12 HF 3 Flashcards
C
Lets do an ARB instead
* ARNI is also CI now
A
systolic HF = HFrEF
C
pregnant
D
B
Aldosterone receptor antagonists (AA) = MRA
aldosterone elevated in HF leads to:
- continued ___ activation
- ___ inhibition
- cardiac and vascular ___
___ (non-selective) and ___ (selective) block aldosterone effects independent of the effects of ACEis or ARBs
- decrease ___ and ___ losses: may protect against ___
- decrease ___ retention: decrease ___ retention
- decreases ___ stimulation
- blocks direct ___ action on myocardium
- sympathetic
- parasympathetic
- remodeling
- spironolactone, eplerenone
- K, Mg, arrhythmias
- Na, fluid
- sympathetoc
- fibrotic
AA
Spironolactone
- ___ agent, structurally similar to ___
- inhibits the effects of ___ at the receptor site and increases the peripheral conversion of ___ into ___
- AE: gynecomastia, impotence, menstrual irregularities
non-selectice, progesterone
dihydrotestosterone, testosterone, estradiol
AA
eplerenone
- ___ agent with a 100-1000x lower affinity for ___ , ___ , and ___ receptors than spironolactone
- no antiandrogenic effects
- substrate of ___
- selective
- androgen, glucocorticoid, progesterone
AA dosing
eplerenone
eCrCl ≥ 50
initial dose: ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
AA dosing
eplerenone
eCrCl 30-49
initial dose: ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
25, every other day
25, daily
AA dosing
spironolactone
eCrCl ≥ 50
initial dose: ___ - ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
12.5-25, daily
25, daily
AA dosing
spironolactone
eCrCl 30-49
initial dose: ___ mg ___ or___
maintenance: ___ - ___mg ___
only if K ≤ 5
12.5, daily, every other day
12.5-25, daily
AA dosing/administration
should be added to ACEi/ARB/ARNi and BB therapy
Avoid:
- SCr > ___ (men) or > ___ mg/dL (women)
- K > ___ mEq/L
- CrCl < ___ mL/min
- Hx of severe ___ kalemia or recent worsening of ___ function
concomitant use of K sparing diuretics or supplements should be avoided (unless hypokalemia K < ___ mEq/L)
2.5, 2
5
30
hyperkalemia, renal
4
AA monitoring
monitor renal function and K within ___ days - ___ week after any change or addition, diseases, or acute illnesses that may influence K concentrations
- then once a ___ for 3 months
- then every ___ - ___ months
- monitor these things when ACEi/ARB increase/change
avoid ___ substitutes
3 days, 1 week
month
3-4
salt
Consensus recommendations for AA
Stage B: No recs
Stage C
- patients with NYHA ___ - ___ and ___ with eGFR > ___ and K < ___
- careful maintenance of ___ , renal function, and diuretic dosing is essential
- patients taking AAs in which K cant be maintained ( < ___ ) should be D/C to avoid life threatening hyperkalemia
II-IV, HFrEF, 30, 5
K
5.5
D
C
SGLT2i
- SGLT2i cause renal afferent arteriolar ___ (cause diuresis, natriuresis, glycosuria, decreased proteinuria)
- ___ preload = decrease ___ wall stress
- ___ afterload
- decrease myocardial ___
- constriction
- decrease, LV
- decrease
- energetics
SGLT2i
- unclear benefit in HF
- osmotic ___ and ___
- decreased arterial ___ and ___
- preload and afterload ___
- associated reduction in hypertrophy and fibrosis ( ___ )
- diuresis, natriuresis
- pressure, stiffness
- reduction
- remodeling
SGLT2i
indications: reduce the risk of CV ___ or ___ for HFrEF patients with NYHA class ___ - ___
dapagliflozin and empagliflozin are both ___ mg ___
- dapa: eGFR > ___
- empa: eGFR > ___
AE
- volume depletion
- ___ in DM, ___ glycemia, infection risk ( ___ )
death, hospitalization, II-IV
10, daily
30
20
DKA, hypoglycemia, UTIs
SGLT2i summary
recommended for patients with ___ chronic ___ with or without ___ to reduce ___ and CV ___
if the meet renal requirements, they should be on these for life
symptomatic, HFrEF, DM, hospitalizations, death
A
initiation: titration strategies
initiation: titration strategies
ARNi and MRA: inititate at low doses, titrate in ___ weeks as tolerated
BB: initiate at low doses, titrate in ___ week as tolerated
SGLT2: initiate, continue
2
1
