Exam 2 Flashcards
(234 cards)
1
Q
EF in HFrEF
A
less than or equal to 40%
2
Q
EF in HFpEF
A
greater than or equal to 50%
3
Q
EF in HFpEF, improved
A
greater than 40
4
Q
EF in HFpEF, borderline
A
41-49
5
Q
chronic SNS activation in HF leads to
A
elevated norepi, increased HR and contractility, increased PVR, which lead to cardiac remodeling and worsening LV function
6
Q
chronic RAAS activation in HF leads to
A
increase in angiotensin II and aldosterone, increased SVR (increased afterload), Na+/H20 retention (increased preload), leading to cardiac remodeling and worsening LV function
7
Q
function of natriuretic peptides
A
released by kidneys in response to atrial/ventricular stretch. Increased diuresis, systemic vasodilation, and decreases atrial, venous, and pulmonary pressure. inhibition of renin release leading to decreased angiotensin/aldosterone
8
Q
stage A heart failure
A
high risk of developing HF with no structural disorder of heart
9
Q
Stage B heart failure
A
Structural disorder of heart without ever having developed HF symptoms
10
Q
Stage C heart failure
A
past or current symptoms of HF with underlying heart disease
11
Q
Stage D heart failure
A
End-stage, requiring specialized treatment strategies
12
Q
Class 1 HF
A
no limitation of physical activity
13
Q
Class 2 HF
A
slight limitation of physical activity, comfortable at rest
14
Q
Class 3 HF
A
Marked limitation of physical activity, comfortable at rest
15
Q
Class 4 HF
A
Inability to carry on any physical activity, symptoms present at rest
16
Q
Treatment measures for stage A HF
A
treat HTN, smoking cessation, treat hyperlipidemia, discourage ETOH/drug use, control metabolic syndrome
17
Q
what conditions count as stage A HF
A
HTN, atherosclerosis, DM, obesity, metabolic syndrome, cardiotoxin use
18
Q
treatment measures for stage B HF
A
All measures for stage A plus ACEi or ARB, beta blockers
19
Q
what conditions count as stage B HF
A
previous MI, LV remodeling, asymptomatic valvular disease
20
Q
treatment measures for stage C HF
A
All A and B measures plus salt restriction, diuretics, ARNIs, aldosterone antagonists, nitrates and hydralazine, ivabradine, digoxin
21
Q
what counts as stage C HF
A
known structural heart disease and SOB, fatigue, reduced exercise tolerance
22
Q
What counts as stage D HF
A
marked symptoms at rest despite maximal therapy; recurrently hospitalized or cannot be discharged from hospital.
23
Q
what to assess at every heart failure visit
A
NYHA functional capacity and activity level, volume status, vital signs, social history, changes in body weight, medical history
24
Q
how to assess volume status
A
peripheral edema, JVD, hepatojugular reflux, hepatomegaly, dyspnea, DOE, orthopnea, PND
25
how to assess social history (6)
ETOH, tobacco, recreational drugs, OTC and prescription meds, alternative therapies, diet and sodium intake
26
areas of education for HF patients (6)
weight monitoring, sodium restriction, signs of worsening symptoms and what to do, discharge medications, activity level and life habits, follow-up appointments
27
How to instruct patient to monitor body weight
weigh and record first thing in the am after voiding with scale on a hard surface. Call provider if weight increases 2 lb/day or 5 lb/week
28
sodium restriction for stage A and B
<1500 mg/day
29
sodium restriction for stage C and D
no more than 3,000 mg/day
30
one teaspoon of sodium is equilavent to
2,000 mg
31
patient education for activity level in HF
exercise is safe and recommended to improve functional status. Encourage weight loss, tobacco cessation, and alcohol avoidance
32
patient education for worsening HF symptoms
contact clinic with worsening breathing problems, chest pain, swelling, syncope OR if weight gain of >2 lbs in 1 day or >5 lbs in 1 week
33
1st pharm step after HF diagnosis stage C
initiate ACEi or ARB AND beta blocker with diuretics as needed
34
2nd pharm step for HF stage C, class II-IV if Pt has CrCl>30 and K+<5.0
add aldosterone antagonist
35
2nd pharm step for HF stage C class II-III if adequate BP control on ACEi/ARB and no contraindications to ARB or sacubitril
D/C ACEi or ARB and start ARNI
36
2nd pharm step for HF stage C class III-IV if "black patients"
Add hydralazine/nitrates
37
2nd pharm step for HF stage C class II-III if HR greater than or equal to 70 on max tolerated beta blocker dose
add ivabradine
38
main end goal of using diuretics
decrease preload by achieving euvolemia
39
location of action of thiazides
distal tubule
40
when can thiazides be used
if GFR>30
41
location of action of loops
ascending loop of henle
42
dosage loops
once or twice daily
43
what happens if resistance develops to diuretics
use sequential nephron blockade (loop and thiazide)
44
location of action of carbonic anhydrase inhibitors
proximal convoluted tubule
45
location of action of potassium-sparing diuretics
collecting duct
46
name 3 loop diuretics
bumetanide, furosemide, torsemide
47
which loop diuretic has shortest and longest duration of action
bumetanide, torsemide
48
5 thiazide diuretics
chlorothiazide, hydrochlorothiazide, chlorthalidone, indapamide, metolazone
49
thiazide with longest duration of action
chlorthalidone
50
what must be monitored during diuretic use
electrolytes, renal function, blood pressure, weight, urine output, symptoms
51
how to initiate diuretics
monitor as above for 1-2 weeks and titrate dose until urine output increases and weight decreases 0.5-1 kg daily.
52
how to monitor K+ in diuretic use
must keep K+ between 4-5
53
when to supplement Mg in diuretic use
if Mg2+<1.6
54
when to diminish diuretic dose
if symptomatic hypotension or BUN/SCr > 20
55
dosing consideration of diuretics
may need twice daily dosing for rebound fluid retention
56
what should be monitored 1 week after starting ACEi/ARB
BP, orthostasis, K+, BUN/SCr, cough, angioedema, HF symptoms
57
Baseline labs for ACEi/ARB
BP, BUN/SCr, electrolytes
58
when to start half the usual dose for ACEi/ARB
hypotensive, Cr>2.0, hyponatremic
59
what interferes with efficacy of ACEi/ARB
ASA/NSAIDs. Low-dose ASA is ok but avoid NSAIDs
60
3 beta blockers recommended for HFrEF
Bisoprolol, carvedilol, metoprolol succinate
61
when to follow up when starting beta blockers
in 2 weeks to assess tolerability
62
what to monitor in BB use
HR, BP, weight, volume status, HF symptoms
63
when to hold titration of BB
hypotension, bradycardia, worsening HF symptoms
64
how to start BB dosing
must titrate dose
65
when to use aldosterone receptor antagonists
class II-IV who have LVEF less than or equal to 35% or 40% following an acute MI
66
2 aldosterone receptor antagonists
spironolactone, eplerenone
67
lab requirements to use aldosterone antagonists
SCr<2.5 in men, <2.0 in women
K+<5.0
GFR>30
68
monitoring aldosterone antagonists
K+ and renal function at 3 days, 1 week, monthly for 1st 3 months, and then q 3 months thereafter
69
how to start an ARNI
if on ACEi, must d/c for 36 hours prior to initiation of ARNI due to increased risk of angioedema. Dose is then titrated at 2-4 week intervals
70
major downside of ARNI
almost $500/month
71
which combination of drugs is recommended for "black patients" with HFrEF class III-IV
hydralazine and isosorbide dinitrate
72
indications for hydralazine/isosorbide dinitrate
"back patients" or those who cannot be given ACEi/ARB
73
adverse effects of nitrates/hydralazine
headache, dizziness, hypotension
74
monitoring for nitrates/hydralazine
1-2 weeks post initiation and with each dose change for BP and HR
75
benefit of ivabradine
reduce hospitalizations
76
indications for ivabradine
symptomatic patients with stable chronic HFrEF (LVEF less than or equal to 35%), already on GDMT with sinus rhythm and resting heart rate greater than or equal to 70
77
ivabradine interactions
avoid strong CYP34A inhibitors and grapefruit juice, and St. John's Wort which induces CYP Sa4
78
ivabradine counseling
avoid use in pregnancy, warn about luminous phenomena, notify provider of palpitations, take with food
79
Benefits of digoxin
decreases hospitalizations but not mortality, can be good for comorbid conditions such as rate controlling a fib
80
effects of digoxin
increased CO, decreased PCWP, increased LVEF
81
when should digoxin levels be drawn
>6 hours post PO admin, >4 hours post IV admin
82
which should steady state digoxin levels be monitored
14-21 days post initiation
83
therapeutic digoxin level
0.5-0.9 ng/mL
84
which drugs decrease digoxin clearance
amiodarone and quinidine, diltiazem/verapamil, abx, azole antifungals, propafenone
85
what should you do to the digoxin dose if also administering amiodarone or quinidine
decrease digoxin dose by 50%
86
which drugs have pharmacodynamic effects on digoxin
diuretics, beta blockers, diltiazem/verapamil
87
guidelines for omega-3 PUFA in HF
1 g daily is reasonable to add in order to reduce mortality and hospitalizations
88
SGLT2 inhibitors
dapagliflozin, empagliflozin
89
benefits of SGLT2 inhibitors
once daily PO, reduce blood pressure, weight loss, low risk of hypoglycemia, positive renal and CV outcomes in DM
90
contraindication for SGLT2 inhibitors
GFR<30
91
side effects of SGLT2 inhibitors
genital mycotic infections, UTI, polyuria, hypotension, euglycemic ketoacidosis
92
which SGLT2 inhibitor carries fracture/amputation risk
canaglifozin
93
which medications may reduce contractility and should be avoided in HFrEF
CCBs, antiarrhythmics (except amiodarone and dofetilide), tricyclics, carbamazepine
94
which meds may increase preload and should be avoided in HFrEF
thiazolidinediones (pioglitazone, etc), NSAIDs, pregabalin
95
which meds may increase afterload and should be avoided in HFrEF
sympathomimetics
96
which meds for HF have survival benefit (decreased mortality)
ACEI, ARB, ARNI, beta blocker, aldosterone blocker, hydralazine/nitrates, fish oil
97
which meds for HF decrease hospitalizations
all
98
which meds for HF control symptoms
all except fish oil
99
ICS mechanism of action
control rate of protein synthesis, depress migration of leukocytes/fibroblasts, reverses capillary permeability, stabilizes lysosomal membranes
100
ICS dose response curve
relatively flat: most measures of efficacy achieved at low-medium doses but higher doses may reduce risk of exacerbations
101
major benefits of daily ICS use in asthma
symptom improvement, prevent exacerbations, improve lung function, decrease deaths and hospitalizations
102
expected symptom improvement timeframe for ICS in asthma
1-2 weeks
103
expected PFT improvement timeframe for ICS in asthma
2 months
104
initial dosing for ICS in asthma
usually twice daily
105
which ICS are once daily only
fluticasone furoate and mometasone
106
which ICS contain milk proteins
budesonide, fluticasone furoate, mometasone
107
what is the most important determinant of ICS dosing in asthma and why
clinical judgment (comparative doses between brands are estimated and imprecise)
108
local adverse effects of ICS
thrush, dysphonia, increased risk of pneumonia in susceptible patients (COPD, older, smoker, low BMI)
109
systemic adverse effects of ICS
HPA axis suppression, impaired growth in peds, fractures, skin thinning/bruising, cataracts, hyperglycemia
110
How to reduce potential for adverse effects of ICS
use holding chamber, rinse mouth, use lowest dose possible, use in combo with LABA
111
drug interactions with ICS
potent inhibitors of CYP3A4 (ritonavir, ketoconazole)
112
what is true of use of LABAs in asthma
not appropriate for monotherapy (increase in mortality), should be added to ICS
113
LABA mechanism of action
increases cyclic AMP at bronchial smooth muscle triggering relaxation
114
LABA interactions
ketoconazole, multiple antivirals, some antibiotics: Prolonged QT interval, palpitations, tachycardia
115
salmeterol interactions
CYP3A4 inhibitors increase plasma levels of salmeterol
116
LABAs currently available for asthma
salmeterol, formoterol, vilanterol
117
which LABA has a rapid onset of action
formoterol
118
examples of brand names of combination ICS/LABA
advair, breo Ellipta, symbicort
119
which ICS/LABA cannot be used in pediatrics
Breo Ellipta
120
what is the long-acting anticholinergic (not part of combo inhaler)
spiriva respimat (tiotropium bromide)
121
mechanism of action of LAMA
prolonged binding to M3 receptors to block acetylcholine bronchoconstrictor effects
122
LAMA dosing for asthma
2 inhalations once daily
123
how are LAMAs used in asthma
as add-on therapy to ICS and/or LABA
124
what ages are LAMAs approved for
6 y/o and older
125
what is the combo inhaler that includes a LAMA
Trelegy Ellipta
126
cautions with LAMA use
narrow-angle glaucoma, BPH, bladder obstruction, moderate to severe renal function
127
how to decrease toxicities of oral steroids in asthma
use lowest dose possible, alternate day therapy, taper if over 2 weeks of therapy
128
side effects of oral glucocorticoids (beyond those listed for ICS)
hypertension, moon facies, muscle weakness, psych issues, Na/H2O retention, hypokalemia, pancreatitis, central redistribution of fat
129
Leukotriene modifier administration
PO
130
LTRA prototype
montelukast (singulair)
131
box warning for LTRA
neuropsychiatric events
132
ages approved for LTRA
6 months or older
133
SABA uses in asthma
relief of acute bronchospasm, pre-treatment of exercise-induced bronchoconstriction (scheduled daily use not recommended regularly)
134
what amount of SABA use indicates inadequate asthma control
use of more that 2 days per week for symptom relief
135
SABAs for asthma
albuterol, levalbuterol
136
directions for SABA use for asthma
2-4 puffs as needed for symptoms up to every 4 hours, pre-exercise if needed
137
adverse effects of SABAs
tachycardia, palpitations, nervousness, GI upset, tremor
138
what amount of SABA usage is associated with increased asthma death
more than one canister per month
139
what does SMART therapy consist of
budesonide/formoterol (Symbicort) - not yet approved in US
140
which LABA can be used as a reliever med in asthma (and its exception)
formoterol (with ICS) - except in those using ICS/different LABA as maintenance
141
dosing caution for formoterol
do not exceed 54 mcg/day
142
uses of ICS/formoterol in asthma
moderate to severe persistent
143
what level of PO steroid use for exacerbation indicates inadequate asthma control
more than 3 courses per year
144
follow up intervals after initiating asthma therapy
2-6 week intervals until goal is achieved and then regular follow-up intervals of 1-6 months depending on level of control
145
follow up intervals during asthma step down therapy
every 3 months
146
3 fundamentals of control-based asthma management
assess, adjust treatment, review response
147
step 1 asthma symptoms
infrequent symptoms (less than twice per month)
148
step 2 asthma symptoms
symptoms twice per month or more
149
step 3 asthma symptoms
troublesome symptoms most days or waking up due to asthma once per week or more
150
step 4 asthma symptoms
initial presentation with severely uncontrolled asthma/acute exacerbation
151
step 1 asthma tx
low dose ICS/SABA prn
152
step 2 asthma tx
daily low dose ICS plus prn SABA
153
step 3 asthma tx
daily low dose ICS and LABA plus PRN SABA
154
step 4 asthma tx
daily medium/high ICS and LABA plus PRN SABA
155
step 5 asthma tx
step 4 plus LAMA and refer
156
risk factors for asthma flare-ups: modifiable
no ICS, high SABA use, poor adherence/technique, major psychosocial problems, environmental exposures, comorbidities
157
risk factors for asthma flare-ups: non-modifiable
low FEV1, higher bronchodilator reversibility, eosinophilia, high FeNO, ever intubated, 1 or more severe exacerbations in last 12 months
158
unexpected risk factor for medication side effects
taking P450 inhibitors
159
how to assess asthma severity
retrospectively once patient has been on treatment for several months with appropriate step down attempted
160
when to consider asthma step-down therapy
once good asthma control has been achieved and maintained for at least 3 months
161
how to initiate step-down therapy for asthma
reduce ICS dose by 25-50% at 2-3 month intervals
162
step-down option if on high dose ICS/LABA plus OCS
continue high dose ICS/LABA and reduce OCS
163
step-down if on moderate to high dose ICS/LABA
reduce ICS by 50%
164
step-down if on low-dose ICS/LABA
reduce ICS/LABA to once daily
165
step-down if on medium-high dose ICS
reduce ICS dose by 50%
166
step down if on low dose ICS
switch to once daily dosing OR switch to PRN ICS-formoterol combo OR add LTRA to allow ICS step down
167
non pharmacological therapies in asthma
weight reduction, allergy immunotherapy, avoidance of air pollution, vaccinations, emotional stress reduction, weather conditions
168
what to do before increasing meds in someone with poor asthma control
check inhaler technique, adherence, environmental changes, consider alternative diagnoses
169
components of asthma education
basic facts about asthma, roles of medications, skills
170
components of basic facts about asthma
compare normal and asthmatic airways, what happens during an attack
171
components of asthma skills
inhaler technique/device use, avoid exposures, self-monitoring, how to use written action plan
172
ICS/LABA combinations
fluticasone propionate/salmeterol, fluticasone furoate/vilanterol, budesonide/formoterol, mometasone/formoterol
173
Indications for SAMA in asthma
relief of acute bronchospasm with SABA (additive effects), alternative for patients with SABA intolerance, treatment of choice for bronchospasm due to beta blockers
174
SAMA mechanism of action
blocks action of ach at parasympathetic sites in bronchial smooth muscle
175
mechanism of action of cromolyn
prevents mast cell degeneration
176
cromolyn indications
alternative treatment for mild persistent asthma
177
cromolyn route
nebulizer
178
methylxanthines mechanism, of action
inhibition of phosphodiesterase
179
major problems with methylxanthines
narrow therapeutic index, significant side effects, lots of interactions
180
methylxanthines route
PO
181
which report used for COPD
GOLD 2021
182
SAMA mechanism of action
block M2 and M3 receptors in airway smooth muscle
183
side effects of inhaled muscarinic antagonists
dry moth, urinary symptoms, acute glaucoma if it gets in eyes, additive effect with other anticholinergics
184
which inhaled muscarinic antagonist has bitter/metallic taste
ipratroprium
185
SAMA for COPD
ipratroprium
186
usage for ipratroprium for COPD
2 puffs four times daily, up to 12 puffs/day. Or neb treatment q 6-8 hours
187
LAMAs
all the -iums except ipratropium, glycopyrrolate, revefenacin
188
dosing of LAMAs
once daily
189
examples of LABAs
salmeterol, formoterol, arformoterol, olodaterol
190
LABA+LAMA combos approved for COPD
Anoro Ellipta, Stiolto respimat, bevespir, duaklir
191
benefits of bronchodilators in COPD
improve FEV1, flat dose-response, improve symptoms, exercise performance, health status. Reduce exacerbations and hospitalizations
192
disadvantage to dry powder inhaler
requires forceful inhalation
193
disadvantage to metered dose inhaler
difficult to coordinate - may need valved holding chamber
194
advantage to soft mist inhaler
no shaking or spacer required
195
what type of bronchodilator is preferred in COPD
long-acting (LABA or LAMA), but LAMA has greater effect on exacerbation reduction than LABA
196
indications for ICS use in COPD
blood eosinophils >300 or >100 AND greater than 2 moderate exacerbations OR 1 hospitalization
197
LABA+ICS combos approved for use in COPD
Advair, symbicort, breo Ellipta
198
ICS+LABA+LAMA approved for use in COPD
Trelegy ellipta, breztri aerosphere
199
phosphodiesterase-4 inhibitor in COPD
roflumilast
200
adverse effects of roflumilast
nausea, anorexia, abdominal pain, diarrhea, sleep disturbances, headache. They diminish over time
201
monitoring in roflumilast
weight loss, depression
202
indications for roflumilast in COPD
reduce exacerbations in patients with severe COPD (FEV1<50%, chronic bronchitis, frequent exacerbations)
203
what must be used with roflumilast
at least one long-acting bronchodilator
204
which abx are used in COPD
azithromycin, erythromycin
205
indications for chronic abx use in COPD
reduce risk of exacerbations in patients prone to them (less benefit in active smokers)
206
caution in chronic azithromycin use in COPD
bacterial resistance, hearing loss, prolonged QTc
207
side effect of eryhtromycin
GI discomfort
208
side effects of theophylline
GI discomfort, tremor, arrhythmia, seizure
209
what is not appropriate for monotherapy in COPD
ICS
210
use of PO steroids in COPD
only recommended for short-term management of acute exacerbation
211
mucolytics in COPD
limited evidence
212
leukotriene modifiers in COPD
little evidence for use
213
antitussives in COPD
not recommended
214
GOLD 1
FEV1 at least 80% of predicted, mild
215
GOLD 2
FEV1 50-79% of predicted, moderate
216
GOLD 3
FEV1 30-49% of predicted, severe
217
GOLD 4
FEV1 <30% of predicted, very severe
218
components of COPD assessment of disease
validated questionnaires, exacerbation risk, co-morbidities
219
questionnaires for COPD
COPD Assessment Test (CAT), mMRC
220
non-pharmacologic therapy for COPD
smoking cessation, oxygen, pulmonary rehabilitation, vaccinations, physical activity
221
what COPD group: CAT<10, 0-1 moderate exacerbations
`A
222
what COPD group: CAT greater than or equal to 10, at least 2 moderate exacerbations or at least 1 exacerbation leading to hospitalization
Group D
223
what COPD group: CAT<10, mMRC 0-1, at least 2 moderate or 1 severe exacerbation
Group C
224
what COPD group: CAT at least 10, mMRC at least 2, less than 1 moderate exacerbation
B
225
COPD Group A initial treatment
bronchodilator
226
COPD group C initial treatment
LAMA
227
COPD group B initial treatment
LABA or LAMA
228
COPD group D initial treatment
LAMA OR LAMA+LABA (if CAT at least 20), OR ICS+LABA (if high eosinophils)
229
follow--up treatment of COPD after initial treatment started
if adequate response to initial treatment, maintain it. If not, chose predominant problem (exacerbation or dyspnea) and follow recommendations
230
what if predominant problem during follow-up treatment is both exacerbation and dyspnea
use exacerbation pathway
231
what to monitor every visit for COPD patient
symptoms, physical exam, smoking status, medication regimen
232
what to monitor q 2-3 months for COPD patient
CAT/mMRC
233
what to monitor annually for COPD patient
spirometry
234
2 considerations when treating CV comorbidities and COPD
use of high-dose beta agonists can make afib rate control more difficult, try to use beta selective blockers if possible
