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A - NAPLEX > Chapter 31: Chronic Heart Failure > Flashcards

Chapter 31: Chronic Heart Failure Flashcards

1
Q

How does HF occur

A

when the heart is not able to supply sufficient oxygen-rich blood to the body, because of impaired ability of the ventricle to either fill or eject blood

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2
Q

Symptoms of HF are usually related to _____, which commonly presents as ___ and ___

A

fluid overload

SOB & edema

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3
Q

What is performed when HF is suspected

A

An ECHO

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4
Q

An ECHO provides an estimate of

A

LVEF, which is a measurement of how much blood is pumped out of the left ventricle (the main pumping chamber of the heart) with each contraction

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5
Q

An EF < 40% indicates ___ dysfunction, or HFrEF

A

systolic

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6
Q

Which ACC/AHA stage is described:
At high risk for development of HF, but without structural heart disease or symptoms of HF (e.g. HTN, CAD, DM, obesity, metabolic syndrome)

A

Stage A

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7
Q

Which ACC/AHA stage is described:

Structural heart disease present, but without signs or symptoms of HF (e.g. LVH, low EF, valvular disease, previous MI)

A

Stage B

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8
Q

Which ACC/AHA stage is described:
Structural heart disease with prior or current symptoms of HF (e.g. known structural heart disease, SOB and fatigue, reduced exercise tolerance)

A

Stage C

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9
Q

Which ACC/AHA stage is described:
Advanced structural heart disease with symptoms of HF at rest despite maximal medical treatment (refractory HF requiring specialized intervention)

A

Stage D

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10
Q

Which NYHA Functional Class is described:
No limitations of physical activity. Ordinary physical activity does not cause symptoms of HF (e.g. fatigue, palpitations, dyspnea)

A

NYHA Class I

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11
Q

Which NYHA Functional Class is described:
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity (e.g. walking up a flight of stairs) results in symptoms of HF

A

NYHA Class II

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12
Q

Which NYHA Functional Class is described:
Marked limitation of physical activity. Comfortable at rest but minimal exertion (e.g. bathing, dressing) causes symptoms of HF

A

NYHA Class III

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13
Q

Which NYHA Functional Class is described:
Unable to carry any physical activity without symptoms of HF, or symptoms of HF at rest (e.g. SOB while sitting in a chair)

A

NYHA Class IV

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14
Q

Which labs are increased in HF

A

Increased BNP, Increased NT-proBNP

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15
Q

What are left-sided signs and symptoms of HF

A
  • Orthopnea: SOB when lying flat
  • Paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
  • Bibasilar rales: cracking lung sounds heard on lung exam
  • S3 gallop: abnormal heart sound
  • Hypoperfusion (renal impairment, cool extremities)
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16
Q

General signs and symptoms of HF

A
  • Dyspnea (SOB at rest or upon exertion)
  • Cough
  • Fatigue, weakness
  • Reduced exercise capacity
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17
Q

What are right-sided signs and symptoms of HF

A

(think of congestion)

  • Peripheral edema
  • Ascites: abdominal fluid accumulation
  • Jugular venous distention (JVD): neck vein distension
  • Hepatojugular reflux (HJR): neck vein distension from pressure placed on the abdomen
  • Hepatomegaly: enlarged liver d/t fluid congestion
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18
Q

What is cardiac output

A

volume of blood that is pumped by the heart in 1 minute

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19
Q

How is cardiac output calculated

A

CO = HR x SV

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20
Q

HFrEF is a low cardiac output state, which the body compensates for by activating neurohormonal pathways to _____ or the _____. This can temporarily increase CO, but chronically leads to myocyte damage and _____

A

increase blood volume
force or speed of contractions
cardiac remodeling

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21
Q

The main pathways activated in HF are the ___, the ___ and ___

A

RAAS
SNS
vasopressin

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22
Q

Ang II causes

A

vasoconstriction

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23
Q

Aldosterone causes

A

Na and water retention

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24
Q

Vasopressin causes

A

Vasoconstriction and water retention

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25
Q

NE and EPI release causes ↑ in ___, ___ (positive inotropy) and ____

A

HR
contractility
vasoconstriction

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26
Q

Patients with HF should be instructed to:

A
  • Monitor and document body weight daily
  • Notify provider if weight ↑
  • Restrict Na intake to < 1,500 mg/day
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27
Q

Natural products used in HF

A

Omega-3 FA, hawthorn and Coenzyme Q10

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28
Q

Key drugs that can cause or worsen HF

A
  • Remember: Drug Information NATION*
  • DPP4-I; alogliptin, saxagliptin
  • Immunosuppressants; TNF-I (e.g., adalimumab, etanercept) and interferons
  • Non-DHP CCBs; diltiazem and verapamil (in systolic HF)
  • Antiarrhythmics; Class I agents (e.g., procainamide, quinidine, flecainide) in HF, amiodarone and dofetilide have less risk of worsening HF
  • TZDs ↑ risk of edema
  • Itraconazole
  • Onco drugs; anthracyclines (doxorubicin, daunorubicin)
  • NSAIDs; all including celecoxib
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29
Q

Which drug classes are used to treat HF

A

ACEi/ARB/ARNI + BB + loop

Aldosterone receptor antagonist is usually added next

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30
Q

Which drug classes decrease mortality in HF and are recommended for all pts without CI

A
  • ACEi or ARB
  • ARNI
  • BB
  • Aldosterone receptor antagonist
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31
Q

Which 2 drugs decrease mortality in black patients with NYHA Class III-IV when added to an ACEi/ARB and BB or in other patients who cannot tolerate an ACEi or ARB

A

Hydralazine and nitrates (BiDil)

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32
Q

Which medication classes are also used in HF to improve other aspects, but are not proven to decrease mortality

A

Loops, Digoxin, Ivabradine (Corlanor)

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33
Q

Where do loop diuretics work

A

Thick ascending limb of the loop of Henle

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34
Q

Loop diuretics ↑ excretion of which electrolytes/labs

A

Na, Cl, Mg, Ca and water

note: remember, thiazides increase Ca, while loops decrease Ca levels

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35
Q

Loop diuretic warnings

A

Sulfa allergy; warning does not apply to ethacrynic acid

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36
Q

Loop diuretics increase which electrolytes/labs

A

HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol

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37
Q

Ethacrynic acid or rapid IV administration of loops can cause

A

ototoxicity

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38
Q

Side effects of loops

A

Orthostatic hypotension and photosensitivity

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39
Q

How should furosemide injection be stored

A

at room temp

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40
Q

Dose conversions for oral loop diuretics

A

furosemide 40 mg = torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 50 mg

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41
Q

Furosemide IV:PO ratio

A

1:2

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42
Q

Which drug class should be avoided with loop diuretics

A

NSAIDs (can retain water and Na & lower the effect of loops)

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43
Q

ACEi MOA

A

block conversion of Ang I to Ang II resulting in ↓ vasoconstriction and ↓ aldosterone secretion

44
Q

ARB MOA

A

block Ang II from binding to AT1 receptor

45
Q

Enalapril brand name

A

Vasotec

46
Q

Lisinopril brand names

A

Prinivil, Zestril

47
Q

Quinapril brand name

A

Accupril

48
Q

Ramipril brand name

A

Altace

49
Q

ACEi, ARB & ARNI BW

A

Can cause injury and death to developing fetus when used in 2nd and 3rd trimesters; d/c as soon as pregnancy is detected

50
Q

ACEi should not be used within __ hrs of sacubitril/valsartan (Entresto)

A

36

51
Q

ACEi warnings

A

Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
(same for ARB, but less cough and angioedema)

52
Q

T/F: ARBs do NOT require a washout period with sacubitril/valsartan (Entresto)

A

True

53
Q

Losartan brand name

A

Cozaar

54
Q

Valsartan brand name

A

Diovan

55
Q

Target dose of enalapril

A

10-20 mg PO BID

56
Q

Target dose of lisinopril

A

20-40 mg PO daily

57
Q

Target dose of quinapril

A

20 mg BID

58
Q

Target dose of ramipril

A

10 mg daily

59
Q

Which ACEi is taken TID

A

captopril

only ACEi with a t in it for TID

60
Q

Target dose of losartan

A

50-150 mg daily

61
Q

Target dose of valsartan

A

160 mg BID

62
Q

Which enzyme is responsible for the degradation of several beneficial vasodilatory peptides

A

Neprilysin

63
Q

An ARNI is indicated in NYHA Class II-IV patients to reduce ______

A

HF hospitalizations and CV death

64
Q

The ARNI, Sacubitril/Valsartan (Entresto) is used in place of

A

ACEi or ARB

65
Q

ACEi, ARB and ARNI can decrease clearance of ____ & can increase the risk of toxicity

A

Lithium

66
Q

Unlike ACEi or ARBs, the clinical benefits of BB are not a class effect and only the following BB are recommended for HF patients

A

Bisoprolol, carvedilol (IR, ER), & metoprolol succinate ER

67
Q

Metoprolol succinate ER target dose in HF

A

200 mg daily

68
Q

Carvedilol IR target dose in HF for

  • = 85 kg
  • > 85 kg
A

= 85 kg: 25 mg BID

> 85 kg: 50 mg BID

69
Q

Carvedilol CR target dose in HF

A

80 mg daily

70
Q

Metoprolol IV:PO ratio

A

1:2.5

71
Q

Which XR BB can be cut in half

A

Toprol XL

72
Q

Which BB must be taken with food

A

Carvedilol

73
Q

MOA of aldosterone receptor antagonists

A

DCT and collecting ducts of the nephron

74
Q

Spironolactone target dose in HF

A

25 mg daily or BID

75
Q

ARAs can decrease clearance of which drug, which can increase risk of toxicity

A

Lithium

76
Q

MOA of hydralazine

A

arterial vasodilator which decreases afterload

77
Q

Nitrates MOA

A

increase availability of NO, causing venous vasodilation and decreasing preload

78
Q

Which drugs can be used as an alternative to ACEi or ARBs due to poor renal function, angioedema or hyperkalemia to improve survival in HF

A

Hydralazine or Isosorbide dinitrate IR/ER

79
Q

What is the combination of Hydralazine and Isosorbide Dinitrate called

A

BiDil

80
Q

When is BiDil indicated

A

in self-identified black patients with NYHA Class III or IV who are symptomatic despite optimal treatment with ACEi, ARB or ARNI & BB.

81
Q

Hydralazine warning

A

DILE

82
Q

Hydralazine SE

A

Peripheral edema/HA/flushing/palpitations/reflex tachycardia

83
Q

Isosorbide dinitrate BW

A

Do not use with PDE-5 inhibitors

84
Q

Isosorbide dinitrate SE

A

Hypotension, HA, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 hr nitrate-free interval), syncope

85
Q

Digoxin MOA

A

Inhibits the Na-K-ATPase pump causing a positive inotropic effect (↑ in CO) and exerts a parasympathetic effect, which causes a negative chronotropy (↓ HR)

86
Q

Digoxin can reduce:

A

HF related hospitalizations

87
Q

When should a lower dose of dioxin be used

A

renal insufficiency (CrCl < 50 mL/min, smaller, older or female)

88
Q

Typical dose range for digoxin

A

0.125-0.25 mg PO daily

89
Q

When switching from IV to PO digoxin, how much should the dose be decreased by

A

20-25%

90
Q

What is the therapeutic range of digoxin in HF

A

0.5-0.9 ng/mL

91
Q

Initial s/sx of digoxin toxicity

A

N/V, loss of appetite and bradycardia

92
Q

Severe s/sx of digoxin toxicity

A

blurred/double vision, greenish-yellow halos around lights or objects

93
Q

Digoxin antidote

A

DigiFab

94
Q

What electrolyte abnormalities can increase risk of digoxin toxicity

A

hypokalemia, hypomagnesemia, and hypercalcemia

95
Q

Reduce digoxin dose by ___% when starting amiodarone

A

50%

96
Q

Purpose of ivabradine in HF

A

reduces the risk of hospitalizations for worsening HF but does not affect mortality

97
Q

To initiate ivabradine, patients must already be on mortality-reducing agents, including target or max-tolerated doses of BB (or CI to use), and be in ____ with resting HR > ___ BPM

A

sinus rhythm

70

98
Q

Ivabradine can cause

A

bradycardia, which can increase risk of QT prolongation and ventricular arrhythmias (remember, the word is in the name)

99
Q

Target resting HR for ivabradine

A

50-60 BPM

100
Q

Ivabradine SE

A

Bradycardia, HTN, Afib

101
Q

What should be checked and corrected prior to correcting K levels

A

Magnesium

102
Q

concentration of Oral solution of 10% potassium chloride

A

20 mEq/15 mL

103
Q

KCl oral solution should be mixed with __ oz of water

A

6

104
Q

T/F: capsule contents of ER Capsules of KCl (Micro-K, Klor-Con Sprinkle) can be sprinkled on a small amount of applesauce or pudding

A

True

105
Q

T/F: K-Tab, Klor-Con should be swallowed whole; do not chew, crush, cut, or suck on tablet

A

True

106
Q

T/F: Klor-Con M: If difficult to swallow whole, it can be cut in half or dissolved in water (stir for 2 min and drink immediately); do not chew, crush or suck on the tablet

A

True

A - NAPLEX (83 decks)

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