Heart failure meds Flashcards Preview

Pharm > Heart failure meds > Flashcards

Flashcards in Heart failure meds Deck (87):
1

What reductions bring about heart failure?

Reduction in ventricular filling
Reduction in myocardial contractility

2

What is reduction of ventricular filling also known as?

Diastolic dysfunction

3

What is reduction of myocardial contractility also known as?

Systolic dysfunction

4

With what model do we describe heart failure?

Neurohormonal model

5

What hormones are involved with the neurohormone activation?

Norepinephrine
Angiotensin II
Aldosterone
Proinflammatory cytokines

6

How do we target pharmacotherapy for HF?

We try to antagonize the neurohormonal activation

7

Give the shorthand for diastolic dysfucntion with preserved AND reduced ejection fraction

HFpEF
HFrEF

8

What type of HF pts are most commonly involved in HF drug trials?

Pts with HFrEF

9

Describe pts classified in NYHA functional classification 1

Pt w/ cardiac disease but w/o limitations of physical activity

10

Describe pts classified in NYHA functional classification 2

Pts w/ cardiac disease w/ slight limitations of physical activity

11

Describe pts classified in NYHA functional classification 3

Pts w/ cardiac disease w/ marked limitations of physical activity

12

Describe pts classified in NYHA functional classification 4

Pts w/ cardiac disease w/ inability to carry on physical activity w/o discomfort

13

Do sx of NYHA HF
classification stay the same always?

No, they can change

14

What is the first stage of the ACC/AHA HF stage?

At risk stage

15

What is the second ACC/AHA HF stage?

Pts with structural heart disease

16

What is the third ACC/AHA HF stage?

Pt with structural heart disease and current or previous sx

17

What is the fourth ACC/AHA HF stage?

Refractory HF

18

Do ACC/AHA HF stages changes?

No, they are consistent with the progressive nature of HF

19

What is the primary dysfunction that has been addressed in pharmacotherapy trials?

Systolic dysfunction

20

List two newer agents being used for systolic dysfunction

Ivabradine
Sacubitril/valsartan

21

When are diuretics indicated for HF pts?

In any pt w/ evidence or history of fluid retention

22

Is there a potential for chronic diuretic use for HF pts?

Yes

23

How do we monitor the effects of diuretics for HF pts?

Daily morning weight measurements

24

Are thiazide diuretics weak or strong for HF?

Weak, use with something else

25

What thiazide is added to loops for diuretic resistance?

Metolazone

26

What is the doseage of metolazone?

2.4-10 mg once daily PLUS loop

27

What is the most potent diuretic for HF?

Loop

28

What is the ceiling effect of loop diuretics?

Hit a highest dose, still not totally effective
Give this more frequently, instead of increasing dose

29

When is torsemide preferred?

In pts with persistent fluid retention despite high doses of other loops

30

Give the relationship of IV dosing of Lasix, torsemide, and bumetanide

40 mg Lasix = 20 mg torsemid = 1 mg bumetanide

31

What is the cornerstone of HF pharmacotherapy?

ACE inhibitors

32

When are ACE inhibitors first line therapy for HF

Systolic HF

33

What is the reduction in mortality if HF pt is on an ACEI?

20-30%

34

What do you use with an ACEI unless contraindicated?

Beta blocker

35

When do you add beta blockers to ACEi?

After titrating ACEI to max dose (or even before)

36

What do you have to monitor when a pt is on an ACEI?

Serum K+ and renal function

37

What is a risk of abrupt withdrawal of ACEI?

Decompensation

38

What are some AEs of ACEIs?

Hypotension
Functional renal insufficency
Cough
Angioedema

39

How do you avoid hypotension with ACEIs?

Spread doses of other vasoactive meds out
OR
start on captopril, titrate to max, then switch the ACEI with once daily dosing

40

How do you deal with the ACEI cough?

Switch to an ARB

41

What % of pts on ACEIs develop angioedema? What does this mean?

<1%
Must avoid ACEIs for lifetime

42

When are beta blockers indicated for HF pts?

For use in ALL stable HF pts unless intolerant or contraindicated

43

When should you use a diuretic with your beta blocker?

For current or recent fluid retention

44

Whats the biggest reason you should give your HF pts beta blockers?

They decrease mortality!

45

Give some examples of beta blockers used for HF

Bisoprolol
Carvedilol
Metoprolol succinate (not tartrate)

46

What is the MOA of carvedilol?

Blocks beta 1 and 2 and alpha 1 receptors
*nonselective*

47

When might carvedilol be preferred?

In pts w/ poorly controlled BP due to alpha and beta 1 blockade

48

When should you avoid carvedilol?

In asthmatic pts
Because beta 2 agonists are part of their tx

49

How do you start beta blockers?

Low doses with gradual dose titration

50

If you get AEs, should you keep increasing the BB dose?

No, wait until AEs have disappeared

51

Do you continue long term BB tx even if sx dont improve?

Yes

52

What may happen if you withdraw BB abruptly? How do you deal with that?

Acute decompensation
Taper if d/cing

53

Is there one BB that is better than others

Nope. Great class effect

54

What are the major AEs of BB?

Fluid retention
Fatiuge
Bradycardia
Hypotension

55

What are the minor AEs of BB?

Bronchospasm
Worsening glucose tolerance (won't mask sweating)
Sexual dysfunction in males

56

What is the MOA of ARBs?

Inhibit AT-II at its receptor

57

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

58

What dont you use ARBs with?

ACEI

59

Can angioedema still occur with ARBS?

Yes, just way less

60

When do you start BBs with ARBs?

Before reaching max dose like w/ ACEIs

61

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

62

What are two examples of ARAs?

Spironolactone
Eplerenone

63

What do you discontinue after starting an ARA?

K+ supplements

64

When do you stop ARAs?

During diarrhea, dehydration, or interruptions of diuretic therapy

65

What are some AEs of spironolactone?

Gynecomastia
Hyperkalemia (monitor K+ closely)

66

What are some AEs of epleronone?

Hyperkalemia
Gynecomastia

67

What do you do with epleronone if serum K+ > 6 mEq/L?

Discontinue

68

What do you do with epleronone if serum K+ > 5.5 mEq/L

Discontinue or lower dose

69

What id digoxin?

Only orally active positive cardiac inotrope

70

Does digoxin improve mortality?

No

71

What dose digoxin do?

Improves
LVEF
Quality of life
Exercise tolerance
HF sx

72

Should you give a loading dose of digoxin for HF like you do with afib?

No

73

What is the target plasma level of digoxin?
What do higher levels mean?

0.5-1.0 ng/mL
Higher moretality

74

What does digoxin toxicity occur earlier with?

Hypokalemia
Hypomagnesemia
Hypothyroidism

75

When do you get your first digoxin plasma level?

3-5 days after starting therapy

76

When do you check digoxin levels after changing dosage?

5-7 days

77

When do you check digoxin levels after a general dose?

6-8 hours after (want a trough level)

78

What are some AEs of digoxin?

Cardiac arrythmias
GI sx
Neurological complaints (visual disturbances, altered color perception)

79

What is hydralazine?

An arterial vasodilator
AKA afterload reducer

80

What is isosorbide dinitrate?

Potent venous dilator
AKA preload reducer

81

Which population is hydralazine/isosorbide dinitrate useful in?

African Americans w/ HF

82

When do you start h/isdn for African Americans

On all African Americans on optimum ACEI and BB therapy unless contraindicated

83

When do you start h/isdn for non-African Americans?

On those intolerant to or contraindicated to ACEIs or ARBs

84

What is the MOA of ivabradine?

Decreases HR by inhibiting If pacemaker current in SA node

85

What is the benefit of ivabradine?

Reduces risk of hospitalization for worsening HF

86

What is a new class of HF drugs?
(Includes sacubitril/valsartan)

Angiotensin recepter-neprilysin inhibitor (ARNI)

87

How significantly did ARNI entresto lower CV mortality?

By 20%