Chronic Heart Failure Flashcards by Hannah Lapos

Etiology of HF

Heart is not able to apply sufficient oxygen rich blood to the body because of impaired ability of the left ventricle to fill or eject blood

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Diagnosis ejection fraction

echocardiogram

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LVEF ≥50

HFpEF: impaired ventricular relaxation and filling during diastole

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41-49% EF

HFmrEF

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What is HFimpEF

≤40% at baseline but improves to >40%

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LVEF ≤40%

HFpEF: impaired ability to eject blood during systole

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What is the ACC/AHA staging

Structural classification
A: Patient is at risk with no sx
B: Pre-HF with structural heart disease with no signs of sx
C: Structural abnormalities with sx
D: Advanced (refractory) HF requiring hospitalization (ADHF)

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What are the NYHA functional classes?

I: No limitations to physical activity
II: Slight limitation but ordinary activity → sx of HF
III: Marked limitations with minimal exertion
IV: Unable to carry out physical activity without sx of HF or sx at rest

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What are labs of HF

BNP >100
NT-proBNP >300

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Sx of left sided HF

Orthopnea: SOB when lying flat
Paroxysmal nocturnal dyspepsia: nocturnal cough and SOB
Rales: crackling
S3 gallop
Hypoperfusion: renal impairment or cool extremities

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General sx of HF

Dyspepsia
Cough
Fatigue, weakness
Reduced exercise capacity

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Sx of right sided HF

Peripheral edema
Ascites
JVD
HJR
Hepatomegaly

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What is cardiac output

Volume of blood that is pumped by the heart in 1 min

CO = HR x SV

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How to calculate Cardiac index

CI = CO/BSA

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Describe the compensatory mechanism of HFrEF

Low cardiac output → activation of neurohormonal pathways (RAAS) → ↑ blood volume and force of contraction → chronic compensation leads to cardiac remodeling

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Activity of Ang2

Vasoconstriction → release aldosterone and vasopressin

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Activity of aldosterone

Sodium and water retention

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Activity of vasopressin

Vasoconstriction and water retention

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Lifestyle counseling of HF

Monitor body weight
Notify provider if weight ↑ 2-4 lbs in one day or ≥5 lbs in a week
Avoid sodium ≤1.5g/day
Restrict fluid 1.5-2L

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Natural products used for HF

CoEnzyme Q10
Hawthorn
Omega 3 FA

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Drugs that worsen HF

DDP-4 (alogliptin and saxagliptin)
Immunosuppressants (TNF inhibitors)
Non-DHP CCB
Antiarrhythmics (CI, amiodarone, and dofetalide)
TZDs
Itraconazole
Oncology drugs (Doxorubicin and daunarubicin)
NSAIDs

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What are the GDMT drugs

ARNI, ACEI, or ARB: reduce mortality and morbidity
BB: reduce mortality and hospitalizations
MRAs: reduce morbidity and mortality
SGLT2I: reduce hospitalization and mortality

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Medication that is preferred in HFmrEF?

SGLT2i

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MOA of entresto

Sacubitril: neprilysin inhibitor, an enzyme responsible for degradation of vasodilatory peptides (BNP)

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Target dose of entresto

97/103 mg BID

BBW of entresto? CI?

Teratogenic CI: do not use with or within 36 hrs of an ACI, angioedema

ADRS of entresto?

Angioedema, hyperkalemia, renal impairment (bilateral renal artery stenosis), hypotension, cough

Target dose of enalapril

10-20 mg PO BID

Target dose of lisinopril

20-40 mg QD

Target dose of quinapril

20 mg BID

Target of ramipril?

10 mg QD

Target dose of losartan

50-150 mg QD

Target dose of valsartan?

160 mg BID

BB indicated for HF

Bisoprolol, metoprolol succinate, carvedilol

When do you DC BB for HF

ADHF if hypotension or hypo perfusion is present Intrinsic sympathomimetic activity

Target dose of metoprolol succinate

200 mg QD

Target dose of bisoprolol

10 mg QD

Target dose of carvedilol

CR: 80 mg QD IR: - ≤85 kg: 25 mg BID - >85 kg: 50 mg BID

Warning and ADR of BB

Warning: diabetes (masking hypoglycemia except sweating), asthma, COPD, Raynaud's ADR: bradycardia, hypotension, CNS effects (fatigue, DZ, depression), impotence

Metoprolol IV to PO

IV:PO is 1:2.5 ratio

Counseling of Toprol XL

Can be cut in half and should be taken with or immediately after meals

Counseling of carvedilol

Take with food

Carvedilol CR to IR

Coreg IR 3.125 mg BID = Coreg CR 10 mg QD

Difference between spironolactone and eplerenone

Spir: non-selective → endocrine ADRs Eple: selective → no endocrine ADRs

CI of MRAs

Hyperkalemia >5, severer renal impairment, Addison's

Spironolactone ADR

Gynecomastia, breast tenderness, impotence

Target dose of Spironolactone

25-50 mg QD

Target dose of eplerenone

50 mg QD

Target dose of dapagliflozin

10 mg QD

Target dose of empagliflozin

10 mg QD

Sotagliflozin target dose

200-400 mg QD

When should you not initiate SGLT2I

eGFR <20-25

When should you not initiate MRAs

K >5 mEq/L CrCl ≤30 sCr >2 (females), >2.5 (males)

Site of action for loops

Ascending loop of Henle

What is loops for HF

Doesn't not improve survival but used for sx control

Warning of loops

Ototoxicity Sulfa allergy (not ethacyrnic acid) AKI

Loop conversions

Furosemide = Torsemide = Bumetanide = Ethacrynic acid 40 mg = 20 mg = 1 mg = 50 mg Furosemide IV = PO → 1:2

Loops DDI

↑ lithium levesl

ADR of loops

↓ : K, Mg, Na, Ca, Cl ↑ : UA. BG. TG, TC, HCO3 Orthostatic hypotension, photosensitivity

MOA of hydralazine? Nitrates?

Hydralazine: Direct arterial vasodilator → ↓ afterload Nitrates: Venous vasodilator → ↓ preload

Why is BiDil recommended?

Improves survival: for patients who can't tolerate ACE, ARB, or ARNI due to poor renal function, angioedema, hyperkalemia Indicated for self-identified Blacks

ADR and warning of hydralazine

DILE, peripheral edema, flushing, palpitations, reflex tachycardia

ADR and warning of isosorbide dinitrate?

CI: PDE5I ADR: hypotension, HA, DZ, tachyphylaxis (need 10-12 hr nitrate free interval), syncope

MOA of ivabridine

Disrupts the "funny" current in the SA node → ↓ rate of firing → reduce HR

What is Ivabridine used for?

Adjunct therapy for patients already on GDMT max doses to reach a resting HR ≥70 bpm

MOA of digoxin

Inhibits Na-K-ATPase pump → positive inotropic effect (↑ contractility and CO) but negative chronotropic (↓ HR)

Purpose for digoxin

Improves sx, exercise intolerance, and quality of life

Serum level for digoxin in HF

0.5 - 0.9 ng/mL

Typical dose of digoxin

0.125 - 0.25 mg

Dosing of digoxin PO to IV

Reduce PO dose by 20-25% for IV dose

Signs of digoxin toxicity

N/V, loss of appetite, blurred/double vision, greenish-yellow halos, bradycardia, arrhythmias HYperkalemia, hypomagnesemia, hypercalemia

Antidote for digoxin

DigiFab

Dosing adjustment with concurrent amiodarone

Reduce digoxin dose by 50%

MOA of vericiguat

Soluble guanylate cyclase stimulator → increase cyclic GMP and leads to smooth muscle relaxation and vasodilation

Purpose of veriiciguat

Patient with persistent sx of HF with optimized GDMT

ADR of viriciguat

Hypotention

ER capsules of K

Klor-Con sprinkle, Micro-K

ER tabs of K

K-Tab, Klor-con (M)

PO solution strengths of K

10% (20 mEq/15 mL0 20% (40 mEq/15mL)

Counseling on ER capsules of K

Contents can be sprinkled on applesauce or pudding

Counseling on ER tabs of K

K-tab, Klor-con: swallow whole Klor-con M: if difficult to swallow, cut in half or dissolve in water (stir for 2 min and drink immediately)

Counseling of Po K solution

Mixing each 15 mL with 6 oz of water

Chronic Heart Failure Flashcards

(82 cards)