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Heart Failure Drugs (12c) Flashcards

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1
Q

What group of people are not as benefitted by the use of ACE inhibitors?

A

Afro-Americans

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2
Q

All patients with _____ _____ _____ should be started on ACE inhibitors

A

Left Ventricular Dysfunction

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3
Q

What is an important thing to know about the use of ACEIs in patients with heart failure?

A

They improve the symptoms and survival

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4
Q

What are the ACEIs

A

Captopril Lisinopril Fosinopril

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5
Q

What is the site of action of the ACEIs?

A

Renal Renin-Angiotensin

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6
Q

The MOA of ACEIs

A

Inhibit conversion of Angiotensin I into Angiotensin II, lowering arteriolar resistance and increasing venous capacity, cardiac output and volume Also Lower renovascular resistance

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7
Q

The ACEIs reduce _______ and ________

A

after load and preload

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8
Q

By reducing Afterload, the ACEIs are enhancing what?

A

Stroke volume and ejection fraction

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9
Q

By reducing preload, the ACEs decrease what specifically?

A

Pulmonary and systemic congestion and edema

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10
Q

What are the target doses of the ACEI drugs?

A

Enalopril - 20mg BID Captopril 50mg TID Lisinopril 40 mg QD

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11
Q

How often can you increase the dose of ACEs (as long as the patient remains stable)?

A

Every 2 weeks

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12
Q

What are the major ADR for ACEIs and are therefore contraindicated?

A

Cough Angiogenic Edema!!!

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13
Q

What labs should be monitored on patients on ACEIs?

A
  • Creatinine and K+ within 2 wks of initiation and after increased dose - Then in 3-4 wks if stable - Then 1x to 2x per year unless Cr changes
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14
Q

What are contraindications to ACEIs?

A

Pregnancy (Teratrogenic) Renal Artery stenosis

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15
Q

What is responsible for the cough caused by ACEIs?

A

Increased Bradykinin

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16
Q

What drugs can you not use with ACEIs?

A

ARBs Aliskirin

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17
Q

What do you need to watch for when starting ACEIs?

A

first dose hypotension

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18
Q

What are the indications of ACEIs?

A

HTN

HF

Left Ventricular dysfunction after MI Diabetic nephropathy

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19
Q

What is the Angiotensin Receptor Blocker that we will prescribe?

A

Losartan

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20
Q

What is the site of action of ARBs?

A

Smooth muscle cells of blood vessels

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21
Q

What is the MOA of ARBs?

A

Blocks Angiotensin 1 and Angiotensin 2 receptors, relaxing smooth muscle cells and dilating blood vessels which ini turn causes decreased BP

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22
Q

When do you use ARBs over ACEIs?

A

In patients who can’t tolerate ARBs

Afro-americans

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23
Q

Can you take ARBs and ACEIs together?

A

NO!!

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24
Q

What are adverse side effects of ARBs?

A

Diarrhea

Muscle cramps

Dizziness

Cough (although not as much as ACEIs)

Increased K+

Impotence

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25
Contraindications of ARBs
Pregnancy Severe renal disease Elevated K+
26
What is losartan used for?
HTN diabetic nephropathy in T2DM Stroke risk reduction in HTN LVH
27
Losartan blocks which angiotensin with a greater affinity?
Angiotensin 1 (1000x greater)
28
What drugs should you not use with ARBs?
Direct renin inhibitors ACEI Aliskerin
29
Losartan increases the excretion of what compound?
Uric Acid! Additive benefit for gout pts
30
What are the Vasodilator drugs used for Heart Failure?
Dihydropyridine Ca++ channel blockers Hydralazine/Isosorbide Dinitrate
31
What is important to remember about amlodipine in regards to HF?
That is is not used directly for HF, but it is used in HF patients for treatment of angina and HTN
32
Can you use Non-dihydropyradines for HF?
NO!! They decrease cardiac contractability
33
What is the site of action for the DCCBs?
Vascular smooth muscle
34
What is the MOA for the DCCBs?
Blocks Ca++ channel, decreasing/preventing contraction resulting in vascular relaxation and decreased Total peripheral resistance - Vasodilation of the coronary arteries
35
What are some adverse effects of CCBs? (only at high doses)
- Increased mortality in patients post-MI - High doses increase risk of AMI
36
Indications for Amlodipine?
Angina HTN Can be used in Patients with HF with HTN/angina
37
What is a major contraindication for Amlodipine?
Recent AMI
38
What does amlodipine do?
Vasodilates coronary arteries
39
The combination drug used for HF is what?
BiDil - hydralazine + Isosorbide dinitrate
40
What is the site of action for BiDil?
Vascular smooth muscle
41
What does BiDil do specifically in Heart failure?
It **reduces** the **after load** and strongly **reduces the peripheral resistance**
42
What group of people is BiDil highly recommened in?
Afro-americans
43
What are some adverse effects caused by BiDil?
Elicits a reflex sympathetic stimulation of heart Loss of appetite Diarrhea/HA
44
What are the contraindations to Hydralazine?
CAD Mitral Valve Rheumatic HD
45
What can Hydralazine cause?
Lupus!
46
What drug is the DOC for tx of hypertensive emergency in preganc women?
Hydralazine
47
What is the MOA of Hydralazine?
Diract acting arteriolar vasodilators
48
What are the indications for the use of BiDil?
Adjunctive tx of HF, esp in afroamericans
49
What type of agent is Digoxin?
Positive Inotropic agents: Cardiac Glycosides
50
Cardiac glycosides have a propensity to cause _______ changes
EKG Prolonged PR interval Inverted T wave ST segment Depression Shortened QT interval
51
What is the MOA of digoxin?
Inhibits Na/K ATPase pump in myocardial cells promoting influx Ca++ leading to increased contractility Also, direct suppressor of AV node decreases ventricular rate
52
The cardiac glycososides increase _______ tone, resulting in slowed HR
Vagal
53
True or false: carciac glycosides should be used for the initial tx of acute HF
False!
54
What may happen as a result of using Cardiac glycosides, specifically as a result of increasing intracellular calcium
Arrhythmias, specifically PVCs
55
Can you use Beta blockers with digoxin?
You can, but you should try to avoid it if possible
56
What are some side effects of using digoxin?
Delirium Visual disturbances AV Block/EKG changes Toxic psychosis
57
What is an interesting fact about the glycosides regarding how long they have been used and where they originate from?
3000 years! Milkweed, Lily of valley, foxglove, Oleander
58
What is Digoxin indicated for?
Mild to Moderate HF Afib control
59
Digoxin causes an influx in what Ion, leading to increased contractility?
Ca++
60
Why should Digoxin be avoidedin the elderly?
Can have a proarrhythmic effect
61
The positive Ionotropic Agents that are B agonisits includes what drug?
Dobutamine
62
When do you use Dobutamine?
NOT recommended in acute HF, but it is still used in critical situations Gives End stage HF patients improved Quality of life while awaiting transplant
63
What are the adverse effects of Dobutamine?
Cardiac arrhythmia Precipitate angina in patients with CAD
64
What is Dobutamine used for?
Short term managment of cardiac decompensation
65
What is the MOA of Dobutamine?
Stimualtes B1 adrenergic receptors increasing cardiac contracility and HR Little impact on B2/alpha receptors
66
Dobutamine should not be used in patients who have a history of what type of allergery?
Sulfa
67
68
How do you administer Dobutamine?
IV
69
What is the Positive Ionotropic Agent PDE inhibitor?
Milrinone
70
What is the MOA of Milrinone
Incrases cAMP in heart and vascular muscle, positive inotrope and vasodilator
71
Why do you use Milrinone?
For Refractory HF to improve quality of life in end stage disease
72
Milrinone is contraindicated when?
AMI Severe obstructive/pulmonic valv disease
73
How do you administer Milrinone?
IV
74
What are side effects of Milrinone?
Hypotension Arrhythmias
75
Nesiritide is what class of drug?
B-type naturetic peptide (BNP)
76
When do you use Nesiritide
Acutely decompensated HF with dyspnea at rest or with minimal activity
77
What is the MOA of Nesiritide
Increases intracell GMP in vasc smooth muscle cells and endothilium causing smooth muscle relaxation and reducing Pulm cap wedge pressure and systemic arterial pressure
78
Side effects of nesiritide include...?
Hypotension, increased serum creatinin, arrhythmias
79
What is the direct renin inhibitor drug
Aliskiren
80
How does aliskerin work?
It directly inhibits renin, lowering BP (blocks conversion of angiotesinogen to angiotensin 1, reducing conversion to angiotesin II, producing arteriolar vasodilartion
81
In what patients should you not use Aliskirin?
DM or Renal disease
82
Why do you prescribe aliskirin?
For the Tx of hypertension
83
Ivabradine is used for what?
HF in patients with EF of \<35% who are on max tolerated Bblocker dose/unable to take Bblocker Off label for angina
84
Ivabradine is contraindicated in which patients?
Severe hepatic disease
85
What do you need to monitor occurance for in patients who take Ivabradine?
Visual changes - May see peripheral floaters
86
What is Ivabradine contraindicated in?
Acute Decomensated HF SSS Low BP Low HR Pacemaker Hepatic impairment
87

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