Heart Failure: important stuff pt 1

Question 1

Differentiate stages A, B, C, D of heart failure

Answer 1

1) Stage A: “At risk for heart failure”; just has risk factors (ex: DM, HTN)
2) Stage B: “Pre-heart failure”; structural issue, but no Sx
3) Stage C: “Symptomatic HF”; structural and functional issue
4) Stage D; “Advanced HF”; structural and functional issue (with bad Sx)

Question 2

Describe the NYHA Functional Classes of HF

Answer 2

I) No limitations, comf. at rest
II) Slight limitations, comf. at rest
III) Marked limitations, comf. at rest
IV) Severe limitations, not comf. at rest
-All are considered to have cardiac disease

Question 3

List 2 main etiologies of HF

Answer 3

1) CAD
2) HTN

Question 4

A small increase in end-diastolic volume (preload) results in a _________ increase in CO

Answer 4

large

Question 5

What is a way to estimate preload?

Answer 5

Pulmonary capillary wedge pressure (PCWP)

Question 6

What do you treat amyloid cardiomyopathy with?

Test question

Answer 6

Tafamidis meglumine (Vyndamax)

Question 7

List 2 drugs that affect Arginine vasopressin (AVP) a.k.a. antidiuretic hormone (ADH)

Answer 7

tolvaptan & conivaptan

Question 8

List 3 categories of negative inotropics [that precipitate HF]

Answer 8

1) Antiarrhythmics
2) Beta-blockers
3) Non-dihydro CCBs

Question 9

Drugs precipitating HF: Which are negative inotropics?

Answer 9

1) Antiarrhythmics
2) Beta-blockers
3) Non-dihydro CCBs

Question 10

Drugs precipitating HF: Which are cardiotoxic?

Answer 10

1) Chemotherapy
2) Carbamazepine
3) Ethanol
4) Amphetamines

Question 11

Drugs precipitating HF: Which ↑ Na+ and H20?

Answer 11

1) NSAIDs
2) Pioglitazone (thiazolidinediones)
3) Glucocorticoids
4) Androgens and estrogens

Question 12

Drugs precipitating HF: Which have unknown mechanisms?

Answer 12

1) TNF-α inhibitors (e.g., adalimumab)
2) Dipeptidyl peptidase-4 (DPP-4) inhibitors (e.g., saxagliptin)
-diabetes drugs

Question 13

True or false: patients with HF taking a daily weight is very important

Answer 13

True

Question 14

Acute decompensated HF:
1) PCWP greater than ____mmHg often reflects volume overload and is generally used to distinguish “wet” from “dry” subsets
2) CI less than _______ L/min/m2 is often used to distinguish “cold” from “warm” subsets

Answer 14

1) 18mmHg
2) 2.2

Question 15

S3 gallop is specifically suggestive of what?

Answer 15

Acute decompensated HF

Question 16

A low BNP concentration, often defined as less than _________pg/mL has a 96% predictive value for excluding HF as an underlying etiology for dyspnea

Answer 16

100

Question 17

How do you Tx Stage C HF?

Answer 17

1) ACE inhibitor, ARB, or angiotensin receptor-neprilysin inhibitor (valsartan/sacubitril)
2) Evidence-based β-blocker and aldosterone antagonists (in eligible patients) to reduce morbidity and mortality
3) Loop diuretics, hydralazine-isosorbide dinitrate (ISDN), digoxin, and ivabradine are also used in selected patients

Question 18

Stage A (at risk for HF):
1) What group of meds should you use for prevention in this stage?
2) Give 2 examples of specific drugs

Answer 18

1) Sodium-glucose co-transporter 2 inhibitor (SGLT2i)
2) Empagliflozin (Jardiance) + Dapagliflozin (Farxiga)

Question 19

Stage B (pre-HF): All pts with LVEF <40% should receive an ACE inhibitor or ARB and an evidence-based______________ to prevent the development of HF

Answer 19

β-blocker

Question 20

True or false: Stage D HF includes patients receiving maximally tolerated GDMT that have persistent symptoms

Answer 20

True

Question 21

Describe Tx for HFpEF

Answer 21

1) Patients should have an alternative indication before β-blockers are prescribed
2) Diuretic doses are generally lower
3) Calcium channel blockers such as diltiazem, amlodipine, and verapamil are useful to treat HTN
4) Patients can still take an Farxiga or Jardiance (SGLT2i) and Entresto (ARNi)

Question 22

Describe Tx for HFrEF

Answer 22

1) Chronic therapy with β-blockers improves morbidity and mortality
2) CCBs have little utility in the treatment

Question 23

Describe Tx for HFmrEF

Answer 23

1) Can still take SGLT2i
2) Can consider beta-blocker, ARNi, ACEi/ARB, MRA and PRN diuretics

Question 24

Describe Tx for HFimpEF

Answer 24

Continue medications and optimize regimens from baseline diagnosis

Question 25

What is the use of diuretics in HF?

Answer 25

Just rapid symptom relief; don't prolong survival or alter disease progression

Question 26

Give 3 examples of loop diuretics

Answer 26

Furosemide (Lasix) Bumetanide (Bumex) Torsemide (Demadex)

Question 27

Give the pertinent info for the following Loops: 1) Furosemide (Lasix) 2) Bumetanide (Bumex); IV & PO 3) Give the IV dose equivalence for 3 of these loops

Answer 27

1) If starting a patient on IV furosemide, you’ll need to double the dose to convert to PO 2) IV:PO ratio 1:1 3) Furosemide 20-40 mg = bumetanide 1 mg = torsemide 20 mg -Generally administer on an empty stomach

Question 28

Loop diuretics: with ↓ decreased renal function = ____ max daily doses

Answer 28

↑ increase

Question 29

Give the adverse effects and monitoring for loop diuretics

Answer 29

1) Hypovolemia, hypotension, hyponatremia, hypokalemia, hypomagnesemia, asymptomatic hyperuricemia, renal dysfunction and thirst Ototoxicity risk is more associated with rapid IV administration 2) BP, electrolytes, BUN, creatinine, glucose, uric acid, changes in weight and JVD

Question 30

True or false: You can use loops if patient has a sulfa allergy

Answer 30

True

Question 31

________ inhibitors improve symptoms, slow disease progression, and decrease mortality in patients with HFrEF

Answer 31

ACE

Question 32

ACEi / ARBs: 1) MOA? 2) Which of these improve symptoms, slow disease progression, and decrease mortality in patients with HFrEF?

Answer 32

1) Decrease in angiotensin II and aldosterone 2) ACE inhibitors

Question 33

List the minimum and target doses for the following 3 ACEis: 1) Lisinopril (Zestril) 2) Ramipril (Altace) 3) Enalapril (Vasotec) (need to know)

Answer 33

1) 2.5 – 40 mg PO Qday 2) 1.25 – 2.5 mg PO Qday 3) 2.5 mg – 20 mg PO BID

Question 34

List the minimum and target doses for the following 3 ARBs: 1) Valsartan (Diovan) 2) Losartan (Cozaar) 3) Candesartan (Atacand) (need to know this)

Answer 34

1) 20 – 160 mg PO BID 2) 25 – 150 mg PO Qday 3) 4 – 32 mg PO Qday

Question 35

Describe monitoring for ACEis/ ARBs

Answer 35

Assess BP, BUN, creatinine, and electrolytes at baseline and 1-2 weeks after initiation or increase in dose

Question 36

Name an ANRI (Angiotensin receptor/neprilysin inhibitor)

Answer 36

Valsartan / sacubitril (Entresto)

Question 37

Valsartan / sacubitril (Entresto): ACE inhibitors should be discontinued ______hours prior to initiating ARNI; no waiting period is needed in patients receiving an ARB

Answer 37

36

Question 38

Valsartan / sacubitril (Entresto)(an ANRI): What do you monitor w. this drug?

Answer 38

Assess BP, BUN, creatinine, and electrolytes at baseline and 1-2 weeks after initiation or dose increase

Question 39

β-Blockers are recommended for asymptomatic patients with a reduced __________________ (Stage B) to decrease the risk of progression to HF

Answer 39

left ventricular EF

Question 40

Name 3 β-blockers used for HF

Answer 40

1) Metoprolol succinate ER (Toprol XL) 2) Carvedilol (Coreg) 3) Bisoprolol (Zebeta) (Not approved for HFrEF)

Question 41

Do not start _____________ during acute decompensation

Answer 41

β-Blockers

Question 42

β-Blocker doses should be doubled no more often than every ___ weeks

Answer 42

2

Question 43

HF symptoms may actually worsen during the initiation period of what group of meds?

Answer 43

Beta blockers

Question 44

Give the specifics of dosing the 3 beta blockers

Answer 44

1) Metoprolol succinate ER (Toprol XL): 12.5 mg – 200 mg PO daily 2) Carvedilol (Coreg): 3.125 mg – 25 mg PO BID -Target dose for patients weighing >85 kg is 50 mg twice daily 3) Coreg CR: 10 – 80 mg PO Qday

Question 45

What is an instruction you should give pts with beta blockers?

Answer 45

Take with food

Question 46

What monitoring is needed for beta blockers for HF?

Answer 46

start with low dose and titrate upward no more often than every 2 weeks as tolerated based on BP, HR, and symptoms

Question 47

Low dose aldosterone antagonists are appropriate for who?

Answer 47

1) NYHA class II to IV who are receiving standard therapy 2) Those with left ventricular dysfunction and either acute HF or diabetes early after MI

Question 48

Guidelines recommend adding an aldosterone antagonist to decrease the risk for hospitalization for HF in patients with _______, especially if plasma BNP levels are elevated

Answer 48

HFpEF

Question 49

Aldosterone antagonists: List how to dose the following: 1) Spironolactone (Aldactone) 2) Eplerenone (Inspra)

Answer 49

1) **Spironolactone (Aldactone):** 12.5 – 50 mg PO Qday CrCl 30 – 49 mL / min = 12.5 mg PO Qday or QOD 2) **Eplerenone (Inspra):** 25 – 50 mg PO Qday CrCl 30 – 49 mL / min = 25 mg PO Qday or QOD

Question 50

Describe monitoring with aldosterone antagonists

Answer 50

1) Assess BP, BUN, creatinine, and electrolytes at baseline 2) Check potassium 3 days and 1 week after initiation and then monthly for the first 3 months 3) Change to eplerenone if gynecomastia develops with spironolactone

Question 51

Aldosterone antagonists: _______________ is more likely to cause hyperkalemia, so it's contraindicated for patients with impaired kidney function or type 2 diabetes with proteinuria

Answer 51

Eplerenone

Question 52

Hydralazine; give the: 1) Dosing 2) Monitoring 3) Adverse effects

Answer 52

1) 37.5 mg – 75 mg PO TID 2) BP & HR 3) Hypotension, headache, rash, arthralgia, lupus, tachycardia

Question 53

Isosorbide nitrate; give the: 1) Dosing 2) Monitoring 3) Adverse effects 4) Warning

Answer 53

1) 20 – 40 mg PO TID 2) BP & HR 3) Hypotension, headache, lightheadedness 4) May worsen heart failure; do not use in HFpEF unless there is another indication (e.g., angina)

Question 54

Ivabradine (Corlanor): When do the guidelines recommend the use of this drug? "weird requirements"

Answer 54

In NYHA class II-III patients with HFrEF (EF <35%) in sinus rhythm who have a resting heart rate >70 bpm and are receiving maximally tolerated β-blocker doses

Question 55

Ivabradine (Corlanor): What is the starting dose?

Answer 55

5 mg PO BID w/ meals

Question 56

Ivabradine (Corlanor): 1) What is the monitoring? 2) What are the side effects? (hint: there's a couple weird ones)

Answer 56

1) BP, HR and ECG 2) Bradycardia, **hypertension**, atrial fibrillation, **luminous phenomena** (phosphenes, transiently enhanced brightness in a portion of the visual field)

Question 57

Digoxin 1) How is it dosed? 2) Who should receive a lower dose?

Answer 57

1) 0.125 to 0.25 mg PO Qday 2) Patients with decreased renal function or low body weight, the elderly, or those receiving interacting drugs (e.g., amiodarone) should receive 0.125 mg daily or every other day

Question 58

How do you monitor Digoxin?

Answer 58

1) Electrolytes, BUN, creatinine, ECG 2) Routinely measuring SDCs is not necessary unless digoxin toxicity is suspect or there are other conditions that may significantly affect SDC such as worsening renal function or the initiation of an interacting drug 3) Blood samples for measurement of SDCs should be collected at least 6 hours and preferably 12 hours or more after the last dose

Question 59

List 5 drugs digoxin interacts with (starred)

Answer 59

1) Amiodarone, dronedarone 2) Diuretics 3) Ranolazine 4) Spironolactone 5) Verapamil

Question 60

Calcium channel blockers: What are the initial daily doses for verapamil, diltiazem, and amlodipine?

Answer 60

Verapamil 120 mg, diltiazem 90 mg, and amlodipine 2.5 mg

Question 61

What are the 2 main drugs used for HF + AFIB?

Answer 61

Amiodarone (Pacerone) and dofetilide (Tikosyn)

Question 62

What are the 2 main drugs used for DM + HF?

Answer 62

Dapagliflozin (Farxiga) and empagliflozin (Jardiance)

Question 63

With HF, a patient should report body weight changes of __ to ___ lb in a day to their provider

Answer 63

3 to 5

Question 64

With HF, a serum potassium ≥_____ mEq/L (mmol/L) should be maintained with some evidence suggesting it should be ≥4.5 mEq/L (mmol/L)

Answer 64

4

Question 65

What is the dose of Potassium chloride (KCl) (Klor-Con) for prevention of hypokalemia?

Answer 65

20-40 mEq/day in one to two divided doses