Blocks formation of/effect of Angiotensin II - decrease afterload (vasodilation) - blocks aldosterone (less Na+/water retention) - -lowers BP - decreasing remodeling

Cardio: Heart Failure Drugs Flashcards by Mitch Nichols

What are some drugs used for heart failure?

ACEi
ARBs
Carvedilol
Diuretics (both loop and K+ sparing)
Nitrates
Digoxin
Dobutamine/Dopamine
Milrinone

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What is the difference between systolic and diastolic heart failure?

Systolic=pump issue
-loss of contractility, usually due to volume overload and eccentric hypertrophy

Diastolic=relaxing issue
-hypertrophic and stiff ventricle leads to decrease in filling, contractility is fine though

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Which of the two, systolic or diastolic, has a preserved ejection fraction?

Diastolic

-like I said, systolic is a bad pump so you cannot get the fluid out

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What can make Diastolic HF worse?

A fib leads to less filling, making it worse

Tachycardiac means less filling

Increase in MAP

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MOA of ACEi/ARBs

Blocks formation of/effect of Angiotensin II

decrease afterload (vasodilation)
blocks aldosterone (less Na+/water retention)
-lowers BP
decreasing remodeling

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Clinical applications for Captopril (or other -prils)?

HTN, Systolic HF, diabetic nephropathy

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What are some common toxicities of all ACEi?

Cough, angioedema, Teratogenic!!
-do not use w pregnancy

Also hyperkalemia, hyponatrema

Altered taste (mainly captopril)

Embryotoxic!

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Which ACEi’s have longer half life, permitting once/day dosing and are more widely used today?

Benazepril and lisonopril

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Clinical applications for losaratan (or other sartans)

HTN,
diabetic nephropathy,
CKD,
HF resistent to ACEis

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What are some common toxicities of all ARBs?

Hypotension, hypoglycemia, hyperkalemia

Embryotoxic!

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What make valsartan unique to the other ARBs?

It is not a prodrug, therefore does not need activation and is eliminated primarily in the feces
-works if poor renal function

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What makes candesartan unique to other ARBs?

It has irreversible binding to AT1

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Effects of Valsartan/Sacubitril?

Leads to increased secretion of BNP and ANP
-increases fluid loss, lowers BP

Valsartan is an ARB, so blocks Angiotensin II

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Clinical applications of Valsartan/Sacubitril?

Heart failure w Reduced EF

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How does Sacubitril work?

Inhibits neprilysin NEP through its active metabolite, LBQ657

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Adverse effects of Valsartan/Sacubitril?

Hypotension, hyperkalemia, increased serum Creatinine

Angioedema**

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MOA of carvedilol?

nonselective (inverse agonist) Beta- and alpha-adrenergic blocker
-B>a activity

Slows HR (less O2 use), protects from arrhythmias, reduces Renin

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Clinical applications for carvedilol?

If stable:

recent MI with rEF
HFrEF (systolic HF)
HTN (not first choice)

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Toxicities of carvedilol?

Chest pain, discomfort, dizziness, lightheaded, swelling of LE, pain, SOB, bradycardia

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Which B-blocker is good for HTN emergencies?

Labetalol

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If a patient has had a recent MI and now has reduced ejection fraction, what should be given along with B-blockers?

ACEi

-this has been proven to reduce mortality

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Would you use B-blockers in someone with COPD, Asthma, or heart blocks?

Nope

-can make all worse

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What should you do when taking someone off a B-blocker?

Taper them off!

-abrupt removal can cause acute tachycardia, HTN and ischemia

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MOA of Ivabradine?

blocks If (funny) channels
-prolongs diastole and slows HR

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Clinical applications of Ivabradine?

Treatment of HR>70 with systolic HF

can you use B-blockers with ivabradine?

Yes, but only maximally tolerated doses of B-blockers, or if they are contraindicated

Toxicities of Ivabradine?

``` Bradycardia, HTN (reflex), increase A-fib risk, heart block, SA arrest ```

Contraindications of Ivabradine?

Decompensated HF -meaning regulation isn't working Hypotension, AV block, hepatic impairment

MOA of spironolactone

Competitive aldosterone antagonist - decreases reabsorption of Na and water - -lowers BP Also antagonizes pro-fibrotic effect of aldosterone

Clinical applications of spironolactone

Tx of: - HF without loss of K+** - reduces fibrosis in HFrEF post MI** - Primary hyperaldosteronism

What is interesting about spironolactones pharmacokinetics?

it is a steroid, so it is slow on, slow off | -single dose lasts for a few days

Adverse effects of spironolactone?

Hyperkalemia Amenorrhea, hirsuitism, gynecomastia, impotence Tumorigen

What can happen if you mix loop diuretics with digoxin?

Increases toxic effects! | -hypokalemia increases the effect of digoxin

MOA of loop diuretics?

NKCC blocker, so water will follow - lowers fluid, therefore lowers preload and BP - removes fluid congestion to bring heart to optimal stretch length

Where do loop diuretics work?

Thick ascending loop of Henle

Clinical applications of Furosemide

Loop diuretic for edema in: -HF, cirrhosis, renal issues** Lowers preload and BP

Toxicities in furosemide?

Loss of electrolytes (K, Na, Ca, Mg) Hyperglycemia, Hyperuricemia Ototoxic!* -vertigo, tinnitus Sulfa drug*

What loop diuretics have better oral absorption, so work better in HF?

Torsemide and butemide

What can be given as a loop diuretic in those w a sulfa allergy?

Ethacrynic acid

What drug drug interactions do you need to watch for with loop diuretics?

Digoxin -less K+ can increase toxicity of digoxin Ototoxic drugs -mycin Abs!

What can be given with loop diuretics to prevent hypokalemia?

K+ sparing diuretics | -spironolactone

What class of diuretics loses the least amount of bicarb?

Loop diuretics

Hydrochlorothiazide MOA

Blocks NaCl cotransporter at distal tubule | -decreases Na and Water absorbed to lower BP

What is an off label use of Hydrochlorothiazide

Calcium nephrolithiasis | -counters loss of Ca+

Toxicities of Hydrochlorothiazide

Loss of electrolytes (K, Na, Mg) Hyperglycemia, Hyperuricemia Sulfa drug*

Which thiazide diuretic is a favorite of cardiologists?

Metolazone

Which thiazide diuretic is longest acting?

Chlorthalidone

What are some common causes of diuretic failure?

Nonadherance, excess salty diet Decreased GFR NSAID use

Isosorbide dinitrate decreases ___load while hydralazine decreases ___load

Isosorbide dinitrate decreases preload while hydralazine decreases afterload

What does hydralazine require to become activated?

COX activation, mediated by PGI

Clinical applications of hydralazine?

HTN and HF (especially African Americans, or if ACEi contra)

When is hydralazine used in HTN emergency?

In pregnancy!

Does hydralazine dilate arterioles or veins?

Arterioles | -decrease afterload

Does nitroglycerin dilate arterioles or veins?

Veins | -decrease preload

Adverse effects of hydralazine

angina pectoris, flushing, tachycardia, edema pruritis** drug-induced lupus**

MOA of digoxin

Inhibits Na/K ATPase - increases Na and Ca in heart, increasing contractility (positive inotrope) - directly suppresses AV node

Clinical applications of Digoxin

To.. - control RVR in a-fib - Treat HF by increasing contractility of heart

How is digoxin administered?

Orally | -increases as CO and renal function decrease so needs loading dose!

Is digoxin safe in pregnancy?

Yup, safe to use in SVTs during pregnancy

Adverse effects of digoxin

Cholinergic effects (N/V, diarrhea), blurry yellow vision, arrythmias (PVC), AV block these are the ones in FA

How does digoxin affect ANS activity?

Increases Vagus firing rate, so more response to SA node to ACh

How do you treat digoxin overload?

KCl Lidocaine, Phenytoin (Class IB antiarrythmic) Anti-digitalis Abs

First line Tx of Systolic HF?

ACEi or ARBs or ARNI in conjuction with B-blockers/aldosterone antagonists

Tx of Diastolic HF?

Control BP | -treat symptoms with diuretics

Do nitrates, PDE5 inhibitors, or digoxin have efficacy for treating HFpEF?

No, so dont use

If a patient is hyper/normotensive with Acute Decompensated HF, how should you treat?

Loop Diuretic + Vasodilator (nitrates/nitroprusside)

If a patient is hypotensive with Acute Decompensated HF, how should you treat?

Just a loop diuretic

If a patient has Decompesated HF and signs of symptomatic hypotension with end-organ dysfunction what should be given?

Dobutamine or Dopamine and Discontinue B-blockers if pt has moderate-severe end organ damage

MOA of milrinone

Selective PDE-3 inhibitor | -used as inotropic agent increasing cAMP

Clinical use of milrinone?

Used for unresponsive HF

Adverse effects of milrinone?

Ventricular arrythmias, SVTs, headache

MOA of Dobutamine

Increase B1/B2 activity (+) enantiomer -increase HR and Contractility for cardiac shock Block a-receptors (-) enantiomer

MOA of dopamine

Low doses=activates B1 | -increase HR and contractility for shock and cardiac decompensation

What drugs should you avoid in decompensated HF?

Class I antiarrythmics (consider amiodarone instead), CCBs, NSAIDs

How do you know if digitalis is therapeutic or toxic based on ECG?

Therapeutic -ice cream scoop Toxic -decoupled Atria and ventricular contraction or even PVCs

Cardio: Heart Failure Drugs Flashcards

(75 cards)