144 Heart Failure Tx

Question 1

Prevent Heart Failure

Answer 1

•Control blood pressure

• Control diabetes mellitus
• Control lipids
• Smoking cessation
• Weight control
• Early recognition and treatment of acute coronary syndromes

Question 2

HF: Selected Diagnostic Testing

Answer 2

Question 3

Chronic Medical Treatment of HF with Reduced EF (EF<40%)

Answer 3

Question 4

Vasodilator Drugs: venodilator, mixed, arteriolar dilator

Answer 4

Question 5

Drugs that target: Renin-Angiotensin-Aldosterone System

Answer 5

Question 6

Spironolactone

Answer 6

–Cheap, generic

–Side Effects: Hyperkalemia, Relatively nonselective: sex steroid hormone effects à gynecomastia, irregular menses

–Prodrug. Has active metabolites with long half-lives: long time to steady state

Question 7

Sacubutril

Answer 7

•Sacubutril: Neprilysin Inhibitor: only formulation is sacubutril/valsartan

–sacubutril/valsartan aka “ARNI” Angiotensin Receptor Blocker Neprilysin Inhibitor

Question 8

Aliskiren

Answer 8

Question 9

B-blockers mechanism in HF

Answer 9

Beta-blockers improve beta-receptor sensitivity in the long run, improving myocardial performance

Failing Heart: Toxic Neurohormonal Milieu

Failing Desensitized Heart: Enter Metoprolol: Sensitivity Restored, Accounts for Efficacy in Left Ventricular Systolic Dysfunction (HFrEF)

Question 10

Specific B-blockers for HF

Answer 10

Question 11

Mineralocorticoid Receptor Antagonist Mechanism

Answer 11

• •Spironolactone:
  
  • –Cheap, generic
  • –Side Effects: Hyperkalemia, Relatively nonselective: sex steroid hormone effects à gynecomastia, irregular menses
  • –Prodrug. Has active metabolites with long half-lives: long time to steady state
• •Eplerenone:
  
  • –Quite selective for mineralocorticoid receptor (MR)
  • –Side Effects: Hyperkalemia.
  • –Often used post-myocardial infarction (based on trial data)
• •Other CV Indications (mostly spiro): HTN, HF with preserved EF

Question 12

Nitrates mech and use in HF

Answer 12

Question 13

Eplerenone

Answer 13

–Quite selective for mineralocorticoid receptor (MR)

–Side Effects: Hyperkalemia.

–Often used post-myocardial infarction (based on trial data)

for HFrEF

Question 14

Hydralazine

Answer 14

Question 15

Hydralazine / Isosorbide Mononitrate combination therapy

Answer 15

• •Nitrates:
  
  • –Side Effect: Headache, hypotension
  • –Exhibits tachyphylaxis (effect wanes with time)
  • –Isosorbide Dinitrate (TID dosing) is the evidence-based HF choice
• •Hydralazine:
  
  • –Side Effect: Headache, tachycardia
  • –TID dosing
• •Clinical Use:
  
  • –Evidence for benefit in all patient populations, particularly African-Americans
  • –Use also in patients who can’t tolerate ACE-I or ARB
  • –Three times daily dosing (TID) can be hard to adhere to

Question 16

Ivabradine Mechanism

Answer 16

HF

Question 17

Diurectic sites of action

Answer 17

Question 18

Chronic Medical Treatment of HF with Preserved EF (EF>50%)

Answer 18

• •Volume Control
• •Blood Pressure Control
• •Spironolactone: Near-evidence based therapy (TOPCAT)
• •Weight management (inflammatory adipokines)
• •Exercise

Question 19

HF subtypes

Answer 19

•Signs of congestion: any of the following

–Orthopnea, ­+JVP, rales, ascites, leg swelling

•Signs of poor perfusion: any of the following

–Cool extremities, ¯BP, ¯pulse pressure, sleepy/obtunded, worsening renal function, ¯urine output

Question 20

HF subtypes treatments

Answer 20

Question 21

Treatment of acute pulmonary edema

Answer 21

Question 22

–Phosphodiesterase 3 inhibitors (milrinone)

Answer 22

used in stage IV heart failure

Question 23

IV inotropes

Answer 23