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Naplex 2023 > Chronic Heart Failure > Flashcards

Chronic Heart Failure Flashcards

1
Q

heart “failure”

A

heart not able to supply enough oxygen-rich blood
from impaired ventricle ability to fill or eject blood

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2
Q

causes of HF

A

MI
long-standing hypertension

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3
Q

general symptoms of HF

A

SOB/Dypsnea
cough
fatigue/weakness
reduced exercise capacity

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4
Q

lab/biomarkers of HF

A

inc BNP (norm is <100)
inc NT-proBNP (normal is <300)
shows cardiac vs non-cardiac causes of dyspnea

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5
Q

left-sided signs and symptoms

A

orthopnea: SOB lying flat
paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
bibasilar rales: crackling lung sounds heart on lung exam
S3 gallop: abnormal heart sound
hypoperfusion (renal impairment, cool extremities)

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6
Q

right-sided signs and symptoms

A

peripheral edema
ascites: abdominal fluid
jugular venous distention
hepatojugular reflux
hepatomegaly: enlarged liver from fluid congestion

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7
Q

CO

A

blood pumped by heart in 1 min
HR x SV = CO

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8
Q

stroke volume

A

volume of blood ejected from left ventricle in 1 heartbeat

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9
Q

compensatory mechanisms

A

neurohormonal pathways to inc blood volume or force/speed of contractions
leads to cardiac remodeling
RAAS
SNS
vasopressin
natriuretic peptides that balance become deficient

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10
Q

Angiotensin II

A

vasoconstrictor

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11
Q

aldosterone

A

sodium and water retention

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12
Q

vasopressin

A

vasoconstriction and water retention

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13
Q

SNS activation = NE

A

inc HR
inc contractility (positive inotrope)
vasoconstriction

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14
Q

lifestyle

A

monitor/document body weight daily
notify provider if weight inc 2-4 pounds in 1 day or 3-5 pounds in 1 week or if symptoms worsen
restrict sodium <1500 mg/day in stage A and B

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15
Q

ejection fraction

A

<=40%
HFrEF
systolic dysfunction
impaired ability to eject blood during systole

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16
Q

ACC/AHA

A

american college of cardiology and american heart association

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17
Q

NYHA

A

new york heart association

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18
Q

ACC/AHA Stage B

A

pre-HF
no signs/symptoms of HF but with structural heart disease, abnorm cardiac function, inc biomarkers

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19
Q

ACC/AHA Stage C

A

structural and/or function cardiac abnormality with prior/current symptoms

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20
Q

NYHA Class II

A

in ACC/AHA Stage C
ordinary physical activity results in HF symptoms

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21
Q

NYHA Class IV

A

in ACC/AHA Stage C or D
symptoms of HF with all physical activity or symptoms of HF at rest

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22
Q

ACC/AHA Stage D

A

advanced with severe symptoms, symptoms at rest

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23
Q

natural products

A

omega-3 fatty acids/fish oils
hawthorn and coenzyme Q10

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24
Q

Beta blockers in drug treatment

A

dec SNS = dec HR, dec contractility, negative inotrope
dec mortality

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25
Q

ACEI/ARBs/ARA in drug treatment

A

dec RAAS = dec vasoconstriction/afterload; dec fluid retnetion/preload
dec mortality

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26
Q

loop diuretics in drug treatment

A

dec fluid retention/preload
dec symptoms
no decrease in mortality

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27
Q

digoxin in drug treatment

A

inc CO
dec hospitalizations
no decrease in mortality

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28
Q

sacubitril in drug treatment

A

inc natriuretic peptides = inc vasodilation/diuresis
dec mortality

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29
Q

initial meds rec for all w/o CI

A

ARNI/ACEI/ARB: ARNI preferred bc more morbidity/mortality dec

beta-blockers
control HR/reduce arrhythmia risk

loop diuretics: reduce blood volume = dec edema/congestion

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30
Q

secondary add-on medications

A

ARA: dec morbidity/mortality; more diueresis; dec symptoms; inc EF; meed eGFR, SCr, K criteria

SGLT2i: dec morbidity/mortality; meet eGFR criteria

hydralazine and nitrates (BiDil): dec morbidity/mortality in black patients/patients who cannot tolerate ACEi/ARB

Ivabradine (Corlanor): dec hospitalization; normal sinus rhythm and HR >=70 on max BB

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31
Q

addition medications

A

digoxin: small inc CO; improve symptoms/dec hospitalization (not mortality)

vericiguat, soluble guanylate cyclase stimulator: dec hospitalzation and CV death after hospitalization / need for IV diuretics; not in guidelines

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32
Q

Entresto MOA

A

neprilysin inhibitor (sacubitril) = stops degradation of vasodilatory peptides

dec HF hospitalizations/cardiovascular death

first line

use in place of ACEI/ARB

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33
Q

Entresto BBW

A

injury and death to developing fetus

d/c as soon as pregnancy found

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34
Q

Entresto CI

A

do not use w/i 36 hrs of ACEi
do not use with angioedema history

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35
Q

Entresto warnings

A

angioedema
hyperkalemia
hypotension
renal impairment
bilateral renal artery stenosis (avoid)

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36
Q

Entresto side effects

A

cough
hyerkalemia
inc SCr
hypotension

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37
Q

Entresto monitoring

A

BP
K
renal function
s/sx of HF

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38
Q

Entresto notes

A

do not use with ACEi/ARB

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39
Q

ACEI MOA

A

block angiotensin I to II = dec vasoconstriction and aldosterone secretion

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40
Q

ARBs MOA

A

block Ang II binding to AT1 receptor

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41
Q

captopril dosing

A

TID

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42
Q

enalapril dosing

A

target dose: 10-20 mg PO BID

43
Q

lisinopril dosing

A

target dose: 20-40 mg daily

44
Q

quinapril dosing

A

target dose: 20 mg BID

45
Q

ramipril dosing

A

target dose: 10 mg daily

46
Q

losartan dosing

A

target dose: 50-150 mg daily

47
Q

valsartan dosing

A

target dose: 160 mg BID

48
Q

ACEis/ARBs BBW

A

injury/death to developing fetus; d/c as soon as pregnancy found

49
Q

ACEis/ARBs CI

A

history of angioedema
w/i 36 hrs of Entresto

50
Q

ACEIs/ARBs warnings

A

angioedema
hyperkalemia
hypotension
renal impairment
bilateral renal artery stenosis (avoid)

51
Q

ACEis/ARBs side effects

A

cough
hyperkalemia
inc SCr
hypotension

52
Q

ACEis/ARBs monitoring

A

BP
K
renal function
s/sx of HF

53
Q

differences between ARBs compared to ACEis

A

less cough
less angioedema
no washout period for Entresto

54
Q

ACEi/ARB/ARNI DI

A

hyperkalemia: other drugs that inc potassium (K-sparing diuretics; salt substitutes w/ K)

do not use more than 1 RAAs inhibitor together or triple combination bc renal impair, hypotension, hyperkalemia - ACEi +/- ARNI +/- aliskiren or ACEi + ARB/ARNI + ARA

can dec lithium clearance = toxicity

55
Q

beta blockers MOA

A

antagonize catecholamines (esp NE) effects

dec morbidity and mortality

all HF patients rec

only bisoprolol, carvedilol and metoprolol succinate (ER)

only d/c in acute decompensated HF if hypotension or hypoperfusion

metoprolol/bisoprolol: B-1 selective
carvedilol: non-selective beta blocker; A-1 blocker

56
Q

metoprolol succinate ER dosing

A

target dose: 200 mg daily

57
Q

carvedilol IR dosing

A

target dose: <=85 kg: 25 mg BID
>85 kg: 50 mg BiD

58
Q

carvedilol CR dosing

A

target dose: 80 mg daily

59
Q

BB BBW

A

do not d/c abruptly; taper over 1-2 weeks to avoid tachycardia, HTN, ischemia

60
Q

BB warnings

A

caution in diabetes - worsen hyperglycemia/hypoglycemia; mask hypoglycemia

caution w/ bronchospastic disease (asthma/COPD)

caution withRaynaud’s

61
Q

BB side effects

A

bradycardia
fatigue
hypotension
dizziness
depression
impotence
exacerbate Raynaud’s

62
Q

BB monitoring

A

HR
BP
s/sx of HF

63
Q

BB notes

A

metoprolol IV to PO is 1:2.5

Toprol XL: can cut in half; take w/immediately after meals

64
Q

carvedilol notes

A

take with food to dec rate of absorption/risk of orthostasis

65
Q

beta-blocker DI

A

enhance hpyoglycemia effects of insulin and mask symptoms of hypoglycemia - insulin and SU

caution w/ dec HR: digoxin, verapamil, diltiazem

66
Q

loop diuretics MOA

A

block sodium and Cl reabsorption in ascending LOH

inc excretion of Na, K, Cl, Mg, Ca, H2O

dec fluid volume

do not improve survival

symptom control

67
Q

loop diuretics warning

A

sulfa allergy

does not apply to ethacrynic acid

68
Q

loop diuretics side effects

A

dec electrolytes: K, Mg, Na, Cl, Ca
inc HCO3 (metabolic alkalosis), UA, BG, TG, TC
otoxicity (more with ethacrynic acid/rapid IV of any loop
orthostatic hypotension
photosensitivity

69
Q

loop diuretics monitoring

A

renal function
fluid status (in/out/weight)
BP
electrolytes
audiology testing
s/sx of HF

70
Q

loop diuretics notes

A

furosemide injection: store at room temp

oral equivalent dosing: furosemide 40 mg - torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 5- mg

furosemid IV: PO ratio is 1:2

71
Q

loop diuretics DI

A

avoid NsAIDs: inc sodium and water = counter loop diuretics

dec lithium renal clearance = toxicity

72
Q

ARAs MOAs

A

compete with aldosterone at DCT and CD

spiro: non-selective; also blocks androgen and endocrine side effects

eplerenone: selective; not endocrine side effects

dec morbidity and mortality

73
Q

spironolactone target dose

A

50 mg daily or BID

74
Q

ARA CI

A

do not use if hyperkalemia, severe renal impairment, Addison’s disease (spiro)

75
Q

ARA warnings

A

do not initiate for HF if K >5

76
Q

ARA side effects

A

hyperkalemia
inc SCr
dizziness

spiro: gynecomastia, breast tenderness, impotence

eplerenone: inc TGs

77
Q

ARA monitoring

A

BP
K
renal function
fluid status
s/sx of HF

78
Q

ARA DI

A

hyperkalemia: other drugs that inc K caution

no triple combo with ACEi + ARB/ARNI = hyperkalemia, renal insufficiency

inc lithium renal clearance = inc toxicity

79
Q

dapagliflozin dozing

A

eGFR <25: initiation not recommended

80
Q

empagliflozin

A

eGFR <30: insufficient data

81
Q

hydralazine MOA

A

direct arterial vasodilator
dec afterload

82
Q

nitrate MOA

A

inc NO = vasodilation and dec preload

83
Q

hydralazine + nitrate (BiDil) benefit

A

improve survival

alternative to those who can’t take ACEi/ARBs

indicated in black patients who are symptomatic despite optimal treatment with ARNI, BB, ARA, SGLT2s

84
Q

BiDil notes

A

no nitrate tolerance

85
Q

hydralazine warning

A

drug-induced lupus erythematosus

86
Q

hydralazine side effects

A

peripheral edema
headache
flushing
palpitations
reflex tachycardia

87
Q

isosorbide CI

A

do not use with PDE-5i

88
Q

isosorbide side effects

A

hypotension
headache
dizziness
lightheadedness
flushing
tachyphylaxis (need 10-12 hr nitrate-free interval)
syncope

89
Q

BiDil DI

A

not use PDE-5 inhibitors = hypotension

90
Q

ivabradine MOA

A

disrupts SA node = dec HR

dec hospitalization

not dec mortality

use on those in sinus rhythm with HR >=70

91
Q

Ivabradine dosing

A

target resting HR 50-60 BPM

92
Q

Ivabradine warnings

A

bradycardia = inc QTc and ventricular arrythmias

93
Q

Ivabradine side effects

A

bradycardia
hypertension
atrial fibrillation

94
Q

Digoxin MOA

A

inhibit Na-K-ATPase pump = positive inotrope inc CO
negative chronotropy (dec HR)
does not improve survival; dec hospitalizations
add to improve symptoms, exercise tolerance, QOL

95
Q

digoxin dosing

A

lower dose if renal insufficiency, smaller, older, female
typical: 0.125-0.25 mg daily
CrCl <50: dec dose/frequency
PO to IV: dec 20-25%
therapeutic range: 0.5-0.9

96
Q

Digoxin monitoring

A

electrolytes
renal function
HR

97
Q

Digoxin toxicity

A

initial: n/v, loss of appetite, bradycardia
severe: blurred/double vision, greenish-yellow halos

98
Q

Digoxin notes

A

antidote: DigiFab

99
Q

Digoxin DI

A

those that dec HR (BB, clonidine, non-DHP CCBs, amiodarone)
hypokalemia, hpyomagnesemia, hypercalcium inc risk of digoxin toxicity
substrate of P-gp; inhibitors will inc digoxin (dec dose 50% when starting amiodarone)

100
Q

Vericugat MOA

A

soluble guanylate cyclase stimulator

101
Q

vericugat CI

A

do not use with riociguat

102
Q

Vericugat side effects

A

hypotension

103
Q

potassium oral supplementation

A

KCl most common

104
Q

KCl: hard to swallow

A

Micro-K, Klor-Con Sprinkle: sprinkle of small amt applesauce/pudding

K-tab, Klor-Con: swallow whole

Klor-Con M: can cut in half of dissolved in water (stir 2 min and drink immediately)

oral packet: dissolve in water and drink immediately

oral solution: KCl 10% = 20 mEq/15 mL; mix 15 mL with 6 oz water

comes as injection

Naplex 2023 (21 decks)

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