Chronic Heart Failure

Question 1

When does HF occur?

-This occurs due to ?

Answer 1

When the heart is unable to supply sufficient oxygen rich blood to the body . bc of impaired ability of left ventricle to either fill with or eject blood.

-problem with systolic (contraction) or diastolic (relaxation) functions of the heart

Question 2

HF is commonly classified as either ischemic (due to decr blood supply to heart) such as from an ___ or NON-ischemic, such as from ____ uncontrolled ____

Answer 2

MI

long standing

hypertension

Question 3

1. Sx’s of HF are usually related to ? which commonly presents as?
2. When HF is suspected, what is preferred to visualize and see whats going on with the heart?

-What does it provide an estimate of?

3. What does an EF < 40% indicate?
4. What does EF 55-70% mean?
5. EF >=50%?
6. EF <=40% at baseline but improves to >40%?

Answer 3

1. fluid overload

SOB, and edema

2. echocardiography or echo

-left ventricular ejection fraction (LVEF)

3. systolic dysfunction or HF with reduced ejection fraction (HFrEF)
4. normal
5. HFpEF
6. HFimpEF

Question 4

The ACC/AHA staging system is used to guide tx in order to ___ of structural heart disease (___ , low ___) in asymptomatic pt’s which is stages ____

or in symptomatic pt’s which is stages ___

Answer 4

slow progression

left ventric hypertrophy (LVH), low EF

A and B

C and D

Question 5

HF can also be classified by the level of limitation in ____ using the ___ classification system

Answer 5

1. physical functioning
2. NYHA

Question 6

ACC/AHA staging System

1. Stage A means?
   -NYHA Functional class?
2. Stage B means?
   -NYHA Functional class?
3. Stage C means?
   -NYHA Functional class?
4. Stage D means?
   -NYHA Functional class?

Answer 6

1. At risk for HF, no sx’s, structural heart disease or elevated biomarkers (pt’s with HTN, ASCVD, or diabetes)
   -N/A
2. Pre-HF; structural HD, abnormal cardiac function or elevated biomarkers but WITHOUT SIGNS or SX’s of HF (pt’s with LVH, low ef, valvular disease)
   -Class 1 (no limitations of physical activity)
3. Structural and or functional cardiac abnorms with prior or current sx’s of HF
   -Class 1 ( no limits on physical activity)
   -Class 2 (Slight limits of physical activity. comfortable at rest but ordinary physical activity results in sx’s of HF)
   -Class 3 marked limitations of physical activity. Comfortable at rest but MINIMAL exertion causes sx’s of HF
   -Class 4, unable to carry on any physical activity w/o sx’s of HF or sx’s of HF at rest
4. Advanced HF with severe sx’s or recurrent hospitalizations despite max treatment
   -Class 4 unable to carry on any physical activity w/o sx’s of HF or sx’s of HF at rest

Question 7

Signs and Symptoms of HF :

1. Labs and biomarkers, what is elevated? (2)
2. Left sided signs and symptoms:
   -O, P, B, S, H
3. general signs and symptoms :
   D, C, F, W, R
4. Right sided sx’s:
   -P, A, J, H, H

Answer 7

1. Incr BNP (norm is <100)
   -Incr NT pro BNP (normal is <300)
2. orthopnea (sob when lying flat)
   -Paroxysmal nocturnal dyspnea (PND) : nocturnal cough and SOB
   -Bibasilar rales: crackling lung sounds heard on lung exam
   -S3 gallop
   -hypoperfusion
3. dyspnea (sob at rest or upon exertion)
   -cough
   -fatigue
   -weakness
   -reduced exercise capacity
4. periph edema
   -ascites
   -JVD
   -Hepatojugular reflux
   -Hepatomegaly

Question 8

1. HFrEF is a low ___
2. Body compensates by activating ____ to ___ or the ____. This can incr CO but chronically can lead to __
3. What r the main pathways activated in HF?
4. what does vasopressin do?
5. What does NE and EPI release do?

Answer 8

cardiac output state

2. neurohormonal pathways, incr blood volume, force or speed of contractions
   -cardiac remodeling
3. RAAS, SNS, vasopressin
4. vasoconstriction and water retention
5. causes incr in HR, contractility, and vasoconstriction

Question 9

Lifestyle Management:
Pt’s with HF should be instructed to

1. Monitor and document _____
2. Notify the provider if?
3. avoid excessive ___. consider restricting to ?
4. Restrict fluid to what in stage D HF?
5. Stop ___ . reduce __
6. Reduce weight to?

Answer 9

1. body weight daily, in the morn after voiding and before eating
2. weight incr by 2-4 pounds in 1 day or >= 5 pounds in one week or if sx’s worsen
3. sodium intake. <1500 mg per day
4. 1.5-2L/day
5. smoking , alc intake
6. BMI < 30

Question 10

Whats a natural product thats reasonable supplementation for HF pt’s ?

What can it do?

what can improve HF sx’s?

Answer 10

Omega 3 fatty acids or fish oil

decr mortality and cardiovasc hospitalizations

hawthorn and coenzyme q10

Question 11

Most drugs that cause or worsen HF cause what ?

see physical flashcard

Answer 11

fluid retention, edema, or incr blood pressure or have neg inotropic effects

Question 12

4 backbone of HF treatment? (HFrEF)

Answer 12

1. ACEI/ARB/ARNI
2. Aldost receptor antag (Spiro)
3. Beta blocker
4. SGLT2I

Question 13

In patients with HFmrEF or HFpEF what medications should be are reccomended?

Can u use the other backbone meds?

Answer 13

SGLT2I’s

U could consider them

Question 14

1. Whats recc in all HF patients regardless of sx severity?

Answer 14

1. arni/acei/arb

Question 15

1. Entresto is a ___combined with an ___
2. Neprilysin is the enzyme responsible for ___ of several beneficial ____
3. It’s also FDA approved for treatment of ___
4. whats the target dose? whats the starting dose?
5. BBW?
6. CI’s? (2)
7. Warnings of A, H , R (), H
8. it can also cause __
9. Monitoring: (4)
10. DO NOT USE WITH?

Answer 15

1. neprilysin inhib (sacubitril) , ARB (valsartan)
2. degradation, vasodilatory peptides
3. HFpEF
4. Start 24/26 mg BID
   target: 97/103 mg BID
5. can cause injury and death to devel fetus. dc as soon as pregnancy is detected
6. dont use with or within 36 hrs of an aceI
   -dont use if history of angioedema
7. Angioedema, hyperkalemia, renal impairment (incr risk with bilateral renal artery stenosis so avoid use) , hypotension
8. cough
9. BP, K, renal function, Incr SCr, s/sx’s of HF
10. ACEI or ARB

Question 16

ACEI:
1. Enalapril
-Brand name?
-target dose?

2. Lisinopril
   -brand name?
   -target dose?
3. Quinapril
   -Brand name?
   -target dose?
4. Ramipril
   -brand name?
   -target dose?
5. Boxed warning?
6. CI/s? (2)
7. Warnings:
   A, H, R, H
8. Can also cause ____
9. Monitoring? (4)

Answer 16

1. vasotec
   -10-20 mg PO BID
2. Zestril
   -20-40 mg daily
3. Accupril
   -20 mg BID
4. Altace
   -10 mg daily
5. Injury and death to devel fetus. DC as soon as preg detected

6.dont use with or within 36 hrs of Entresto
-dont use if history of angioedema

7. angioedema, hyperK, renal impairment,(incr risk with bilateral renal artery stenosis so avoid use) , hypotension
8. cough

9.BP, K, renal function, Incr SCr, s/sx’s of HF

Question 17

ARBS

1. Losartan
   -brand name?
   -target dose?
2. Valsartan
   -Brand name?
   -target dose?
3. AE profile same as ACEI’s except
   Less ___
   Less ____
   No __

Answer 17

1. Cozaar
   -50-150 mg daily
2. Diovan
   -160 mg BID
3. Cough
   angioedema
   no washout period required with entresto

Question 18

ACEI/ARB/ARNI DDI’s

1. Does what to lithium?

Answer 18

1. decr lithium renal clearance and incr risk of lithium toxicity

Question 19

Beta Blockers:

1. Which beta blockers r recc for all HF pt’s?
2. When should Beta blockers be dc’ed?

Answer 19

1. Bisprolol, Carvedilol (IR and CR), metoprolol succinate ER
2. only during acute decompensated HF if hypotension or hypoperfusion are present

Question 20

Beta Blockers:

Beta 1 Selective:
1. Metoprolol Succinate ER
-Brand name?
-target dose?

and Bisoprolol

Non selective Beta 1 and Alpha 1 Blocker:

2. Carvedilol
   -Brand name?
   -target dose for IR? (2)
   -target dose for CR?

Answer 20

1. toprol xl
   -200 mg daily
2. coreg, coreg CR

<= 85 kg 25 mg BID
>85 kg 50 mg BID

-80 mg daily

Question 21

Beta Blockers Cont:

1. BBW?
2. Warnings:
   -use caution in ___ bc can worsen ___ and mask ____

-use caution with ____

-use caution with ___

3. Side effects :
   B, H, C, I, can exacerbate ___
4. Monitoring:
   H, B, S
5. Whats the metoprolol conversion ratio for IV to PO
6. Which version can be cut in half (not crush or chew) ?
   -This should also be taken with ___ or ___
7. For coreg specifically, it should be taken ____
   -for Coreg CR, the capsule can be ___
8. For Coreg, whats the dose equivalence of Coreg to Coreg CR
9. BB DDI’s:
   -Use caution with other drugs that decr HR such as ?
10. BB DDI’s:
    -Coreg inhibits PGP and can incr concentrations of PGP substrates such as ?

Answer 21

1. dont discontinue abruptly, gradually taper over 1-2 weeks to avoid acute tachycardia, HTN or ischemia
2. diabetes, hypoglycemia, hypoglycemic sx’s

bronchospastic disease (asthma, or copd)

raynauds

3. bradycardia, hypotension, cns effects (fatigue, dizzi, depression), impotence , raynauds
4. HR (decr dose if symptomatic bradycardia) , BP, S/sx’s of HF
5. IV:PO = 1:2.5
6. toprol XL
   -food, immediately after meals
7. with food (all forms)
   -opened
8. Coreg 3.125 mg BID = Coreg CR 10 mg daily
9. Digoxin, verapamil, dilt, amiodarone
10. digoxin, cyclosporine, dabigatran, ranolazine

Question 22

Aldost Receptor Antags:
1. Where do they work?
2. Spironolactone is ___, it also blocks ___ and exhibits ____

3. Eplerenone is ___ and does not exhibit these ae’s
4. Spironolactone
   -brand name?
   -target dose?
5. CI’s?
   -Dont use in ___, ___, ____
6. Warnings:
   Dont initiate for HF if K is? CrCL (eGFR)<= ? or SCr > ___ for females or ___ for males?
7. AE’s:
   H, Incr __, D

Spiro has additional ae’s such as: G, B, I

8. Monitoring: (5)

Answer 22

1. Distal convoluted tubule and collecting ducts of nephron
2. non selective
   -androgen
   -endocrine ae’s
3. selective
4. Aldactone
   -25-50 mg daily
5. hyperkalemia, severe renal impairment, addison’s disease (spiro)
6. 5
   30
   2, 2.5
7. hyperkalemia, incr SCr, dizziness

gynecomastia, breast tenderness, impotence

8. BP, K, renal function, fluid status, s/sx’s of HF

Question 23

SGLT2I’s :
1. Dapagliflozin
-Brand name
-Dosing for HF

2. Empagliflozin
   -Brand name
   -Dosing for HF
3. Generally shouldnt be initiated for HF if egFR IS?

Answer 23

1. farxiga
   10 mg daily
2. jardiance
   10 mg daily
3. < 20-25

Question 24

Loop Diuretics:

1. Block na and Cl reabs in the ____ of the ___
2. they incr excretion of?
3. Furosemide
   -brand name
   -max dose /day
4. Bumetanide
   -brand name
   -max dose /day
5. Torsemide
   -brand name?
   -max dose /day

Answer 24

1.thick ascending limb, loop of henle

2. Na, K, Cl, Mg, Ca , water
3. lasix
   600 mg
4. bumex
   10 mg
5. soaanz
   200 mg

Question 25

Loop Diuretics: 1. Warnings for ? S, O, A 2. AE's ? -Which electrolytes does it decr? -Which does it incr? -O, P 3. Monitoring: R, F, B, E, S 4. Lasix Injections must be stored at ? 5. Oral Equiv Dosing for the Loop diuretics? 6. Lasix IV:PO ratio? 7. Avoid which drug while on loop diuretics? 8. Can alter ___ levels leading to ?

Answer 25

1. Sulfa allergy -doesnt apply to ethacrynic acid Ototoxicity (more with ethacrynic acid or rapid IV admin) Acute kidney injury 2. K, Mg, Na, Cl, Ca HCO3 (metab alkalosis), UA, BG, TG's, total cholesterol ortho hypo, photosensitivity 3. renal fxn, fluid status, BP, electrolytes, s/sx of HF 4. room temp 5. Lasix 40 mg = torsemide 20 mg = bumex 1 mg = ethacrynic acid 50 mg 6. 1:2, Furos 20 mg IV = furosemide 40 mg PO 7. NSAIDS 8. Lithium , lithium toxicity

Question 26

1. Hydralazine is a direct ____ which decr ____. 2. Nitrates incr the availability of nitric oxide which causes venous ___ and decr ___ 3. this combination improves___ in HF and can be used as an alt in pt's who cant tolerate an ____ 4. Whats the name of the combo product? 5. This product is indicated for? 6. Whats the generic of BiDil? 7. Whats a benefit of the combo product? 8. Hydralazine has a warning for? 9. Hydralazine AE's? (5) 10.Isosorbide dinitrate CI's? 11. AE's?

Answer 26

1.vasodilator, afterload 2. vasodilation, preload 3. survival -ARNI/ACEI/ARB 4. BiDil 5. Self identified black pt's with NYHA class 3 or 4 HF who are symptomatic despite optimal treatment 6. Isosorbide Dinitrate/Hydralazine 7. no nitrate tolerance 8. DILE (drug induced lupus erythematosus) 9. Periph edema HA Flushing Palpitations Reflex tachycardia 10. dont use with PDE5 Inhibs or riociguat 11. hypotension HA, dizziness tachyphylaxis (need 10-12 hr nitrate free interval) Syncope

Question 27

1. What does Ivabradine work to do? 2. It can decrease __ for worsening HF and may also reduce CV death 3. When is it recc? -What r the conditions 4. Ivabradine : -target a resting HR between? 5. Ivabradine Warnings? (2) 6. AE's? (2)

Answer 27

1. It ultimately decreases HR 2. hospitalizations 3. adjunct tx in symptomatic (NYHA Class 2-3) stable chronic HF (EF <=35%). -Pt's must alrdy be receiving GDMT, including max tolerated or target dose of BB and be in sinus rhythm with resting HR >=70 BPM 4. 50-60 BPM 5. Can cause bradycardia -incr risk of afib 6. Bradycardia and HTN

Question 28

Digoxin 1. Inhibits ___, causing a ____, and also causing a ___ 2. Does not improve survival but can decr ___ 3. can be added to GDMT to ___ 4. When should u use a smaller dose ? 5. What should the serum concentration be in HF?

Answer 28

1. Na-K-ATPase pump in myocard cells , positive inotropic effect (Incr CO) , neg chronotropic effect (decr HR) 2. HF related hospitalizations 3. improve sx's, exercise tolerance and QOL 4. Renal insufficiency, smaller, or older 5. 0.5-0.9 ng/mL

Question 29

DIGOXIN: 1. Brand name? 2. Typical dose? 3. What if CrCL < 60? 4. What should u do when u go from PO to IV forms? 5. Therapeutic range for HF? 6. What should be monitored? 7. Symptoms of Toxicity? (6) 8. This toxicity can have an incr risk with? 9. Antidote?

Answer 29

1. Digitek, lanoxin 2. 0.125 -0.25 mg po daily 3. decr dose or frequency 4. decr dose by 20-25% 5. 0.5-0.9 ng/mL 6. Electrolytes, renal function, and HR 7. N/V Loss of appetite blurred/double vision green/yellow halos bradycardia life threatening arrhythmias 8. hypokalemia, hypomag, hypercalcemia 9. Digifab

Question 30

Digoxin DDI's: 1. Digoxin is a substrate of __ and ___ 2. What should u do when starting amio or dronedarone? 3. Use caution with other drugs that decr HR such as?

Answer 30

1. PGP, CYP3A4 2. reduce digoxin dose by 50% 3. Beta blockers, clonidine, non DHP ccbs, amiodarone and precedex

Question 31

Vericiguat: 1. MOA? 2. DOnt use with? 3. Main AE's?

Answer 31

1. soluble guanylate cyclase stimulator 2. riociguat 3. hypotension

Question 32

When should potassium be checked? 2. When should Mg be checked/corrected?

Answer 32

1. with changes in renal function and after any changes in diuretic, ARNI, ACEI, ARB or ARA dose 2. prior to correcting potassium level

Question 33

Potassium Chloride : 1. ER tabs brands? 2. Oral packet brand? 3. Oral solution how supplied? 4. also avail as an ? 5. Dosing for prevention of hypokalemia? 6. Tx of mild hypokalemia? 7. Warnings?

Answer 33

1. k tab, klor-con, klor con 10, klor con M10/M15/M20 2. Klor-Con 3. 10% (20 mEq/15 mL) 4. Injection 5. 20-40 mEQ/day in 1-2 divided doses 6. 40-100 mEq/day in 2-4 divided doses 7. risk of hyperkalemia

Question 34

1. Potassium ER Capsules contents can be ? 2. ER tabs like KTab or Klorcon should be ? 3. ER Tabs: Klor-Con M if difficult to swallow whole, can be ? 4. Oral packet should be dissolved in water and drank ____ 5. Oral solution -KCL 10% = ____ -Mix each 15 mL with?

Answer 34

1. sprinkled on a small amount of applesauce or pudding 2. swallowed whole, no crushing, cutting, chewing, or sucking on tab 3. cut in half or dissolved in water (stir for 2 mins and drink immed). dont chew, crush, or suck on tab 4. imediately 5. 20 mEq/15mL -6 oz water