12 HF 3 Flashcards
C
Lets do an ARB instead
* ARNI is also CI now
A
systolic HF = HFrEF
C
pregnant
D
B
Aldosterone receptor antagonists (AA) = MRA
aldosterone elevated in HF leads to:
- continued ___ activation
- ___ inhibition
- cardiac and vascular ___
___ (non-selective) and ___ (selective) block aldosterone effects independent of the effects of ACEis or ARBs
- decrease ___ and ___ losses: may protect against ___
- decrease ___ retention: decrease ___ retention
- decreases ___ stimulation
- blocks direct ___ action on myocardium
- sympathetic
- parasympathetic
- remodeling
- spironolactone, eplerenone
- K, Mg, arrhythmias
- Na, fluid
- sympathetoc
- fibrotic
AA
Spironolactone
- ___ agent, structurally similar to ___
- inhibits the effects of ___ at the receptor site and increases the peripheral conversion of ___ into ___
- AE: gynecomastia, impotence, menstrual irregularities
non-selectice, progesterone
dihydrotestosterone, testosterone, estradiol
AA
eplerenone
- ___ agent with a 100-1000x lower affinity for ___ , ___ , and ___ receptors than spironolactone
- no antiandrogenic effects
- substrate of ___
- selective
- androgen, glucocorticoid, progesterone
AA dosing
eplerenone
eCrCl ≥ 50
initial dose: ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
AA dosing
eplerenone
eCrCl 30-49
initial dose: ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
25, every other day
25, daily
AA dosing
spironolactone
eCrCl ≥ 50
initial dose: ___ - ___ mg ___
maintenance: ___ mg ___
only if K ≤ 5
12.5-25, daily
25, daily
AA dosing
spironolactone
eCrCl 30-49
initial dose: ___ mg ___ or___
maintenance: ___ - ___mg ___
only if K ≤ 5
12.5, daily, every other day
12.5-25, daily
AA dosing/administration
should be added to ACEi/ARB/ARNi and BB therapy
Avoid:
- SCr > ___ (men) or > ___ mg/dL (women)
- K > ___ mEq/L
- CrCl < ___ mL/min
- Hx of severe ___ kalemia or recent worsening of ___ function
concomitant use of K sparing diuretics or supplements should be avoided (unless hypokalemia K < ___ mEq/L)
2.5, 2
5
30
hyperkalemia, renal
4
AA monitoring
monitor renal function and K within ___ days - ___ week after any change or addition, diseases, or acute illnesses that may influence K concentrations
- then once a ___ for 3 months
- then every ___ - ___ months
- monitor these things when ACEi/ARB increase/change
avoid ___ substitutes
3 days, 1 week
month
3-4
salt
Consensus recommendations for AA
Stage B: No recs
Stage C
- patients with NYHA ___ - ___ and ___ with eGFR > ___ and K < ___
- careful maintenance of ___ , renal function, and diuretic dosing is essential
- patients taking AAs in which K cant be maintained ( < ___ ) should be D/C to avoid life threatening hyperkalemia
II-IV, HFrEF, 30, 5
K
5.5
D
C
SGLT2i
- SGLT2i cause renal afferent arteriolar ___ (cause diuresis, natriuresis, glycosuria, decreased proteinuria)
- ___ preload = decrease ___ wall stress
- ___ afterload
- decrease myocardial ___
- constriction
- decrease, LV
- decrease
- energetics
SGLT2i
- unclear benefit in HF
- osmotic ___ and ___
- decreased arterial ___ and ___
- preload and afterload ___
- associated reduction in hypertrophy and fibrosis ( ___ )
- diuresis, natriuresis
- pressure, stiffness
- reduction
- remodeling
SGLT2i
indications: reduce the risk of CV ___ or ___ for HFrEF patients with NYHA class ___ - ___
dapagliflozin and empagliflozin are both ___ mg ___
- dapa: eGFR > ___
- empa: eGFR > ___
AE
- volume depletion
- ___ in DM, ___ glycemia, infection risk ( ___ )
death, hospitalization, II-IV
10, daily
30
20
DKA, hypoglycemia, UTIs
SGLT2i summary
recommended for patients with ___ chronic ___ with or without ___ to reduce ___ and CV ___
if the meet renal requirements, they should be on these for life
symptomatic, HFrEF, DM, hospitalizations, death
A
initiation: titration strategies
initiation: titration strategies
ARNi and MRA: inititate at low doses, titrate in ___ weeks as tolerated
BB: initiate at low doses, titrate in ___ week as tolerated
SGLT2: initiate, continue
2
1
initiation: titration strategies after 42 days
- maintenance or additional titration of the big 4: ___ , ___ , ___ , ___
- consideration of EP device or transcatheter ___ valve repair
- consideration of add-on medications
- manage comorbidities
RASi, AA, BB, SGLT2
mitral
ISDN/Hydralazine
combo produces balanced vasodilator effects, causing reductions in both ___ and ___
- less effective than ACEi
- ___ indicated for the treatment of HF in ___ patients as an ___ to standard therapy
Nasty AE profile
- headache, nausea, flushing, dizziness, tachycardia, ___ -like syndrome, hypotension, myocardial ischemia, fluid retention
preload, afterload
BiDil, black, adjunct
lupus
ISDN/hydralazine
hydralazine
principle site of action: ___ vasodilation
initial: ___ mg ___ / ___
target: ___ mg ___
max: ____ mg ___
arteriolar
25, TID/QD
75, TID
100, TID
ISDN/hydralazine
ISDN
principle site of action: ___ vasodilation
initial: ___ mg ___ / ___
target: ___ mg ___
max: ___ mg ___
venous
20, TID/QD
40, TID
80, TID
ISDN/hydralazine
ISDN/hydralazine (BiDil)
initital: ___ / ___ mg ___
target: ___ / ___ mg ___
20/37.5, TID
40/75, TID
Consensus recommendations for ISDN/hydralazine
Stage B: no recommendations
Stage C:
- in ___ patients with NYHA ___ - ___ receiving optimal medical therapy to imporve symptoms and reduce mortality
- patients with symptoms or previous symptoms who cant receive ARNi, ACEi, or ARB due to drug tolerance or ___ insufficiency might be considered
black, III-IV
renal
Other therapies (after GDMT optimization)
NYHA II-III; HFrEF; NSR
- HR > 70 bpm
- on max tolerated BB
Ivabradine
Corlanor
Other therapies (after GDMT optimization)
NYHA II-IV; LVEF < 45%
- recent HFH
- IV diuretics
- elevated NP levels
Vericiguat
Other therapies (after GDMT optimization)
symptomatic HFrEF
digoxin
Other therapies (after GDMT optimization)
NYHA II-IV
PUFA
Other therapies (after GDMT optimization)
patients with HF with hyperkalemia while taking RAASi
potassium binders
Ivabradine
indications: reduce the risk of ___ for symptomatic HF, EF < ___ % (HFrEF) in ___ with rHR > ___ bpm in max tolerated BB or with BB CI
dosing: ___ - ___ mg ___, adjust every 2 weeks based on ___
max: ___ mg ___
hospitalization, 35%, NSR< 70
2.5-5, BID, HR
7.5, BID
Ivabradine dosing adjustments
- HR > 60: ___ - ___ mg ___, up to max: ___ mg ___
- HR: 50-60: maintain dose
- HR < 50 or s/s of bradycardia: decrease dose by ___ mg (given ___ ); if thats current dose, D/C
- 2.5-5, BID, 7.5, BID
- 2.5, BID
Ivabradine AE
- ___ toxicity
- ___ fibriliation
- ___ and conduction disturbances
CYP ___ substrate
- ___ CI, avoid ___ and ___ , no grapefruit juice
- fetal
- atrial
- bradycardia
- CYP3A4
- ketoconazole, diltiazem, verapamil
cost > $6,000
Digoxin/digitalis glycosides
MOA 1)
- decreases ___ pump
- ___ Ca2+
- ___ force
MOA 2:
- ___ vagal activity
- ___ AV conduction
- ___ rate
- Na/K-ATPase
- increases
- increases
- increase
- decrease
- decrease
Digoxin/digitalis glycosides
benefits are due to ___ modulation effects
- increases ___ activity
- reduces ___
- re-sensitization of ___
inhibits ___ which alters excitiation-contraction coupling
- increase in intracellular __ , enhancing ___ of contraction
- relatively mild ___ inotrope
neurohormonal
- parasympathetic
- HR
- baroreceptors
- Na-K-ATPase
- Ca, force
- positive
Place of Digoxin in HF treatment
efficacy in HF with ___ is well established
- reduces ___ , not mortality
consider in patients with symptomatic HFrEF despite optimized GDMT
Afib, hospitalizations
Digoxin Dosing
___ - ___ mg ___
- ___ mg will be used in majority of patients
- ___ - ___ ng/mL is the goal serum digoxin concentration (SDC)
- lower doses in > ___ years, impaired ___ function, low weight
name 5 drugs that increase SDC
0.125-0.25
0.125
0.5-0.9
70, renal
- amiodarone, quinidine, verapamil, itraconazole, ketoconazole
Digoxin AE and s/s of toxicity
CNS
- anorexia, N/V, abdominal pain
- ___ , photophobia, altered color perception
- fatigue, weakness, HA, neuralgias, confusion, delirium, psychosis
Cardiac
- ventricular: PVCs, bigeminy, trigeminy, VT, VF
- AV ___
- AV junctional escape rhythms, junctional tachycardia
- atrial ___ with slowed AV conduction or block
- ___ brady cardia
halos
block
arrhythmias
sinus
B
B
Vericiguat (Verquvo)
soluble ___ stimulator
reduces CV death and hospitalization
- ___ mg daily, up to ___ mg daily
CI: ___
AE: ___ and ___ most common
consider in selected high risk pateints with recent worsening with symptomatic HFrEF despite optimized GDMT
just know it exists
guanylate cyclase
- 2.5, 10
- pregnancy
- hypotension, anemia
MSC topis
PUFA = ___
- reduce risk in HF II-IV
antiplatelets
- long term ___ ___ mg therapy is recommended in patients with HF and ___
omega-3 polyunsaturated fatty acids
- ASA, 81, IHD/CAD/ASCVD
MSC topics
anticoagulants
- recommended in HF if ___
- or in patients with other indications like pulmonary embolism
- ___ anticoagulation is not recommended
CCB
- ___ , ___ , and ___ should not be routinely used
- ___ and ___ may be useful in managing angina/HTN if not effectively managed with HF therapies
- Afib
- routine
- diltiazem, verapamil, nifedipine
- felodipine, amlodipine
Non-PCOL
ICD
- LVEF < 35%, at least 40 days post-MI, NYHA ___ - ___
- LVEF < 30%, at least 40 days post-MI, NYHA ___
Cardiac resynchronization therapy
- NYHA II-III-IV pts on optimal medical therapy
- ___ duration greater than ___ ms and LVEF less than ___ %
know it exists
II-III
I
QRS, 150, 35
HFrEF
___ dysfunction: decreased ___
- EF < ___ - ___ %
HFpEF
___ dysfunction: impairment in ventricular ___ / ___
- EF > ___ %
systolic, contractility
- 35-40%
diastolic, relaxation/filling
- 50%
summary of HFpEF treatment
- SBP/DBP should be controlled
- ___ should be used for relief of ___ due to volume overload (no mortality benefits)
- management of AFib can improve symptomatic HF
- ___ may reduce hospitalizations and CV mortality
- the use of ARBs, ARNis, ACEi, and MRAs may ben considered to decrease hospitalizations
diuretics, symptoms
SGLT2s
summary of HFpEF treatment
- ACEi and ARBs have not been shown to reduce mortality, but they do reduce ___
- MRA may improve ___ function and reduce ___
- ___ has no affect on mortality or hospitalizations
- nitrates should be limited to use in patients with HFpEF who may need treatment for symptomatic ___
- CCBs may be useful to treat HTN
- hospitalizations
- diastolic, remodeling
- digoxin
- CAD
