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Cardio > CHF Pharm > Flashcards

CHF Pharm Flashcards

1
Q

Difference between treating HFpEF vs HFrEF

A

Different functional deficiencies of the heart. HFrEF is due to a systolic dysfunction, therefore we can improve the condition by reducing preload and afterload

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2
Q

What is the suffix for ACEi drugs?

A
  • pril

* Captopril, Enalapril, Benzapril, Lisinopril

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3
Q

What is the suffux for ARBs (angiotensin receptor blockers)?

A
  • sartan

* Losartan, Valsartan, Candesartan

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4
Q

Which B-blockers are used to treat heart failure?

A
  • Carvedilol***
  • Metoprolol
  • Bisoprolol
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5
Q

What aspects of HF do ACEi and ARB’s help with?

A

Decreased action of angiotensin II

  • decreased vasoconstriction (decreasing afterload)
  • decreased aldosterone secretion (decreasing preload)
  • decreased cell proliferation and remodeling (vascular stenosis)
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6
Q

Clinical indications for ACEi

*Captopril, Enalapril, Benzapril, Lisinopril

A

HTN, HFrEF, diabetic neuropathy

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7
Q

Classic toxicities associated with ACEi

*Captopril, Enalapril, Benzapril, Lisinopril

A
  • Cough
  • Angioedema
  • Fetal toxicity (teratogenic)
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8
Q

Which ACEi are most commonly prescribed today?

A

Lisinopril, Benazepril

*longer half-life permits 1x/day dosing

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9
Q

ACEi MOA

*Captopril, Enalapril, Benzapril, Lisinopril

A

Competitively binds ACE, preventing the conversion of angiotensin I to angiotensin II

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10
Q

Clinical indications for ARB’s

*Losartan, Valsartan, Candesartan

A

HF if intolerant to ACEi

HTN

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11
Q

Classic toxicities associated with ARB’s

*Losartan, Valsartan, Candesartan

A
  • Cough (not as bad as ACEi)
  • Fetal toxicity (teratogenic)

*angioedema is feared but should not happen

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12
Q

ARB MOA

*Losartan, Valsartan, Candesartan

A

Non-peptide angiotensin II receptor antagonist (AT1)

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13
Q

Which ARB is metabolized to its active form in the liver by CYP enzymes?

*Losartan, Valsartan, Candesartan

A

Losartan

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14
Q

Which ARB is notable for not being a prodrug, therefore it does not need to be metabolized to its active form in the liver?

*Losartan, Valsartan, Candesartan

A

Valsartan

*may be useful in pt intolerant to ACEi who also has liver failure

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15
Q

Which ARB is noteworthy because it is able to irreversibly bind?

*Losartan, Valsartan, Candesartan

A

Candesartan

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16
Q

ACEi and ARB contraindications

A
  • Not tolerated
  • Pregnant (teratogenic)
  • Hypotensive
  • Creatinine .3 mg/dL
  • Hyperkalemia (okay up to 5.5)
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17
Q

Sacubitril MOA

*valsartan/sacubitril

A

Inhibits NEP (enteropeptidase that breaks down BNP and ANP)

  • leads to increased levels of ANP and BNP, which act as a check on RAAS, leading to decreases in all of renin, aldosterone, ADH
  • Considered best initial treatment for HFrEF… but $$$
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18
Q

Which B-blockers can be used in HF?

A

Carvedilol***
Bisoprolol
Metoprolol

*should be given to all HF patients with LVEF <40% unless contraindicated

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19
Q

Clinical indications for Carvedilol

A
  • HFrEF to prevent symptomatic HF
  • rEF after MI or ACS

*Pt must be stable! Don’t want to slow down their heart if they already are not stable. Start with low dose.

20
Q

Carvedilol MOA

A

Non-selective B>a blocker with no sympathomimetic activity

  • Lowers HR
  • keeps heart responsive to sympathetic drive
21
Q

Carvedilol contraindications

A
  • Bronchospastic disease (due to B2 block)
  • Symptomatic bradycardia

WARNING: do not abruptly stop B-blockers, can lead to acute tachycardia, HTN, ischemia

22
Q

Ivabradine MOA

A

Specific inhibition of Funny Na channels in the SA node

  • prolongs diastole and slows HR
  • called hyperpolarization-activated cyclic neucleotide gated (HCN) Funny channels
23
Q

Ivabradine clinical applications

funny channel blocker

A

Treat HR >70 bpm in pt with stable, sinus rhythm, symptomatic HF with LVEF <35% who are on max B-blocker dose or intolerant to B-blockers

24
Q

Ivabradine contraindicatoins

funny channel blocker

A

-ADHF, hypotension, bradycardia, heart block, arrhythmia

25
Q

Spironolactone, Eplerenone MOA

A

Competitive antagonist of aldosterone receptors
*Eplerenone is more selective to aldosterone receptor

  • K sparing diuretic (aldosterone inhibition)
  • Antagonizes pro-fibrotic effects of aldosterone on local vasculature
26
Q

Spironolactone clinical applications

A
  • Reduce fibrosis HFrEF and post-MI HF

- Counteracts K loss induced by other diuretics in treatment of HTN, HF

27
Q

How do diuretics help with HF?

A

Decrease edema (congestion)

28
Q

Loop diuretic MOA

Furosemide, Toresemide, Bumetanide
Ethactynic acid

A

Block Na K 2Cl cotransporter in the TAL

  • Prevents reabsorption of Na, K, Cl
  • Prevents paracellular reabsorption of Ca and Mg
29
Q

Clinical applications of loop diuretics

Furosemide, Toresemide, Bumetanide
Ethactynic acid

A
  • Edema
  • HF (decreases preload)
  • HTN

*also works in pt with low GFR (unlike thiazides)

30
Q

What toxicities are associated with loop diuretics (furosemide)?

A

Hypokalemia, Hyponatremia, Hypochloremia (inhibition of NKCC cotransporter)

  • also hypomagnesemia and hypocalcemia
  • hyperglycemia and hyperuricemia
  • **Ototoxicity
  • **Sulfonamide! allergy risk
31
Q

Which loop diuretic is not a sulfonamide, and can therefore be used in patients with sulfa allergies?

A

Ethacrynic acid

32
Q

Diuretic use in HF (1st line, 2nd line, 3rd line)

A
  1. Loop diuretic
  2. add K sparing diuretic if needed (hypokalemia)
  3. add thiazide if more diuresis needed
33
Q

Thiazide diuretic MOA

*Hydrochlorothiazide, Chlorothiazide, Chlorthlidone, Metolazone

A

Inhibits Na reabsorption via blocking Na/Cl cotransporter in the DCT

*K-losing diuretic

34
Q

Clinical applications of thiazide diuretics

*Hydrochlorothiazide, Chlorothiazide, Chlorthlidone, Metolazone

A
  • HTN
  • Ca nephrolithiasis
  • Adjunct tx in HF

*not effective in pt with low GFR

35
Q

What toxicities are associated with thiazide diuretics?

*Hydrochlorothiazide, Chlorothiazide, Chlorthlidone, Metolazone

A
  • Hypokalemia, Hyponatremia, Hypomagnesemia, Hypocholoremia

* Sulfonamide!!!

36
Q

What thiazide diuretic is long acting, and commonly used as an adjunct diuretic in heart failure?

A

Metolazone

37
Q

Nitrate drug MOA

*Nitroglycerin, Isosorbide dinitrate

A

MOA: forms NO, more prominently causes venodilation

38
Q

Clinical application for nitrate drugs

A
  • Angina pectoris

- Acute decompensated HF (ADHF)

39
Q

Which nitrate drug is administered orally and has a slower onset of action, and may specifically be used for HFrEF

A

Isosorbide dinitrate

40
Q

What drug causes direct vasodilation of arterioles and is specifically indicated for African Americans with HFrEF?

A

Hydralazine

  • hydralazine/isosorbide nitrate combo drug
  • can also treat HTN

*may cause drug induced lupus-like synd

41
Q

How do vasodilators help in the treatment of HFrEF?

A

Reduced afterload (decreased work needed to be done by heart)

42
Q

Digoxin MOA

A

inhibition of Na/K ATPase in myocardial cells, indirectly stimulating Na/Ca exchanger, leading to increased Ca within the myocardial cell

  • increased Ca = increased contractility
  • suppresses AV conduction via increased vagal tone, slowing HR
43
Q

Clinical application of Digoxin

A

Not commonly used any longer

  • Controls Afib
  • HF
  • can only be administered if HR is normal
44
Q

What happens in digoxin toxicity?

A

Ca overload can cause arrhythmias

45
Q

Major Digoxin drug interaction

A

Diuretics

  • digoxin competes with K at the Na/K ATPase
  • diuretics cause hypokalemia
  • hypokalemia increases digoxin binding, increasing likelihood of toxicity
46
Q

Sympathomimetics used to treat acute decompensated HF in the ER (rescue therapy)

*indicated if symptomatic hypotension with end-organ dysfunction despite adequate filling pressures

A

Dobutamine, Dopamine

47
Q

Milrinone MOA

A

PDE3 inhibitor, increases cAMP and therefore contractility

*used as inotropic therapy in pt unresponsive to dobutamine or dopamine

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