31. Chronic HF Flashcards
1
Q
EF< ____% indicates systolic dysfunction or HF with reduced ejection fraction (HFrEF)
A
<40%
2
Q
Explain HFrEF
A
Systolic dysfunction - impaired ability to eject blood during systole
3
Q
What labs/biomarkers do we use to dx HF?
A
Increased BNP and NT-proBNP - used to distinguish etween cardiac and non-cardiac causes of dyspnea
Normal BNP <100 pg/mL
Normal NT-proBNP <300 pg/mL
4
Q
Left sided s/sx of HF
A
Orthopnea: SOB when lying flat
Paroxymal nocturnal dyspnea (PND): nocturnal cough and SOB
Bibasilar rales: crackling sounds heard on lung exam
S3 gallop: abnormal heart sound
Hypoperfusion (renal impairment, cool extremities)
5
Q
General s/sx of HF
A
Dyspnea (SOB at rest or upon exertion)
Cough
Fatigue, weakness
Reduced exercise capacity
6
Q
Right sided s/sx of HF
A
Peripheral edema
Ascites: abdominal fluid accumulation
Jugular venous distention (JVD): neck vein distention
Hepatojugular reflux (HJR): neck vein distention from pressure placed on abdomen
Hepatomegaly: enlarged liver d/t fluid congestion
7
Q
Which ACC/AHA stages are for symptomatic patients?
A
C or D
Asymptomatic = 1 or 2
8
Q
What NYHA functional class is a patient who gets SOB after walking up stairs?
A
II - slight limitation of physical acitivty, comfortable at rest, but s/sx of HF with ordinary physical activity (walking up stairs)
9
Q
What NYHA functional class is a patient who gets SOB while getting dressed?
A
III - marked limitation of physical activity, comfortable at rest, but s/sx of HF with minimal physical activity (e.g. bathing, dressing)
10
Q
What NYHA functional class is a patient who gets SOB at rest?
A
IV - unable to carry on any physical activity without s/sx of HF or s/sx of HF at rest (e.g. SOB while sitting in a chair)
11
Q
What is cardiac output (CO)?
A
Volume of blood that is pumped by the heart in 1 minute
12
Q
What is cardiac output determined by?
A
HR and strove volume (SV, volume of blood ejected from the left ventricle during 1 complete heartbeat (Cardiac cycle))
CO = HR * SV
13
Q
What does stroke volume depend on?
A
Preload, afterload, and contractility
14
Q
What is cardiac index related to?
A
CO and the size of the patient (body surface area)
CI = CO/BSA
15
Q
HFrEF is a (low/high) cardiac output state?
A
low
16
Q
What are main pathways that are activated in HF?
A
Renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), and vasopressin
Note: the neurohormones that normally balance these systems (e.g. natriuretic peptides) become insufficient
17
Q
What effect does angiotensin II have?
A
Vasoconstriction and stimulates release of aldosterone from the adrenal gland and vasopressin from the pituitary gland
18
Q
What effect does aldosterone have?
A
Sodium and water retention and increases potassium excretion
19
Q
What effect does vasopressin have?
A
Vasoconstriction (vasopressin = presses on vessels) and water retention
20
Q
When SNS is activated, what effect does the release of NE and Epi have?
A
Increase in HR, contractility (positive inotropy) and vasoconstriction
21
Q
Lifestyle management points for HF patients
A
Monitor and document weight daily - notify provider if weight increases by 2-4lbs in 1 day or 3-5lbs in 1 week
Restrict sodium intake to <1.5g/day (1500mg/day) in stage A and B HF
Restrict fluid (1.5-2L/day) in stage D HF
Smoking cessation and limit alcohol intake, exercise
22
Q
What are some natural products that people may use for HF?
A
Omega-3 fatty acid - decrease mortality and CV hospitalization
Hawthorn and coenzyme Q10 - may improve HF symptoms
Note: avoid use of products containing ephedra (ma hurang) or ephedrine
23
Q
What are some drugs that can cause or worsen HF?
A
Drugs that cause fluid retention/edema, increased BP, or negative inotropic effects
Drug Information Nation = D I NATION
DPP4-i: alogliptin, saxagliptin
Immunosuppressants: TNFi (e.g. adalimumab, etanercept) and interferons
Non-DHP CCBs: diltiazem, verapamil (if LVEF <50%)
Antiarrhythmics: class I agents (e.g. quinidine, flecainaide) and dronedarone [‘amiodarone and dofetilide are preferred in HF pts)
Thiazolidinediones (increased risk of dema)
Itraconazole
Oncology drugs: anthracyclines (doxorubicin, daunorubicin)
NSAIDs
Others: Cilostazol, systemic steroids, amphetamines, sympathomimetics (stimulants), illicit drugs (cocaine), Triptans (CI with hx of CVD or uncontrolled HTN), oncology drugs (some tyrosine kinase inhibitors (e.g. lapatinib, sunitinib) and drugs that cause fluid retention (e.g. trastuzumab, imatinib, docetaxel), excessive alcohol)
24
Q
HFrEF Treatment benefit of ARNI/ACEi/ARB
A
Decreased mortality
Note: ARNI > ACI/ARB to further reduce morbidity and mortality
25
HFrEF Treatment benefit of Beta-blocker
Select agents decrease mortality, controlling HR and reducing arrhythmia risk
26
HFrEF Treatment benefit of aldosterone receptor antagonists
Decrease morbidity and mortality in NYHA class II-IV HF
Note: must meet eGFR, SCr, and K criteria for use
27
HFrEF Treatment benefit of SGLT2i
Select agents decrease morbidity and mortality in pts with or without diabetes
Note: must meed eGFR criteria for use
28
HFrEF Treatment benefit of loop diuretics
Reduce blood volume, decrease edema and congestion; most HF pts need loop diuretic for symptom relief
29
HFrEF Treatment benefit of Hydralazine and nitrate (BiDil)
Decrease morbidity and mortality in self-identified Black pts with NYHA class III-IV HF when added to optimized (i.e. titrated to target doses) initial medications
30
HFrEF Treatment benefit of ivabradine (Corlanor)
Decrease risk of hospitalizations in stable NYHA class II-III HF with a resting HR ≥70 BPM in normal sinus rhythm on max tolerated dose of beta-blockers
31
HFrEF Treatment benefit of Digoxin
Provides small increase in CO, improved symptoms and decreases cardiac hospitlizations (does NOT decrease mortality); can be considered in pts who remain symptomatic with (or cannot tolerate) first-line therapies
32
HFrEF Treatment benefit of vericiguat (sGC stimulator)
Decrease risk of hospitalization and CV death after HF hospitalization or need for IV diuretics; can be used in select pts with worsening HF despite first-line therapies
33
EF≤ ____% improved to >___% indicates HFimpEF
≤40% improve to >40%
Note: recommended to continue treatments to prevent relapse, even if asymptomatic
34
EF___% indicates HFmrEF
41-49
35
EF___% indicates HFpEF
≥50%
36
In pts with HFmEF (EF 41-49%) or HFpeF (EF≥50%), ___ are recommended as they have demonstrated benefit in decrease HF hospitalizations and CV mortality.
SGLT2i
37
Which medication is recommended in all HF patients regardless of symptom severity?
ARNI, ACEi, or ARB
38
ACEi/ARB/ARNI effect on HF patients
Decrease RAAS activation, resulting in decrease preload and afterload
Decrease cardiac remodeling, improve left ventricular function, and decrease morbidity and mortality
39
Combining ACEi or ARB or ARNI with ____ has added survival benefits
Aldosterone receptor antagonists
40
ACEi + ARB + ARA is NOT recommended d/t higher risk of ____ and ___
hyperkalemia and renal insufficiency
41
In pts with hx of angioedema, which HF medications should be avoided?
ACEi, ARB, ARNI
42
T/F: ARNI is preferred first-line treatment in all HFrEF pts over ACEi or ARBs
True
Note: should not be used in combo with ACEi or ARB
43
What is the starting and target dose for Entresto (sacubitril/Valsartan)
24/25mg BID (if previously on mod-high dose of ACEI/ARB, start 49/51mg BID)
97/103 mg BID
44
Boxed warning for Entresto (sacubitril/Valsartan)
Ca cause injury or death to developing fetus when used in 2nd or 3rd trimesters - d/c as soon as pregnancy is detected
45
Contraindications for Entresto (sacubitril/Valsartan)
Do not use with or within 36 hours of an ACEi
Do not use if hx of angioedema
Do not use with aliskiren in diabetes
46
ARNIs should not be used with or within ____hrs of an ACEi
36 hrs
47
Warning for Entresto (sacubitril/Valsartan)
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (Avoid use)
48
Side effects Entresto (sacubitril/Valsartan)
Generally well-tolerated
Cough, hyperkalemia, increased SCr, hypotension (increased risk if volume depleted (e.g. with concurrent diuretic), headache
49
Monitoring for Entresto (sacubitril/Valsartan)
BP, K, renal function, s/sx of HR, angioedema
50
HF patient is switching from losartan to Entresto. When can they start taking their new med?
No washout period required - take when next ARB was due
51
HF patient is switching from lisinopril to Entresto. When can they start taking their new med?
36 hour washout period required
52
MOA of ACEi
Block conversion of angiotensin I and angiotensin II, resulting in decreased vasoconstriction and aldosterone secretion
Block degradation of bradykinin, which may contribute to vasodilatory effects and side effects of cough and angioedema
53
MOA of ARBs
Block angiotensin II from binding to angiotensin II type-1 (AT-1) receptors
54
Boxed warning for ACEI
Can cause injury and death to developing fetus when used in 2nd and 3rd trimesters, d/c as soon as pregnancy is detected
55
Contraindications for ACEi
Do NOT use with hx of angioedema
Do NOT use within 36 hrs of sacubitril/valsartan (Entresto)
Do NOT use with aliskiren in diabetes
56
Warnings for ACEi
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (Avoid use)
57
Side effects of ACEi
generally well tolerated
Cough, hyperkalemia, increased SCr, hypotension (increased risk if volume-depleted (e.g. with concurrent diuretic)), HA
58
Monitoring for ACEi
BP, K, renal function, s/sx of HF, and angioedema
59
Starting and target dose of enalapril (Vasotec)
2.5mg PO BID
10-20mg PO BID
60
Starting and target dose of lisinopril (Prinivil, Zestril)
2.5-5mg PO daily
20-40mg PO daily
61
Starting and target dose of quinapril (Accupril)
5mg PO BID
20mg PO BID
62
Starting and target dose of ramipril (Altace)
1.25-2.5mg PO daily
10mg PO daily
63
Starting and target dose of losartan (Cozaar)
25-50mg PO daily
50-150mg PO daily
64
Starting and target dose of valsartan (Diovan)
40mg PO BID
160mg PO BID
65
ACEi and ARBs have similar side effects. Which one has less cough and angioedema?
ARB has less cough and angioedema compared to ACEi
66
T/F: ARNI/ACEi/ARBs can all decrease lithium renal clearance and increase risk of lithium toxicity
True
67
Which beta-blockers are recommended in the HF guidelines?
Bisoprolol, carvedilol (IR and ER), and metoprolol succinate ER
68
Of the beta-blockers recommended in HF guidelines, which ones are selective vs non-selective beta-blockers?
Beta-1 selective: Bisoprolol and metoprolol succinate ER
Non-selective beta-blocker and alpha-1 blocker: carvedilol (IR and ER)
69
What is the starting and target dose of metoprolol succinate ER (Toprol XL)
12.5-25mg PO daily
200mg PO Daily
70
What is the starting and target dose of bisoprolol
1.25mg PO daily
10mg PO daily
71
What is the starting and target dose of Carvedilol (Coreg, Coreg CR)
IR
3.125mg PO BID
Target dose ≤85kg = 25mg PO BID // >85kg = 50mg PO BID
CR
10mg PO daily
80mg PO daily
72
Boxed warning for beta-blockers
Do NOT d/c abruptly (particularly in pts with CHD/IHD); taper over 1-2 weeks to avoid acute tachycardia, HTN, and/or ischemia
73
Contraindications for beta-blockers
Severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
Carvedilol: severe hepatic impairment
74
Warnings for beta-blockers
Caution in diabetes - may worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms
Caution in bronchospastic diseases (e.g. asthma, COPD); beta-1 selective agent may be preferred
Caution in Raynaud's or other peripheral vascular diseases and pheochromocytoma
May mask signs of hyperthyroidism (e.g. tachycardia), can worsen CNS depression
Carvedilol: intraoperative floppy iris syndrome has occurred in cataract surgery pts who were on or previously treated with alpha-1 blocker
75
Side effects for beta blockers
Bradycardia, fatigue, hypotension, dizziness, depression, impotence, cold extremities (can exacerbate Raynaud's)
76
Monitoring for beta blockers
HR (decrease dose if HR < 55), BP, s/sx of HF
77
Metoprolol IV:PO ratio
1:2.5
78
T/F: you cannot cut metoprolol succinate ER tablets
False - can be cut in half; take with or immediately after meals
79
HF patient cannot swallow tablets. What formulation do you recommend for beta-blockers?
Metoprolol succinate ER (Kapspargo Sprinkle)
swallow whole; if needed, capsule can be opened and contents sprinkled on a teaspoon of soft food (e.g. apple sauce, yogurt, or pudding)
80
Why is it recommended to take food with carvedilol?
decrease rate of absorption and risk of orthostatic hypotension
81
T/F: carvedilol CR and IR dose conversions are 1:1
False - CR has less bioavailability than IR (e.g. Coreg 3.125mg BID = Coreg CR 10 mg daily)
82
Use caution when using beta-blockers with other drugs that decrease HR such as ____
digoxin, verapamil, diltiazem
83
Which beta blockers are CYP 2D6 substrates?
Carvedilol and metoprolol
84
Which enzymes does carvedilol affect?
inhibits P-gp - can increase conc of P-gp substrates (e.g. digoxin, cyclosporine, dabigatran, ranolazine)
85
Aldosterone receptor antagonists (ARA) compete with aldosterone at receptor sites in the ____ and ___ of the nephron
Distal convoluted tubule and collecting ducts
86
Compare spironolactone vs eplerenone
Spironolactone = non-selective; blocks androgen and exhibits endocrine side effects
Eplerenone = selective; does NOT exhibit endocrine side effects
87
ARAs decrease morbidity and mortality and should be first like in combination with ____ in pts with NYHA class II-IV HF
ARNI/ACEi/ARB, beta-blocker, and SGLT2i
88
Starting and target dose for spironolactone (Aldactone)
12.5-25mg PO daily
Target: 25mg PO daily or BID
89
Contraindications for ARAs
Do NOT use if hyperkalemia, severe renal impairment, Addison's disease (spironolactone), or taking strong CYP3A4 (eplerenone)
90
Do NOT initiate spironolactone for HF if K > ____ (> ___ for eplerenone) , CrCl (eGFR) ≤ ____ or SCr > ____(females) or SCr > ___ (males)
K>5 (spironolactone), 5.5 (eplerenone)
CrCl (eGFR) ≤ 30
SCr > 2 (females), 2.5 (males)
91
Sdie effects of ARAs
Hyperkalemia, increased SCr, dizziness, hyperchloremic metabolic acidosis (Rare)
Spironolactone: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
Eplerenone: increase TG
92
Monitoring for ARAs
BP, K , renal function, fluid status, s/sx of HF
93
Do NOT use triple combination of _____ d/t higher risk of hyperkalemia and renal insufficiency
ACEi + ARB/ARNI + ARA
94
Which HF meds can decrease lithium clearance and increase risk of lithium toxicity?
ACEi/ARBs/ARNI, ARA, diuretics
95
Eplerenone is a major substrate of ____. Do NOT use with strong inhibitors.
CYP3A4
Inhibitors: azole antifungals, clarithromycin, ritonavir
96
SGLTi are recommended first line in HF pts in combination with ____
ARNI (or ACEi/ARB), BB, and ARA
97
Dapagliflozin (Farxiga) eGFR limit
eGFR < 25 - initiation not recommended (but those on treatment may continue)
98
Empagliflozin (Jardiance) eGFR limit
eGFR <20 - benefits not establishedW
99
hat is the dose of Dapagliflozin (Farxiga) and Empagliflozin (Jardiance)
both 10mg daily in the morning
100
MOA Loop diuretics
Block sodium and chloride reabsorption in thick ascending limb or the loop of Henle
Increase excretion of sodium, potassium, chloride, magnesium, calcium, and water
Decrease in fluid volume = easier for heart to pump, reduces congestive symptoms (Decrease preload) and restores euvolemia ("dry" weight)
101
If response to loop diuretics is poor, adding ___ can be useful
thiazide-type diuretic such as metolazone
102
Loop diuretics have a warning for __ allergies (though not likely to cross-react) with an exception to ____
Sulfa allergy
Ethacrynic acid is the exception
103
What electrolytes/labs decrease with loop diuretic use?
K, Mg, Na, Cl, Ca (different than thiazides which increase Ca)
104
What electrolytes/labs increase with loop diuretic use?
HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol
105
What are some side effects of loop diuretics?
Electrolyte imbalances (decrease K, Mg, Na, Cl, Ca / increased HCO3)
Increase HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol
Ototoxicity (more with ethacrynic acid or rapid IV administration)
Orthostatic hypotension
Photosensitivity
Myalgias
106
Monitoring for loop diuretics
Renal function, fluid status, BP, electrolytes, audiology testing, s/sx of HF
107
Furosemide injection storage instructions
Store at room temp (refrigeration causes crystals to form, may dissolve upon warming)
Solution must be clear, do not use if yellow in color
108
Which furosemide formulation is a single-dose prefilled cartridge for use with an on-body infusor (SC infusion)
Furoscix
109
PO Loop diuretic conversions
furosemide 40mg = torsemide 20mg = bumetanide 1mg = ethacrynic acid 50mg
110
Furosemide (Lasix) IV:PO ratio
1:2 (furosemide 20mg IV = 40mg PO)
111
Bumetanide (Bumex) and ethacrynic acid (Edecrin) IV:PO ratio
1:1
112
Which loop diuretic injections are light-sensitive?
Bumetanide and furosemide (store in amber bottles); IV admixtures do not require light protection
113
Why should NSAIDs be avoided when using loop diuretics?
Increase sodium and water retention can decrease effect of loop diuretics and cause renal impariment
114
MOA Hydralazine
direct arterial vasodilator which decreases afterload
115
MOA nitrates
Increase availability of nitric oxide, causing venous vasodilation and decrease prload
116
___ combination improves survival in HF (but to lesser degree than ACEi) and can be used as an alternative in pts who cannot tolerate ACEi/ARBs d/t poor renal function, angioedema, or hyperkalemia
Hydralazine/nitrate
117
____ is indicated in self-identified black patients with NYHA class III or IV HF who are symptomatic despite optimal treatment with ARNI (or ACE/ARB), BB, ARA, and SGLT2i
Combination product BiDil (hydralazine/isosorbide dinitrate)
118
T/F: Hydralazine or oral nitrate monotherapy can be used in HF to improve survival though it is superior to use in combination
False - no role for monotherapy of either product in HF
119
Contraindication for hydralazine
Mitral valve, rheumatic heart disease, CAD
120
Warning for hydralazine
Drug-induced lupus erythematosus (DILE - dose and duration related), peripheral neuritis, blood dyscrasias, hypotension
121
Side effects for hydralazine
Peripheral edema, HA, flushing, palpitations, reflex tachycardia
N/V
122
Contraindications for isosorbide dinitrate
do NOT use with PDE-5i (e.g. avanafil, sildenafil, tadalafil, vardenafil) or riociguat
can cause severe hypotension
123
Side effects for isosorbide dinitrate
Hypotension, HA, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 nitrate-free interval), syncope
124
T/F: combo product BiDil has no nitrate tolerance
True
125
MOA ivabradine (Corlanor)
hypopolarization-activated cyclic nucleotide-gated channel blockers
Disrupts "funny" current (If) in the SA node resulting in less firing = decrease HR
126
Ivabradine is recommended as adjunct treatment in symptomatic stable chronic HF (EF ≤35%) pts who are already on mortality-reducing meds and be in sinus rhythm with a resting HR of ____
≥70 BPM
127
Ivabradine (Corlanor) target HR
Resting HR between 50-60 BPM
128
Warnings for ivabradine (Corlanor)
Can cause bradycardia - increase risk of QT prolongation and ventricular arrhythmias; not recommended in 2nd degree AV block
Increase risk of Afib
Fetal toxicity (females should use effective contraception)
129
Contraindications for ivabradine (Corlanor)
ADHF; sick sinus syndrome, SA block or 3rd degree AV block (unless permanent pacemaker is in place)
Clinically significant hypotension or bradycardia
HR maintained exclusively by pacemaker
Severe hepatic impairment
Use with strong CYP3A4 inhibitors
130
Side effects of ivabradine (Corlanor)
Bradycardia, HTN, Afib, luminous phenomena (phosphenes - seeing flashes of light)
131
Ivabradine (Corlanor) should NOT be used with ____ inhibitors or ___ inducers
moderate or strong CYP3A4 inhibitors
Strong 3A4 inducers
132
Ivabradine (Corlanor) should be used with caution when used with other drugs that decrease HR such as ____
digoxin, BB, clonidine, non-DHP CCBs, amiodarone, dexmedetomidine
133
MOA digoxin
Inhibits Na-K-ATPase pump, causing positive inotropic effect (increased CO) and exerts parasympathetic effect - negative chronotropy (decrease HR)
134
____ is typically added for Afib in those with HFrEF and low blood pressure
Digoxin
135
When would you start digoxin at a lower dose?
If renal insufficiency, smaller, older, or female
136
What should K and Mg be maintained at to decrease risk of digoxin toxicity?
K between 4-5
Mg > 2
137
Imbalances in which electrolytes can cause increased risk of digoxin toxicity?
Hypokalemia, hypomagnesmia, and hypercalcemia
138
Digoxin (Digitek, Lanoxin) typical dose
0.125-0.25mg PO daily
139
T/F: digoxin requires loading dose in HF
False - no LD for HF
140
Patient was hospitalized and is switching from PO digoxin to IV. How does the dosing change?
Decrease dose by 20-25%
141
Digoxin therapeutic range in HF
0.5-0.9 ng/mL (higher range for Afib)
142
Contraindications for digoxin
Ventricular fibrilation
143
Warnings for digoxin
2nd/3rd degree heart bock without a pacemaker, Wolff-Parkinson-White syndrome with AF, vesicant (avoid extravasation)
144
Monitoring for digoxin
electrolytes, renal function, HR
Others: ECG, BP, digoxin level (draw 12-24 hrs after dose)
145
S/sx of digoxin toxicity
N/V, loss of appetite, abdominal pain, blurred/double vision, greenish-yellow halos (or altered color perception), confusion, delirium, bradycardia, life-threatening, arrhythmias
Increased risk with hypokalemia, hypomagnesemia, and hypercalcemia
Hypothyroidism can increase digoxin levels
146
What conditions can increase risk of digoxin toxicity?
Hypokalemia, hypomagnesemia, and hypercalcemia
Hypothyroidism
Dehydration
147
What is the antidote for digoxin?
DigiFab
148
Digoxin is the substrate of _____. Inhibitors will increased digoxin levels
Pgp and CYP3A4 (minor)
149
Reduce digoxin dose by ___ when starting amiodarone or dronedarone
50%
150
Use caution when using digoxin with other drugs that decrease HR such as ____
BB, clonidine, non-DHP CCBs, amiodarone, clonidine, and dexmedetomidine
151
MOA vericiguat (Verquvo)
Soluble guanylate cyclase stimulator
Increases cyclic GMP and leads to smooth muscle relaxation and vasodilation
152
Contraindications for vericiguat (Verquvo)
Do NOT use with riociguat (another soluble guanylate cyclase stimulator)
153
Side effects for vericiguat (Verquvo)
Hypotension, anemia, dyspepsia
154
Boxed warning for vericiguat (Verquvo)
Do NOT use if pregnant - contraception during use and for one month after stopping treatment
155
What is your concern with using vericiguat + PDE5i?
May enhance hypotensive effects of PDE5i, avoid this combo
156
___ deficiency can aggravate hypokalemia
Magnesium
157
____ should be checked and corrected (prn) prior to correcting potassium levels
Magnesium
158
___ is use most commonly for potassium supplementation (when neeeded)
KCl ( potassium chloride)
159
Examples of KCl extended release capsules
Klor-Con Sprinkle, Micro-K
160
Examples of KCl extended release tablets
K-Tab, Klor-Con 10, Klor-Con M10/M15/M20
161
Examples of KCl packets
Klor-Con
162
What strengths does KCl solutions come in?
10% (20mEq/15mL)
20% (40mEq/15mL)
163
Why is potassium often divided into 20-25mEq doses?
To avoid GI discomfort
164
Which potassium chloride ER tablets can be cut?
Klor-Con M can be cut in half or dissolved in water (stir for 2 minutes and drink immediately); do not chew, crush, or suck on tablet
K-Tab, Klor-Con must be swallowed whole
165
Patient has a hard time swallowing tablets. What are good potassium chloride options for this patient?
ER capsules - contents can be sprinkled on small amt of apple sauce or pudding
Klor-Con M - can be cut in half or dissolved in water (stir 2 mins and drink immediately) // do NOT chew, crush, or suck on tablet
Oral packet - dissolve contents in water and drink immediately
Oral solution - mix each 15mL with 6 oz of water
166
All patients with HF should be assessed for ___ because it is a/w HF disease severity and mortality
anemia
167
What are some signs HF is worsening?
Weight gain: 2-4lbs in a day, 3-5lbs in a week
Increased number of pillows to sleep
Increased swelling or coughing
SOB with activity
Danger:
weight gain > 5lbs in a week
Waking at night d/t SOB
Dizziness or falling
SOB at rest, chest tightness, or wheezing
168
What are key diagnostic tests for HF?
Echocardiogram
Plasma B-type natriuretic peptide
169
Eplerenone is a suitable alternative for pts experiencing which side effect of spironolactone?
Gynecomastia, breast tenderness, impotence, or other endocrine side effects that occur with spironolactone
