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Chronic Heart Failure Flashcards

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1
Q

What drug classes decrease HFrEF morbidity and mortality?

A
  1. RAAS inhibitors
  2. select Beta Blockers
  3. ARA (aldosterone antagonist)
  4. SGLT2i
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2
Q

What drug classes decrease hospitalizations and CV mortality in patients with HFmrEF (EF 41-49)?

A
  1. SGLT2i
  2. consider RAASi esp if comorbid conditions
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3
Q

What is considered HFrEF?

A
  1. EF ≤40%
  2. impaired ability to eject blood during systole (systolic dysfunction)
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4
Q

What is considered HFpEF?

A
  1. EF ≥50%
  2. impaired ventrical relaxation/filling during diastole (diastolic dysfunction)
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5
Q

What is considered HFmrEF?

A
  1. EF 41-49%
  2. likely mixed diastolic and systolic dysfunction
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6
Q

What is considered HFimpEF?

A
  1. EF ≤40% at baseline but EF improved >40% with treatment
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7
Q

How does ACC/AHA classify HF?

A

A= RFs only, no structural disease, biomarkers/sx
B= structural heart dx, abnorm cardiac function, or elevated biomarkers w/o s/sx
C= Structual and/or functional cardiac abnormalities with prior/current sx
D= Advanced/refectory with severe sx or recurrent hospitalization despite max tx

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8
Q

How does NYHA classify HF?

A

I= No limitations of phys activity and activity does not cause sx
II= Comfortable at rest but ordinary phys activity causes sx (walking up stairs); slight limitation
III= Comfortable at rest but minimal exertion causes sx (bathing, dressing); marked limitation
IV= No activity w/o sx or sx at rest

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9
Q

What are general s/sx/labs with HF?

A
  1. Dyspnea/SOB
  2. Cough
  3. Fatigue/weakness
  4. Reduced exercise capacity
  5. Elevated BNP (>100 pg/ml)
  6. Elevated NT-proBNP (>300 pg/ml)
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10
Q

What are s/sx of left sided HF?

A
  1. Pulmonary congestion
  2. Orthopenea (SOB when lying flat)
  3. Paroxsymal nocturnal dyspnea (nocturnal cough/SOB)
  4. Bibasilar rales (cracking lung sounds)
  5. S3 gallop
  6. Hypoperfusion (renal impairment/cold extremities)
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11
Q

What are s/sx of right sided HF?

A
  1. Systemic congestion/Peripheral edema
  2. Acities
  3. Jugular Venous Disstension (JVD)
  4. Hepatojugular reflux (neck vein distension from pressure on the abdomen)
  5. Hepatomegaly (enlarged liver due to congestion)
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12
Q

What is the pathophysiology of HF?

A
  1. High RAAS, SNS, and vasopressin increase CO
  2. Compensatory neurohormone (BNP) cannot keep up
  3. Increased HR, contractility, and vasoconstriction
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13
Q

What drugs cause/worsen HF?

A

DI NATION
1. DPP4i (saxagliptin, alogliptin)
2. Immunosuppressants (TNFi and IFs)
3. Non-DHP CCBs (if LVEF <50%)
4. Antiarrhythmiacs (amiodarone/dofetilide preferred in HF)
5. TZDs (pioglitazone)
6. Itraconazole (neg inotrope)
7. Oncology drugs (anthracyclines rubucin)
8. NSAIDs
Others:
1. systemic steroids
2. stims
3. Triptans
4. cilostazol

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14
Q

What are non-pharm therapies for HF?

A
  1. Document weight in the morning after voiding and before eating
  2. Notify provider if 2-4lb gain in 1 day, or ≥5lbs in 1 wk, or if sx worsen with activity
  3. <1,500mg/day Na if also have HTN
  4. 1.5-2L/day if stage D
  5. BMI<30
  6. exercise
    7.Pneumonia/flu
  7. Avoid smoking, alcohol, drugs
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15
Q

What herbs are used in HF?

A
  1. Omega 3s- decrease mortality and hospitalization
  2. Hawthorne- sx improvement
  3. CoQ10- sx improvement
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16
Q

When is an ARNI preferred over an ACE/ARB?

A
  1. NYHA class II-IV
  2. HFpEF
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17
Q

What is the target dose of Entresto for HFrEF?

A

97/103 mg BID

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18
Q

What are BBW with ARNI?

A

Injury/death to developing fetus; D/C asap if preg detected

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19
Q

What are CIs with ARNI?

A
  1. Use w/in 36h of ACE
  2. Hx angioedema
  3. use w/ aliskiren in DM
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20
Q

What are warnings with ARNI?

A
  1. Angioedema
  2. Hyperkalemia
  3. Renal impairment (more risk with Bilateral Renal Artery Stenosis)
  4. Hypotension/dizziness (caution esp with diuretics)
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21
Q

What are SEs with ARNI?

A
  1. Warnings
  2. cough
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22
Q

What should be monitored with ARNI?

A
  1. BP
  2. K
  3. renal function
  4. s/sx HF
  5. angioedema
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23
Q

Entresto

A

Sacubitril/Valsartan

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24
Q

What is the target dose of Enalapril for HF?

A

10-20mg PO BID

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25
What is the target dose of lisinopril for HF?
20-40 mg QD
26
What is the target dose of Quinapril for HF?
20mg BID
27
What is the target dose of Ramipril for HF?
10mg QD
28
Enalapril
Vasotec Epaned- oral sol
29
Quinapril
Accupril
30
Lisinopril
Prinivil Zestril
31
Ramipril
Altace
32
What is the target dose of Candesartan for HF?
32mg QD
33
What is the target dose of Losartan for HF?
50-150mg QD
34
What is the target dose of Valsartan for HF?
160mg BID
35
Candesartan
Atacand
36
Losartan
Cozaar
37
Valsartan
Diovan
38
What are DIs with RAASi?
1. Risk of hyperkalemia 2. 36h washout period w/ entresto and ACE 3. Decreases clearance of Li+, increasing toxicity
39
What is the target dose of Metoprolol for HF?
200mg QD with/immediatly after a meal
40
What is the target dose of Bisoprolol for HF?
10mg QD
41
What is the target dose of Carvedilol for HF?
Take all forms with food IR: ≤85kg- 25mg BID >85kg-50mg BID CR: 80mg QD
42
What is the MOA of ARA?
Compete with aldosterone rec sites in the distal convoluted tubule and collecting ducts
43
When should an ARA not be initiated in someone with HF?
1. K>5 mEq/L 2. CrCl (eGFR)≤ 30 3. SCr > 2mg/dL (female) or SCr >2.5 mg/dL (males)
44
What is the target dose of Spironolactone for HF?
25-50mg QD
45
What SGLT2i are approved for HF to decrease mortality and hospitalization?
1. Dapagliflozin (Farxiga) 2. Empagliflozin (Jardiance) 3. Sotagliflozin (Infepa)- SGLT1/2i approved to decrease CV death , hospitalization, and urgent visits for HF
46
What is the renal cut off for INITIATION of SGLT2i in HF (any indication)?
Dapagliflozin (Farxiga): eGFR <25 Empagliflozin (Jardiance): eGFR<20 *** can continue if eGFR falls below 20-25 while on the medication, cutoffs just for initiation
47
What is the MOA of loop diuretics?
Block Na+Cl reabsorption in the thick ascending loop of Henle, increasing excretion of Na, Cl, K, Mg, Ca, and water; reduces fluid volume, which reduces preload
48
What role do loop diuretics have in HF?
Symptomatic control; does NOT improve survival
49
What are BBWs with loop diuretics?
May cause profound diuresis, resulting in fluid/electrolyte depletion
50
What are CIs with diuretic use?
1. Anuria 2. Hepatic coma (bumetanide/torsemide)
51
What are the warnings with loop diuretics?
1. Sulfa allergy (not likely to cross react, but can) 2. Ototoxicity, more common with rapid IV admin or ethacrynic acid (tinnitus, hearing loss, vertigo) 3. AKI
52
What are SEs with loop diuretics?
1. Decreased K, Mg, Na, Cl, Ca 2. Elevated HCO3 (met alkalosis), UA, BG, TG, TC 3. Orthostatic hypotension 4. Photosensitivity 5. myalgias 6. nocturia if taken later in the day
53
What should be monitored with loop diuretics?
1. Renal function 2. Fluid status (I/O, weight) 3. BP 4. Electrolytes 5. s/sx HF
54
How are doses of loop diuretics interconverted?
Oral dosing: Furosemide 40mg= Torsemide 20mg= Bumetanide 1mg= Ethacrynic Acid 50mg IV dosing: Furosemide IV: PO 1:2
55
What loop diuretics are available IV?
1. Furosemide (Lasix)- 1:2 2. Bumetanide (Bumex)- 1:1 3. Ethacrynic acid (Edecrin)- 1:1
56
What are the storage requirements for loop diuretics?
Bumetanide and furosemide injections are light-sensitive and should be stored in amber bottles when not in IV admixture
57
What are DIs with loop diuretics?
1. Avoid NSAIDs due to decreased diuresis 2. Caution with drugs that lower BP, increase diuresis, electrolyte abnormality, or ototoxicity (additive effect) 3. Can alter Li levels leading to toxicity/ subtheraputic
58
What is the MOA of hydralazine/ isosorbide dinitrate?
1. Hydralazine is an arterial vasodilator (decreases afterload) 2. Nitrates increase NO, leading to vasodilation (decreases preload)
59
What role does hydralazine/ isosorbide dinitrate have in HF?
Improves survival to a lesser degree: 1. Indicated as adjunct in self-identified black patients with NYHA III-IV HF who are symptomatic despite optimal treatment 2. Alternative in patients who cannot tolerate a RAAS I due to poor renal function, angioedema, or hyperkalemia
60
What are warnings with BiDIl?
1. Worsening of ischemic heart disease 2. DILE (dose/duration related, reversible with D/C)
61
What are CIs with BiDil?
1. Mitral valve rheumatic heart disease 2. CAD 3. PDE-5i or riociguat
62
What are SEs with BiDIl
Hydralazine: Peripheral edema/ Headache/ Flushing/ Palpitations/ Reflex tachycardia, N/V, peripheral neuritis, blood dycrasis, hypotension Nitrate: Hypotension/ Headache/ Dizziness
63
What should be monitored with BiDil?
1. HR/BP 2. ANA titer 3. s/sx HF
64
What are DIs with BiDil?
Do NOT use with PDE5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil) causes severe hypotension
65
What role does ivabridine have in HF?
Reduces hospitalizations and maybe CV death: 1. Recommended as adjunct treatment in symptomatic HF NYHA II-III stable chronic HF EF≤35% 2. Patients MUST be receiving GDMT and be in normal sinus rhythm and HR≥70 3. Replaces beta blocker if CI or "boosts" effect
66
Ivabridine
Corlandor
67
What is the target goal we titrate Ivabridine to in HF?
resting HR 50-60
68
What are CIs to using ivabridine?
1. Acute decompensated HF 2. sick sinus syndrome 3. 3rd degree AV block unless pacemaker in place 4. significant hypotension bradycardia 5. HR maintain exclusively by pacemaker 6. hepatic impairment 7. strong CYP3A4 inhibitors
69
What are the warnings/ SEs with ivabridine?
1. Bradycardia: can increase the risk of QT prolongation/ ventricular arrhythmias; not recommended in 2nd degree heart block 2. Increased risk of AFib (why normal sinus rhythm required) 3. Fetal toxicity (females should use effective contraception) 4. luminous phenomena (phosphenes- flashes of light)
70
What should be monitored with ivabiridine?
1. HR 2. ECG 3. BP
71
What are DIs with Ivabridine?
1. Do not use with strong/moderate CYP3A4 inducers/inhibitors 2. Caution with other drugs that decrease HR including amiodarone and dexmedetomidine
72
Digoxin
Digitek Lanoxin
73
What is the MOA of digoxin?
1. Inhibits the Na-K-ATPase pump in myocardial cells causing a positive inotropic effect (increase CO) 2. Parasympathetic effect which slows Av node conduction causing a negative inotropic effect
74
What role does digoxin have in HF?
Can reduce HF related hospitalization but does NOT improve survival; improves symptoms, exercise tolerance, quality of life
75
What is a typical dose of digoxin for HF?
0.125-0.25mg QD, NO LD
76
When should doses of digoxin be decreased?
Starting dose: if underweight/small, old age, renal insufficiency CrCl<60: Reduce dose/frequency, hold in AKI PO to IV: Decrease dose by 20-25%
77
What is the therapeutic range of digoxin?
0.5-0.9 ng/mL
78
What are CIs with digoxin?
Ventricular firillation
79
What are warnings/SEs with digoxin?
Warnings: 2nd/3rd degree heart block w/o pace maker, Wolff-Parkinson White syndrome with AF, vesicant SE: dizziness, visual, mental disturbance, headache, N/V/D
80
What are signs of digoxin tocicity?
1. N/V, ab pain, loss of appetite 2. Blurred/ double vision 3. Green-yellow halos/ altered color perception 4. confusion/ delirium 5. Bradycardia 6. Life threatening arrhythmia
81
What increases the risk of digoxin toxicity?
1. Hypokalemia/ hypomagnesemia 2. Hypercalcemia 3. Hypothyroidism
82
What should be monitored with digoxin?
1. Electrolytes 2. Renal function 3. HR 4. ECG 5. BP 6. digoxin level 12-24h after dose
83
What is the antidote for digoxin toxicity?
DigiFab
84
What are DIs with digoxin?
1. P-gp inhibitors increase digoxin 2. Reduce digoxin dose by 50% when starting amiodarone/ dronedadrone 3. Caution with verapamil, cyclosporine, itraconazole, erythromicin, clarithromycin, quinidine, propafone, and others 4. Caution with other drugs that decrease HR
85
Vericiguat
Verquvo
86
What is the MOA of vericiguat?
soluble guanylate cyclase stimulator leads to vasodialation
87
What role does vericiguat have in HF?
Reduces CV death and HF hospitalization following a hospitalization for HF or need for IV diuretics with chronic sx HF EF<45% on GDMT
88
What is a BBW with vericiguat?
Do NOT use if pregnant; contraception required during use and for 1 mo after stopping tx
89
What are CIs with vericiguat?
Do not use with riociguat (same class)
90
What are SEs with vericiguat?
1. Hypotension 2. anemia 3. dyspepsia
91
What are DIs with vericiguat?
1. PDE5 inhibitors 2. Long acting nitrates Both cause profound hypotension
92
When should K and Mg levels be checked in patients with HF?
1. Check levels with any change in renal function, dose changes of RAASi, ARA, or diuretic 2. Correct Mg first then correct K
93
Potassium Chloride
ER tablets: K-Tab, Klor-Con, Klor-Con 10, Klor-Con M10/ M15/ M20 Oral packet: Klor-Con Oral solution: 10% (20mEq/15mL), 20% (40meQ/15mL) Injection: KCl high alert medication
94
What is the dosing of K for hypokalemia treatment/prevention?
Prevention: 20-40 mEq/day on 1-2 doses Treatment: 40-100 mEq/day in 2-4 divided doses Take with meals and a full glass of water to minimize the risk of GI irritation *** No more than 40 mEq as a single dose to reduce GI sx
95
What are CIs with KCl?
Solid oral formulation: obstruction /delayed passage thru GI tract hyperkalemia
96
What are warnings/SEs with KCl?
1. Abdominal pain/cramping 2. nausea/diarrhea/flatulence 3. risk of hyperkalemia: caution with renal impairment, untreated addision's
97
What should be monitored with KCl?
K/ Mg/ Cl/ pH/ urine out put
98
How can different forms of KCl be modified for patients with swallowing difficulty?
ER capsules: sprinkled on a small amt of apple sauce/pudding Klor-Con M (ER tab): cut in half or dissolve in water (stir for 2 min and drink immediately) Oral packet: dissolve contents in water and drink immediately Oral solution: mix 15mL sol with 6 oz water ***ER tabs (Klor-Con, K-Tab): Must be swallowed whole; do not crush, chew, or suck on any dosage forms
99
What foods are high in sodium?
1. Prepared sauces/condiments 2. Canned vegtables/soups 3. Frozen meals 4. Deli meat 5. Pickles, olives, cheese, nuts chips
100
What are examples of a heart failure action plan?
1. Monitor weight daily; notify provider if increase 2-4 lbs in 1 day or ≥5lbs in a week 2. Increased number of pillows/ unable to sleep/lay flat 3. shortness of breath with activity/rest 4. Increased swelling/ coughing 5. Dizziness, confusion, depression 6. Call 911 of having severe chest pain
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