmatic pressure or dyspnea, use drugs to remove the restWhen removing fluid from the abdomen, how much should you aim to remove?False (may be sufficiency in early or mild CHF)True or false: Low Na diets are never enough on their own to help control heart disease in animals, no matter what their stage isTrueTrue or false: very low Na diets may promote neurohumoral activation, so there is debate about what type of Na restriction is best in animalsFalse (there are a lot of options commercially)True or false: there are very few commercial options for restricted Na diets, most owners need to switch to home cooked dietsMild CHF, severe requires cage rest onlyWhen should we institute exercise limitation in heart disease?Vasoconstriction, release aldosterone, increase thirst, stimulate ADH, SNS stim, myocardial fibrosis and cardiac remodelingWhat is the normal action of angiotensin II?Improves survival, reduces clinical signs, slows cardiac remodeling, delay onset of CHFWhat are the beneficial effects of using ACE inhibitors for CHF?False (There are several studies that show inhibiting RAAS improves outcome in CHF)True or false: similar to furosemide, there are few studies that show ACE inhibitors are beneficial in therapy for CHF, but we continue to use them due to anecdotal evideceCHF, systemic hypertension, glomerulonephritis, advanced heart disease before CHFWhat are some clinical scenarios in which you would use an ACE inhibitor?Use in all dogs and cats with L or biventricular CHF, use lowest dose of furosemide, monitor renal functionWhat are the current recommendations regarding use of ACE inhibitors?HypotensionWhat animals with CHF should we delay the use of ACE inhibitors in?DCM, HCM with marked LAEWhat heart diseases does use of ACE inhibitors likely delay the onset of CHF?Enalapril, Lisinopril, BenazeprilWhat are examples of ACE inhibitors?Hypotension, azotemia, renal failure, GI upsetWhat are the potential side effects of ACE inhibitors?False (uncommon in dogs and cats)True or false: cough is a common side effect of ACE inhibitors, similar to seen in peopleExcessive concurrent diureticWhat typically causes azotemia with ACE inhibitor use?Aldosterone antagonist, conserves potassium, restores baroreceptor function towards normalWhat is the MOA of spironolactone?MildWhat is the strength of K sparing diuretics like spironolactone?TrueTrue or false: Spironolactone is sometimes used to counterbalance the hypokalemic effects of loop or thiazide diureticsHyperkalemia, lethargy, weakness, anorexia, GI signsWhat are potential side effects of use of spironolactone?Can be used in all dogs, sometimes added to furosemide if there is diuretic resistance, sometimes used only in refractory CHFWhat are the ways that spironolactone can be used in treating CHF?False (can be used at higher doses when required, seems to be tolerated well)True or false: Pimobendan should never be used at a higher dose than is labeledLoop diuretic with minor K sparing properties, effective at low dosesWhat is the MOA of torsemide?Dilates systemic veins, moves blood away from heart and lungs, reduces preloadWhat is the effect of venous vasodilators that makes it beneficial in CHF?Dilates systemic arteries, reduces afterload, increases LV ejection fraction, reduces mitral regurgWhat are the benefits of using arterial vasodilators in heart disease?SildenafilWhat is an example of a pulmonary vasodilator?Pulmonary hypertensionWhat is sildenafil used to treat?Phosphodiesterase V inhibitor, NO donor, reduces PA pressureWhat is the MOA of sildenafil?NitroglycerineWhat is an example of a venous vasodilator?Hydralazine, amlodipineWhat are examples of arterial vasodilators?ACE inhibitors, Na nitroprusside, some sedatives and narcoticsWhat are examples of balanced vasodilators?Venous and coronary artery vasodilator, IV or transcutaneousWhat are the characteristics of nitroglycerine?Short term treatment of severe pulmonary edema, chronic CHF management with other drugsWhen is nitroglycerine used to treat CHF?Hypotension, GI upset, lethargy, depression, azotemiaWhat are potential side effects of nitroglycerine use?Ca channel blocker, selective for arteries, reduces afterload and systemic hypertensionWhat is the MOA of amlodipine?Systemic hypertension, dogs with mitral regurg due to valve disease (esp if borderline hypertensive)What are some indications for use of amlodipine?Balanced vasodilator, very potent and effective, short duration of action so give CRIWhat are the characteristics of Na nitroprusside?ICU setting only, sensitive to light so keep wrapped, monitor BPWhat must be done when using Na nitroprusside for treatment?Acute severe pulmonary edema (short term use of 1-3 days while in hospital)What are indications for use of Na nitroprusside?Hypotension, GI signs, cyanide intoxWhat are the side effects of Na nitroprusside use?Inhibit Na, Cl absorption in distal tubule, weaker than loop diuretics and ineffective in renal failureWhat is the MOA of thiazide diuretics?Hypokalemia, azotemiaWhat are some potential side effects of thiazide diuretics?Combination with other diuretics for suspected diuretic resistance in CHF, used alone in mild CHFWhat are the indications for use of thiazide diuretics?HydrochlorothiazideWhat is an example of a thiazide diuretic?Diuretics in subclinical heart disease may increase neurohumoral activationWhy should you avoid use of diuretics unless there is clear presence of congestion or fluid accumulation?Sympathomimetic amines, digoxin, phosphodiesterase inhibitors, Ca sensitizersWhat are examples of drug categories that are positive inotropes?Short half lives, CRI only, stimulate adrenergic receptorsWhat are the characteristics of sympathomimetic amines?VasoconstrictionWhat is the effect of sympathomimetic amine binding at an alpha 1 receptor?Positive inotrope and chronotropeWhat is the effect of sympathomimetic amine binding at a beta 1 receptor?Vasodilation and bronchodilationWhat is the effect of sympathomimetic amine binding at a beta 2 receptor?Coronary, cerebral, mesenteric, renal arteriolesWhat are the locations of dopaminergic receptors in the body?Dobutamine, dopamine, Epi, NE, isoproterenolWhat are examples of sympathomimetic amines?B1What receptor does dobutamine bind to primarily?Positive inotrope increases CO, limited effect on HR or arrhythmogenesisWhat is the effect of dobutamine binding?Acute CHF with reduced COWhen is dobutamine most commonly used?False (tolerance can develop, only short term CRI use in ICU for 1-4 days recommended)True or false: There is no risk of tolerance developing from dobutamine useB1, A1What receptors does dopamine primarily work through?VasodilationWhat is the result of dopamine binding dopaminergic receptors?Positive inotrope to increase COWhat is the effect of dopamine when given at a 5-10mg/kg/min CRI?Alpha stim causes significant BP increaseWhat is the effect of dopamine when given at a 10-30mg/kg/min CRI?B1, B2What receptors does isoproterenol work through?Significant arrhythmogenesis, sometimes drop in BP (no alpha action)What are the effects of isoproternol use?Positive inotrope and chronotrope for severe bradyarrhythmiasWhat is isoproterenol used for?B1, A1What receptors mainly mediate effects of epinephrine?Positive inotrope increases CO, chronotrope increases HR, dramatic BP rise, significant arrhythmogenesisWhat are the effects of epinephrine use on the CV system?2-4 minutesHow frequently are epi boluses given during CPR?B1, A1What receptors does NE work at?Positive inotrope increases CO, chronotrope increases HR, significant arrhythmogenesis, rise in BPWhat is the effect of NE use on the CV system?NEWhat drug is used for refractory hypotension after fluids, dopamine, and other therapies have failed?Arrhythmogenic, increase HR, vasoconstriction, renin release, cardiomyotoxic, promotes myocardial fibrosis and remodelingWhat are the results of chronic SNS activation in CHF?False (no evidence of improvement with Beta blockers in animals with CHF)True or false: similar to people, beta blockers are the mainstay of treatment of CHF in vet speciesCan take months to build up, acutely negative inotropic effects will worsen CHFWhy aren't beta blockers commonly used in vet med?Active CHF signsWhat is a contraindication for beta blocker use?False (possible for use in animals in which CHF is well controlled or before onset of CHF)True or false: there is no situations in which we would use beta blockers in animals at risk of developing CHFMetoprolol, carvedilolWhat are 2 examples of beta blockers?Start low dose, double in 2 weeks if no side effects at that timeHow can beta blockers started in a patient?Concurrent respiratory disease (generally not used in isolated cardiac disease)When are bronchodilators indicated for use in CHF?ACE inhibitor, beta blocker, change dietWhat can generally be done for dogs that are asymptomatic for CHF but have underlying heart disease?ACE inhibitors, pimobendan, furosemide, sometimes beta blocker after CHF controlled, continued diet and exercise controlWhat are some drugs that can be used in mild CHF in dogs?Digoxin, spironolactone, amlodipineWhat are the drugs that can be added in dogs with moderate to advanced CHF?Beta blocker, avoid salty treatsWhat are the options for management of cats that are asymptomatic for CHF but have underlying heart disease?ACE inhibitor, furosemide, ATE prevention drugs, diet change, beta blocker discontinuedWhat are the drugs that can be used in cats with mild CHF or with an increase in LA size?Pimobendan, spironolactoneWhat drugs can be added for management of cats with moderate to advanced CHF?