HF pt 2

Question 1

what are the goals of therapy for Asymptomatic rEF and HFrEF?

Answer 1

1. slow disease progression
2. reduce symptoms, improve QOL, and prevent/reduce hospitalization and need for emergency care
3. reduce mortality

Question 2

what are general measures HF pts can take?

Answer 2

treat underlying cause (HTN, CAD, DM)
remove precipitating causes (excessive fluid, inappropriate drug tx)
exercise

Question 3

how can a HF pt exercise?

Answer 3

encouragement of regular exercising like walking and cycling in stable HF
dynamic exercise to increase HR to 60-80% of maximum for 20-60 minutes 3-5 times/week

Question 4

how should sodium be limited in HF?

Answer 4

2-3g/day if possible
avoid salty food and salt at table
if severe, under 2g/day

Question 5

how should alcohol be limited in HF?

Answer 5

pt with EtOh induced HF should abstain totally from it
2 drinks/day if male, 1 drink/day if female

Question 6

how should fluid intake be limited in HF?

Answer 6

restrict to under 2L/day in pts with hyponatremia
tx with diuretics if difficult in maintaining fluid volume

Question 7

what are some other general measures to take for HF?

Answer 7

weight monitoring
general education of pts and families
smoking cessation
immunization
monitor and replace electrolytes (esp. K/Mg)
appropriate thyroid dz management

Question 8

what are the educational points for pts and families?

Answer 8

non-drug and drug therapies
symptoms of worsening HF like weight and changes
prognosis

Question 9

what drugs therapies reduce intravascular volume/preload?

Answer 9

diuretics
SGLT2i

Question 10

what drugs increase myocardial contractility?

Answer 10

positive inotropes

Question 11

what drus decrease ventricular afterload?

Answer 11

ACEi
vasodilators
SGLT2i

Question 12

what drugs make up a neurohormonal blockade?

Answer 12

ARNIs
BB
ACEi/ARBs
MRAs
SGLT2i

Question 13

how should stage A be treated?

Answer 13

if atherosclerotic vascular disease is present, then ACEi/ARB

Question 14

how should Stage B be treated?

Answer 14

if previous MI or asymptomatic rEF, then ACEi/ARB and BB

Question 15

how should stage C be treated?

Answer 15

ARNI (ACEi/ARB if not tolerated)
BB
MRA
SGLT2i
Loop diuretics prn for excessive fluid

Question 16

what pt population favors the usage of hydral-nitrates?

Answer 16

AA with NYHA III-IV, Stage C, and persistently symptomatic on GDMT

Question 16

what pt population favors the usage of ivabradine?

Answer 16

stage C and NYHA class II-III if persistently symptomatic
needs to have normal sinus rhythm and HR over 70 bpm on maximally tolerated BB dose

Question 17

what pts should be on diuretics?

Answer 17

all HF pts with s/sx of fluid retention

Question 18

why should diuretics be used?

Answer 18

reduce hospitalization and symptoms associated with fluid overload
improve exercise tolerance and QOL

Question 19

what are short-term benefits of diuretics?

Answer 19

reduce fluid retention via decreased edema, pulmonary congestion, and JVD by reducing preload and cardiac filling pressure

Question 20

what are the long term benefits of diuretics?

Answer 20

reduce daily symptoms and improve ability to exercise

Question 21

why are loop diuretics prefered in HF?

Answer 21

block Na and Cl reabsorption in the ascending limb of LOH
enhance renal release of prostaglandins

Question 22

why is it good that loop diuretics enhance renal release?

Answer 22

increases renal blood flow which enhances venous capacitance (amount of blood in renal veins at a certain pressure)

Question 23

what loop diuretic is first-line?

Answer 23

furosemide due to be cheap, having good dosgae forms, and doctors being comfortable with use

Question 24

what is the main drawback of furosemide?

Answer 24

erratic bioavailability (10-90%) --> switching to torsemide may be an advantage

Question 25

what is the dosing of furosemide?

Answer 25

initial: 20-40mg QD or BID usual: 20-160 mg QD or BID

Question 26

what is the dosing of bumetanide?

Answer 26

initial: 0.5-1mg QD/BID usual: 1-2mg QD/BID

Question 27

what is the dosing of torsemide?

Answer 27

initial: 10-20mg QD usual: 10-90mg QD

Question 28

what is the equivalence of oral furosemide to other diuretics?

Answer 28

40 mg = B 1 mg = T 20 mg = E 50 mg

Question 29

what is the equivalence of IV furosemide to other diuretics?

Answer 29

20 mg = B 1mg = T X = E 1mg

Question 30

why are thiazides diuretics not prefered?

Answer 30

relative weak at blocking Na/Cl reabsorption in the DCT lose effectiveness as renal function decreases (higher doses needed if eGFR under 30)

Question 31

what pt populations may benefit from thiazide diuretics?

Answer 31

mild HF and small amounts of fluid retention anything else --> use loop

Question 32

what is unique about matolazone (MTZ)?

Answer 32

erratically absorbed and has a longer half life can be used in combination with a loop diuretic in pts who become resistant to single-drug (same thing with HCTZ)

Question 33

what is the dosing of HCTZ (esidrix, hydrodiuril)?

Answer 33

initial: 25 mg/day max: 100 mg/day

Question 34

what is the dosing of MTZ (mykrox, zaroxolyn)?

Answer 34

initial: 2.5 mg/day max: 10 mg/day

Question 35

what is the dosing of chlorthalidone?

Answer 35

initial: 12.5-25 mg/day max: 50 mg/day

Question 36

what is the dosing of CTZ?

Answer 36

initial: 250-500 mg/day IV max: 2000 mg/day IV

Question 37

what is the dosing of indapamide?

Answer 37

initial: 2.5 mg/day max: 5 mg/day

Question 38

what are the major adverse effects of diuretics?

Answer 38

decreased Mg, K, Na decrease renal function, volume depletion, pre-renal azotemia increased uric acid Ca increases with THZ and decreases with loops

Question 39

how should loop diuretics be initiated?

Answer 39

initiate at low-doses then double and titrate adjustments based on weights and symptoms

Question 40

how should weight be monitored with diuretics?

Answer 40

report if there is weight gain of 3-5 pounds/week pt should try and reduce weight by 1-2 lbs/day if fluid overload

Question 41

what factors are indicative of volume depletion while on loop diuretics?

Answer 41

hypotension increased Se Cr or BUN/Cr ratio

Question 42

when is monitoring required in diuretics?

Answer 42

1-2 weeks after initiation and at every increase of dose

Question 43

what should be monitored in diuretic therapy?

Answer 43

fluid intake and urinary output; body weight; signs of congestion/JVD BP, serum electrolytes, and renal function

Question 44

when should K and Mg be supplemented during diuretics?

Answer 44

if K is under 4 or Mg is under 2

Question 45

what stages required a diuretic?

Answer 45

B - maybe thiazide for HTN C - yes, at lowest possible dose to keep euvolemic