Alternative Pharmacotherapy of Heart Failure with HF-Reduced

Question 1

How does Aldosterone antagonist aid in the treatment of Heart Failure

Answer 1

Decreased preload and cardiac remodeling

Question 2

T/F: Aldosterone antagonist are use to replace ACEs and ARBs in HF-Reduced

Answer 2

False: Aldosterone antagonist are used in ADDITION to standard therapy (ACE-I or ARB Plus BB)

Question 3

What patients potentially take an Aldosterone antagonist for HF-Reduced

Answer 3

Patients classified as Stage C/D, post MI, EF less than 40, Has Diabetes, Stage B with resistant HTN

Question 4

What Aldosterone antagonists used in HF-Reduced, what is the initial dose and the Target high dose

Answer 4

Spironolactone: 12.5-25 mg every day, 25 mg every day
Eplerenone: 25 mg every day, 50 mg every day

Question 5

When should Aldosterone antagonists be avoided

Answer 5

Potassium is greater than or equal to 5, Serum Creatinine is greater than 2.5, CrCl is less than 30

Question 6

How should a patient on Aldosterone antagonist be monitored

Answer 6

Within 3 days and again at 1 week after initiation, monthly for 1st 3 months, every 3-4 months thereafter (especially if also on ACEs or ARBs)

Question 7

T/F:New bradycardia can be caused by using Aldosterone and ACE/ARB leading to severe hyperkalemia

Answer 7

True

Question 8

How does Hydralazine and Isosorbide Dinitrate aid in the treatment of HF-Reduced

Answer 8

Isosorbide dinitrate causes venous dilation decreasing preload and donating Nitrous Oxide, Hydralazine causes arterial dilation and inhibits destruction of Nitrous Oxide

Question 9

T/F: Hydralazine/Isosorbide is used in addition to optimal therapy in RAAS-I plus BB in Class 3 and 4 black patients or alternative to patients unable to tolerate an ACE/ARB

Answer 9

True

Question 10

What is the initial dosing for hydralzaine/isosorbide dinitrate and Target high dose

Answer 10

Initial: hydralazine 25-50 and ISDN 20-30 mg TID or QID
Target: Hydralazine 300 and ISDN 120 in divided doses

Question 11

What is the MOA of sacubitril

Answer 11

Inhibts neprilysin leading to an increase in BNP

Question 12

When would Sacubitril/Valsartan be used

Answer 12

Replaces ACE/ARB in patients with symptomatic Heart Failure

Question 13

What is key CONTRADICTION for using sacubitril/valsartan

Answer 13

Any history of angioedema with ACEs/ARBs

Question 14

T/F: If a patient is on a high dose ARB or ACE the low dose of sacubitril/valsartan should be given and then titrated every 2 weeks to target as tolerated

Answer 14

True

Question 15

How long should the discontinue period be between ACE/ARB and sacubutril/valsartan

Answer 15

36 hours

Question 16

What is the mechanism of Ivarbradine

Answer 16

Reduces the influx of Na causing less action potentials and slowing the heart rate down

Question 17

What is the heart rate reduction in Ivarbidine, what should be expeceted

Answer 17

Dependent on dose and baseline heart rate, at recommended doses of 10 bpm during rest and exercise

Question 18

T/F: Ivarbidine bioavalability is consistent

Answer 18

False: Ivabridine has a 60-80% increase in bioavailability with food

Question 19

When would Ivarbidine be used

Answer 19

ADD to standard therapy in patients with symptomatic Heart failure and a resting HR greater than 70 bpm and the patient MUST be in sinus rhythm (Cannot use if arrhythimic)

Question 20

T/F: Ivarbidine should be used if their Beta blocker is at less than 50% of the target dose

Answer 20

True

Question 21

What is the MOA of digoxin

Answer 21

Inhibit Na/K ATPase

Question 22

What is a possible drug interaction between digoxin

Answer 22

Pgp inducers or inhibitors

Question 23

How is digoxin distributed

Answer 23

4-6 after the dose is given BUT never distributes to the adipose tissue

Question 24

T/F: Digoxin should be ADDED to standard care of HF-Reduced and it lowers preload

Answer 24

False: Digoxin should be ADDED to standard care of Hf=Reduced and has NO effect on mortality but treats SYMPTOMS

Question 25

What are side effects of using digoxin

Answer 25

ECG (AV Block or Bradycardia), Nausea/vomitting/diarrhea, Visual changes, confusion

Question 26

T/F: All patients should be on a ACEi or ARB and BB titrated to target dose regardless of symptoms

Answer 26

True

Question 27

What alternative drugs can be used as substitutes, for what drugs

Answer 27

Sacubitril/Valsartan and Hydralazine/Nitrates

Question 28

What alternative drugs will be added on to standard HF-Reduced therapy

Answer 28

Aldosterone Receptor Antagonist, Ivarbidine, Digoxin, Hydralazine/Nitrates

Question 29

When would hydralazine be added on to standard therapy, substitute

Answer 29

If patient is black or functional class III to IV, intolerance or contraindication to ACEs or ARBs

Question 30

When would a aldosterone antagonist be added to therapy, Ivarbidine

Answer 30

Potassium is less than 5 and CrCl is less than 30/ HR greater than 70 and is in sinus rhythm