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NAPLEX Review > Chronic Heart Failure (CHF) > Flashcards

Chronic Heart Failure (CHF) Flashcards

1
Q

Most common causes of heart failure

A

long-standing HTN or MI

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2
Q

What ejection fraction (EF) indicates systolic dysfunction or HFrEF

A

<40%

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3
Q

What ejection fraction is associated with normal heart function?

A

55-70%

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4
Q

What ejection fraction is associated with HF with preserved EF (HFpEF) or diastolic dysfunction

A

50-54%

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5
Q

What ejection fraction is associated with heart failure with mid-range EF (HFmrEF)

A

40-49%

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6
Q

Which ACC/AHA HF stages and NYHA functional class indicate HF?

A 
ACC/AHA stages C and D
NYHA class I (symptomatic)-IV
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7
Q

ACC/AHA stages A, B, C, D

A

A - High risk for developing HF, no structural disease or symptoms
B - Structural heart disease with NO s/sx of HF
C - Structural heart disease WITH symptoms of HF
D - Advanced structural heart disease with symptoms of HF at REST

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8
Q

NYHA functional classes I-IV

A

I - no limitations; physical activity does not cause s/sx of HF
II - Slight limitation of physical activity; s/sx with ordinary physical activity
III - Marked limitation of physical activity; minimal exertion causes s/sx
IV - Unable to carry on physical activity; sx at rest

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9
Q

What lab values indicate HF?

A 
Increased BNP (normal <100)
Increased NT-proBNP (normal <300)
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10
Q

How do you calculate Cardiac output?

A

CO = HR x SV

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11
Q

How do you calculate cardiac index?

A

CI = CO/BSA

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12
Q

What are the main pathways activated to compensate for HF?

A

Renin-angiotensin-aldosterone system (RAAS), the sympathetic nervous system (SNS), and vasopressin

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13
Q

If a patient has heart failure when should they notify their doctor of weight changes?

A

Increase by 2-4 pounds in one day
Increase by 3-5 pounds in one week
If symptoms worsen

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14
Q

For someone with HF how much should they restrict sodium and water intake?

A

Sodium <1,500 mg/d

Fluid <1.5-2 L/d in stage D

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15
Q

What natural products are used for HF?

A

Omega-3 - decrease mortality and CV hospitalization

Hawthorne and coenzyme Q10 - may improve HF symptoms

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16
Q

What drugs can cause or worsen HF?

A 
Drug Information NATION
DPP4 inhibitors (alo and saxagliptin)
Immunosuppressants
Nondihydropyridine CCBs
Antiarrhythmics
Thiazolidinediones
Itraconazole
Oncology drugs
NSAIDs (except celecoxib)
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17
Q

For drugs that cause or worsen HF what effects do they have?

A

Fluid retention/edema
Increased BP
Negative inotropic effects

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18
Q

What medications are used in HF?

A 
BB
ACEi/ARBs
Loop diuretics
Aldosterone receptor antagonists (ARAs)
Digoxin
Sacubitril
SGLT2 inhibitors
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19
Q

What medications decrease mortality in patients with HF

A

ACEi/ARBs
ARNI
BB
Aldosterone receptor antagonists (ARAs)

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20
Q

What medications decrease mortality in patients with HF

A

Hydralazine and nitrates

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21
Q

What SGLT2 inhibitors are used for HF?

A

Dapagliflozin

Empagliflozin

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22
Q

What loop diuretics are used for HF?

A

Furosemide
Bumetanide
Torsemide
Ethacrynic acid

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23
Q

Which BB are used in HF? Which are selective?

A

Bisoprolol - selective
Metoprolol succinate - selective
Carvedilol - non-selective (alpha 1 and BB)

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24
Q

Loop diuretic MOA

A

block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle; incresae excretion of Na, K, Cl, Mg, Ca, and water

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25
Q

Loop diuretic BBW, CI, Warnings, SE

A

BBW: fluid and electrolyte depletion
CI: Anuria
Warnings: Sulfa allergy (not ethacrynic acid)
SE: decrease K, Mg, Na, Cl, Ca; increase HCO3, UA, GB, TG, total cholesterol; orthostatic hypotension, photosensitivity

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26
Q

Which loop diuretic can be used in sulfa allergy?

A

Ethacrynic acid

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27
Q

Loop vs thiazide effect on electrolytes

A

Loops decrease Ca

Thiazide increase Ca

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28
Q

Which loop diuretic can cause ototoxicity

A

all but more with ethacrynic acid or IV administration

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29
Q

Loop diuretic IV/PO conversion

A

PO: Furosemide 40 = torsemide 20 = bumetanide 1mg = ethacrynic acid 50mg
IV: Same but furosemide is 20

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30
Q

ACEi MOA

A

block the conversion of angiotensin I and ang II decreasing vasoconstriction and aldosterone secretions

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31
Q

ARB MOA

A

Block ang II from binding angiotensin II type-a (AT1) receptor

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32
Q

ACEi BBW, CI, Warnings

A

BBW: injury and death to developing fetus when used in 2nd and 3rd trimester
CI: Do not use with hx of angioedema; do not use within 36 hours of Entresto
Warnings: Angioedema, low K and BP, renal impairment, bilateral renal artery stenosis

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33
Q

Which ACEi are used in HF

A 
Captopril
Enalopril
Fosinopril
Lisniopril
Perindopril
Quinapril
Ramipril
Trandolapril
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34
Q

Which ARBs are used in HF

A

Candasartan
Losartan
Valsartan

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35
Q

ARB BBW, CI, warnings, SE

A

Same as ACEi except
Less cough
Less angioedema
No washout period required with Entresto

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36
Q

What medications make up Entresto? What classes are they from?

A

Sacubitril/Valsartan

ARB and nephrilysin inhibitor

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37
Q

Entresto MOA

A

Sacubitril - inhibits the enzyme that degrades vasodilatory peptides
ARB: Block ang II from binding angiotensin II type-a (AT1) receptor

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38
Q

Entresto BBW, CI, warnings, SE

A

BBW: injury/death to fetus when used in 2nd and 3rd trimesters
CI: Do not use <36 hours of ACEi, hx of angioedema
Warnings: angioedema, hyperkalemia, low BP, renal impairment, bilateral renal artery stenosis
SE: cough, high K, SCr, and BP

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39
Q

Why should you not use more than one RAAS inhibitor together? What are these medications?

A

Increased risk of renal impairment, low BP, and high K

ACEi, ARB/ARNI, aliskiren

40
Q

When should you d/c BB in HF?

A

ONLY during acute decompensated HF if hypotension or hypoperfusion is present

41
Q

BB BBW, CI, SE

A

BBW: Do not d/c abruptly
CI: 2nd/3rd degree heart block, cardiogenic shock, bradycardia
Warning: caution in DM (can mask hypoglycemia), caution with bronchospastic disease, caution with Raynaud’s disease
SE: Bradycardia, fatigue, depression, impotence, cold extremities

42
Q

Metoprolol IV:PO ratio

A

IV:PO
1:2.5

43
Q

Which heart failure BB should be taken with food?

A

Carvedilol

44
Q

Furosemide max dose

A

600mg/d

45
Q

Bumetanide max dose

A

10mg/d

46
Q

Torsemide max dose

A

200mg/d

47
Q

Ethacrynic acid max dose

A

400mg/d

48
Q

Enalapril target dose

A

10-20mg PO BID

49
Q

Lisinopril target dose

A

20-40mg daily

50
Q

Quinapirl target dose

A

20mg BID

51
Q

Ramipril target dose

A

10mg daily

52
Q

Losartan target dose

A

50-150mg/d

53
Q

Valsartan target dose

A

160mg BID

54
Q

Candesartan target dose

A

32mg/d

55
Q

Entresto target dose

A

200mg BID

97/103 mg sac/val

56
Q

Metoprolol Succinate target dose

A

200mg daily

57
Q

Bisoprolol target dose

A

10mg daily

58
Q

Carvedilol target dose IR and CR

A

IR: 25-50mg daily
CR: 80mg daily

59
Q

Aldosterone receptor antagonists (ARAs) MOA

A

compete with aldosterone at receptor sites in the distal convoluted tubule and collecting ducts

60
Q

Which aldosterone receptor antagonists are non-selective and selective? Which exhibits endocrine side effects?

A

Non-selective: spironolactone
Selective: epleronone
Endocrine side effects: spironolactone

61
Q

Spironolactone target dose

A

25mg daily or BID

62
Q

Eplerenone target dose

A

50mg daily

63
Q

Aldosterone receptor antagonists CI, Warnings, SE

A

CI: Hyperkalemia, severe renal impairment, Addison’s disease (spironolactone)
Warnings: do not initiate if K>5, ErCl <30, or SCr >2 (F) or 2.5 (M)
SE: hyperkalemia, increased SCr, dizziness, gynecomastia (spironolactone) and increased TG (eplerenone)

64
Q

Hydralazine MOA

A

direct arterial vasodilator

65
Q

Nitrates MOA

A

increase availability of nitric oxide, causing veous vasodilation and decreased preload

66
Q

When are nitrates indicated

A

As an alternative to ACEi or ARB in patients that cannot tolerate ACEi or ARB

67
Q

What medications are included in BiDil

A

Hydralazine/Isosorbide Dinitrate

68
Q

BiDil target dose

A

40/75mg TID

69
Q

Hydralazine target dose

A

400mg daily in divided doses

70
Q

Isosorbide dinitrate IR/ER target dose

A

120mg daily

71
Q

Does BiDil cause nitrate tolerance?

A

No

72
Q

Hydralazine CI, warnings, and SE

A

CI: mitral valve rheumatic heart disease, CAD
Warnings: Drug-induced lupus erythematosus
SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia

73
Q

Isosorbide dinitrate CI and SE

A

CI: do not use PDE-5 inhibitors
SE: hypotension, HA, dizziness, flushing, tachyphylaxis, syncope

74
Q

Digoxin MOA

A

inhibits the Na/K ATPase pump causing a positive inotropic effect and increase in CO and negative chronotropy and decreased HR

75
Q

Does digoxin improve survival?

A

No - decreases HF related hospitalizations

76
Q

Digoxin typical daily dose

A

0.125-0.25mg daily

77
Q

Digoxin therapeutic range for HF (different for afib)

A

0.5-0.9 ng/mL

78
Q

Digoxin CI, warnings, SE

A

CI: V-fib
Warnings: heart block, Wolff-Parkinson-White syndrome, vesicant
SE: dizziness, mental disturbances, HA, N/V/D

79
Q

S/sx of digoxin toxicity

A

Initial: N/V, loss of appetite, bradycardia
Severe: blurred/double vision, greenish-yellow halos, altered color perception, abdominal pain, prolonged PR interval, arrhythmias

80
Q

Digoxin antidote

A

DigiFab

81
Q

Digoxin dose adjustment when used with amiodarone or dronedarone

A

Decrease by 50%

82
Q

What electrolyte abnormalities can increase the risk of digoxin toxicity

A

Low K and Mg

High Ca

83
Q

Ivabradine MOA

A

Disrupts the “funny” (If) current in teh sinoatrial node causing a decreased rate of firing and decreased HR

84
Q

When is Ivabradine indicated?

A 
adjunct treatment in symptomatic (NYHA class II-III) stable HF (EF<35%)
Sinus rhythm withresting HR>70
85
Q

Ivabradine CI, warnings, SE

A

CI: ADHF, SSS, hypotension or bradycardia, use with strong CYP3A4 inhibitor
Warnings: Bradycardia, increased risk of QT prolongation and ventricular arrhythmias, fetal toxicity
SE: bradycardia, HTN, AFib, luminous phenomena

86
Q

Ivabradine target dose

A

whatever dose causes resting heart rate between 50-60

87
Q

What electrolyte abnormality can aggravate hypokalemia?

A

Low magnesium

88
Q

Potassium chloride CI, warnings, SE

A

CI: severe renal impairment, hyperkalemia
Warnings: mild-mod renal impairment, use with medications that increase K
SE: abdominal pain/cramping, N/D, flatulence, high K

89
Q

Which potassium formulation can be opened and sprinkled on applesauce or pudding?

A

Micro-K, Klor-Con sprinkle

90
Q

Which ER potassium formulation should be swallowed whole; do not chew, crush, cut, or suck on tablet

A

K-Tab, Klor-Con

91
Q

Which ER potassium tablet can be cut in half or dissolved in water?

A

Klor-Con M

Do not chew, crush, or suck on the tablet

92
Q

CHF green, yellow, red meaning

A

Green - follow medication, weight and diet advice
Yellow - may need to change medications
Red - Go to doctor today; call 911

93
Q

When should a CHF patient call their doctor

A

Weight gain of 2-4 pounds in 1 day or 3-5 pounds in 1 week
Increased number of pillows to sleep
Increased swelling or coughing
SOB with activity

94
Q

When should a CHF patient see a doctor immediately or call 911?

A

Weight gain of >5 pounds in 1 week
Dizziness or falling
Waking at night due to SOB
SOB at rest, chest tightness, wheezing

Call 911 if severe chest pain

95
Q

What class of medications should be avoided in HF patients?

A

NSAIDs

Can worsen sodium and water retention

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