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Cardiology Exam > CHF Drugs > Flashcards

CHF Drugs Flashcards

1
Q

medication classes used to treat HFrEF

A

*use “BAANDAIDS”:
-beta blockers
-ACE inhibitors
-angiotensin receptor blockers (ARBs)
-neprilysin inhibitors/ARB combination
-diuretics
-aldosterone antagonists
-ivabradine
-digoxin
-SGLT-2 inhibitors

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2
Q

cornerstone (most important) medication classes used to treat HFrEF

A
  1. beta blockers (only metoprolol, carvedilol, and bisoprolol)
  2. anti-RAAS agents (ACEi, ARBs, ARNI [ARB/Neprilysin inhibitor combination])
  3. aldosterone antagonists
  4. SGLT-2 inhibitors

*improve cardiovascular outcomes (improve survival), either alone or in combination

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3
Q

beta blockers for HFrEF - MOA

A

*blockade of antiarrhythmic effects
*antiarrhythmic effects
*blunts cardiotoxic effects of catecholamines

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4
Q

role of beta blockers in HFrEF

A

*favorable long term benefit
*improve functional status
*decreased risk of sudden cardiac death

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5
Q

beta blockers used for HFrEF - only 3 are shown to be beneficial in heart failure

A
  1. bisoprolol (long-acting formulation)
  2. metoprolol
  3. carvedilol [probably the best]
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6
Q

bisoprolol - HFrEF class uses

A

*class II-III/stage B-D

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7
Q

metoprolol - HFrEF class uses

A

*class II-IV/stage B-D

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8
Q

carvedilol - HFrEF class uses

A

*class II-IV/stage B-D

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9
Q

guide to using beta blockers in pts with HFrEF

A

*select an agent with survival benefit (carvedilol, metoprolol, or bisoprolol)
*use when patients are EUVOLEMIC (NOT in fluid overload)
*monitor BP/MAP, HR, CNS, pulmonary side effects

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10
Q

anti-RAAS agents - 3 classes

A
  1. ACE inhibitors
  2. ARBs
  3. ARNI (ARB/Neprilysin inhibitor combination)
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11
Q

ACE inhibitors - HFrEF class uses

A

*any HFrEF in which the goal is to decrease afterload and decrease blood pressure
*class I-IV, stages A-D
*examples: captopril, enalapril, lisinopril, ramipril

*compelling indication: HTN + heart failure

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12
Q

angiotensin II receptor blockers (ARBs) - HFrEF class uses

A

*any HFrEF in which the goal is to decrease afterload and decrease blood pressure
*class I-IV, stages A-D
*examples: losartan, valsartan

*compelling indication: HTN + heart failure

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13
Q

ARB/Neprilysin Inhibitor combination (ARNI) - MOA

A

*combination of valsartan (ARB) + sacubitril (neprilysin inhibitor)
*aka Entresto
*sacubitril prevents the degradation of bradykinin, ANP, BNP → decreased sympathetic nervous system outflow, decreased vasoconstriction (DRAMATIC AFTERLOAD + BP REDUCTION), decreased release of aldosterone, increased diuresis & natriuresis

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14
Q

ARB/Neprilysin Inhibitor combination (ARNI) - ADEs

A

*hypotension
*hyperkalemia
*acute kidney injury
*angioedema

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15
Q

guide to using anti-RAAS agents in patients with HFrEF

A

*select ONE agent from: ACEi, ARB, or ARNI
*if pt is hypertensive, probably use ARNI; if lower BP, probably use ACEi or ARB
*monitor BP, MAP, SCr, K+

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16
Q

if a patient develops ACEi-induced angioedema, can you use an ARNI? can you use an ARB?

A

*ARNI: NO (risk of cross-reactivity)

*ARB: probably safe

17
Q

diuretics - urine output comparison

A

loop diuretics > thiazides > acetazolamide

*loop diuretics produce the largest increase in urine output

18
Q

use of diuretics in HFrEF

A

*not proven to improve survival
*however, still an important component of management due to reduction of symptoms when they have volume overload

19
Q

classes of diuretics used in HFrEF

A

*loop diuretics
*thiazide diuretics
*aldosterone antagonists

20
Q

acetazolamide - drug class, MOA

A

*carbonic anhydrase inhibitor
*MOA: inhibits resorption of HCO3- by tubular cells (increased HCO3- in tubular lumen → loss of HCO3-, loss of increased sodium)

21
Q

acetazolamide - ADEs

A

*hyponatremia (low sodium)
*hypokalemia (low potassium)
*hyperuricemia
*metabolic acidosis

22
Q

thiazide diuretics for HFrEF

A

*METOLAZONE is the most potent

*hydrochlorothiazide (HCTZ), chlorthalidone, and chlorothiazide are approved for use in HFrEF too

23
Q

aldosterone antagonists - MOA in HFrEF

A

*block the effects of aldosterone in the body
1. prevent progression of atherosclerosis, LV stiffening, progression of heart failure
*shown to IMPROVE SURVIVAL in HFrEF patients

24
Q

aldosterone antagonists - uses in HFrEF

A

*class III-IV, stage C-D
*aka mineralocorticoid receptor antagonists (MRAs)

25
Q

ivabradine - MOA & ADEs

A

*selectively inhibits “funny” sodium channels (If) → prolongs slow depolarization (phase IV) → decreases HR

*ADEs: bradycardia, visual disturbances

26
Q

digoxin - MOA

A

*direct inhibition of Na+/K+ ATPase → indirect inhibition of Na/Ca2+ exchanger
*stimulates vagus nerve → decreased HR
*increases calcium concentration → INCREASES LEFT AND RIGHT VENTRICULAR CONTRACTILITY (MARGINALLY)

27
Q

digoxin - ADEs

A

*N/V/D
*mental status changes
*confusion
*bradycardia
*visual disturbances - YELLOW VISION
*brady- or tachyarrhythmias

28
Q

digoxin - metabolism

A

*cleared by the KIDNEYS (do NOT use in patients with renal dysfunction)

29
Q

SGLT-2 inhibitors - examples

A

*dapagliflozin
*empaglifozin
*canagliflozin

30
Q

SGLT-2 inhibitors - MOA

A

*inhibit the sodium-glucose co-transporter-2, located in the proximal convoluted tubule
*leads to reduced glucose reabsorption
*may work as an indirect diuretic

31
Q

SGLT-2 inhibitors - ADEs

A

*hypoglycemia
*hypovolemia
*hypotension
*UTIs
*yeast infections

32
Q

HFrEF meds if patient can’t tolerate ACEI/ARB/ARNI

A

*hydralazine + nitrates

-hydralazine = arterial vasodilator (decreases afterload/BP)
-nitrates = venous dilators (decrease preload & relax blood vessels)

33
Q

HFrEF med combination shown to be beneficial in African American patients, stacked on top of background HF therapy

A

*hydralazine + nitrates [in addition to background HF patients]

-hydralazine = arterial vasodilator (decreases afterload/BP)
-nitrates = venous dilators (decrease preload & relax blood vessels)

34
Q

treatment strategy for treating HFrEF - sequentially

A

1st: anti-RAAS agent
2nd: add beta blocker if/when needed
3rd: add aldosterone antagonist if/when needed
4th: add SGLT2 inhibitor if/when needed

*deliver maximally tolerated dose
*initiate, titrate, discontinue based on symptoms/comorbidities

35
Q

advanced HF strategies: parental inotrope therapy

A

*dobutamine (beta1 receptor agonist → increases contractility, cardiac output, HR, decreases SVR)
*milrinone (PDE inhibitor, selective in cardiac and vascular beds → increases cardiac output & HR, decreases SVR)

36
Q

drugs to AVOID in HFrEF

A

*NSAIDs
*COX-2 inhibitors (celebrex)
*corticosteroids
*most antiarrhythmics [safer = dofetilide & amiodarone]
*most calcium channel blockers [safer = amlodipine & felodipine]

37
Q

medications used for HFpEF

A

*SGLT2 inhibitors are the only one demonstrated to be beneficial in HFpEF
*diuretics, aldosterone antagonists, anti-RAAS agents, beta blockers?

Cardiology Exam (52 decks)

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