11 HF 2 Flashcards
HF drugs by indication
mortality or mortality and hospitalization
- chronic HFrEF (18)
metoprolol succinate, carvedilol, captopril, enalapril, ramipril, trandolapril, quinapril, fosinopril, lisinopril, candesartan, valsartan, sacubitril/valsartan, spironolactone, eplerenone, isosorbide/hydralazine
bisoprolol (not US), empagliflozin, dapagliflozin
BB, ACEi, ARBs, ARNi, MRA, SGLT2, ISDN/hydralazine
HF drugs by indication
hospitalization
- chronic HFrEF (2)
digoxin, ivabradine
HF drugs by indication
hemodynamic or physical function
- chronic HFrEF (2)
- AHF (4)
- digoxin, isosorbide/hydralazine
- inotropes, milrinone, sodium nitroprusside, nesiritide
HF drugs by indication
QOL or symptoms
- chronic HFrEF (2)
- AHF: (2)
- digoxin, diuretics
- nesiritide, diuretics
Neurohormonal Blockers
RAS Inhibitors
- angiotensin receptor ___ inhibitors (ARNi)
- ACEi
- ARB
BB
SGLT2
MRA
___ / ___
neprilysin
hydralazine/ISDN
ACEi
T or F: benefit occurs regardless of etiology or severity of disease, must be used in all without contraindications
T
ACEi MOA and benefit in HF
MOA: inhibition of ___ formation, enhancement of ___
- improved endothelial function
- ___ NE
- inhibition of cardiac ___
- improved cardiac ___
- ___ aldosterone
- decreased endothelin-1
- decreased arginine ___
- ___ vasoconstriction
- reduced ___ and ___ retention
angiotensin II, bradykinin
- decreased
- hypertrophy
- hemodynamics
- reduced
- vasopressin
- reduced
- Na, Cl
Clinical use of ACEi - dosing
enalapril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Vasotec
2.5-5, BID
10 BID
Clinical use of ACEi - dosing
captopril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Capoten
6.25-12.5, TID
50, TID
Clinical use of ACEi - dosing
lisinopril ( ___ , ___ )
initial: ___ - ___ mg ___
target: ___ - ___mg ___
Prinivil, Zestril
2.5-5, QD
20-40, QD
Clinical use of ACEi - dosing
quinapril ( ___ )
initial: ___ - ___ mg ___
target: ___ - ___ mg ___
Accupril
5-10, BID
20-40, BID
Clinical use of ACEi - dosing
ramipril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___ - ___ mg ___
Altace
1.25-2.5, QD
5, BID, 10, QD
Clinical use of ACEi - dosing
fosinopril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Monopril
5-10, QD
40, QD
enalapril___ mg = capropril ___ mg = lisinopril ___ mg
total daily amounts
20
150
20
total daily amounts
Dosing ACEi
titrate slowly to target dose used in clinical trials
- start low and double dose every ___ - ___ weeks
Caution if: ___ depleted, SBP < ___ , K > ___ , SCr > ___
- lower doses and more monitoring are required with SCr > ___ and/or CrCl < ___ mL/min
- can do ___ of the inital/survival
1-4
volume, 80, 5, 3
3, 30
half
absolute ACEi CI
- pregnancy
- history of ___ or hypersensitivty
- ___ renal artery ___
- history of well documented intolerance due to symptomatic ___ , decline in ___ function, ___ kalemia, or cough
- angioedema
- bilateral, stenosis
- hypotension, renal, hyperkalemia
Monitoring
volume status (normalize prior to initiation)
regular maintenance of ___ function and ___
- prior to therapy, ___ - ___ weeks after each increase in dose and ___ - ___ month intervals
- SCr may rise after initiation ( < ___ % acceptable)
BP
- avoid symptomatic ___
renal, K
- 1-2, 3-6
- 30%
- hypotension
ACEi AE
- hypo ___
- functional ___ insufficiency
- hyper ___
- skin rash and __
- ___ (20%)
- ___ (1%)
- hypotension
- renal
- hyperkalemia
- dysgeusia
- cough
- angioedema
dysgeusia = altered taste
ARBs do not get the benefit of inhibiting that breakdown of ___
bradykinin
ARBs dosing
losartan ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Cozaar
25-50, daily
150, daily
ARBs dosing
valsartan ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Diovan
20-40, BID
160, BID
ARBs dosing
candesartan ( ___ )
initial: ___ mg ___
target: ___ mg ___
Atacand
4, daily
32, daily
ARBs vs ACEis
not superior to ACEi
alternative if:
- unable to take ACEi due to ___ or ___
monitoring: pretty much everything that you would monitor for ACEi (except ___ )
cough, angioedema
cough
sacubitril/valsartan inhibits ___ from degrading ___ and blocks ___ receptor
neprilysin, BNP, AT1
sacubitril/valsartan
BNP causes ___
- ___ BP
- decreases ___ tone
- ___ aldosterone
- ___ fibrosis
- ___ hypertrophy
- natriuresis/diuresis
vasodilation
- decreases
- sympathetic
- decreases
- decreases
- decreases
sacubitril/valsartan
angiotensin II binding to the AT1 receptor causes ___
- ___ BP
- increases ___ tone
- increases ___
- ___ fibrosis
- ___ hypertrophy
vasocontriction
- increases
- sympathetic
- aldosterone
- increases
- increases
sacubitril/valsartan
indications: reduce the risk of CV ___ / ___ for HFrEF patients with NYHA class ___ - ___
sacubitril ( ___ , ___ , ___ mg)
valsartan ( ___ , ___ , ___ mg)
- valsartan equivalents: = ___ , ___ , and ___ respecitively
death/hospitalization
II-IV
24, 49, 97
26, 51, 103
- 40, 80, 160
sacubitril/valsartan
T or F: the way that the drug is packaged makes valsartan more bioavailable
T
26 = 40, 51 = 80, 103 = 160
sacubitril/valsartan AEs
same as ACEi/ARB
- ___ rare
PARADIGM-HF trials
- hypotension ___ enalapril
- elevation in SCr and K ___ enalapril
- angioedema
- >
- <
sacubutril/valsartan dosing
population:
- high dose ACEi ( > ___ mg total daily enalapril or equivalent)
- high dose ARB ( > ___ mg total daily valsartan or equivalent)
initial dose: ___ / ___ mg ___
max dose: ___ / ___ mg ___
- 10
- 160
- 49/51, BID
- 97/103, BID
sacubutril/valsartan dosing
population:
- low-to medium dose ACEi or ARB
- ACEi/ARB ___
- eGFR < ___
- moderate ___ impairment
- age > ___ years
initial dose: ___ / ___ mg ___
double the dose every ___ - ___ weeks to target ___ / ___ mg ___ as tolerated
- naive
- 30
- hepatic
- 75
24/26, BID
2-4, 97/103, BID
enalapril ___ mg/day = captopril ___ mg/day = lisinopril ___ - ___ mg/day
20, 150, 20-40
sacubutril/valsartan CI
- taking within ___ hours of ACEi use
- angioedema/known hypersensitivity to ACEi/ARB
- pregnancy/lactation
- severe heaptic impairment
- concomitant ___ use in patients with diabetes
36
aliskiren
recommendations for ARNi/ACEi/ARB
Stage B
- ACE or ARBs if not tolerant
Stage C
- ARNi: patients with current or previous ___ (replacing ACEi/ARB with ARNi further reduces ___ )
- ACEi: patients with current or previous symptoms when use of an ___ is not feasible $$$
- ARBs: if intolerant to ___ and ___ isn’t feasible
- ARBs are reasonable alternatives as first line agents, especially if taking an ARB for another indication
class = evidence
- symptoms, mortality
- ARNi
- ACEi, ARNi
ACE/AHA Guidelines
- ARNi should not be administered concomitantly with ACEi or within ___ hours for the last dose
- ARNi should not be administered to patients with Hx of ___
- inhibition of RAS with ARNi, ACEi, or ARB is recommended to reduce ____
- ___ is preferred and can be used rather than with pre-treatmnt with ACEi/ARBs
- 36
- angioedema
- mortality/morbidity
- ARNi
BB
reverse ___ is proposed as one mechanism of benefit
3 approved BBs: ___ , ___ , ___
remodeling
carvedilol, metoprolol XL, bisoprolol
rationale B-AR pathway in HF
increased cardiac ___
1) B-AR pathway ___ leads to impaired ___ tolerance resulting in HF
2) ___ toxicity leads to myocardial ___ resulting in HF
NE
1) desensitization, exercise
2) myocytes, dysfunction
rationale BB in HF
decrease
- ___ arrythmias
- cardiac ___ and cell death
- ___ and ___
- cardiac ___
- ventricular
- hypertrophy
- VC, HR
- remodeling
BB Patinet Selection
- Stable and ___ patients
- symptomatic patients should receive ___ , especially with current or recent histroy of fluid retentiion
- should be considered in patients with bronchospastic disease and asymptomatic bradycardia, but ___
- dont abruptly D/C
- dont start initially in hospital, but if patients are already on them while being admitted, dont ___
Sowinski wouldnt do if patient has hospitalized uncontrolled asthma
- euvolemic
- diuretics
- cautiously
- D/C
BB Dosing
bisoprolol ( ___ )
initial dose: ___ mg ___
target: ___ mg ___
Zebeta
1.25, daily
10, daily
BB Dosing
carvedilol ( ___ )
initial: ___ mg ___
target: ___ - ___ mg ___
Coreg
3.125, BID
25-50, BID
BB Dosing
carvedilol CR ( ___ )
initial: ___ mg ___
target: ___ mg ___
Coreg CR
10, daily
80, daily
BB Dosing
metoprolol XL ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___
Toprol XL
12.5-25, daily
200, daily
BB
___ and ___ are FDA approved and ___ is a european thing
carvedilol, metoprol, bisoprolol
BB Dose titration
Double the dose every ___ weeks and monitor vital signs and symptoms
- planned dose increases can be slowed if necessary
aim for target dose in ___ - ___ weeks or highest tolerated dose
2
8-12
NAPLEX weight and carvedilol
< 85 kg = ___ mg ___
> 85 kg = ___ mg ___
25, BID
50, BID
dose conversion between Coreg and Coreg CR
- 3.125 mg BID = __ mg QD
- ___ mg BID = 20 mg QD
- 12.5 mg BID = ___ mg QD
- ___ mg BID = 80 mg QD
10
6.25
40
25
BB monitoring
BP, symptomatic hypotension, HR ___ - ___ weeks
- symp. hypotension, bradycardia, and dizziness are uncommon is slow ___ (reduce dose ~ ___ % if necessary)
- if hypotension only, reduce other drugs first
- Goal HR is not defined
edema, fluid retention, signs of congestion ( ___ - ___ weeks)
fatigue or weakness
1- 2
- titration, 50
1-2
Consensus panel recommendations for BB
Stage B
- in all patients with a recent or remote history of ___ and ___ should receive at least one of the agents shown to reduce ___
- all other patients should also receive at least one of the agents shown to reduce ___
Stage C
- Use one of the agents shown to reduce ___ in all patients, with current or previous symptoms unless CI
ACS, rEF, mortality
mortality
mortality
