Exam 2 - Heart Failure Flashcards
what is stage A heart failure?
high risk: HTN, CAD, diabetes, family history
what is stage B heart failure?
asymptomatic LVD (pre-heart failure): includes previous MI, LV systolic dysfunction asymptomatic valvular disease
what is stage C heart failure?
symptomatic HF
what is stage D heart failure?
refractory end-stage HF: marked symptoms at rest despite maximal medical therapy
NYHA class I
cardiac disease with no symptoms
NYHA class II
symptoms with moderate exertion
NYHA class III
symptoms with minimal exertion (limitations of physical activity)
NYHA class IV
symptoms at rest
what is JVD?
jugular vein distention -> jugular vein is swollen/bulging (usually a sign of HF)
true or false: HF is the most common hospital discharge for pts > 65 yo
true
CAD, HTN, cardiomyopathy, and valvular disease all lead to _____ _____ _____
left ventricular dysfunction (LVD)
how does LVD eventually lead to death?
LVD -> remodeling -> reduced EF -> death
which HF is due to systolic dysfunction: decreased contractility?
a. HFrEF
b. HFpEF
a. HFrEF
which HF is due to diastolic dysfunction: impairment in ventricular relaxation/filling?
a. HFrEF
b. HFpEF
b. HFpEF
cause of HFrEF
dilated ventricle (there is more, look at slide 9)
most common cause of HFpEF (> 60%)
HTN
what is EF of 41-49% called?
HFmrEF (mildly reduced EF)
what is HFimpEF?
EF > 40%, previously had HFrEF
3 determinants of left-ventricular performance (stroke volume)
preload, myocardial contractility, afterload
what are the 3 classes of drugs we talked about for drug-induced HF?
-drugs that reduce contractility (negative inotropes)
-direct cardiac toxins
-drugs that lead to sodium/water retention
how do antiarrhythmics, beta blockers, CCBs, and itraconazole lead to drug-induced HF?
a. they reduce contractility
b. they are direct cardiac toxins
c. they lead to sodium/water retention
a. they reduce contractility
which of the following is a direct cardiac toxin?
a. itraconazole
b. glucocorticoids
c. doxorubicin
d. flecainide
c. doxorubicin
the clinical presentation of right ventricular failure is primarily
a. pulmonary congestion
b. systemic venous congestion
b. systemic venous congestion
the clinical presentation of left ventricular failure is primarily
a. pulmonary congestion
b. systemic venous congestion
a. pulmonary congestion
peripheral edema, JVD, HJR, hepatomegaly, and ascites are signs of
a. right ventricular failure
b. left ventricular failure
a. right ventricular failure
what is orthopnea?
SOB when lying down (how many pillows do patients need to sleep?)
what is paroxysmal nocturnal dyspnea?
sudden SOB at night
DOE, orthopnea, PND, rales, pulmonary edema, and bendopnea are major signs/symptoms of
a. systemic venous congestion
b. pulmonary congestion
b. pulmonary congestion
Low cardiac output results in the activation of compensatory neurohormonal pathways. Activation of the SNS results in which one of the following effects?
A. Peripheral vasodilation
B. Fluid retention
C. Decreased cardiac contractility
D. Increased heart rate
E. Diuresis
D. Increased heart rate
Which one of the following medications may
exacerbate HFrEF?
A. Metformin
B. Amlodipine
C. Atorvastatin
D. Ibuprofen
D. Ibuprofen
(any NSAIDs except 81 mg aspirin)
Which of the following are common causes of heart failure (Select all that apply)?
A. Bipolar Disorder
B. Asthma
C. MI
D. HTN
E. Gout
C. MI
D. HTN
via what 4 methods can we use to evaluate LV function and measure EF in clinic?
-echocardiogram
-nuclear testing
-cardiac cath
-MRI and CT
sodium restriction per day for HF pts
2-3 grams/day
fluid intake restriction for HF pts
< 2 L/day in pts with hyponatremia (< 130 mEq/L) or if Tx with diuretics is difficult in maintaining fluid volume
diuretics and SGLT2s reduce _____ _____
intravascular volume
positive inotropes increase _____ _____
myocardial contractility
ACEi’s, vasodilators, and SGLT2s decrease _____ _____
ventricular afterload
what 2 drug classes should be used in stage B pt if previous MI or asymptomatic rEF?
ACE/ARB and beta blocker
true or false: diuretics reduce mortality in HF
false (reduce hospitalizations but not mortality or disease progression)
true or false: pts without symptoms of volume overload should still receive a diuretic
false (only those with symptoms should; slide 50)
loop diuretics block ___ and ___ reabsorption in the _____ limb of the loop of Henle
Na, Cl, ascending
initial oral dose for furosemide
20-40 mg QD or BID
initial oral dose for bumetanide
0.5-1 mg QD or BID
initial oral dose for torsemide
10-20 mg QD
initial oral dose for ethacrynic acid
25-50 mg QD or BID
what are the IV equivalent doses for the loop diuretics?
furosemide 40 = bumetanide 1 = torsemide 20 = ethacrynic acid 50
usual dose range for furosemide
a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD
a. 20-160 mg QD or BID
usual dose range for bumetanide
a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD
b. 1-2 mg QD or BID
usual dose range for torsemide
a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD
c. 10-80 mg QD
torsemide dose for Cr-Cl 20-50 mL/min
40 mg QD
Which one of the following doses would be
considered “equivalent” to 1 mg PO bumetanide?
A. Furosemide PO 80 mg
B. Furosemide IV 20 mg
C. Torsemide PO 10 mg
D. Bumetanide IV 0.5 mg
a. Furosemide PO 80 mg
(B. is furosemide IV 40; C. is torsemide 20 mg; not sure about D)
thiazides block Na and Cl reabsorption in which part of the nephron?
DCT
HCTZ’s initial and max doses for HF
a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
a. initial: 25 mg/day; max: 100 mg/day
metolazone’s initial and max doses for HF
a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
chlorthalidone initial and max doses for HF
a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
CTZ’s initial and max doses for HF
a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
indapamide’s initial and max doses for HF
a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day
which of the following is NOT a mechanism of ACE inhibitor benefit in HF?
a. increased aldosterone
b. inhibition of cardiac hypertrophy
c. reduced vasoconstriction
d. decreased endothelin-1
a. increased aldosterone (it is decreased)
which of the following is a mechanism of ACE inhibitor benefit in HF?
a. increased NE
b. increased Na and water retention
c. decreased endothelial function
d. decreased arginine vasopressin
d. decreased arginine vasopressin
(a. and d. are decreased; c. is increased)
enalapril initial dose for HF
2.5-5 mg BID
captopril initial dose for HF
6.25-12.5 mg TID
lisinopril initial dose for HF
a. 2.5-5 mg QD
b. 5-10 mg BID
c. 1.25-2.5 mg QD
a. 2.5-5 mg QD
quinapril initial dose for HF
5-10 mg BID
ramipril initial dose for HF
a. 2.5-5 mg QD
b. 5-10 mg BID
c. 1.25-2.5 mg QD
c. 1.25-2.5 mg QD
fosinopril initial dose for HF
a. 1.25-2.5 mg QD
a. 2.5-5 mg BID
b. 5-10 mg QD
c. 5-10 mg BID
c. 5-10 mg QD
what are the dose equivalents for enalapril, captopril, and lisinopril?
20 mg enalapril = 150 mg captopril = 20 mg lisinopril
enalapril target dose for HF
10 mg BID
captopril target dose for HF
50 mg TID
lisinopril target dose for HF
20-40 mg QD
quinapril target dose for HF
a. 20-40 mg QD
b. 20-40 mg BID
c. 10 mg BID
d. 40 mg QD
b. 20-40 mg BID
fosinopril target dose for HF
a. 20-40 mg QD
b. 20-40 mg BID
c. 10 mg BID
d. 40 mg QD
d. 40 mg QD
ramipril target dose for HF
5 mg BID-10 mg QD
true or false: SCr goes down in almost every pt upon initiation of an ACE inhibitor
false (goes up)
losartan initial and target doses for HF
a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily
a. initial: 25-50 mg daily; target: 150 mg daily
valsartan initial and target doses for HF
a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
candesartan initial and target doses for HF
a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily
c. initial: 4 mg daily; target: 32 mg daily
sacubitril inhibits the degradation of ___ and ultimately leads to __________
BNP; vasodilation
entresto indication
reduce risk of CV death/hospitalization for HFrEF pts with NYHA class II-IV
is hypotension more common in entresto or enalapril?
entresto
is elevations in SCr and potassium more common in entresto or enalapril?
enalapril
which of the following pt populations get an initial dose of entresto 49/51 mg BID? SELECT ALL THAT APPLY
a. eGFR < 30
b. low to medium dose ACEi or ARB
c. high dose ACEi
d. high dose ARB
e. age > 75 yrs
f. ACEi/ARB naive
c. high dose ACEi
d. high dose ARB
what is considered a high dose ACEi?
> 10 mg total daily enalapril (or therapeutic equiv)
what is considered a high dose ARB?
> 160 mg total daily dose valsartan
how long after an ACEi can we take an ARNI?
36 hours
true or false: a stage B pt should be on an ARNI
false (not indicated for stage B)
Sacubitril/valsartan is contraindicated in patients with HFrEF and with which one of the following?
A. Hypokalemia
B. Angioedema with ramipril
C. Concomitant therapy with furosemide
D. Heart rate <65 BPM
B. Angioedema with ramipril
how long after starting entresto can we follow up to titrate?
2-4 weeks (I would say 2 weeks to assess tolerability)
true or false: you can abruptly discontinue beta blockers for HF
false (slowly titrate due to rebound HTN)
true or false: metoprolol tartrate can be used for HF
false
bisoprolol initial dose for HF
1.25 mg daily
bisoprolol target dose for HF
10 mg daily
Coreg vs Coreg CR initial and target doses for HF
Coreg- initial: 3.125 mg BID; target: 25-50 mg BID
Coreg CR: initial: 10 mg daily; target: 80 mg daily
metoprolol CR/XL initial and target doses for HF
initial: 12.5-25 mg daily; target: 200 mg daily
true or false: beta blockers are negative inotropes
true
carvedilol dose for < 85 kg pt
25 mg BID
carvedilol dose for > 85 kg pt
50 mg BID
dose conversion for carvedilol vs Coreg CR
carvedilol vs Coreg CR
3.125 mg BID = 10 mg QD
6.25 mg BID = 20 mg QD
12.5 mg BID = 40 mg QD
25 mg BID = 80 mg QD
true or false; all stage B HF pts should be on a beta blocker
true
GV was brought to the ED for difficulty breathing and notable swelling of the face, lips and tongue. His medical history is significant for diabetes and HFrEF. He currently takes rosuvastatin, metformin, spironolactone, carvedilol, fosinopril, bumetanide, and digoxin. Which med should be discontinued?
a. bumetanide
b. spironolactone
c. carvedilol
d. fosinopril
e. digoxin
d. fosinopril (due to angioedema)
which BB reduces mortality in systolic HF?
a. labetalol
b. metoprolol tartrate
c. atenolol
d. nebivolol
e. bisoprolol
e. bisoprolol
(systolic HF = HFrEF)
how long after stopping quinapril can a pt take their first dose of entresto?
36 hours
KG has been diagnosed with HF and is beginning carvedilol IR. He is 5 ft 7 in and weighs 78 kg. Assuming he tolerates the dose titrations, what is the target dose of carvedilol IR for KG?
a. 12.5 mg BID
b. 25 mg BID
c. 50 mg BID
d. 75 mg BID
e. 100 mg BID
b. 25 mg BID
which MRA is non-selective?
a. spironolactone
b. eplerenone
a. spironolactone
which drug is a selective agent with 100- to 1000- fold lower affinity for androgen, glucocorticoid, and progesterone receptors than spironolactone?
eplerenone
what CrCl and K levels should we avoid for spironolactone?
CrCl < 30 mL/min
K > 5 (due to hyperkalemia)
when do we increase the dose for aldosterone antagonists?
every 2 weeks until max tolerated/target dose achieved
how often should we monitor for aldosterone antagonists?
monitor electrolytes (especially K) and renal function 2-3 days after starting, then 7 days after. Then check monthly for 3 months and every 3 months after.
true or false: aldosterone antagonists are recommended for stage B HF patients
false
which pts are aldosterone antagonists recommended for?
pts with NYHA II-IV and HFrEF, eGFR > 30 and K < 5
EG is a 67 yo white female with NYHA functional class III HFrEF. The cardiologist wants to start spironolactone. Which finding would prohibit the use of this medication?
a. CrCl = 60 mL/min
b. sulfa allergy
c. history of angioedema
d. K = 5.6 mEq/L
e. hemoglobin = 10.2 mg/dL
d. K = 5.6 mEq/L
(need K < 5)
SGLT2 inhibitors causes _______ arteriolar constriction
a. afferent
b. efferent
a. afferent
true or false: SGLT2s reduce preload and afterload and cause diuresis
true
what is dose for either SGLT2 inhibitor for HF?
10 mg once daily
true or false: SGLT2s reduce hospitalizations and mortality
true
what are the eGFR cutoffs for dapagliflozin vs empagliflozin?
dapa -> 30 or greater
empa -> 20 or greater
true or false: digoxin and ivabradine reduce mortality
false
which drug is indicated for treatment of HF in black pts as adjunct to standard therapy?
BiDil (ISDN/Hydralazine)
(first drug combo with reduction in mortality)
what is the initial and target dose for ISDN/Hydralazine?
initial: 20/37.5 mg TID
target: 40/75 mg TID
(titrate after 2 weeks)
does ISDN/Hydralazine reduce preload, afterload, or both?
both
JG is a 59 yo black male with stage C HFrEF. He is on bumetanide, dapagliflozin, enalapril, toprol XL, and prilosec. Which medication would be best to recommend adding to JG’s regimen?
a. Cozaar
b. Entresto
c. Hydralazine and isosorbide dinitrate
d. furosemide
e. carvedilol
c. Hydralazine and isosorbide dinitrate
which drug is an additional therapy for NYHA II-III pts in normal sinus rhythm with HR of 70 or more on max tolerated beta blocker?
a. ivabradine
b. vericiguat
c. digoxin
d. PUFA
e. potassium binders
a. ivabradine
digoxin MOA (2 things)
-inhibits Na+/K+ ATPase pump, which leads to inc calcium, enhancing force of contraction
-inc PNS -> inc vagal activity -> dec AV conduction -> dec HR
therapeutic range for digoxin when used to treat HF
0.5-0.9 ng/mL
which drug is used as add-on for pts with symptomatic HFrEF despite max GDMT to dec hospitalization for HF?
a. ivabradine
b. vericiguat
c. digoxin
d. PUFA
e. potassium binders
c. digoxin
digoxin dose range
0.125-0.25 mg daily
digoxin drug interactions (4 of them; part 3 slide 47)
amiodarone
quinidine
verapamil
itra/KTZ
A pt with systolic HF is taking ramipril, digoxin, carvedilol, spironolactone, and furosemide. He is diagnosed with A Fib and prescribed amiodarone. Which medication dose should be reduced by 50% when starting amiodarone?
a. carvedilol
b. digoxin
c. furosemide
d. ramipril
e. spironolactone
b. digoxin
true or false: vericiguat does NOT reduce mortality and hospitalization
false (it reduces both)
true or false: PUFA (omega 3 polyunsat FAs) have been shown to reduce risk in HF II-IV when used as adjunct
true
what drug should be used as needed for pt with HPpEF?
diuretic
