Drugs to Treat CHF Flashcards by Billy Harrah

What ACE inhibitors are used to treat HF?

Captopril and other __prils

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What angiotensin receptor blockers (ARBS) are used to treat HF?

Losartan and other __sartans

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What is the prototypical beta-blocker used to treat HF?

Carvedilol

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What is the prototypical aldosterone antagonist used to treat HF?

Spironolactone

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What are the diuretics used to treat HF?

1) Furosemide (loop)

2) Thiazide

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What are the direct vasodilators used to treat HF?

1) Nitroglycerin/isosorbide dinitrate
2) Nitroprusside
3) Hydralazine

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What is the cardiac glycoside used to treat HF?

Digoxin

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What are the adrenergic agonists used to treat HF?

1) Dobutamine

2) Dopamine

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What is the phosphodiesterase inhibitor used to treat HF?

Milrinone

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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

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What type of left sided heart failure is diastolic?

What is is due to?

1) Heart Failure preserved Ejection Fraction (HFpEF)

1) Ventricular hypertrophy

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ACE inhibitors and ARBs both lead to?

Less angiotensin II

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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

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What are the clinical applications of captopril?

1) HTN
2) HFrEF
3) Diabetic nephropathy

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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

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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

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What type of inhibitor is captopril to ACE?

Competitive

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What advantage does ARBs have over ACE inhibitors?

They do not potentiate bradykinin so less coughing is seen

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What type of inhibitor is losartan to angiotensin II receptor?

Competitive nonpeptide

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What are the clinical applications of losartan?

1) Diabetic nephropathy
2) HTN
3) HF if intolerant of ACE inhibitors

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What is the black box warning associated with captopril and losartan?

Fetal toxicity

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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

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The blockage of neutral endopeptidase has what effect on ANP and BNP?

Prolongs half-life

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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

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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