HF pt 3

Question 1

what drugs are approved to reduce mortality or mortality/hospitalization in chronic HFrEF?

Answer 1

metoprolol succinate, carvedilol, captopril, enalapril, rampiril, trandolapril, quinapril, fosinopril, lisinopril, candesartan, valsartan, entresto, spironolactone, eplerenone, isosorbide/hydralazine, bisoprolol (not US), farxiga, jardiance

Question 2

what drugs are approved to reduce hospitalization only in chronic HFrEF?

Answer 2

digoxin
ivabradine

Question 3

what drugs are approved to improve hemodynamic or physical function in chronic HFrEF?

Answer 3

digoxin
isosorbide/hydralazine

Question 4

what drugs are used to improve hemodynamic or physical function in AHF?

Answer 4

inotropes
milrinone
sodium nitroprusside
nesiritide

Question 5

what drugs are approved to improve QOL or symptoms in chronic HFrEF?

Answer 5

digoxin
diuretics

Question 6

what drugs are approved to improve QOL or symptoms in AHF?

Answer 6

nesiritide
diuretics

Question 7

what pt population would benefit from ACEi therapy?

Answer 7

benefit in all pts regardless of etiology or severity of disease, must be used in all without CI
additional benefits in IHD, CKD, post-MI, or DM

Question 8

when bradykinin is prevented from degraded by the use of ACEi, what happens?

Answer 8

increased NE, vasodilation, vessel permeability, and tPA/prostaglandin release

Question 9

how does a cough develop with ACEi?

Answer 9

ACEi block the degradation of bradykinin which leads to the increase production of tPA/prostaglandin release which is what makes a cough occur

Question 10

what is the moa of ACEi?

Answer 10

inhibition of angiotensin I converting into angiotensin II

Question 11

what are the good effects of ACEi?

Answer 11

improved cardiac hemodynamics
reduced aldosterone
decreased endothelin-1
decreased arginine vasopressin
reduced vasoconstriction
reduce Na and water retention

Question 12

what is the dosing of enalapril (vasotec)?

Answer 12

initial: 2.5-5 mg BID
target: 10 mg BID

Question 13

what is the dosing of captopril?

Answer 13

initial: 6.25-12.5mg TID
target: 50mg TID

Question 14

what is the dosing of lisinopril (prinivil, zestril)?

Answer 14

initial: 2.5-5mg QD
target: 20mg QD

Question 15

what is the dosing of quinapril (accupril)?

Answer 15

initial: 5-10mg BID
target: 20-40mg BID

Question 16

what is the dosing of ramipril (altace)?

Answer 16

initial: 1.25-2.5mg QD
target: 5mg BID or 10 mg QD

Question 17

what is the dosing of fosinopril (monopril)?

Answer 17

initial: 5-10 mgQD
target: 40 mg QD

Question 18

how should ACEi be dosed?

Answer 18

should be titrated to dose that shows reduction in mortality, not by symptoms or BP goal
start low and double dose every 1-4 weeks

Question 19

how should ACEi be dosed in CKD?

Answer 19

lower doses if CrCl is under 30 mL/min
1/2 of initial and 1/2 target mortality dose

Question 20

when should titrate of ACEi be cautioned?

Answer 20

if volume depleted and SBP under 80
if K over 5 and SeCr over 3

Question 21

what are absolute CI of ACEi?

Answer 21

pregnancy or intending to become pregnant
history of angioedema or hypersensitivity
bilateral renal artery stenosis
history of well-documented intolerance due to symptomatic hypotension, decline in renal function, hyperkalemia, or cough

Question 22

what should be monitored with ACEi/ARBs?

Answer 22

volume status (prior to initiation)
renal function and K
BP
other adverse effects

Question 23

when should renal function and K be monitored in ACEi/ARBs?

Answer 23

prior to therapy
1-2 weeks after each increase in dose
at 3-6 months intervals
when other treatments are added that may decrease renal function
in pts with hx of renal dysfunction

Question 24

what is an unacceptable increase in SeCr?

Answer 24

over 30%

Question 25

what are AE of ACEi/ARBs?

Answer 25

hypotension functional renal insufficiency hyperkalemia skin rash and dysgeusia cough (ACEi only) angioedema

Question 26

how do ARBs differ from ACEi?

Answer 26

no cough because it doesn't block bradykinin degradation blocks nonspecific chymas

Question 27

what is the dosing of losartan (cozaar)?

Answer 27

initial: 25-50mg daily target: 150 mg daily

Question 28

what is the dosing valsartan (diovan)?

Answer 28

initial: 20-40 mg BID target: 160 mg BID

Question 29

what is the dosing of candesartan (Atacand)?

Answer 29

initial: 4 mg daily target: 32 mg daily

Question 30

when should an ARB be used?

Answer 30

unable to take ACEi due to cough ACEi-induced angioedema

Question 31

if a pt has persistent Scr or K, does it make sense to switch from an ACEi to an ARB?

Answer 31

no probably will see same effect

Question 32

what is moa of an ARNI?

Answer 32

part ARB so blocks the Angiotensin II from activating the AT1-receptor and inducing vasoconstriction part Neprilysin inhibitor so stops Neprilysin from binding to BNP and blocking vasodilation

Question 33

what is the AE of ARNIs?

Answer 33

hypotension (more so than enalapril) elevations in SeCr, SeK (less than enalapril) angioedema rare pregnancy

Question 34

how should entresto be dosed?

Answer 34

based on previous use of ACEi/ARB or other factors

Question 35

when should the initial dose of 49/51mg BID be used?

Answer 35

pt alr on high dose ACEi or high dose ARB

Question 36

when should initial dose of 24/26mg BID be used?

Answer 36

pt alr on medium to low dose ACEi/ARB ACEi/ARB naive eGFR under 30 moderate hepatic impairment age over 75 years

Question 37

what is the equivalence of ACEi?

Answer 37

enalapril 20 = captopril 150 = lisinopril 20

Question 38

what are the CI of ARNI?

Answer 38

within 36 hours of ACEi use angioedema with an ACEi or ARB previously pregnancy lactation severe hepatic impairment concomitant aliskiren use in pt with DM known hypersensitivity

Question 39

what are the cautions of ARNI?

Answer 39

renal impairment hepatic impairment renal artery stenosis hypotension volume depletion hyponatremia post MI

Question 40

in what class is ACEi recommended?

Answer 40

Stage B Stage C if ARNI use not feasible

Question 41

in what class is ARB use recommendeD?

Answer 41

Stage B if intolerant to ACEi Stage C if intolerant to ACEi and ARNI not feasible reasonable alternative in Stage C if taking an ARB for another indication

Question 42

in what stage is an ARNI recommended?

Answer 42

Stage C in all pts

Question 43

what is the monitoring of ARNIs?

Answer 43

BP electrolytes renal function after initiation and during titration

Question 44

how should ARNIs be titrated?

Answer 44

after 2 weeks of usage, assess tolerability and titrate if possible dose stepwise to target dose of 97/103 mg BID