12 HF 3 Flashcards

1
Q
A

C

Lets do an ARB instead
* ARNI is also CI now

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2
Q
A

A

systolic HF = HFrEF

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3
Q
A

C

pregnant

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4
Q
A

D

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5
Q
A

B

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6
Q

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

A
  • sympathetic
  • parasympathetic
  • remodeling
  • spironolactone, eplerenone
  • K, Mg, arrhythmias
  • Na, fluid
  • sympathetoc
  • fibrotic
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7
Q

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

A

non-selectice, progesterone
dihydrotestosterone, testosterone, estradiol

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8
Q

AA

eplerenone
- ___ agent with a 100-1000x lower affinity for ___ , ___ , and ___ receptors than spironolactone
- no antiandrogenic effects
- substrate of ___

A
  • selective
  • androgen, glucocorticoid, progesterone
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9
Q

AA dosing

eplerenone
eCrCl ≥ 50
initial dose: ___ mg ___
maintenance: ___ mg ___

only if K ≤ 5

A
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10
Q

AA dosing

eplerenone
eCrCl 30-49
initial dose: ___ mg ___
maintenance: ___ mg ___

only if K ≤ 5

A

25, every other day
25, daily

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11
Q

AA dosing

spironolactone
eCrCl ≥ 50
initial dose: ___ - ___ mg ___
maintenance: ___ mg ___

only if K ≤ 5

A

12.5-25, daily
25, daily

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12
Q

AA dosing

spironolactone
eCrCl 30-49
initial dose: ___ mg ___ or___
maintenance: ___ - ___mg ___

only if K ≤ 5

A

12.5, daily, every other day
12.5-25, daily

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13
Q

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)

A

2.5, 2
5
30
hyperkalemia, renal
4

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14
Q

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

A

3 days, 1 week
month
3-4
salt

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15
Q

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

A

II-IV, HFrEF, 30, 5
K
5.5

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16
Q
A

D

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17
Q
A

C

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18
Q

SGLT2i

  • SGLT2i cause renal afferent arteriolar ___ (cause diuresis, natriuresis, glycosuria, decreased proteinuria)
  • ___ preload = decrease ___ wall stress
  • ___ afterload
  • decrease myocardial ___
A
  • constriction
  • decrease, LV
  • decrease
  • energetics
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19
Q

SGLT2i

  • unclear benefit in HF
  • osmotic ___ and ___
  • decreased arterial ___ and ___
  • preload and afterload ___
  • associated reduction in hypertrophy and fibrosis ( ___ )
A
  • diuresis, natriuresis
  • pressure, stiffness
  • reduction
  • remodeling
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20
Q

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 ( ___ )

A

death, hospitalization, II-IV
10, daily
30
20
DKA, hypoglycemia, UTIs

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21
Q

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

A

symptomatic, HFrEF, DM, hospitalizations, death

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22
Q
A

A

23
Q

initiation: titration strategies

A
24
Q

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

A

2
1

25
Q

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
A

RASi, AA, BB, SGLT2
mitral

26
Q

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

A

preload, afterload
BiDil, black, adjunct
lupus

27
Q

ISDN/hydralazine

hydralazine
principle site of action: ___ vasodilation
initial: ___ mg ___ / ___
target: ___ mg ___
max: ____ mg ___

A

arteriolar
25, TID/QD
75, TID
100, TID

28
Q

ISDN/hydralazine

ISDN
principle site of action: ___ vasodilation
initial: ___ mg ___ / ___
target: ___ mg ___
max: ___ mg ___

A

venous
20, TID/QD
40, TID
80, TID

29
Q

ISDN/hydralazine

ISDN/hydralazine (BiDil)
initital: ___ / ___ mg ___
target: ___ / ___ mg ___

A

20/37.5, TID
40/75, TID

30
Q

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

A

black, III-IV
renal

31
Q
A
32
Q

Other therapies (after GDMT optimization)

NYHA II-III; HFrEF; NSR
- HR > 70 bpm
- on max tolerated BB

A

Ivabradine

Corlanor

33
Q

Other therapies (after GDMT optimization)

NYHA II-IV; LVEF < 45%
- recent HFH
- IV diuretics
- elevated NP levels

A

Vericiguat

34
Q

Other therapies (after GDMT optimization)

symptomatic HFrEF

A

digoxin

35
Q

Other therapies (after GDMT optimization)

NYHA II-IV

A

PUFA

36
Q

Other therapies (after GDMT optimization)

patients with HF with hyperkalemia while taking RAASi

A

potassium binders

37
Q

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 ___

A

hospitalization, 35%, NSR< 70

2.5-5, BID, HR
7.5, BID

38
Q

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
A
  • 2.5-5, BID, 7.5, BID
  • 2.5, BID
39
Q

Ivabradine AE

  • ___ toxicity
  • ___ fibriliation
  • ___ and conduction disturbances

CYP ___ substrate
- ___ CI, avoid ___ and ___ , no grapefruit juice

A
  • fetal
  • atrial
  • bradycardia
  • CYP3A4
  • ketoconazole, diltiazem, verapamil

cost > $6,000

40
Q

Digoxin/digitalis glycosides

MOA 1)
- decreases ___ pump
- ___ Ca2+
- ___ force

MOA 2:
- ___ vagal activity
- ___ AV conduction
- ___ rate

A
  • Na/K-ATPase
  • increases
  • increases
  • increase
  • decrease
  • decrease
41
Q

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

A

neurohormonal
- parasympathetic
- HR
- baroreceptors
- Na-K-ATPase
- Ca, force
- positive

42
Q

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

A

Afib, hospitalizations

43
Q

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

A

0.125-0.25
0.125
0.5-0.9
70, renal
- amiodarone, quinidine, verapamil, itraconazole, ketoconazole

44
Q

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

A

halos
block
arrhythmias
sinus

45
Q
A

B

46
Q
A

B

47
Q

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

A

guanylate cyclase
- 2.5, 10
- pregnancy
- hypotension, anemia

48
Q

MSC topis

PUFA = ___
- reduce risk in HF II-IV

antiplatelets
- long term ___ ___ mg therapy is recommended in patients with HF and ___

A

omega-3 polyunsaturated fatty acids
- ASA, 81, IHD/CAD/ASCVD

49
Q

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

A
  • Afib
  • routine
  • diltiazem, verapamil, nifedipine
  • felodipine, amlodipine
50
Q

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

A

II-III
I
QRS, 150, 35

51
Q

HFrEF
___ dysfunction: decreased ___
- EF < ___ - ___ %

HFpEF
___ dysfunction: impairment in ventricular ___ / ___
- EF > ___ %

A

systolic, contractility
- 35-40%
diastolic, relaxation/filling
- 50%

52
Q

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
A

diuretics, symptoms
SGLT2s

53
Q

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
A
  • hospitalizations
  • diastolic, remodeling
  • digoxin
  • CAD