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Therapeutics II (Spring) > HF questions > Flashcards

HF questions Flashcards

1
Q

Low cardiac output results in the activation of compensatory neurohormonal pathways. Activation of the SNS results in which one of the following effects?

A

Increased HR

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2
Q

Which of the following meds may exacerbate HFrEF?

A. Metformin B. Amlodipine C. Atorvastatin D. Ibuprofen

A

-ibuprofen
-Na retention bc block prostaglandins = no renal dilation = reduce flow

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3
Q

Physical exam findings consistent w symptomatic HF

A

-Dyspnea
-JVD
-peripheral edema
-rales

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4
Q

Which of the following are common causes of heart failure (Select all that apply)?

A

-MI
-HTN

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5
Q

Which of the following doses would be considered “equivalent” to 1 mg PO bumetanide?

A

-Furosemide 40mg PO
-Furosemide 20mg IV

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6
Q

TZDs

A

-relatively weak blockage of Na Cl absorption in DCT
-may use in mild HF w small amt of fluid retention
-lose effectiveness as renal fx dec = give higher dose when GFR < 30
-HCTS and MTZ used in combo w loops in resistant pt

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7
Q

TZD drugs for HF

A

-HCTZ (Esidrix, Hydrodiuril): 25-100mg/day
-Metolazone (Mykrox, Zaroxolyn): 2.5-10mg/day

-use in combo w loop in pt that are resistant

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8
Q

Diuretic adverse effects

A

-dec K, Mg, Na, Ca
-TZD inc Ca
-volume depletion
-dec renal fx
-pre-renal azotemia
-postural hypotension
-inc uric acid

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9
Q

Loop diuretic initiation

A

-low dose then double and titrate based on wt and sx
-if fluid overload, dec wt 1-2 lbs/day (500mL to 1L/day)
-hypotension and inc SeCr or BUN/Cr ratio may be indicitive of volume depletion
-might need to adj during ACE/ARB/ARNI or BB titration

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10
Q

indication of volume depletion

A

-hypotension
-inc SeCr and BUN/Cr ratio

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11
Q

Loop use and monitoring

A

-1-2 weeks
-fluid intake/output
-wt
-congestion
-JVD
-BP
-electolytes (replace K and Mg if needed)
-renal fx

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12
Q

Stage B recommendation for diuretic

A

-no need
-maybe TZD in HTN

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13
Q

drugs w highest reduction in mortality

A

-ISDN/Hyd
-BB

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14
Q

Neurohormonal blockers

A

-RAS inhibitors
-BBs
-SGLT2i
-MRAs
-hyd/ISDN

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15
Q

ACEi MOA

A

-blocks angiotensin I to II (arterial dilation, dec fibrosis, dec NE, dec constriction)
-blocks bradykinin breakdown (venous dilation, incNE, permeability, prostaglandin release, cough)

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16
Q

ACEi benefits

A

-inc endothelial fx
-dec NE
-inhibit hypertrophy
-improve hemodynamics
-dec aldosterone
-dec arginine vasopressin
-dec endothelin-1
-dec vasoconstriction
-dec Na and water retention

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17
Q

ACE drugs

A

-Enalapril (Vasotec): 2.5-5 up to 10mg BID
-Captopril (Capoten): 6.25-12.5 upto 50mg TID
-Lisinopril (Prinivil, Zestril): 2.5-5 upto 20-40mg QD
-Quinapril (Accupril): 5-10 upto 20-40mg QD
-Ramipril (Altace): 1.25-2.5 upto 5mg BID-10mg QD
-Fosinopril (Monopril): 5-10mg up to 40mg QD

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18
Q

Dosing of ACEi considerations

A

-IF CrCL< 30, START W HALF DOSE AND GET TO HALF TARGET DOSE
-push for target dose in hypotension unless sx
-start low and double q1-4 weeks
-CAUTION if: volume depleted, SBP<80, K>5, SeCR >3
-lower doses and more monitoring required in SCr >3 and CrCl <30

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19
Q

Absolute contraindications to ACEis

A

-pregnancy
-angioedema
-bilateral artery stenosis (BP will drop)
-hx of intolerance due to sx hypotension, decline in renal fx, hyperkalemia, cough

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20
Q

ACEi monitoring

A

-volume status
-renal fx
-K
-BP
-prior to tx, 1-2 weeks after inc, then 3-6 month intervals
-when other tx that might dec renal function
-SeCR may rise after initiation (30% acceptable)

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21
Q

Acceptable rise ini SeCr after ACE initiation?

A

up to 30%

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22
Q

ACE adverse effe

A

-fx renal insufficiency
-hyperkalemia
-skin rash/dysgeusia
-cough
-angioedema

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23
Q

How does ARB mech differ from ACE

A

-blocks angiotensin II to AT1 receptor
-no cough and less venodilation (bradykinin breakdown)
-might block some receptors that ACEs miss

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24
Q

ARB drugs

A

-Losartan (Cozaar): 25-50mg up to 150mg QD
-Valsartan (Diovan): 20-40mg up to 160mg BID
-Candesartan (Atacand): 4mg upto 32mg QD

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25
Angiotensin Receptor Neprilysin Inhibitors
-blocks NEP and AT1 receptors -valsartan (ARB) blocks AT1 -sacubitril metabolite blocks NEP and inhibits degradation of BNP -dec Na retention -dilate -dec SNS hypertrophy, fibrosis, permeability
26
Sacubitril/Valsartan
-ARNI -use in stage C pt -Entresto -valsartan equivalents? -EXPENSIVE!
27
Sacubitril/Valsartan AEs
-hypotension (more than ACE) -inc SeCr and K (less than ACE) -angioedema rare -DO NOT USE in pregnancy
28
S/V dosing
-if high dose ACE/ARB: -49/51mg BID initial -97/103mg BID max -if none/low/medium dose ACE/ARB, eGFR <30, mod hepatic impairment (inc LFTs), or over age of 75: -24/26mg BID -high dose ACE: enalapril 10 = captopril 75 = lisinopril 10-20mg qd -high dose ARB: >160mg valsartan qd
29
Entresto (S/V) contraindications
-same as ACE/ARB -do NOT take within 36 hours of ACEi
30
Entresto (S/V) side effects
-renal/hepatic impairment -renal artery stenosis -HYPOtension -volume depletion -HYPOnatremia -post MI
31
Sacubitril/valsartan is contraindicated in patients with HFrEF and with which one of the following?
angioedema with ramipril
32
Beta blockers benefit for HF
-dec ventricular arrhythmias -dec hypertrophy and cell death -dec VC and HR -dec remodeling -by blocking NE and EPI
33
Beta blocker patient selection
-EUVOLEMIC!!!! -sx pt should receive diuretics -caution in bronchospastic disease and asx bradycardia -initiation in hospital -do NOT abruptly dc -may take months to see effects (reverse remodeling)
34
Beta blocker drugs for HF
-bisoprolol () 1.25-10mg qd -carvedilol 3.125-25(if less than 85kg)-50mg BID -carvedilol CR: 10-80mg -metoprolol succinate XL (Toprol XL): 12.5-25-200mg qd -
35
Beta blocker dose titration
-double every 2 weeks -monitor vitals and sx -aim for target dose or highest tolerated dose in 8-12 weeks
36
Dose conversion between agents
-carvedilol to Coreg CR -3.125/10 -6.25/20 -12.5/40 -25/80 -BID to qd
37
BB monitoring
-BP -sx hypotension (if only hypotension, change other drugs first -HR (no defined goal) -less common if slow titration -edema/fluid retention -fatigue
38
Use of BB
-Stage B and C
39
Aldosterone
-elevated in HF =SNS activation =PSNS inhibition =remodeling -use MRAs
40
MRAs (aldosterone antagonists)
-blocks aldosterone effects independent of effects of ACE/ARBs -dec K and Mg loss (might protect against arrhythmias) -dec Na retention -dec SNS -block fibrotic action on heart
41
Spirinolactone
-MRA -cheap -NON-selective -similar to progesterone -inhibits testosterone and inc conversion of testosterone into estrogen -gynecomastia, impotence, menstrual probs -12.5-25mg
42
Eplerenone
-SELECTIVE -less affinity for receptors than spirinolactone -no antiandrogenic effects -CYP3A4 substrate -25-50mg
43
Spirinolactone dosing
-initial: 12.5-25mg qd, if CrCl <50, 12.5mg qd or qotherd -maintenance: 25mg or 12.5-25mg if CrCl <50
44
Eplerenone dosing
-initial: 25mg qd, if CrCl <50 25mg every other day -maintenance: 50mg qd, if CrCl < 50 25mg qd
45
When to avoid MRAs
-SeCR > 2.5 or 2 -CrCl <30 -SeK>5 -history of hyperkalemia or worsening kidney fx
46
What to avoid w MRAs
-K-sparing diuretics unless hypokalemia -NSAIDs, and caution in high dose ACE/ARB
47
MRA monitoring
-renal fx and K within 1 week after any change -then q3 months and with inc ACE or ARB restart -pt should avoid salt substititues bc high potassium
48
MRA guidelines
-not in stage B -Stage C pt w GFR > 30 and K<5 -careful mx of K, renalfx, and diuretic dose -dc if K wont stay <5.5
49
SGLT2 inhibitor mech
-unclear mech -diuresis and natriuresis -dec arterial pressure/stiffness -preload and afterload reduction and associated reduction in hypertrophy and fibrosis -reduced remodeling
50
SGLT2 drugs
-dapagliflozin (Farxiga) 10mg -Empagliflozin (Jardiance) 10mg -starts to work right away -inititiate at 10mg dose
51
SGLT2 side effects
-volume depletion -KTA in DM -hypoglycemia -infection risk -empagliflozin might be good for eGFR
52
Titration of therapy after 42 days (6 weeks)
-maintenance or additional titration -consider EP device or transcatheter valve repair -consider add-ons -manage comorbidities
53
Blood pressure monitoring on 4 main therapies
-SBP>100 -all have side effect of hypotension
54
RASi and MRA labs
-K <5.5 -eGFR > 30 -SeCr inc < 30% in 4 weeks
55
BB labs
-SBP > 100 -HR >60
56
SGLT2 labs
-eGFR > 20 -watch for genital infection -SeCr inc >30% within 4 weeks -ketones/lactones
57
ISDN/hydralazine (BiDil) mech
-reduce preload and after load -ISDN venodilator -hydralazine arterial dilator -first drug combo w reduction in mortality! -less effective than ACEs
58
ISDN/hydralazine (Bidil) indication
-black patients receiving optimal therapy to improve sx -pt that can't receive ACE/ARB/ARNi (preg, angiodema, renal insufficiency)
59
ISDN/Hydralazine (BiDil) side effects
-sig problem, limiting factor -HA, N -flushing, dizziness -tachycardia! -lupus-like syndrome -hypotension -inc HR -myocardial ischemia -fluid retention
60
ISDN/Hydralazine dosing
-initial 20/37.5mg TID -target: 40/75mg TID
61
Ivabradine (Corlanor) indication
-reduce risks/death in stage C HFrEF (<35%) treated w max BB (or CI) who have HR > 70 bpm at rest
62
Ivabradine dosing
-2.5-5 mg BID initial, max 7.5mg BID -adjust q2weeks based on HR -if HR >60 inc dose by 2.5mg up to 7.5mg BID -if HR 50-60: maintain -if HR<50 or sx of bradycardia: dec dose 2.5mg BID or dc if 2.5mg
63
Ivabradine (Corlanor) side effects
-fetal toxicity -AFib -bradycardia -conduction disturbances -CYP3A4 substrate =AVOID: KTZ, diltiazem, verapamil, GFJ -expensive
64
Digoxin/Digitalis MOA
-blocks Na/K ATPase channel -inc Ca = inc force (mild positive ionotrope) -PSNS activation = dec conduction (AFIB tx) = low HR rate -resensitization of baroreceptors
65
Digoxin indication
-HF w Afib -does NOT reduce mortality (reduce hospitalization tho) -consider in pt w sx despite optimized tx or in pt who cant tolerate GMDT to dec hospitalization
66
Digoxin dosing
-NTI! -0.125-0.25mg qd -0.125mg good for most pt w 0.5-0.9ng/mL goal serum digoxin concentration (SDC) -lower dose in >70 yo, renanl probs, low wt, drug interactions
67
When to lower digoxin dosing
->70yo -renal probs -low wt -drug interactions: amiodarone, quinidine, verapamil, Itra/KTZ
68
Digoxin drug interactions
-amiodarone -quinidine -verapamil -Itra/KTZ -all inc digoxin concentration -half dose of digoxin
69
Digoxin side effects (CNS)
-Non-cardiac (CNS): -ana, N/V, ab pain -visual disturbances (halos, color perception) van gogh! -fatigue, weakness, dizziness, HA -neuralgias, confusion, delirium, psychosis
70
Digoxin cardiac toxicity
-ventricular: PVCs, bigeminy, trigeminy, VT, VF -AV block: 1,2,3rd degree -AV junctional escape rhythyms, junctional tachycardia -atrial arrhythmias w slowed AV conduction or AV block -sinus bradycardia
71
Vericiguat MOA
-soluble guanylate cyclase stimulator -reduce death/hospitalization
72
Vericiguat indication
-stage C still sx on standard therapy
73
Vericiguat dosing
-2.5mg qd upto 10mg qd
74
Vericiguat side effects
-hypotension and anemia -CI in pregnancy
75
misc topics
-Omega-3 has some evidence as adj tx -long term 81mg ASA in pt w IHD/CAD/ASCVD, otherwise dont use routinely -anticoagulants rec in HF w Afib or hx of PE, otherwise NO -CCBs: only felodipine and amlodipine MAY be used for angina/HTN if still not managed
76
Non-pharma HFrEF options
-implant ICD (cardio defibrilator) -cardiac resynchronization therapy

Therapeutics II (Spring) (50 decks)

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