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Humber Cardio FINAL > Chronic Heart Failure > Flashcards

Chronic Heart Failure Flashcards

1
Q

Signs and Sx’s are 2ndary to a lack of forward blood flow

For each, state what happens in each body system

  1. Backward failure (Back up of blood from the heart)
    -Pulmonary
    -heart
    -Hepatic
    -Abdomen
    -Feet
  2. Forward Failure (LACK of blood delivery from the heart)
    -Brain
    -Heart
    -liver
    -Kidney
    -SKin
A
  1. -Back up of blood to the pulm vasculature
    -incr volume of blood in ventricles (INCR PRELOAD)
    -Backup of fluid to hepatic vein
    -Back up of fluid to abdomen
    -back up of fluid in feet
  2. Decr perfusion to brain
    - decr coronary blood flow
    -decr perfusion to liver
    -decr perfusion to kidneys
    -Decr perfusion to SKIN
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2
Q

What are the sx’s of backward failure?
(Lungs, abdomen, feet)

What are sx’s of forward failure?
(brain, heart, kidneys, skin)

A
  1. Dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea
    -Abdom swelling , cramps, weight gain
    -Swelling in feet and ankles
  2. Fatigue or confusion
    -irreg heart beats, exercise intolerance
    -decr urine output
    -Cold skin
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3
Q

Signs of backward failure

-Lung specific? (3)
-Heart specific? (3)
-Hepatic? (2)
-Legs?

What’s the value of the elevated jugular venous pressure or JVP?

In HF, what might the BNP and NTproBNP values be?

Signs of FORWARD failure
-Heart specific ?
-Liver specific?
-Kidney speciifc?

A
  1. rales, crackles, pleural effusion
  2. Elevated BNP, NTproBNP, S3 heart sound
  3. Elevated INR, Hepatojug reflex
  4. Pitting edema

-JVP >= 5 cm H20

BNP > 100-400 pg/mL
NTproBNP > 900 pg/mL

  1. Tachycardia, arrhythmia
  2. Elevated AST and ALT
  3. Elevated creatinine
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4
Q
  1. If pt has HFrEF, whats the EF?
    -what kind of dysnfunction ?
  2. If pt has HFmrEF whats EF?
    -Kind of dysfunction ?
  3. If pt has HFpEF whats EF?
    -What kinda dysfunction?
  4. If pt has HFimpEF whats EF?
A
  1. EF<= 40%
    -systolic. Cant pump out well
  2. Midrange EF 41-49%
    -Either or both dysfunction
  3. EF >= 50%
    -Diastolic , cant fill well
  4. Previously <=40%, but now improved to > 40%
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5
Q

NYHA Classification System

Class 1
2
3
4

A
  1. Asx’s
  2. Syptomatic with physical activity (exercise)
  3. Sx’s with ordinary activities (doing dishes, folding clothes)
  4. Sx at rest
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6
Q

AHA/ACC Stages of HF

Stage A
Stage B
Stage C
Stage D

A

a. at risk for HF (pt’s without sx’s or structural hd)

b. Pre-HF
-Pts without current or prev sx’s but have structural HD or elevated filling pressures in LV

c. Symptomatic HF
-pt’s with current or previous sx’s/signs of HF

d. Advanced HF
-pt’s with sx’s and recurrent hospitalizations despite optimal med therapy

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7
Q

What to ask when interviewing pt with Heart Failure :

  1. S
  2. Difficulty ___
  3. Wake from ___
  4. Can you ___
  5. ___ in feet or ankles
  6. Home ____
  7. Home ___ trends
  8. Missed ___
A
  1. SOB
  2. laying down flat
  3. sleep, gasping for air
  4. Can you climb a flight of stairs?
  5. Swelling
  6. weight trends
  7. BP and HR
  8. Missed doses of meds
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8
Q

Non Pharm TX and Home monitoring

  1. What are some interventions? (6)
  2. What should pt’s avoid? (4)
A
  1. exercise
    -immunizations
    -salt ~2gm/day
    -Fluids <2L/day
    -Weigh daily (call clinic if u gain more than 2 pounds in 1day or > 5 pounds in 1 week)
    -Daily BP and HR
  2. Nsaids, tobacco, execessive alc, NON DHP CCBS
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9
Q

ACEi’s for HfrEF :
1. They reduce ___ and ___
2. AceI Dosing ? For enalapril or Lisiniprol?
3. How often do u titrate?
4. Whats the target dose?
5. AE’s? (5)
6. CI’s? (2)
7. What should u check in 2 weeks after starting or incr dose?

A
  1. mortality and hf hospitalizations
  2. Enalapril (vasotec) is 2.5 mg BID
    Lisinopril : 2.5-5 mg daily
  3. double dose every 2 weeks until target dose
  4. enal 10-20 mg BID
    Lisinopril : 20-40 mg DAILY
  5. Hyperkalemia, cough, angioedema, AKI, Sx’s of hypotension
  6. Preg, hx of angioedema
  7. serum potassium and creatinine
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10
Q

ARB for HFrEF :
1. Reduces __ and __
2. Dosing ? Losartan ? For rest see chart *
3.Titrate by ? Whats losartan target dose ?
4. ARB AE’s (4) ?
5. ARB CI? (2)

Check serum creatinine and potassium 2 weeks after starting or incr dose

A
  1. mortality and HF hospitalizations
  2. 25-50 mg daily
  3. double dose evry 2 weeks
    - 50-150 mg daily
  4. Hyperkalemia
    angioedema
    aki
    sx’s of hypotension
  5. preg and history of angioedema with an ARB, but can still use if only hx of angioedema with ACEI
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11
Q

ARNI : Entresto (Sacubitril/Valsartan) for HFrEF

  1. What can it reduce?
  2. Initial Dose?
    -titrate by doubling dose every 2 weeks
  3. target Dose?
A
  1. Reduces HF hospitalizations better than ACEI or ARB, Reduces mortality BETTER than ACEI or ARB
  2. 24/26 mg BID
  3. 97/103 mg BID
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12
Q

ARNI : Transition from LOW DOSE ACEI or ARB

1) if on low dose ACEI, how do u switch?
2) If on Low dose ARB or no ACEI/ARB, how do u switch?

3) Whats a low dose ACEI?
4) Low dose ARB?

A
  1. wait 36 hrs then switch to 24/26 mg BID
  2. Switch immed to 24/26 mg BID
  3. Total daily dose of <= 10 mg enalapril equivs (lisinopril <=10 mg, ramipril <= 5 mg)
  4. Total daily dose <=160 mg valsartan equivs (Losartan <= 50 mg, candesartan <=16 mg)
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13
Q

ARNI transition from HIGH DOSE ACEI OR ARB

1) If high dose ACEI?
2) If high dose ARB?
3) WHats high dose ACEI?
4) High dose ARB?

5) the 36 hr wait reduces risk for?

A
  1. wait 36 hrs , then 49/51 mg BID
  2. SWITCH IMMED 49/51 mg BID
  3. Total daily dose of >10 mg enal, lisino > 10, ramipril > 5 mg
  4. Total daily dose > 160 mg valsart, Losartan > 50 mg, candesartan > 16 mg
  5. ANGIOEDEMA. If u dont stop ACEI and add on entresto right away u have a build up of bradykinin
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14
Q

ARNI AE’s? (4)
CI? (2)
Check serum creatinine and potassium ~2weeks!!

A

Hyperkalemia, ANGIOEDEMA, AKI, Hypotension

Preg, hx of angioedema w/ either ACEI or ARB

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15
Q

MRA : HfrEF Dosing
1) Reduces ? (2)
2) Whats the starting eplerenone dose ? Spironolactone?
-titrate by doubling dose q2weeks
3) Whats the target dose?

A
  1. HF hospitalizations, mortality
  2. 25 mg daily
    -25 mg daily if egfr > 50, 12.5 mg daily if egfr 30-50***
  3. Eplerenone 50 mg daily
    Spirono 25-50 mg daily
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16
Q

MRA : monitoring

  1. AE’s (5)
  2. CI? 4 for spirono, 2 for eplerenone
  3. DDI’s for eplerenone only ?
A
  1. Hyperkalemia
    hyponatremia
    Gynecomastia (more with spiro)
    Dysmenorrhea (more with spiro)
    Dehydration (Mild diuretic effect)
  2. Spiro : preg,
    egfr < 30,
    Scr>2.5 men, and 2 for women ,
    potassium > 5 meq/L

Epler : ClCR < 30 mL,min
-Potassium > 5.5 meq/L

  1. Strong CYP 3A4 inhibs and inducers
17
Q

Beta Blockers : HFrEF
1. Reduces? (2)
2. Initial Dose for Carvedilol and Metoprolol Succinate?
Target Dose?
3. Monitoring for AE’s (5)
4. CI? (2)

A
  1. HF hospitalizations, mortality
  2. Carved : 3.125 mg BID
    Target : 25-50 mg BID
    Metoprolol : 12.5-25 mg daily
    target : 200 mg daily
  3. -Bradycardia
    -Fatigue/drowsiness
    -can worsen congestive sx’s if NOT euvolemic (ONLY START OR TITRATE UP if EUVOLEMIC)
    -sx’s of hypotension
    -beta blocker withdrawal
  4. Acute decomp HF !!
    -Active airway disease (asthma copd)
18
Q

SGLT2I : HFrEF
1) Reduces ___and ___
2) Dosing Dapa, Empag, Sota
3) AE’s (3)
4) CI’s:
For ALL? (1)
For DAPA?

-NO RENAL LIMITS with empag or sota

A
  1. hf hospitalizations, mortality
  2. Dapa 10 mg po daily
    Empag 10 mg po daily
    Sota 200 mg po daily (titrate to 400 mg daily in 2 weeks)
  3. genitourinary tract infections
    -euglycemic ketoacidosis
    -dehydration
  4. Recurrent UTI’s
    DAPA :
    Dont start if eGFR < 25 , ok to continue if on therapy and eGFR decreases to < 25
19
Q

What 4 meds are considered guideline directed medical therapy (GDMT) ?

make the effort to titrate up all 4 med classes, but how many changes should u make at a time?

A
  1. Beta blocks
    ACEI/ARB/ARNI
    MRA
    SGLT2I
  2. only 1-2 changes at a time
20
Q

What do loop Diuretics do for HFrEF :
1) treat sx’s of ?
2) DONT PROVIDE!!!!!
3) Initial Dosing for Lasix, Torsemide, Bumetanide, Ethacrynic acid
4) What should be monitored? (3)

Dose Titration

1) If they arent producing goal urine output and they’re not losing enough weight, how should the dose be titrated?

A
  1. congestion
  2. Mortality benefit
  3. lasix : 20-40 mg po daily
    Tors : 10-20 mg PO daily
    Bumex : 0.5-1 mg po daily
    Etha : 25-50 mg PO daily
  4. Weight loss, resolution of congestive sx’s, urine output

The dose should be DOUBLED until goal is met, THEN U CAN CONSIDER incr freq of dosing

21
Q

LOOP Diuretics : Monitoring

1) AE’s ?
Hypo (4)
D
A
M
O

2) CI? (1)

A
  1. Hypo kalemia, natremia, magnesemia, chloremia
    -Dehydration
    -AKI
    -Metab alkalosis
    -ototoxicity
  2. sulfa allergy (Ok to use ethacrynic acid)
22
Q

Describe the stepwise approach to overcoming loop diuretic resistance :

1) WHats the PO conversion of 40 mg furosemide into torsemide, bumex, and ethacrynic acid ?

2) IV conversion from 20 mg furosemide to tors, to bumex, to etha?

A

If taking Furosemide, SWITCH IT TO ANOTHER

–> then, add Thiazide Diuretic –> COnsider IV admin

40 mg lasix = 20 mg tors = 1 mg bumex = 50 mg ethacyrnic acid

20 mg furo = 20 mg tors = 1 mg bumex = 50 mg etha

23
Q

Thiazide Diuretics : HFrEF
1. Treat sx’s of ___ but do not provide __
2. Dosing for Metolazone and Chlorothiazide
3. Give thiazide diuretics with __ for sequential nephron blockade
4. Thiazides AE’s? (6)
5. When should you consider giving Thiazides?

A
  1. congestion, mortality benefit
  2. Metol : 2.5-10 mg PO daily or in divided doses, admin 30 min before loop

Chlor: 250-1000 mg IV DAIlLY or BID, admin 30 min before Loop

  1. Loops diuretics
  2. Hypokalemia (LOTS)
    -HYPOnatremia, magnesemia , chloremia, dehydration and AKI
  3. If pt is volume overloaded on :
    -80 mg lasix PO daily/BID
    -4mg Bumex PO Daily/BID
    -80 mg Torsemide PO daily/BID
24
Q

Hydralazine/Isosorbide Dinitrate : HFrEF

in pt’s who are :
intolerant to ACEI/ARNI/ARB or
Black and on max backbone drugs, or
Sx HFrEF EF <= 40%

  1. it reduces ___ AND reduces ___
  2. Whats the initial dose? dont need to know
    -Titrate by doubling dose q2weeks until target dose
  3. Whats the target dose?
    -Can be given as ___ or __
A
  1. hf hospitalizations, mortality
  2. 25/20 mg PO TID

3.100/40 mg PO TID

Separate pills, as combo pill

25
Q

Hydralazine/Isosorbide Dinitrate

1) AE’s for Hydral (3)
2) Ae’s for Isos
3) DDI’s for Isosorbide Dinitrate

A
  1. Sx’s of hypotension
    -reflex tachycardia
    -Drug induced LUPUS at doses > 300 mg daily
  2. Headache (very common)
  3. PDE5I’s (tadal, silden)
26
Q

Ivabradine
1. Reduces ___ but DOES NOT ___

  1. What patients can u use it in? (4)
  2. Starting Dose?
A
  1. HF hospitalizations, reduce mortality
  2. Sx HFrEF with EF <=35%
    -max tolerated Beta Blocker
    -Normal Sinus rhythm (not in afib)
    -Resting HR >= 70 bpm
  3. 5 mg BID
27
Q

Ivabradine
1) AE’s (4) (BAAP)
2) CI’s? (4) (PASA)
3) DDI’s

A
  1. Bradycardia, av block , afib, phosphene (see light without light entering eye)
  2. Preg, acute decomp HF, sick sinus syndrome, 2nd-3rd degree AV block
  3. Strong CYP 3A4 inhibs/inducers
28
Q

Vericiguat : HFrEF
1) Reduces ___ does not ___
2) Which pt’s can u use it in? (3)
3) Initial dose?

5) AE’s (2)
6) CI?
7) DDI?s

A
  1. Hf hospitalizations
    -NO MORTALITY REDUCTION
  2. Sx HFrEF with EF < 45% ,
    -max optimized backbone
    -Recent hospitalization for HF or clinic visit requiring IV diuretics
  3. 2.5 mg PO daily
  4. Sx’s of hypotension, anemia
  5. Pregnancy
  6. PDE5 inhibs
29
Q

Digoxin : HFrEF
1. Will it reduce mortality ?
2. How do you choose a dose?
3. Whats the goal steady state level in HF?
4. After initiation, obtain level at steady state (3-5 half lives ~7 days) and at least how long after a given dose?
-ADjust dose using

  1. AE’s? (5)
  2. CI? (4)
  3. DDI’s ?

PK : First order kinetics
-Terminal Half life 36-48 hrs
-Half life 3.5-5 days in CKD*

A
  1. No
  2. Use Ideal body weight , and eCrCL
  3. 0.5-0.9 ng/mL
  4. at least 6-8 hrs
    -1st order kinetics
  5. N/V, Color perception changes, Bradycardia, Hyperkalemia, Alt ment status
  6. Ventric fibrillation, sick sinus syndrome, 2nd or 3rd degree AV block, avoid in worsening renal function
  7. PGP inducers (rifampin, carbam, phenytoin)
    -PGP inhibs (amio, verap)

Humber Cardio FINAL (13 decks)

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