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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
Loop diuretic BBW, CI, Warnings, SE
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
26
Which loop diuretic can be used in sulfa allergy?
Ethacrynic acid
27
Loop vs thiazide effect on electrolytes
Loops decrease Ca | Thiazide increase Ca
28
Which loop diuretic can cause ototoxicity
all but more with ethacrynic acid or IV administration
29
Loop diuretic IV/PO conversion
PO: Furosemide 40 = torsemide 20 = bumetanide 1mg = ethacrynic acid 50mg IV: Same but furosemide is 20
30
ACEi MOA
block the conversion of angiotensin I and ang II decreasing vasoconstriction and aldosterone secretions
31
ARB MOA
Block ang II from binding angiotensin II type-a (AT1) receptor
32
ACEi BBW, CI, Warnings
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
33
Which ACEi are used in HF
``` Captopril Enalopril Fosinopril Lisniopril Perindopril Quinapril Ramipril Trandolapril ```
34
Which ARBs are used in HF
Candasartan Losartan Valsartan
35
ARB BBW, CI, warnings, SE
Same as ACEi except Less cough Less angioedema No washout period required with Entresto
36
What medications make up Entresto? What classes are they from?
Sacubitril/Valsartan | ARB and nephrilysin inhibitor
37
Entresto MOA
Sacubitril - inhibits the enzyme that degrades vasodilatory peptides ARB: Block ang II from binding angiotensin II type-a (AT1) receptor
38
Entresto BBW, CI, warnings, SE
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
39
Why should you not use more than one RAAS inhibitor together? What are these medications?
Increased risk of renal impairment, low BP, and high K | ACEi, ARB/ARNI, aliskiren
40
When should you d/c BB in HF?
ONLY during acute decompensated HF if hypotension or hypoperfusion is present
41
BB BBW, CI, SE
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
Metoprolol IV:PO ratio
IV:PO 1:2.5
43
Which heart failure BB should be taken with food?
Carvedilol
44
Furosemide max dose
600mg/d
45
Bumetanide max dose
10mg/d
46
Torsemide max dose
200mg/d
47
Ethacrynic acid max dose
400mg/d
48
Enalapril target dose
10-20mg PO BID
49
Lisinopril target dose
20-40mg daily
50
Quinapirl target dose
20mg BID
51
Ramipril target dose
10mg daily
52
Losartan target dose
50-150mg/d
53
Valsartan target dose
160mg BID
54
Candesartan target dose
32mg/d
55
Entresto target dose
200mg BID | 97/103 mg sac/val
56
Metoprolol Succinate target dose
200mg daily
57
Bisoprolol target dose
10mg daily
58
Carvedilol target dose IR and CR
IR: 25-50mg daily CR: 80mg daily
59
Aldosterone receptor antagonists (ARAs) MOA
compete with aldosterone at receptor sites in the distal convoluted tubule and collecting ducts
60
Which aldosterone receptor antagonists are non-selective and selective? Which exhibits endocrine side effects?
Non-selective: spironolactone Selective: epleronone Endocrine side effects: spironolactone
61
Spironolactone target dose
25mg daily or BID
62
Eplerenone target dose
50mg daily
63
Aldosterone receptor antagonists CI, Warnings, SE
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
Hydralazine MOA
direct arterial vasodilator
65
Nitrates MOA
increase availability of nitric oxide, causing veous vasodilation and decreased preload
66
When are nitrates indicated
As an alternative to ACEi or ARB in patients that cannot tolerate ACEi or ARB
67
What medications are included in BiDil
Hydralazine/Isosorbide Dinitrate
68
BiDil target dose
40/75mg TID
69
Hydralazine target dose
400mg daily in divided doses
70
Isosorbide dinitrate IR/ER target dose
120mg daily
71
Does BiDil cause nitrate tolerance?
No
72
Hydralazine CI, warnings, and SE
CI: mitral valve rheumatic heart disease, CAD Warnings: Drug-induced lupus erythematosus SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia
73
Isosorbide dinitrate CI and SE
CI: do not use PDE-5 inhibitors SE: hypotension, HA, dizziness, flushing, tachyphylaxis, syncope
74
Digoxin MOA
inhibits the Na/K ATPase pump causing a positive inotropic effect and increase in CO and negative chronotropy and decreased HR
75
Does digoxin improve survival?
No - decreases HF related hospitalizations
76
Digoxin typical daily dose
0.125-0.25mg daily
77
Digoxin therapeutic range for HF (different for afib)
0.5-0.9 ng/mL
78
Digoxin CI, warnings, SE
CI: V-fib Warnings: heart block, Wolff-Parkinson-White syndrome, vesicant SE: dizziness, mental disturbances, HA, N/V/D
79
S/sx of digoxin toxicity
Initial: N/V, loss of appetite, bradycardia Severe: blurred/double vision, greenish-yellow halos, altered color perception, abdominal pain, prolonged PR interval, arrhythmias
80
Digoxin antidote
DigiFab
81
Digoxin dose adjustment when used with amiodarone or dronedarone
Decrease by 50%
82
What electrolyte abnormalities can increase the risk of digoxin toxicity
Low K and Mg | High Ca
83
Ivabradine MOA
Disrupts the "funny" (If) current in teh sinoatrial node causing a decreased rate of firing and decreased HR
84
When is Ivabradine indicated?
``` adjunct treatment in symptomatic (NYHA class II-III) stable HF (EF<35%) Sinus rhythm withresting HR>70 ```
85
Ivabradine CI, warnings, SE
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
Ivabradine target dose
whatever dose causes resting heart rate between 50-60
87
What electrolyte abnormality can aggravate hypokalemia?
Low magnesium
88
Potassium chloride CI, warnings, SE
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
Which potassium formulation can be opened and sprinkled on applesauce or pudding?
Micro-K, Klor-Con sprinkle
90
Which ER potassium formulation should be swallowed whole; do not chew, crush, cut, or suck on tablet
K-Tab, Klor-Con
91
Which ER potassium tablet can be cut in half or dissolved in water?
Klor-Con M | Do not chew, crush, or suck on the tablet
92
CHF green, yellow, red meaning
Green - follow medication, weight and diet advice Yellow - may need to change medications Red - Go to doctor today; call 911
93
When should a CHF patient call their doctor
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
When should a CHF patient see a doctor immediately or call 911?
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
What class of medications should be avoided in HF patients?
NSAIDs | Can worsen sodium and water retention

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