Drugs to Treat CHF Flashcards
What ACE inhibitors are used to treat HF?
Captopril and other __prils
What angiotensin receptor blockers (ARBS) are used to treat HF?
Losartan and other __sartans
What is the prototypical beta-blocker used to treat HF?
Carvedilol
What is the prototypical aldosterone antagonist used to treat HF?
Spironolactone
What are the diuretics used to treat HF?
1) Furosemide (loop)
2) Thiazide
What are the direct vasodilators used to treat HF?
1) Nitroglycerin/isosorbide dinitrate
2) Nitroprusside
3) Hydralazine
What is the cardiac glycoside used to treat HF?
Digoxin
What are the adrenergic agonists used to treat HF?
1) Dobutamine
2) Dopamine
What is the phosphodiesterase inhibitor used to treat HF?
Milrinone
What type of left sided heart failure is systolic?
What is it due to?
1) Heart Failure reduced Ejection Fraction (HFrEF)
2) Failure of the pump function
What type of left sided heart failure is diastolic?
What is is due to?
1) Heart Failure preserved Ejection Fraction (HFpEF)
1) Ventricular hypertrophy
ACE inhibitors and ARBs both lead to?
Less angiotensin II
What does less angiotensin II lead to?
1) Less vasoconstriction (Decrease afterload)
2) Less aldosterone secretion and less sodium/water retention (Decrease preload)
3) Decrease cell proliferation and remodeling
What are the clinical applications of captopril?
1) HTN
2) HFrEF
3) Diabetic nephropathy
What toxicity is the most common reason why patients stop taking captopril?
What is the most deadly toxicity of captopril?
1) Cough (Due to bradykinin levels)
2) Angioedema
What benefit does other ACE inhibitors such as benazepril and lisinopril have over captopril?
They have a longer half life permitting 1 dose a day
What type of inhibitor is captopril to ACE?
Competitive
What advantage does ARBs have over ACE inhibitors?
They do not potentiate bradykinin so less coughing is seen
What type of inhibitor is losartan to angiotensin II receptor?
Competitive nonpeptide
What are the clinical applications of losartan?
1) Diabetic nephropathy
2) HTN
3) HF if intolerant of ACE inhibitors
What is the black box warning associated with captopril and losartan?
Fetal toxicity
Either ACEI or ARBs should be administered to all patients with LV systolic failure or LV dysfunction without heart failure unless?
1) Pregnant
2) Hypotensive
3) Serum creatinine > 3 mg/dL
4) Hyperkalemia
The blockage of neutral endopeptidase has what effect on ANP and BNP?
Prolongs half-life
What does sacubitril inhibit?
What does this cause?
What drug is it paired and co-crystallized with?
1) Neprilysin (neutral endopeptidase)
2) Increase levels of ANP and BNP
3) Valsartan
What toxicity is seen with sacubitril?
Angioedema
Carvedilol is non selective for what receptors?
Beta and alpha receptors
What is the clinical application for carvedilol?
Given to the clinically stable with history of MI and HFrEF to prevent symptomatic HF
Carvedilol is used to prevent down-regulation of?
β1 adrenergic receptors
How and to who is carvedilol prescribed?
Low doses and in stable patients
Patients with what type of HF should be given carvedilol because they will benefit from a lower heart rate?
Diastolic HF
Unless there are contraindications, carvedilol or metoprolol or bisoprolol should also be given along with ACE inhibitors to all patients with?
Left ventricular systolic dysfunction caused by MI to reduce mortality
What are some contraindications for beta-blockers?
1) Bronchospastic disease like asthma
2) Symptomatic bradycardia
What black box warning is associated with beta-blockers?
Beta-blocker therapy should not be withdrawn abruptly
What does ivabradine inhibit?
Where?
1) Hyperpolarization-activated cyclic nucleotide gated (HCN) channels (If- channels)
2) SA node
What effect does ivabradine have?
Disrupts If (funny current) to prolong diastole and slow HR
What is the clinical applications for ivabradine?
It is used when there is a maximally tolerated dose to or contraindication to what drug?
1) Tx of resting HR greater than 70 bpm in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤35%
2) Beta blockers
What type of antagonist is spironolactone to aldosterone receptors?
Competitive
What effect does spironolactone have?
1) K+ sparing diuretic
2) Antagonizes profibrotic effects of aldosterone
What are the clinical applications for spironolactone?
1) Counteracts K+ loss induced by other diuretics in the tx of HF
2) Reduce fibrosis in HFrEF and postMI heart failure
What toxicity is associated with spironolactone?
Hyperkalemia
What are common clinical reasons for administering diuretics?
1) Essential HTN
2) Edema associated with CHF
Triamterene, amiloride, and spironolactone make up what class of diuretics?
Thiazides and loop diuretics make up what class of diruetics?
1) K+ sparing
2) K+ losing
Why are K+ losing diuretics and digitalis not given together?
Because hypokalemia increases the toxicity of digitalis
Where do loop diuretics act upon?
What do they block?
What is the prototypical loop diuretic?
1) Thick ascending limb of Henle
2) Na+-K+- 2Cl- cotransporter
3) Furosemide
What is the clinical application for furosemide?
1) Edema associated with HF
2) HTN
3) Rapid dyspnea relief
4) Works in patients with low GFR
What does furosemide decrease?
1) Decreases preload
2) Decreases extracellular volume
What toxicities are associated with furosemide?
1) Low electrolytes
2) Ototoxicity
3) Sulfa allergy
What loop diuretic can be used in patients with sulfa allergy?
Ethacrynic acid
Which diuretic causes the largest Na+ loss and the smallest HCO3- loss?
Loop diuretics (furosemide)
What is the order in which you should prescribe diuretics?
1) Use loop diuretics first
2) Add K+ sparing to correct possible hypokalemia
3) Use thiazide if more diuresis is needed
What do diuretics accomplish by getting rid of excess volume?
Relieve the congestion and return ventricular fiber length to more optimal range
Hydrochlorothiazide blocks what transporter?
What is its clinical application?
When is it not effective?
What is another long-acting thiazide diuretic that is a favorite of cardiologists for use as an adjunct diuretic in the treatment of congestive heart failure?
1) Na+ Cl- cotransporter
2) Antihypertensive
3) In patients with low GFR
4) Metolazone
What is the vasodilator combination that is especially useful in African Americans?
Isosorbide dinitrate and Hydralazine
What is the role of isosorbide dinitrate?
Of hydralazine?
1) Dilate veins and decrease preload
2) Dilate arteries and decrease afterload
Nitroglycerin is a vasodilator that has effects on?
Veins
Nitroglycerin and isosorbide dinitrate are similar drugs that have what clinical application?
1) Prevention of angina
2) Tx HF with reduced ejection fraction
Digoxin works by inhibiting what?
Na+ K+ ATPase
What are the effects of digoxin?
1) Increase myocardial contractility
2) Suppress AV node
3) Decrease ventricular rate
What are the clinical applications for digoxin?
1) Control ventricular response rate in adults with chronic Afib
2) Tx heart failure by increasing myocardial contractility
Digoxin cardiac toxicity occurs in part because myocytes become overloaded with?
Ca2+
What hemodynamic benefits does digoxin cause?
What electrical effects does it have?
What effect does this electical change have?
1) Increases cardiac output
2) Increase firing rate of vagal fibers
3) Increase SA node response to ACh
Toxic effect of digitalis on A-V conduction involves?
Toxic effect of digitalis on Purkinje automaticity and ventricular refractory period results in?
What is important to make sure of before administering digoxin?
1) AV dissociation (Lack of relationship between P and QRS)
2) Ectopic ventricular beats
3) HR must be normal
What drug interaction is notable with digoxin?
What can happen?
1) Diuretics
2) If diuretics cause hypokalemia it can lead to increased digoxin binding causing toxicity
What is recommended treatment regimen of HFrEF?
ACE inhibitor or ARB in conjunction with beta blockers and aldosterone antagonists
What is the approach in treating HFpEF?
Treat the symptoms and associated conditions (ie give loop diuretics to treat edema)
What drug should be given first for acute decompensated HF (ADHF)?
Why?
1) Diuretics
2) They are in volume overload
If a ADHF patient is hypertensive what do you want to give them along with the loop diuretic?
Vasodilator
What is indicated in the short term treatment of ADHF if the patients present with symptomatic hypotension with end-organ dysfunction despite adequate filling pressure?
Inotropic agents such as dobutamine or dopamine
For patients with severe ADHF what is recommended with beta blockers?
Withhold
Which sympathomimetic stimulates beta-1 and beta-2 adrenergic receptors?
Which activates beta-1 adrenergic receptors and alpha adrenergic receptors at high doses?
1) Dobutamine
2) Dopamine
What inotropic therapy is pretty much the last resort for patients unresponsive to other acute HF therapies?
What does it inhibit?
This causes increase is?
1) Milrinone
2) Phosphodiesterase
3) cAMP
