Flashcards in Heart failure meds Deck (87):
What reductions bring about heart failure?
Reduction in ventricular filling
Reduction in myocardial contractility
What is reduction of ventricular filling also known as?
What is reduction of myocardial contractility also known as?
With what model do we describe heart failure?
What hormones are involved with the neurohormone activation?
How do we target pharmacotherapy for HF?
We try to antagonize the neurohormonal activation
Give the shorthand for diastolic dysfucntion with preserved AND reduced ejection fraction
What type of HF pts are most commonly involved in HF drug trials?
Pts with HFrEF
Describe pts classified in NYHA functional classification 1
Pt w/ cardiac disease but w/o limitations of physical activity
Describe pts classified in NYHA functional classification 2
Pts w/ cardiac disease w/ slight limitations of physical activity
Describe pts classified in NYHA functional classification 3
Pts w/ cardiac disease w/ marked limitations of physical activity
Describe pts classified in NYHA functional classification 4
Pts w/ cardiac disease w/ inability to carry on physical activity w/o discomfort
Do sx of NYHA HF
classification stay the same always?
No, they can change
What is the first stage of the ACC/AHA HF stage?
At risk stage
What is the second ACC/AHA HF stage?
Pts with structural heart disease
What is the third ACC/AHA HF stage?
Pt with structural heart disease and current or previous sx
What is the fourth ACC/AHA HF stage?
Do ACC/AHA HF stages changes?
No, they are consistent with the progressive nature of HF
What is the primary dysfunction that has been addressed in pharmacotherapy trials?
List two newer agents being used for systolic dysfunction
When are diuretics indicated for HF pts?
In any pt w/ evidence or history of fluid retention
Is there a potential for chronic diuretic use for HF pts?
How do we monitor the effects of diuretics for HF pts?
Daily morning weight measurements
Are thiazide diuretics weak or strong for HF?
Weak, use with something else
What thiazide is added to loops for diuretic resistance?
What is the doseage of metolazone?
2.4-10 mg once daily PLUS loop
What is the most potent diuretic for HF?
What is the ceiling effect of loop diuretics?
Hit a highest dose, still not totally effective
Give this more frequently, instead of increasing dose
When is torsemide preferred?
In pts with persistent fluid retention despite high doses of other loops
Give the relationship of IV dosing of Lasix, torsemide, and bumetanide
40 mg Lasix = 20 mg torsemid = 1 mg bumetanide
What is the cornerstone of HF pharmacotherapy?
When are ACE inhibitors first line therapy for HF
What is the reduction in mortality if HF pt is on an ACEI?
What do you use with an ACEI unless contraindicated?
When do you add beta blockers to ACEi?
After titrating ACEI to max dose (or even before)
What do you have to monitor when a pt is on an ACEI?
Serum K+ and renal function
What is a risk of abrupt withdrawal of ACEI?
What are some AEs of ACEIs?
Functional renal insufficency
How do you avoid hypotension with ACEIs?
Spread doses of other vasoactive meds out
start on captopril, titrate to max, then switch the ACEI with once daily dosing
How do you deal with the ACEI cough?
Switch to an ARB
What % of pts on ACEIs develop angioedema? What does this mean?
Must avoid ACEIs for lifetime
When are beta blockers indicated for HF pts?
For use in ALL stable HF pts unless intolerant or contraindicated
When should you use a diuretic with your beta blocker?
For current or recent fluid retention
Whats the biggest reason you should give your HF pts beta blockers?
They decrease mortality!
Give some examples of beta blockers used for HF
Metoprolol succinate (not tartrate)
What is the MOA of carvedilol?
Blocks beta 1 and 2 and alpha 1 receptors
When might carvedilol be preferred?
In pts w/ poorly controlled BP due to alpha and beta 1 blockade
When should you avoid carvedilol?
In asthmatic pts
Because beta 2 agonists are part of their tx
How do you start beta blockers?
Low doses with gradual dose titration
If you get AEs, should you keep increasing the BB dose?
No, wait until AEs have disappeared
Do you continue long term BB tx even if sx dont improve?
What may happen if you withdraw BB abruptly? How do you deal with that?
Taper if d/cing
Is there one BB that is better than others
Nope. Great class effect
What are the major AEs of BB?
What are the minor AEs of BB?
Worsening glucose tolerance (won't mask sweating)
Sexual dysfunction in males
What is the MOA of ARBs?
Inhibit AT-II at its receptor
What is something ARBs dont do that ACEIs do? What does that mean
Dont inhibit bradykinin metabolism (no increase in bradykinin)
Means less cough and angioedema
What dont you use ARBs with?
Can angioedema still occur with ARBS?
Yes, just way less
When do you start BBs with ARBs?
Before reaching max dose like w/ ACEIs
What are the serum requirements for starting aldosterone receptor antagonists (ARAs)?
SCr <2.5 mg/dL (M) or < 2.0 (F)
CrCl > 30 mL/min
Serum K+ < 5.0 mEq/L
What are two examples of ARAs?
What do you discontinue after starting an ARA?
When do you stop ARAs?
During diarrhea, dehydration, or interruptions of diuretic therapy
What are some AEs of spironolactone?
Hyperkalemia (monitor K+ closely)
What are some AEs of epleronone?
What do you do with epleronone if serum K+ > 6 mEq/L?
What do you do with epleronone if serum K+ > 5.5 mEq/L
Discontinue or lower dose
What id digoxin?
Only orally active positive cardiac inotrope
Does digoxin improve mortality?
What dose digoxin do?
Quality of life
Should you give a loading dose of digoxin for HF like you do with afib?
What is the target plasma level of digoxin?
What do higher levels mean?
What does digoxin toxicity occur earlier with?
When do you get your first digoxin plasma level?
3-5 days after starting therapy
When do you check digoxin levels after changing dosage?
When do you check digoxin levels after a general dose?
6-8 hours after (want a trough level)
What are some AEs of digoxin?
Neurological complaints (visual disturbances, altered color perception)
What is hydralazine?
An arterial vasodilator
AKA afterload reducer
What is isosorbide dinitrate?
Potent venous dilator
AKA preload reducer
Which population is hydralazine/isosorbide dinitrate useful in?
African Americans w/ HF
When do you start h/isdn for African Americans
On all African Americans on optimum ACEI and BB therapy unless contraindicated
When do you start h/isdn for non-African Americans?
On those intolerant to or contraindicated to ACEIs or ARBs
What is the MOA of ivabradine?
Decreases HR by inhibiting If pacemaker current in SA node
What is the benefit of ivabradine?
Reduces risk of hospitalization for worsening HF
What is a new class of HF drugs?
Angiotensin recepter-neprilysin inhibitor (ARNI)