HF pt 4

Question 1

what is the rationale behind BB usage in HF?

Answer 1

decreases ventricular arrythmias
cardiac hypertrophy and cardiac cell death
VC and HR
cardiac remodeling

Question 2

what pts should receive BB but cautiously?

Answer 2

in pts with bronchospastic disease and asymptomatic bradycardia
while initiating BB in hospitalized pts

Question 3

what is the dosing of bisoprolol?

Answer 3

initial: 1.25 mg daily
targeT: 10 mg daily

Question 4

what is the dosing of carvedilol?

Answer 4

initial: 3.125 mg BID
target: 25-50mg BID

Question 5

when should 25 or 50 mg BID be targeted in carvedilol?

Answer 5

if pt under 85 kg, 25 mg
if pt over 85 kg, 50 mg

Question 6

what is the dosing of carvedilol CR?

Answer 6

initial: 10 mg daily
target: 80 mg daily

Question 7

what is the dosing of metoprolol succinate?

Answer 7

initial: 12.5-25 mg daily
target: 200 mg daily

Question 8

how should BB be titrated?

Answer 8

double the dose every 2 weeks
monitor closely vital signs and symptoms (if get worse, then maybe change diuretic dose instead of BB)

Question 9

how long after initiation should the target dose be achieved?

Answer 9

aim for in 8-12 weeks or highest dose

Question 10

what is the conversion between carvedilol and carvedilol CR?

Answer 10

3.125 mg BID = 10 mg QD
6.25 mg BID = 20 mg QD
12.5 mg BID = 40 mg QD
25 mg BID = 80 mg QD

Question 11

what are the core monitoring parameters of BB?

Answer 11

BP (and symptomatic hypotension)
HR (no goal)

Question 12

when should a reduction of BB dose be considered?

Answer 12

if pt is on a slow titrate and is experiencing symptomatic hypotension, bradycardia, and dizziness –> reduce dose by 50%
if hypotension only, reduce other drugs like diuretics first

Question 13

what are other monitoring parameters of BB?

Answer 13

edema and fluid retention
weight
fatigue or weakness

Question 14

in what stage should BB be recommended?

Answer 14

stage B and stage C unless CI

Question 15

what is angioedema?

Answer 15

notable swelling of the face, lips, and tongue

Question 16

when aldosterone is elevated in HF, what does it lead to?

Answer 16

continued sympathetic activation
parasympathetic inhibition
cardiac and vascular remodeling
BAD THINGS

Question 17

how does selectivity vary in MRAs?

Answer 17

spironolactone is non-selective
eplerenone is selective

Question 18

what are the main effects of MRAs?

Answer 18

decrease K and Mg losses
decrease sodium retention
decrease sympathetic simulation
block direct fibrotic action on myocardium

Question 19

why is it important that MRAs decrease K/Mg losses?

Answer 19

may protect against arrhythmias

Question 20

why is it important MRAs decrease Na retention?

Answer 20

decrease fluid retention

Question 22

what are the AE unique to spironolactone?

Answer 22

gynecomastia
impotence
menstrual irregularities

Question 23

why is eplerenone not preferred over spironolactone?

Answer 23

usually comes down to $$
also a substrate of CYP3A4 so need to avoid interactions with KTZ

Question 23

what is the dosing of eplerenone if eCrCl is over 50?

Answer 23

initial: 25 mg QD
maintenance: 50 mg QD

Question 24

what is the dosing of eplerenone if eCrCL is between 30-49?

Answer 24

initial: 25 mg QOD maintenance: 25mg QD

Question 25

what is the dosing of spironolactone if eCrCl over 50?

Answer 25

initial: 12.5-25mg QD maintenance: 25 mg QD

Question 26

what is the dosing of spironolactone if eCrCl is between 30-49?

Answer 26

initial: 12.5 mg QD or QOD maintenance: 12.5-25mg QD

Question 27

when should MRAs be avoided?

Answer 27

if SeCr is over 2.5 in males or 2.0 in females if SeK is over 5 if CrCl is under 30 hx of severe hyperkalemia or recent worsening kidney function

Question 28

what concomitant usage should be avoided with MRAs?

Answer 28

K sparing diuretics or supplements (unless hypokalemia of under 4) NSAIDs triple therapy of ACEi/ARB/MRA caution with high dose of ACEi/ARB

Question 29

what should be monitored with MRAs?

Answer 29

renal function and K within 3 days-1 week after any change or addition, disease, or acute illnesses that may influence K concentrations, then every 3 months, then every 3-4 months and with increase ACEi or ARB restart

Question 30

what is important counseling of MRAs?

Answer 30

avoidance of salt substitutes (due to K being in most of them -- use Mrs. Dash instead) close questioning for all other sources of K

Question 31

what stage is MRA recommended?

Answer 31

Stage C only if eGFR over 30 and K under 5

Question 32

when should MRAs be d/c?

Answer 32

if K cannot be maintained to under 5.5 then needs to avoid life threatening hyperkalemia

Question 33

what are the benefits of SGLT2i?

Answer 33

osmotic diuresis and natriuresis decreased arterial pressure and stiffness preload/afterload reduction and associated reduction in hypertrophy and fibrosis (reduced myocardial remodeling)

Question 34

what is the dosing of SGLT2i?

Answer 34

10mg QD

Question 35

under what eGFR should SGLT2 be not used?

Answer 35

under 30 for dapagliflozin under 20 for empagliflozin

Question 36

what are the AE of SGLT2i?

Answer 36

volume depletion KTA in DM, hypoglycemia, infection risk (UTI/PN, NFP, mycotic)

Question 37

when are SGLT2i recommended?

Answer 37

in pts with symptomatic chronic HFEF w/wo DM to reduce hospitalization and CV mortality stage C