Block II: HF

Question 1

Describe HFrEF

Answer 1

EF < 40%
decreased in V ability to contract
systolic failure

Question 2

Describe HFpEF

Answer 2

Normal EF, EF > 50%
Decreased ability to fill
Diastolic failure

Question 3

BNP of [] is less likely to indicate HF

Answer 3

BNP < 100

Question 4

BNP of [] is more likely to indicate HF

Answer 4

BNP > 400

Question 5

Where do diuretics play a role in HF?

Answer 5

Can treat HF patients with fluid retention, overload

ONLY symptomatic, do NOT decrease Morbidity/mortality

Question 6

MOA Loop diuretics

Answer 6

1. increase Na excretion by 20-25%
2. Increase free water clearance (increase urination)
3. maintain effects unless renal function sig. impaired

Question 7

MOA Thiazides

Answer 7

1. increase Na excretion by 5-10%
2. decrease free water clearance
3. lose efficacy with impaired renal function

Question 8

if pt. is hospitalized with symptomatic fluid retention, what drug should they receive?

Answer 8

IV loop

Question 9

SE diuretics

Answer 9

1. hypotension
2. renal dysfunction
3. electrolyte disturbance
4. hearing diff. if IV pushed too quickly

Question 10

Role/benefits ACEI in HFpEF

Answer 10

decrease production aldosterone, decrease BP and Na+, decrease fluid overload via excretion Na and water

decrease ventricular remodeling

decrease hypertrophy

decrease NE release (anti-adrenergic)

decrease myocyte death

Question 11

[] should be initiated in all HFrEF pts first line (esp. with left ventricular dysfunction)

Answer 11

ACEI

reduce morbidity and mortality, may slow disease progression

Question 12

SE ACEI

Answer 12

1. angioedema
2. cough
3. hypokalemia
4. decrease renal function (widen efferent arteriole, decrease P in glomerulus)

Question 13

What can be used first line if ACEI not tolerated or CI

Answer 13

ARB

Question 14

role ARB in HFrEF

Answer 14

block vasoconstriction & aldosterone secreting effects aniotensin II (block receptor on target cell)

Question 15

SE ARB

Answer 15

1. hypotension
2. hypokalmia
3. worsening renal function
   * LESS Likely to prod. angioedema

Question 16

Role Sacubatril/Valsartan

Answer 16

ARNI!!
Should be used first line (instead on ACEI) in ALL pts. who can afford

Decreases morbidity and mortality

Question 17

MOA ARNI

Answer 17

1. Sacubatril: inhibits enzyme that breaks down, BNP (with reverses RAAS)
2. Valsartan: ARB

Question 18

CI ARNI

Answer 18

1. Hx angioedema with ACEI/ARB (ARB in it)
2. pt. on ACEI (increases rx angioedema)
3. pregnancy
4. aliskiren (renin inhib)

Question 19

SE ARNI

Answer 19

1. hypotension
2. hypokalemia
3. cough
4. dizziness
5. renal failure
6. angio (rare)

Question 20

How long should you wait to start an ARNI after taking ACEI

Answer 20

36 hr. washout period

Question 21

What is the role BB in HFrEF

Answer 21

inhibit sympathetic activation, inhibit peripheral vasoconstriction, inhibit NE release. inhib. hypertrophy from MI and NE

decrease tachycardia, decrease cardiac myocyte apoptosis, decrease arrythmia potential

Question 22

who gets a BB?

Answer 22

ALL pt. with EF < 40%

Question 23

benefits BB

Answer 23

1. improve EF and symptoms
2. decrease hospitalizations
3. decrease mortality

Question 24

AE BB

Answer 24

1. fluid retention (diuretic may help)
2. fatigue
3. bradycardia/heart block
4. hypotnesion

Question 25

What BB are used in HFrEF

Answer 25

1. Metoprolol Succ. 2. Carvedilol 3. Bisoprolol

Question 26

Role SGLT2 inhibitors in HFrEF

Answer 26

Flozins 1. decrease hospitalizations and death

Question 27

who gets an SGLT2 inhib?

Answer 27

everyone who can afford

Question 28

CI SGLT2 inhib.

Answer 28

1. type 1 DM 2. lactation 3. pregnancy 2nd/3rd trim.

Question 29

SE SGLT2 inhib

Answer 29

1. hypotention 2. genital mycotic infection 3. UTI

Question 30

Role Aldosterone antagonist

Answer 30

inhibition aldosterone mediated cardiac fibrosis and ventriculare remodeling decrease morbidity and mortality

Question 31

Who should be on aldosterone antag?

Answer 31

LF < 35% AHA class II-IV *should have prior hospitalization OR elevated plaman BNP (400+)

Question 32

CI aldosterone antag

Answer 32

1. K >/= 5 2. SCr >/= 2.5 M 3. SCr >/= 2 W 4. CrCl < 30

Question 33

SE Aldosterone antag

Answer 33

Gynecomastia, spiro | hyperkalemia (spiro, and eplerenone)

Question 34

MOA hydralazine

Answer 34

Aterial vasodilator , antioxidant? may halt destruction NO

Question 35

MOA isodorbide dinitrate

Answer 35

venous dilation, notric oxide donor? | may decrease dyspnea on exertion

Question 36

Role Hydralazine/Isosorbide dinitrate

Answer 36

Decrease morality/morbidity in AA pts. class III-IV in combo with ACEI or BB or w/o

Question 37

AE hydralazine/isosorbide dinitrate

Answer 37

1. HA, GI, orthostatic hypotension, syncope, palpitations, tachycardia 3. SLE with hydralazine over 200 mg/day

Question 38

Role Digoxin in HFrEF

Answer 38

symptomatic therapy

Question 39

MOA Digoxin

Answer 39

inhibit Na+-K+ ATPase to increase contractility (+ inotrope) | may curtail neurohumoral system, and decrease CNS symp. outflow and decrease RENIN_

Question 40

when should digoxin be used?

Answer 40

consider when pt. still symptomatic despite, ACEI, diuretic, BB, aldosterone antag. May decrease hospitalization but WONT DECREASE MORT.

Question 41

Why should digoxin be monitored?

Answer 41

for toxicity, too much drug causes toxicity

Question 42

AE dig.

Answer 42

arrythmia, GI, neurological complaints!! | hypokalemia, hypomagnesia

Question 43

MOA Ivabradine

Answer 43

If channel inhibitor, decrease risk hospitalization for worsening HF w/ stable symptomatic HFrEF if in sinus rythm w/ resting HR > 70 BPM

Question 44

Who should take Ivabradine?

Answer 44

Pt. on MAX dose BB or where BB CI (not proven to save lives, but BB is)

Question 45

CI ivabradine

Answer 45

1. decomp. HF 2. BR < 90/50 mmHG 3. arrythmia 4. HR < 60 5. Hepatic impairment 6. CYP3A4 inhib. (azole, macrolide, protease inhib) 7. Pregnancy (fetal toxicity)

Question 46

SE ivabradine

Answer 46

2. bradycardia 3. HTN 4. afib 5. luminous phenomena* 6. fetal tox

Question 47

MOA variciguat

Answer 47

PO quanyl cyclase activator, can be used as adjunct therapy to reduce risk of HF hospitalizations in symptomatic patient with evidence of worsening HF

Question 48

Role Variciguat HFrEF

Answer 48

Symptomatic

Question 49

CI variciguat

Answer 49

1. pregnancy 2. other SG c activators 3. posphodiesterase inhibitors (sildafenil, etc.)

Question 50

SE variciguat

Answer 50

hypotension, anemia

Question 51

Name some nonh-pharm ways to imrpove HFrEF

Answer 51

1. stop excess alcohol consumption 2. avoid if alcoholic cardiomyopathy 3. Na restirction 4. smoking cessation

Question 52

What meds may worsen HF

Answer 52

1. NSAIDS 2. antiarrythmias 3. CCB (amlodipine) 4. amphetamines (cocaine, danomycin, doxirubivin, etoh)

Question 53

How to treat HFpEF

Answer 53

1. control systolic and diastolic BP - ACEI/ARB (ARB reduce hospitalization) - BB - diuretics to reduce/relieve symptoms - SGLT2 inhib. (dec. hospitaliztation, no MORT) - ARNI (good sub if SGLT2 in. to expensive) - aldosterone antagonists