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Spring 2024 Therapeutics 3 > Exam 2: Heart Failure > Flashcards

Exam 2: Heart Failure Flashcards

1
Q

Do patients with heart failure tend to have high or low blood pressures?

A

Low BP

-because cardiac output is low

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2
Q

What is the cardinal sign of heart failure?

A

Edema

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3
Q

What are the 2 most common causes of heart disease?

A

CAD

Chronic hypertension

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4
Q

What are the survival rates associated with heart failure?

A

5 years : about 50%

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5
Q

What is Heart Failure?

A

An abnormality of myocardial function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues

-Not a single disease state, but the final common pathway for CV diseases

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6
Q

What are the 2 most common reasons why people die relating to heart failure?

A

Arrythmia

Pump Failure

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7
Q

What 2 non-cardiac factors does Entresto work on?

A

-Endothelial dysfunction

-Neurohormonal activation

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8
Q

What 4 factors contribute to Left Ventricular Dysfunction?

A

CAD

HTN

Cardiomyopathy

Valvular disease

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9
Q

How does Left Ventricular Dysfunction lead to death?

A

LV dysfunction -> Remodeling -> Decreased EF -> Death

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10
Q

What is the only effective cure for heart failure?

A

Heart transplant

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11
Q

What are the 5 types of heart failure?

A

Asymptomatic reduced EF

HFrEF (HF with reduced ejection fraction)

HFpEF (HF with preserved ejection fraction)

HFmrEF (Heart failure with mildly reduced ejection fraction)

HFimpEF (Heart failure with improved ejection fraction)

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12
Q

What is the definition of HFrEF?

A

HF symptoms with EF <40%

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13
Q

If a patient has an EF < 40% but is not experiencing symptoms, what do they have?

A

Asymptomatic reduced EF

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14
Q

What is the definition of HFpEF?

A

HF symptoms with EF > 50%

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15
Q

What impairment in cardiac function is caused by HFrEF?

A

Systolic dysfunction: decreased contractility

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16
Q

What impairment in cardiac function is caused by HFpEF?

A

Diastolic dysfunction: impairment in ventricular relaxation/filling

(inability of heart to fill/relax)

*note: many patients have a combination of systolic and diastolic dysfunction

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17
Q

What is the cause of HFrEF?

A

Dilated ventricle (dilated cardiomyopathy)
(CAD)*

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18
Q

What is the most common cause of HFpEF?

A

Hypertension

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19
Q

What is the definition of HFmrEF?

A

Heart failure with mildly reduced ejection fraction

EF: 41-49%

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20
Q

What is the definition of HFimpEF?

A

Heart failure with improved ejection fraction

Improved EF > 40%, previously had HFrEF

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21
Q

What are the 3 determinants of Left-Ventricular Performance (Stroke-Volume)?

A

Preload

Myocardial Contractility

Afterload

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22
Q

What makes up preload?

A

Venous return

LV end-diastolic volume

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23
Q

What makes up Myocardial Contractility?

A

Force generated at any given left ventricular end diastolic volume (LVEDV)

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24
Q

What makes up Afterload?

A

Aortic impedance

Wall stress

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25
Q

True or False:
As preload increases, stroke volume increases

A

True

(the more volume you put in, the more the sarcomeres stretch causing the force of blood exiting to be stronger)

(think of a balloon)

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26
Q

What factors cause the heart to remodel?

A

Increased pressure

Extra fluid

(remodels to try and increase efficiency of pumping blood)

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27
Q

True or False:
Some drugs that decrease afterload may increase stroke volume

A

True

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28
Q

On a Frank-Starling curve, what drug is able to move a patient down and to the left? (decrease stroke volume and LVEDP [preload])?

*decreases preload is why it is good

A

Diuretics

(reduce fluid)
*gets patient out of pulmonary congestion

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29
Q

How do we estimate afterload?

A

Blood pressure

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30
Q

In a patient with heart failure, how does increasing afterload affect stroke volume?

A

Greatly decreases it

(in a normal patient, it would not have an effect unless the afterload was very greatly increased)

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31
Q

Decreased cardiac output leads to decreased blood pressure + organ perfusion which ultimately leads to increases in what 5 things?

A

SNS *bad

RAAS *bad

Vasopressin *bad

Atrial natriuretic peptides (ANP) *good

Brain natriuretic peptides (BNP) *good

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32
Q

What do increases in the SNS, RAAS, and Vasopressin lead to?

A

Cell death/fibrosis

Arrythmias
(catecholamines released from the SNS predispose patients to arrythmias)

Reduced cardiac output

Vasoconstriction

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33
Q

What causes increased preload in HF?

A

Na/Water retention

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34
Q

What is the main reason why patients develop heart failure exacerbations?

A

Lack of compliance with drugs or diet

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35
Q

What are the negative inotropes that can induce heart failure?

A

Antiarrhythmics (disopyramide, flecainide)

Beta-Blockers (atenolol, propranolol, metoprolol)

CCBs (verapamil, diltiazem)

Itraconazole

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36
Q

What are the direct cardiac toxins that can induce heart failure?

A

Doxorubicin, Epirubicin, Daunomycin
CYP
Trastuzumab, Bevacizumab
5-FU
Blue Cohosh
Imatinib, Lapatinib, Sunitinib
Ethanol**, Cocaine, Amphetamines

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37
Q

What are the drugs that cause sodium + water retention that can also cause heart failure?

A

Glucocorticoids
Androgens, Estrogens
NSAIDs, COX-2 inhibitor
Rosiglitazone, Pioglitazone
Sodium containing drugs (DiNa+ containing)

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38
Q

What are the signs/symptoms of Right Ventricular Failure?

A

*Systemic venous congestion (fluid backed up in right side of heart)

Signs:
*Peripheral edema
*JVD
HJR
*Hepatomegaly
Ascites

Symptoms:
Abdominal pain
Anorexia
Nausea
Bloating
Constipation

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39
Q

What are the signs and symptoms of Left Ventricular Failure?

A

*Pulmonary congestion
(fluid in lungs)

Signs:
*Rales
*S3 gallop
*Pulmonary edema
Pleural effusion
Cheyne-stokes respiration

Symptoms:
*DOE
*Orthopnea
*PND
Tachypnea
*Bendopnea
Cough
Hemoptysis

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40
Q

Failure of which ventricle involves pulmonary congestion?

A

Left ventricular failure

(fluid in lungs)

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41
Q

Failure of which ventricle involves systemic venous congestion?

A

Right ventricular failure

(fluid backed up in right side of heart/systemic)

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42
Q

What are the 6 major signs of pulmonary congestion (left ventricular failure)?

A

Exertional dyspnea (SOB w/ exertion)

Orthopnea (SOB when lying down, quantified by pillow number used to sleep)

Paroxysmal nocturnal dyspnea (PND) (SOB at night, feelings of suffocation/ drowning)

Rales (rattling of air through liquid in lungs)

Pulmonary edema (fluid in lungs, wispiness)

Bendopnea (SOB when bent over)

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43
Q

What are the 4 major signs of systemic venous congestion (right ventricle failure)?

A

-Peripheral edema

-Jugular vein distension (JVD) (estimate of amount of fluid in right venous circulation)

-Hepatojugular reflux (HJR) (fluid from liver goes into jugular vein when pushed)

Hepatomegaly, ascites (tap on side of stomach and see fluid wave)

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44
Q

How does CAD cause HF?

A

Scar tissue forms and does not move like regular skin (more fibroblasts)

-does not contract anymore
*we do not regenerate heart tissue
-initiates remodeling of ventricle that leads to dysfunction

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45
Q

Why does hypertension cause HF?

A

Increased pressure causes the heart to remodel itself to try and overcome it

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46
Q

Why should we assess natriuretic peptides with HF?

A

Can be used to rule out other cardiac causes of dyspnea and point towards a diagnosis of HF

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47
Q

What are the 2 natriuretic peptides that we should assess?

A

BNP
NT-proBNP

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48
Q

What level of BNP points to heart failure?

A

> 35 pg/mL

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49
Q

What level of NT-proBNP points to heart failure?

A

> 125 pg/mL

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50
Q

What is the main laboratory assessment we want to do on patients with HF?

A

Evaluation of LV function and measurement of ejection fraction (EF)

*LVEF allows us to diagnose what type of HF it is

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51
Q

What are the 4 ways we can measure LV function and EF?

A

-Echocardiogram

-Nuclear testing
(MUGA: multi-gated acquisition scanning is the gold standard***)

-Cardiac catheterization

-MRI and CT

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52
Q

What patients classify as NYHA Functional Class 1?

A

Patients with cardiac disease but no limitations of physical activity

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53
Q

What patients classify as NYHA Functional Class 2?

A

Patients with cardiac disease with slight limitations of physical activity

(slight symptoms)

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54
Q

What patients classify as NYHA Functional Class 3?

A

Patients with cardiac disease with limitations of physical activity

(symptoms with moderate activity)

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55
Q

What patients classify as NYHA Functional Class 4?

A

Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort

(symptoms at rest)

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56
Q

What patients classify as AHA Stage A?

A

*High risk of developing HF
-No identified structural or functional abnormalities
-Have never shown signs or symptoms of HF

(HTN, CAD, DM, etc)

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57
Q

What patients classify as AHA Stage B?

A

Structural heart disease that is strongly associated with HF but NO SIGNS OR SYMPTOMS of HF

(stage 1 patients)

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58
Q

What patients classify as AHA Stage C?

A

Current or prior symptoms of HF
-Associated with underlying structural heart disease

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59
Q

What patients classify as AHA Stage D?

A

Advanced structural heart disease + marked symptoms of HF AT REST

*despite maximal medication therapy and who require specialized interventions

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60
Q

What NYHA classes and AHA stages line up with each other?

A

A - none (high risk, no HF yet)
B - 1 (asymptomatic)
C - 2, 3 (symptoms w/ mod exertion)
D - 4 (symptoms at rest)

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61
Q

What is the definition of Asymptomatic rEF?

A

No heart failure symptoms with EF < 40%

*AKA Asymptomatic LV systolic dysfunction

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62
Q

What is the definition of HFrEF?

A

Heart failure symptoms with EF < 40%

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63
Q

What is the definition of HFimpEF?

A

Previous symptoms of rEF now improved

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64
Q

What is the definition of HFmrEF?

A

Heart failure symptoms with EF 41-49%

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65
Q

How should exercise be recommended to HF patients?

A

-Recommend regular exercise (walking + cycling) for all patients with stable HF

-Dynamic exercises to increase HR to 60-80% of maximum for 20-60 minutes 305 times/week

**use caution during acute symptoms

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66
Q

What 3 dietary changes should be made in HF patients?

A

Sodium: restrict to 2-3 g/day

Alcohol: In EtOH induced HF need to abstain, otherwise no more than 2 drinks/day for men or 1 for women

Fluid intake: Restrict < 2 L/day in patients with hyponatremia (<130 mEq/L) or fluid volume is difficult to maintain with diuretics

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67
Q

What sodium level indicates hyponatremia?

A

< 130 mEq/L

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68
Q

What are the general measures that should be taken in HF patients?

A

-Weight monitoring
-Education of patients + families
*Smoking cessation
-Immunizations
-Replace electrolytes
-Thyroid disease management
-Herbal products (may help)

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69
Q

What are the 4 strategies to target in HF with drugs?

A

-Reduce intravascular volume
-Increase myocardial contractility
-Decrease ventricular afterload
-Neurohormonal blockade

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70
Q

What drugs reduce intravascular volume?

A

Diuretics

SGLT2i

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71
Q

What drugs increase myocardial contractility?

A

Positive inotropes

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72
Q

What drugs decrease ventricular afterload?

A

ACEi

vasodilators

SGLT2i

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73
Q

What drugs cause a neurohormonal blockade?

A

ARNIs
Beta blockers
ACEIs
ARBs
MRAs
SGLT2i

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74
Q

What drugs should be used in Stage A HF?

A

ACEi/ARB

(if atherosclerotic vascular disease is present)

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75
Q

What drugs should be used in Stage B HF?

A

ACEi/ARB
Beta Blocker

(if previous MI or asymptomatic rEF)

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76
Q

What are the 4/5 initial drugs to initiate for stage C/D HF?

A

ARNi (II-II)/ ACEi or ARB (II-IV)

Beta blocker

MRA

SGLT2i

Diuretic **prn (loop preferred)

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77
Q

If a stage C patient is started on the big 4 and their LVEF improves to > 40% (HFimpEF) what do you do?

A

Continue the big 4 with serial reassessment and optimize dosing

-assess adherence and patient education
-address goals of care

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78
Q

If a stage C patient is started on the big 4 but their LVEF stays at or below 40%, what do you do?

A

Class 3,4 and African American:
Hydralazine/ Isosorbide Dinitrate

Class 1-3, LVEF <or = 35%:
ICD (implantable cardioverter-defibrillator)

Class 2-3, Ambulatory IV, LVEF < or = 35%, NSR and QRS > or = 150 ms with LBB:
CRT-D (cardiac resynchronization therapy)

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79
Q

When is ISDN/Hydralazine used?

A

Select patients:
-African American patient with continuing symptoms after receiving the big 4

-If ARNI/ACEI/ARB intolerant

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80
Q

When is Digoxin given?

A

If persistently symptomatic on big 4

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81
Q

Who should receive diuretics?

A

All HF patients with signs/symptoms of FLUID RETENTION

(SYMPTOMATIC patients)

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82
Q

Do diuretics reduce mortality?

A

NO, only reduce hospitalizations

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83
Q

What are the 3 benefits that diuretics provide?

A

-Reduce symptoms of fluid overload

-Improve exercise tolerance

-Improve QOL

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84
Q

What dose of diuretics should patients be put on?

A

Lowest dose that maintains euvolemia

(LOWEST DOSE POSSIBLE to achieve steady state)

85
Q

True or False: patients who do not have symptoms of volume overload should not receive diuretics

A

TRUE

(could imbalance electrolytes)

86
Q

How do we determine the fluid status of a person?

A

By weighing them

87
Q

What is the MOA of diuretics?

A

-Increase sodium + water excretion by reducing sodium reabsorption in the nephron

**Reduce preload and cardiac filling pressure

88
Q

Diuretics must be able to get to their site of action to elicit a response, what does this mean/ where is their site of action?

A

Work in the KIDNEYS!

*Must note that patients with HF often have a hard time perfusing their kidneys

89
Q

Where/How do loop diuretics work?

A

Thick ascending loop of henle

*This is responsible for 25% of sodium reabsorption

*Loops block the Na and Cl reabsorption here

*Downstream of this, only 5-15% of sodium is reabsorbed so it is not able to make-up for this blockage

90
Q

What 3 diuretics are the most potent?

A

Loop
Thiazides
Thiazide-like diuretics

91
Q

What is an additional benefit of loop diuretics?

A

Enhance renal release of prostaglandins

(increases renal blood flow + enhances renal capacitance)

92
Q

What drug class blocks the action of loop diuretics?

A

NSAIDs

**do not use in HF because of this

93
Q

What are the 4 loop diuretics that can be used?

A

Furosemide
Bumetanide
Torsemide
Ethacrynic acid (***patients with sulfa-allergy)

94
Q

What is an advantage of Torsemide over Furosemide?

A

Furosemide has erratic bioavailability
-torsemide may have advantage in some patients

95
Q

What is the initial oral dose + usual dose range of Furosemide?

A

In: 20-40 mg QD or BID

Us: 20-160mg QD or BID

96
Q

What is the initial oral dose+ usual dose range of Bumetanide?

A

In: 0.5-1mg QD or BID

Us: 1-2 mg QD or BID

97
Q

What is the initial oral dose + usual dose range of Torsemide?

A

In: 10-20 mg QD

Us: 10-80 mg QD

98
Q

What is the initial oral dose of ethacrynic acid?

A

25-50 mg QD or BID

99
Q

What are the IV equivalent doses of Furosemide-Bumetanide-Torsemide-Ethacrynic Acid?

A

F 40mg = B 1mg = T 20mg = E 50mg

*note: these are also all the upper bound amounts for the initial oral dosing of the medications
*KNOW

100
Q

What is an important thing to consider with Bumetanide dosing?

A

Has good oral bioavailability, use same IV dose as oral dose

101
Q

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

A. Furosemide PO 80 mg

*note: bumetanide bioavailability is the same in both po and IV

*IV F 40mg = IV B 1mg

*Have to multiply F IV dose by 2 for PO dosing

102
Q

When would we use thiazide and thiazide-like diuretics?

A

In patients with mild HF and small amounts of fluid retention

As an add-on to loop diuretics when resistant

103
Q

How are thiazides affected by renal function?

A

*Lose effectiveness as renal function decreases (like all diuretics)

-Higher doses necessary when GFR is < 30mL/min

104
Q

True or False: Thiazides are used in combination with loop diuretics in patients who become resistant to single-drug therapy

A

TRUE

105
Q

What are the thiazide diuretics used in HF?

A

HCTZ **common
Metolazone **common
Chlorthalidone
CTZ (IV)
Indapamide

106
Q

What are initial and max doses of HCTZ?

A

In: 25 mg/day

Max: 100 mg/day

107
Q

What are the initial and max doses of Metolazone?

A

In: 2.5 mg/day

Max: 10 mg/day

108
Q

What are the initial and max doses of Chlorthalidone?

A

In: 12.5-25 mg/day

Max: 50 mg/day

109
Q

What are the adverse effects of Thiazides and Loop diuretics?

A

-Decrease Mg
-Decrease K
-Decrease Na
-Increase or Decrease Ca (loop decrease)
-Volume depletion, decrease renal function, pre-renal azotemia
*Postural hypotension
-Increase Uric Acid

110
Q

When dosing loop diuretics, what is the target weight loss per day?

A

1-2 pounds/day

(1 L of fluid)

111
Q

What are the 3 indicators of volume depletion?

A

-Increased SeCr

-Increased BUN/Cr ratio

-Hypotension

112
Q

What is a normal BUN and Cr?

A

BUN: 10-20

Cr: 1

**a ratio greater than 20/1 indicates dehydration

113
Q

How do you dose loop diuretics?

A

Start at low dose and double based on weight loss and diuresis

114
Q

When/what should you monitor loop diuretics?

A

1-2 weeks after initiation or increase

-Fluid intake
-Urinary output
-Body weight
-S/s of congestion or JVD
-BP
-Electrolytes (K and Mg)
-Renal function

115
Q

When do we replace K during treatment?

A

If K < 4, replace to > or = 4.0 mEq/L

116
Q

When do we replace Mg during treatment?

A

If Mg < 2, replace to > or = 2.0 mEq/L

117
Q

What stage patients should receive diuretics?

A

Stage B: No, unless they have hypertension or rEF and use HCTZ already

Stage C: Everybody with symptoms gets lowest dose possible

118
Q

What are the 3 types of RAS inhibitors?

A

ARNi
ACEi
ARB

119
Q

Why do we want to block the RAAS system?

A

-Enhances hypertrophy of cardiac cells
-Cell death
-Fibrosis
-Arrhythmias

120
Q

Who should receive ACEi?

A

ALL HF PATIENTS
-regardless or type or severity of disease

121
Q

What is the MOA of ACEi?

A

Block the conversion of Angiotensin I to Angiotensin II
*however, this can still happen by a non-specific pathway but it is substantially lower

Also prevent the degradation of bradykinin
*this is what causes the cough side effect!

(think of ACEi as dual vasodilator, venous and arterial effects)

122
Q

What are the 3 most commonly used ACEi in HF and what is the TARGET DOSING of each that equal each other?

A

Enalapril 20mg = Captopril 150mg = Lisinopril 20 mg

123
Q

What is the initial and target dosing of Enalapril?

A

In: 2.5-5 mg BID

Targ: 10 mg BID (20)

124
Q

What is the initial and target dosing of Captopril?

A

In: 6.25-12.5 mg TID

Targ: 50 mg TID

125
Q

What is the initial and target dosing of Lisinopril?

A

In: 2.5-5 mg QD

Targ: 20-40 mg QD

126
Q

In patients with CrCl<30 OR Serum Creatinine > 3, how do we adjust mortality dosing?

A

Target dose should be 1/2 of the mortality dose for that drug

127
Q

How should we titrate ACEi?

A

Start low and double every 1-4 weeks until target dose is reached

128
Q

In what patients should we use caution when prescribing ACEi?

A

Volume depleted
SBP < 80
K > 5
SeCr > 3

129
Q

What serum creatinine level is considered high (bad)?

A

> 3

*requires ACEi dose adjustment

130
Q

What are the contraindications for ACEi?

A

-Pregnancy

-Angioedema or hypersensitivity

-Bilateral renal artery stenosis (atherosclerosis in both arteries leading to kidneys)

-Well-documented intolerance (symptomatic hypotension, decline in renal function, hyperkalemia, cough)

131
Q

What should we monitor when starting ACEi?

A

-Volume status
-Renal function
-Potassium
-SeCr (rise expected, <30% is ok)
-Blood pressure

132
Q

When should we monitor renal function and K levels with ACEi?

A

Prior to therapy

1-2 weeks after each dose increase

3-6 month intervals

When other treatments added that may decrease renal function

Patients with history of renal dysfunction

133
Q

When starting an ACEi, what level of SeCr RISE is acceptable?

A

<30%

134
Q

What are the side effects of ACEi?

A

-Hypotension
-Functional renal insufficiency
-Hyperkalemia
-Skin rash and dysgeusia (captopril)
-Cough
-Angioedema

135
Q

What is the MOA of ARBs?

A

Directly antagonize the effects of Angiotensin at the Angiotensin 2 receptor

*no effect on bradykinin but more blockade of angiotensin

136
Q

What are the 3 main ARBs used in HF?

A

Losartan (Cozaar)
Valsartan (Diovan)
Candesartan (Atacand)

137
Q

What is the initial and target dosing of Losartan?

A

In: 25-50 mg QD

Targ: 150 mg QD

138
Q

What is the initial and target dosing of Valsartan?

A

In: 20-40 BID

Targ: 160 BID

139
Q

What is the initial and target dosing of Candesartan?

A

In: 4 mg QD

Targ: 32 mg QD

140
Q

When would we use an ARB?

A

-Already on it for another reason
-ACEi induced cough
-ACEi induced angioedema (carefully monitor)

141
Q

What is the MOA of Angiotensin Receptor Neprilysin Inhibitors (ARNi)?

A

Affect both the NP system and the RAAS system
-blocks the angiotensin receptor
-inhibits BNP degradation

*dual action makes drug more beneficial

142
Q

What is the only ARNi currently available?

A

Sacubitril/Valsartan
(Entresto)

143
Q

What are the available doses of Entresto?

A

S 24mg, V 26mg

S 49mg, V 51mg

S 97mg, V 103mg

144
Q

What are the adverse effects of Entresto (Sacubitril/Valsartan)?

A

-Hypotension
-Elevated SeCr, k
-Angioedema

-Pregnancy contraindicated

145
Q

What is the cost of Entresto?

A

about $600/month

146
Q

What was the trial that tested ARNi vs ACEi?

A

Paradigm-HF trial

(think that the goal of the trial was to create a paradigm shift in HF treatment)

147
Q

What are the 3 specific criteria that patients had to meet in the Paradigm-HF trial for use of ARNi?

A

SBP >100
K <5.2
eGFR >30

148
Q

For patients currently taking a high-dose ACEi or ARB, what are the starting and max doses of Entresto they can receive?

A

Start: S 49/V 51 mg BID

Max: S 97/ V 103 mg BID

*High dose ACEi= >10 mg/day enalapril or equivalent

*High dose ARB= > 160 mg/ day valsartan or equivalent

149
Q

What is considered a high-dose ACEi?

A

> 10 mg/day enalapril or equivalent

150
Q

What is considered a high-dose ARB?

A

> 160 mg/day valsartan or equivalent

151
Q

What Entresto dose should patients on a low-medium ACEi/ARB dose or who are ACEi/ARB naive receive?

A

24/26 mg BID

152
Q

Besides low-medium dose ACEi/ARB patients, who else should receive an initial Entresto dose of 24/26 mg BID?

A

eGFR < 30
Moderate hepatic impairment
Age > 75

153
Q

How soon before starting an ARNi should an ACEi be stopped?

A

36 hours

154
Q

What are the contraindications for ARNi’s?

A

Angioedema with an ACEi or ARB
Pregnancy
Lactation
*Starting within 36 hours of being on an ACEi

155
Q

What RAAS inhibitor should be used as first-line treatment in Stage B patients?

A

ACEi

(then ARB if intolerant)

156
Q

What RAAS inhibitor should be used as first-line treatment in Stage C patients?

A

ARNi preferred!!!!

-Then ACEi, then ARB

157
Q

True or False: Replacing an ACEi or ARB with an ARNi further reduces mortality

A

TRUE

158
Q

What Stages of heart failure should ARNi’s be used in?

A

Stage C

**not B!!!

159
Q

What are the 3 beta blockers we use in HF treatment?

A

Carvedilol
Metoprolol Succinate (XL)
Bisoprolol

160
Q

One is a proposed benefit of beta blocker usage?

A

Able to reverse remodeling

161
Q

What is the MOA of beta blockers in HF?

A

Increased norepinephrine in the heart has many detrimental effects:
-Beta-adrenergic receptor pathway desensitization leads to impaired exercise tolerance
-Myocyte toxicity leads to myocardial dysfunction

*These both lead to HF

*Want to block the effects of increased cardiac NE with beta blockers

162
Q

What neurotransmitters are blocked by beta blockers?

A

Norepinephrine
Epinephrine
Angiotensin II

*all blocked from reaching the myocyte and stimulating beta and AT receptors

163
Q

By blocking neurotransmitters, what are beta blockers decreasing?

A

-Arrythmias
-Cardiac hypertrophy and cell death
-Vasoconstriction
-Heart Rate
-Cardiac remodeling

164
Q

What patients should not receive beta blockers or have them titrated if already on?

A

Unstable HF patients

Patients who are not euvolemic

*Cautiously consider in patients with bronchospastic disease and asymptomatic bradycardia

*CAN administer to hospitalized patients, but do so later in their stay

165
Q

Why should beta blockers not be discontinued abruptly?

A

Rebound hypertension

(because of upregulation in beta receptors while on a beta blocker that can now all be activated)

166
Q

What is the initial and target dose of bisoprolol (Zebeta)?

A

Init: 1.25 mg daily

Target: 10 mg daily

167
Q

What is the initial and target dose of Carvedilol (Both Coreg and Coreg CR)?

A

Coreg:
Init: 3.125 mg BID
Targ: 25-50 mg BID

Coreg CR:
Init: 10 mg daily
Targ: 80 mg daily

168
Q

What is the initial and target dose of Metoprolol CR/XL (succinate)?

A

Init: 12.5-25 mg daily

Targ: 200 mg daily

169
Q

How do we titrate beta blockers?

A

Double the dose ever 2 weeks

Aim for target dose in 8-12 weeks

Monitor for symptomatic hypotension and HR
Monitor for edema, fluid retention, fatigue, and weakness

170
Q

What is the goal heart rate of beta blockers in HF?

A

NO GOAL
-just want to get to therapeutic dose
-do not push HR below 50 bpm
-avoid symptomatic brdycardia

171
Q

What stage of heart failure patients should receive beta blockers?

A

BOTH B and C!

*all patients

172
Q

What does elevated aldosterone in HF lead to?

A

-Continued sympathetic activation
-Parasympathetic inhibition
-Cardiac and vascular remodeling

173
Q

What are the two Aldosterone Receptor Antagonists (MRA)?

A

Spironolactone (nonselective)

Eplerenone (selective)

174
Q

What affect do MRA’s have on electrolytes?

A

Decrease K and Mg losses (increase these)
(protects against arrythmias)

Decrease Na retention
(decreases fluid retention)

175
Q

What are the adverse effects of spironolactone?

A

Gynecomastia
Impotence
Menstrual Irregularities

176
Q

What is the initial and maintenance dosing of eplerenone?

A

CrCl > = 50:
Init: 25 mg QD
Maint: 50 mg QD

CrCl 30-49:
Init: 25 mg every other day
Maint: 25 mg QD

177
Q

What is the initial and maintenance dosing of spironolactone?

A

CrCl > = 50:
Init: 12.5-25 mg QD
Maint: 25 mg QD

CrCl 30-49:
Init: 12.5 mg QD or every other day
Maint: 12.5-25 mg QD

178
Q

When should MRA’s be avoided?

A

SeCr > 2.5 mg/dL (men) or >2 mg/dL (women)

CrCl < 30 mL/min

K > 5 mEq/L *

History of severe hyperkalemia

Recent worsening renal symptoms

179
Q

What drug class should be avoided with MRA’s?

A

NSAIDs

180
Q

What should be monitored with MRA’s?

A

Renal function and K: within 3 days-1 week after a change, then every month for 3 months, then every 3-4 months and with ACEi or ARB change

181
Q

What Stage heart failure patients should receive MRA’s?

A

NOT STAGE B

Stage C: Patients with class II-IV and HFrEF

182
Q

At what K level should MRA’s be DISCONTINUED?

A

5.5

*if it cannot be maintained be low this level, discontinue

183
Q

What are the mechanisms by which SGLT2i work?

A

-Reduce preload
-Reduce afterload
-Cause diuresis

Possible ways they reduce mortality:

-Myocardial energetics and metabolomics (effect mitochondrial use of oxygen)
-Direct effects on myocardium
**Reduced myocardial remodeling

184
Q

What are the 2 SGLT2i used in HF and how are they dosed?

A

Dapagliflozin (Farxiga): 10 mg QD

Empagliflozin (Jardiance): 10 mg QD

185
Q

What levels of renal function are required to use the two SGLT2i?

A

Dapa: eGFR >= 30

Empa: eGFR >= 20

186
Q

What are the adverse effects associated with SGLT2i?

A

-Volume depletion
-Ketoacidosis
-Hypoglycemia
-Infection risk (UTI* empagliflozin*)

187
Q

Who should receive SGLT2i?

A

ALL HFrEF patients with symptoms

188
Q

What are the effects of ISDN/Hydralazine?

A

Reduces both preload and afterload

(balanced vasodilatory effects)

*First drug combo to reduce mortality

189
Q

When do we use ISDN/Hydralazine (BiDil)?

A

ADJUNCT to standard treatment of HF in black patients

190
Q

What is a problem associated with ISDN/Hydralazine (BiDil) use?

A

Many adverse effects!

-Headache, nausea, flushing, dizziness, tachycardia, hypotension, high HR, myocardial ischemia, fluid retention
**Lupus-like syndrome

*does not help that we have to use it at high doses

191
Q

What are the initial and target doses of ISDN/Hydralazine (BiDil)?

A

Init: I 20/ H 37.5 mg TID

Target: I 40/ H 75 mg TID

192
Q

What class of HF patients should receive ISDN/Hydralazine (BiDil)?

A

NOT STAGE B

Stage C:
-black patients who are class 3-4, receiving optimal therapy, and continue to have symptoms
-patients who cannot receive ARNI, ACEi, or ARB

193
Q

When would we use Ivabradine (Corlanor)?

A

To reduce the risk of hospitalizations in patients with:
EF <= 35%
HR >= 70 *on max beta blocker

194
Q

What is the dosing of Ivabradine (Corlanor)?

A

Initial: 2.5-5 mg BID

Adjust every 2 weeks based on HR:
>60: Increase by 2.5 up to 7.5 mg BID
50-60: Maintain dose
<50: Decrease dose by 2.5 mg BID

195
Q

What are the adverse effects of Ivabradine?

A

-Fetal toxicity
-Afib
-Bradycardia and conduction disturbances

*cost is a major downside of this drug (>$6000/year)

196
Q

what drugs should be avoided with Ivabradine?

A

Ketoconazole
Diltiazem + Verapamil

*Grape Fruit Juice

*Drug is a CYP3A4 substrate

197
Q

What is the MOA of Digoxin?

A

Blocks the Na/K ATPase
*this leads to an increase of intracellular Ca concentrations which INCREASES CONTRACTILITY
*positive inotrope

Stimulates the PSNS which counteracts the SNS to REDUCE HR
(neurohormonal modulation effects)

198
Q

When do we use Digoxin?

A

In patients with symptoms despite optimized therapy or who cannot tolerate the guideline directed therapy

*Decreases hospitalizations in these patients but not mortality

199
Q

What is the typical dosing of Digoxin?

A

0.125-0.25 mg QD

*Note: narrow therapeutic index drug, have to be careful dosing

200
Q

What is the goal serum digoxin concentration?

A

0.5-0.9 ng/mL

201
Q

Who should receive lower doses of Digoxin?

A

> 70 yrs old
Impaired renal function
Low weight

202
Q

What drugs interact with Digoxin?

A

-Amiodarone
-Quinidine
-Verapamil***
*Itraconazole/Ketoconazole

*Need to decrease digoxin dosing when these are started!

203
Q

What are the adverse effects associated with Digoxin?

A

Anorexia, nausea, vomiting, abdominal pain
*Visual disturbances
Fatigue, weakness, dizziness, headache, neuralgias, confusion, delirium, psychosis

Many cardiac symptoms

204
Q

When should we use Vericiguat?

A

To reduce CV death and hospitalization

*Consider in select high-risk patients with recent worsening symptoms despite optimized therapy

205
Q

When is aspirin recommended in HF?

A

For patients with HF and IHD/CAD/ASCVD

*otherwise not indicated
*use 75-81 mg/day

206
Q

If we need to manage angina/HTN, what CCBs can be used?

A

Felodipine or Amlodipine

*DO NOT USE diltiazem, verapamil, or nifedipine

207
Q

What drug classes should all HFpEF patients be put on?

A

SGLT2i
-decrease mortality

**no other drugs decrease mortality and should be considered on case-to-case basis to reduce hospitalizations

208
Q

True or False: We do not use Digoxin in HFpEF

A

TRUE
-no affect on mortality or hospitalizations

Spring 2024 Therapeutics 3 (24 decks)

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