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NAPLEX 2024 > 31. Chronic HF > Flashcards

31. Chronic HF Flashcards

1
Q

EF< ____% indicates systolic dysfunction or HF with reduced ejection fraction (HFrEF)

A

<40%

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2
Q

Explain HFrEF

A

Systolic dysfunction - impaired ability to eject blood during systole

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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

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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)

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5
Q

General s/sx of HF

A

Dyspnea (SOB at rest or upon exertion)
Cough
Fatigue, weakness
Reduced exercise capacity

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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

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7
Q

Which ACC/AHA stages are for symptomatic patients?

A

C or D

Asymptomatic = 1 or 2

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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)

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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)

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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)

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11
Q

What is cardiac output (CO)?

A

Volume of blood that is pumped by the heart in 1 minute

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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

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13
Q

What does stroke volume depend on?

A

Preload, afterload, and contractility

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14
Q

What is cardiac index related to?

A

CO and the size of the patient (body surface area)
CI = CO/BSA

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15
Q

HFrEF is a (low/high) cardiac output state?

A

low

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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

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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

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18
Q

What effect does aldosterone have?

A

Sodium and water retention and increases potassium excretion

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19
Q

What effect does vasopressin have?

A

Vasoconstriction (vasopressin = presses on vessels) and water retention

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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

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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

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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

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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)

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24
Q

HFrEF Treatment benefit of ARNI/ACEi/ARB

A

Decreased mortality
Note: ARNI > ACI/ARB to further reduce morbidity and mortality

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25
Q

HFrEF Treatment benefit of Beta-blocker

A

Select agents decrease mortality, controlling HR and reducing arrhythmia risk

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26
Q

HFrEF Treatment benefit of aldosterone receptor antagonists

A

Decrease morbidity and mortality in NYHA class II-IV HF

Note: must meet eGFR, SCr, and K criteria for use

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27
Q

HFrEF Treatment benefit of SGLT2i

A

Select agents decrease morbidity and mortality in pts with or without diabetes

Note: must meed eGFR criteria for use

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28
Q

HFrEF Treatment benefit of loop diuretics

A

Reduce blood volume, decrease edema and congestion; most HF pts need loop diuretic for symptom relief

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29
Q

HFrEF Treatment benefit of Hydralazine and nitrate (BiDil)

A

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

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30
Q

HFrEF Treatment benefit of ivabradine (Corlanor)

A

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

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31
Q

HFrEF Treatment benefit of Digoxin

A

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

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32
Q

HFrEF Treatment benefit of vericiguat (sGC stimulator)

A

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

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33
Q

EF≤ ____% improved to >___% indicates HFimpEF

A

≤40% improve to >40%
Note: recommended to continue treatments to prevent relapse, even if asymptomatic

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34
Q

EF___% indicates HFmrEF

A

41-49

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35
Q

EF___% indicates HFpEF

A

≥50%

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36
Q

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.

A

SGLT2i

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37
Q

Which medication is recommended in all HF patients regardless of symptom severity?

A

ARNI, ACEi, or ARB

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38
Q

ACEi/ARB/ARNI effect on HF patients

A

Decrease RAAS activation, resulting in decrease preload and afterload
Decrease cardiac remodeling, improve left ventricular function, and decrease morbidity and mortality

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39
Q

Combining ACEi or ARB or ARNI with ____ has added survival benefits

A

Aldosterone receptor antagonists

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40
Q

ACEi + ARB + ARA is NOT recommended d/t higher risk of ____ and ___

A

hyperkalemia and renal insufficiency

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41
Q

In pts with hx of angioedema, which HF medications should be avoided?

A

ACEi, ARB, ARNI

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42
Q

T/F: ARNI is preferred first-line treatment in all HFrEF pts over ACEi or ARBs

A

True
Note: should not be used in combo with ACEi or ARB

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43
Q

What is the starting and target dose for Entresto (sacubitril/Valsartan)

A

24/25mg BID (if previously on mod-high dose of ACEI/ARB, start 49/51mg BID)
97/103 mg BID

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44
Q

Boxed warning for Entresto (sacubitril/Valsartan)

A

Ca cause injury or death to developing fetus when used in 2nd or 3rd trimesters - d/c as soon as pregnancy is detected

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45
Q

Contraindications for Entresto (sacubitril/Valsartan)

A

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

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46
Q

ARNIs should not be used with or within ____hrs of an ACEi

A

36 hrs

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47
Q

Warning for Entresto (sacubitril/Valsartan)

A

Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (Avoid use)

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48
Q

Side effects Entresto (sacubitril/Valsartan)

A

Generally well-tolerated
Cough, hyperkalemia, increased SCr, hypotension (increased risk if volume depleted (e.g. with concurrent diuretic), headache

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49
Q

Monitoring for Entresto (sacubitril/Valsartan)

A

BP, K, renal function, s/sx of HR, angioedema

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50
Q

HF patient is switching from losartan to Entresto. When can they start taking their new med?

A

No washout period required - take when next ARB was due

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51
Q

HF patient is switching from lisinopril to Entresto. When can they start taking their new med?

A

36 hour washout period required

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52
Q

MOA of ACEi

A

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

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53
Q

MOA of ARBs

A

Block angiotensin II from binding to angiotensin II type-1 (AT-1) receptors

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54
Q

Boxed warning for ACEI

A

Can cause injury and death to developing fetus when used in 2nd and 3rd trimesters, d/c as soon as pregnancy is detected

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55
Q

Contraindications for ACEi

A

Do NOT use with hx of angioedema
Do NOT use within 36 hrs of sacubitril/valsartan (Entresto)
Do NOT use with aliskiren in diabetes

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56
Q

Warnings for ACEi

A

Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (Avoid use)

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57
Q

Side effects of ACEi

A

generally well tolerated
Cough, hyperkalemia, increased SCr, hypotension (increased risk if volume-depleted (e.g. with concurrent diuretic)), HA

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58
Q

Monitoring for ACEi

A

BP, K, renal function, s/sx of HF, and angioedema

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59
Q

Starting and target dose of enalapril (Vasotec)

A

2.5mg PO BID
10-20mg PO BID

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60
Q

Starting and target dose of lisinopril (Prinivil, Zestril)

A

2.5-5mg PO daily
20-40mg PO daily

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61
Q

Starting and target dose of quinapril (Accupril)

A

5mg PO BID
20mg PO BID

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62
Q

Starting and target dose of ramipril (Altace)

A

1.25-2.5mg PO daily
10mg PO daily

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63
Q

Starting and target dose of losartan (Cozaar)

A

25-50mg PO daily
50-150mg PO daily

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64
Q

Starting and target dose of valsartan (Diovan)

A

40mg PO BID
160mg PO BID

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65
Q

ACEi and ARBs have similar side effects. Which one has less cough and angioedema?

A

ARB has less cough and angioedema compared to ACEi

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66
Q

T/F: ARNI/ACEi/ARBs can all decrease lithium renal clearance and increase risk of lithium toxicity

A

True

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67
Q

Which beta-blockers are recommended in the HF guidelines?

A

Bisoprolol, carvedilol (IR and ER), and metoprolol succinate ER

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68
Q

Of the beta-blockers recommended in HF guidelines, which ones are selective vs non-selective beta-blockers?

A

Beta-1 selective: Bisoprolol and metoprolol succinate ER
Non-selective beta-blocker and alpha-1 blocker: carvedilol (IR and ER)

69
Q

What is the starting and target dose of metoprolol succinate ER (Toprol XL)

A

12.5-25mg PO daily
200mg PO Daily

70
Q

What is the starting and target dose of bisoprolol

A

1.25mg PO daily
10mg PO daily

71
Q

What is the starting and target dose of Carvedilol (Coreg, Coreg CR)

A

IR
3.125mg PO BID
Target dose ≤85kg = 25mg PO BID // >85kg = 50mg PO BID

CR
10mg PO daily
80mg PO daily

72
Q

Boxed warning for beta-blockers

A

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
Q

Contraindications for beta-blockers

A

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
Q

Warnings for beta-blockers

A

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
Q

Side effects for beta blockers

A

Bradycardia, fatigue, hypotension, dizziness, depression, impotence, cold extremities (can exacerbate Raynaud’s)

76
Q

Monitoring for beta blockers

A

HR (decrease dose if HR < 55), BP, s/sx of HF

77
Q

Metoprolol IV:PO ratio

A

1:2.5

78
Q

T/F: you cannot cut metoprolol succinate ER tablets

A

False - can be cut in half; take with or immediately after meals

79
Q

HF patient cannot swallow tablets. What formulation do you recommend for beta-blockers?

A

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
Q

Why is it recommended to take food with carvedilol?

A

decrease rate of absorption and risk of orthostatic hypotension

81
Q

T/F: carvedilol CR and IR dose conversions are 1:1

A

False - CR has less bioavailability than IR (e.g. Coreg 3.125mg BID = Coreg CR 10 mg daily)

82
Q

Use caution when using beta-blockers with other drugs that decrease HR such as ____

A

digoxin, verapamil, diltiazem

83
Q

Which beta blockers are CYP 2D6 substrates?

A

Carvedilol and metoprolol

84
Q

Which enzymes does carvedilol affect?

A

inhibits P-gp - can increase conc of P-gp substrates (e.g. digoxin, cyclosporine, dabigatran, ranolazine)

85
Q

Aldosterone receptor antagonists (ARA) compete with aldosterone at receptor sites in the ____ and ___ of the nephron

A

Distal convoluted tubule and collecting ducts

86
Q

Compare spironolactone vs eplerenone

A

Spironolactone = non-selective; blocks androgen and exhibits endocrine side effects
Eplerenone = selective; does NOT exhibit endocrine side effects

87
Q

ARAs decrease morbidity and mortality and should be first like in combination with ____ in pts with NYHA class II-IV HF

A

ARNI/ACEi/ARB, beta-blocker, and SGLT2i

88
Q

Starting and target dose for spironolactone (Aldactone)

A

12.5-25mg PO daily
Target: 25mg PO daily or BID

89
Q

Contraindications for ARAs

A

Do NOT use if hyperkalemia, severe renal impairment, Addison’s disease (spironolactone), or taking strong CYP3A4 (eplerenone)

90
Q

Do NOT initiate spironolactone for HF if K > ____ (> ___ for eplerenone) , CrCl (eGFR) ≤ ____ or SCr > ____(females) or SCr > ___ (males)

A

K>5 (spironolactone), 5.5 (eplerenone)
CrCl (eGFR) ≤ 30
SCr > 2 (females), 2.5 (males)

91
Q

Sdie effects of ARAs

A

Hyperkalemia, increased SCr, dizziness, hyperchloremic metabolic acidosis (Rare)
Spironolactone: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
Eplerenone: increase TG

92
Q

Monitoring for ARAs

A

BP, K , renal function, fluid status, s/sx of HF

93
Q

Do NOT use triple combination of _____ d/t higher risk of hyperkalemia and renal insufficiency

A

ACEi + ARB/ARNI + ARA

94
Q

Which HF meds can decrease lithium clearance and increase risk of lithium toxicity?

A

ACEi/ARBs/ARNI, ARA, diuretics

95
Q

Eplerenone is a major substrate of ____. Do NOT use with strong inhibitors.

A

CYP3A4
Inhibitors: azole antifungals, clarithromycin, ritonavir

96
Q

SGLTi are recommended first line in HF pts in combination with ____

A

ARNI (or ACEi/ARB), BB, and ARA

97
Q

Dapagliflozin (Farxiga) eGFR limit

A

eGFR < 25 - initiation not recommended (but those on treatment may continue)

98
Q

Empagliflozin (Jardiance) eGFR limit

A

eGFR <20 - benefits not establishedW

99
Q

hat is the dose of Dapagliflozin (Farxiga) and Empagliflozin (Jardiance)

A

both 10mg daily in the morning

100
Q

MOA Loop diuretics

A

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
Q

If response to loop diuretics is poor, adding ___ can be useful

A

thiazide-type diuretic such as metolazone

102
Q

Loop diuretics have a warning for __ allergies (though not likely to cross-react) with an exception to ____

A

Sulfa allergy
Ethacrynic acid is the exception

103
Q

What electrolytes/labs decrease with loop diuretic use?

A

K, Mg, Na, Cl, Ca (different than thiazides which increase Ca)

104
Q

What electrolytes/labs increase with loop diuretic use?

A

HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol

105
Q

What are some side effects of loop diuretics?

A

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
Q

Monitoring for loop diuretics

A

Renal function, fluid status, BP, electrolytes, audiology testing, s/sx of HF

107
Q

Furosemide injection storage instructions

A

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
Q

Which furosemide formulation is a single-dose prefilled cartridge for use with an on-body infusor (SC infusion)

A

Furoscix

109
Q

PO Loop diuretic conversions

A

furosemide 40mg = torsemide 20mg = bumetanide 1mg = ethacrynic acid 50mg

110
Q

Furosemide (Lasix) IV:PO ratio

A

1:2 (furosemide 20mg IV = 40mg PO)

111
Q

Bumetanide (Bumex) and ethacrynic acid (Edecrin) IV:PO ratio

A

1:1

112
Q

Which loop diuretic injections are light-sensitive?

A

Bumetanide and furosemide (store in amber bottles); IV admixtures do not require light protection

113
Q

Why should NSAIDs be avoided when using loop diuretics?

A

Increase sodium and water retention can decrease effect of loop diuretics and cause renal impariment

114
Q

MOA Hydralazine

A

direct arterial vasodilator which decreases afterload

115
Q

MOA nitrates

A

Increase availability of nitric oxide, causing venous vasodilation and decrease prload

116
Q

___ 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

A

Hydralazine/nitrate

117
Q

____ 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

A

Combination product BiDil (hydralazine/isosorbide dinitrate)

118
Q

T/F: Hydralazine or oral nitrate monotherapy can be used in HF to improve survival though it is superior to use in combination

A

False - no role for monotherapy of either product in HF

119
Q

Contraindication for hydralazine

A

Mitral valve, rheumatic heart disease, CAD

120
Q

Warning for hydralazine

A

Drug-induced lupus erythematosus (DILE - dose and duration related), peripheral neuritis, blood dyscrasias, hypotension

121
Q

Side effects for hydralazine

A

Peripheral edema, HA, flushing, palpitations, reflex tachycardia
N/V

122
Q

Contraindications for isosorbide dinitrate

A

do NOT use with PDE-5i (e.g. avanafil, sildenafil, tadalafil, vardenafil) or riociguat
can cause severe hypotension

123
Q

Side effects for isosorbide dinitrate

A

Hypotension, HA, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 nitrate-free interval), syncope

124
Q

T/F: combo product BiDil has no nitrate tolerance

A

True

125
Q

MOA ivabradine (Corlanor)

A

hypopolarization-activated cyclic nucleotide-gated channel blockers
Disrupts “funny” current (If) in the SA node resulting in less firing = decrease HR

126
Q

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 ____

A

≥70 BPM

127
Q

Ivabradine (Corlanor) target HR

A

Resting HR between 50-60 BPM

128
Q

Warnings for ivabradine (Corlanor)

A

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
Q

Contraindications for ivabradine (Corlanor)

A

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
Q

Side effects of ivabradine (Corlanor)

A

Bradycardia, HTN, Afib, luminous phenomena (phosphenes - seeing flashes of light)

131
Q

Ivabradine (Corlanor) should NOT be used with ____ inhibitors or ___ inducers

A

moderate or strong CYP3A4 inhibitors
Strong 3A4 inducers

132
Q

Ivabradine (Corlanor) should be used with caution when used with other drugs that decrease HR such as ____

A

digoxin, BB, clonidine, non-DHP CCBs, amiodarone, dexmedetomidine

133
Q

MOA digoxin

A

Inhibits Na-K-ATPase pump, causing positive inotropic effect (increased CO) and exerts parasympathetic effect - negative chronotropy (decrease HR)

134
Q

____ is typically added for Afib in those with HFrEF and low blood pressure

A

Digoxin

135
Q

When would you start digoxin at a lower dose?

A

If renal insufficiency, smaller, older, or female

136
Q

What should K and Mg be maintained at to decrease risk of digoxin toxicity?

A

K between 4-5
Mg > 2

137
Q

Imbalances in which electrolytes can cause increased risk of digoxin toxicity?

A

Hypokalemia, hypomagnesmia, and hypercalcemia

138
Q

Digoxin (Digitek, Lanoxin) typical dose

A

0.125-0.25mg PO daily

139
Q

T/F: digoxin requires loading dose in HF

A

False - no LD for HF

140
Q

Patient was hospitalized and is switching from PO digoxin to IV. How does the dosing change?

A

Decrease dose by 20-25%

141
Q

Digoxin therapeutic range in HF

A

0.5-0.9 ng/mL (higher range for Afib)

142
Q

Contraindications for digoxin

A

Ventricular fibrilation

143
Q

Warnings for digoxin

A

2nd/3rd degree heart bock without a pacemaker, Wolff-Parkinson-White syndrome with AF, vesicant (avoid extravasation)

144
Q

Monitoring for digoxin

A

electrolytes, renal function, HR
Others: ECG, BP, digoxin level (draw 12-24 hrs after dose)

145
Q

S/sx of digoxin toxicity

A

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
Q

What conditions can increase risk of digoxin toxicity?

A

Hypokalemia, hypomagnesemia, and hypercalcemia
Hypothyroidism
Dehydration

147
Q

What is the antidote for digoxin?

A

DigiFab

148
Q

Digoxin is the substrate of _____. Inhibitors will increased digoxin levels

A

Pgp and CYP3A4 (minor)

149
Q

Reduce digoxin dose by ___ when starting amiodarone or dronedarone

A

50%

150
Q

Use caution when using digoxin with other drugs that decrease HR such as ____

A

BB, clonidine, non-DHP CCBs, amiodarone, clonidine, and dexmedetomidine

151
Q

MOA vericiguat (Verquvo)

A

Soluble guanylate cyclase stimulator
Increases cyclic GMP and leads to smooth muscle relaxation and vasodilation

152
Q

Contraindications for vericiguat (Verquvo)

A

Do NOT use with riociguat (another soluble guanylate cyclase stimulator)

153
Q

Side effects for vericiguat (Verquvo)

A

Hypotension, anemia, dyspepsia

154
Q

Boxed warning for vericiguat (Verquvo)

A

Do NOT use if pregnant - contraception during use and for one month after stopping treatment

155
Q

What is your concern with using vericiguat + PDE5i?

A

May enhance hypotensive effects of PDE5i, avoid this combo

156
Q

___ deficiency can aggravate hypokalemia

A

Magnesium

157
Q

____ should be checked and corrected (prn) prior to correcting potassium levels

A

Magnesium

158
Q

___ is use most commonly for potassium supplementation (when neeeded)

A

KCl ( potassium chloride)

159
Q

Examples of KCl extended release capsules

A

Klor-Con Sprinkle, Micro-K

160
Q

Examples of KCl extended release tablets

A

K-Tab, Klor-Con 10, Klor-Con M10/M15/M20

161
Q

Examples of KCl packets

A

Klor-Con

162
Q

What strengths does KCl solutions come in?

A

10% (20mEq/15mL)
20% (40mEq/15mL)

163
Q

Why is potassium often divided into 20-25mEq doses?

A

To avoid GI discomfort

164
Q

Which potassium chloride ER tablets can be cut?

A

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
Q

Patient has a hard time swallowing tablets. What are good potassium chloride options for this patient?

A

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
Q

All patients with HF should be assessed for ___ because it is a/w HF disease severity and mortality

A

anemia

167
Q

What are some signs HF is worsening?

A

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
Q

What are key diagnostic tests for HF?

A

Echocardiogram
Plasma B-type natriuretic peptide

169
Q

Eplerenone is a suitable alternative for pts experiencing which side effect of spironolactone?

A

Gynecomastia, breast tenderness, impotence, or other endocrine side effects that occur with spironolactone

NAPLEX 2024 (74 decks)

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