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CDM 2 > Exam 2: HF > Flashcards

Exam 2: HF Flashcards

1
Q

Maladaptive responses of NE

A

Down regulation of beta receptor

Arrhythmias

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2
Q

Maladaptive responses of ATII

A

Loss of flow-mediated vasodilation
Thickening and rigidity of arteries
Inceased afterload

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3
Q

Maladaptive responses of Aldosterone and vasopressin

A

Mechanical stress on the heart from too much preload
Thickening of LV
Apoptosis of LV endothelial cells

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4
Q

Maladaptive Responses of Endothelin

A

Hypertrophy of smooth muscles cells in vasculature

Fibrotic changes

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5
Q

Evidence-based cornerstone medications for HF

A

ACEi
BB
Aldosterone antagonists
SGLT-2i

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6
Q

Lisinopril dosing (initial and target)

A

2.5-5mg once daily

Target: 20-40mg once daily

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7
Q

Losartan dosing (initial and target)

A

25-50mg once daily

Target: 50-150mg once daily

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8
Q

Entresto dosing (initial and target)

A

49/51mg BID (or 24/26mg BID)

Target: 97/103mg BID

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9
Q

Carvedilol dosing (initial and target)

A

3.125mg BID

Target: 25-50mg BID

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10
Q

Metoprolol XL dosing (initial and target)

A

12.5-25mg once daily

200mg once daily

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11
Q

Spironolactone dosing (initial and target)

A

12.5-25mg once daily

Target: 25-50mg once daily

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12
Q

Dapagliflozin and Empagliflozin dosing (initial and target)

A

10mg once daily

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13
Q

Cautions for ACEI/ARBs

A

Cough -20% exp dry cough

Angioedema (life threatening edema of face, throat, airway)

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14
Q

ACEI/ARB monitor

A

Potassium and Scr

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15
Q

When to give reduced dose of Entresto

A

No prior ACEI/ARB or prior low dose

Severe renal impairment

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16
Q

CI of Entresto

A

Hx of angioedema related to ACEi/ARB
Concomitant ACEI (do not administer within 36hrs of ACEI)
Concomitant aliskiren in DM pts

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17
Q

When to reach target dose of Entresto

A

2-4 weeks

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18
Q

Recommendations to switch from ACEI/ARB to ARNI

A

If tolerated ACEI/ARB for 4 weeks, had recent hospitalization for HF, and no hx of angioedema

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19
Q

___ should be used in ALL pts with reduced LVEF to prevent symptomatic HF

A

BB

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20
Q

BB titration

A

Titrate every 2 weeks when pt is stable and reach optimal dose in 8-12 weeks

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21
Q

Bisoprolol vs Carvedilol vs Metoprolol XL

Bisoprolol

A

Selective B1 blocker
least lipophilic
most bioavailable

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22
Q

Bisoprolol vs Carvedilol vs Metoprolol XL

Carvedilol

A

Nonselective BB with alpha receptor blockade
Take w food
May increase digoxin levels

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23
Q

Bisoprolol vs Carvedilol vs Metoprolol XL

Metoprolol XL

A

Selective B1 blocker
XL form releases the drug over 20 hrs
May be preferred if BP is marginal

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24
Q

____ is NOT used for diuresis effects, only antagonizes effects of aldosterone on ventricular remodeling

A

Spironolactone

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25
Q

Caution for Spironolactone

A

Renal impairment SCr ≤2.5 male, ≤2 female

Potassium ≤5

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26
Q

Spironolactone vs Eplerenone

Which is more potent

A

Spironolactone

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27
Q

Spironolactone vs Eplerenone differences in MOA

A

Spironolactone: nonselective antagonist on mineralocorticoid and progesterone, androgen receptors

Eplerenone: Selective antagonist on mineralocorticoid receptor in kidney, heart, vessels

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28
Q

Spironolactone ADE

A

Gynecomastia

Increase K

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29
Q

Eplerenone ADE

A

Increase K

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30
Q

Spironolactone and Eplerenone caution

A

Hyperkalemia and CKD

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31
Q

Dapa and Empagliflozin reducing glucose reabsorption effects

A

reduce preload via natriuresis and diuresis
Improve afterload (reducing arterial pressure)
Inhibit Na/H exchange in cardiac tissue reducing/preventing hypertrophy, remodeling, fibrosis
Stimulation of glucagon producing increasing cardiac index and alternative energy supply via beta-hydroxybutyrate

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32
Q

eGFR for Dapa

A

> 30

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33
Q

eGFR for Empa

A

> 20

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34
Q

____ diuretics are the gold standard

A

Loop diuretics

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35
Q

____ may be added to loop diuretics for “diuretic resistance”

A

Thiazide (hydrochlorothaizide, metolazone)

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36
Q

Furosemide: Bumetanide: Torsemide

Equivalent PO dosing

A

40mg F:1mg B: 20mg T

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37
Q

Furosemide: Bumetanide: Torsemide

Bioavailability

A

40-70% vs 70-90% vs 85-95%

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38
Q

Furosemide: Bumetanide: Torsemide: Duration of action

A

4-6hrs vs 6-8hrs vs 12-16hrs

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39
Q

Metolazone Dosing

A

2.5mg to 10mg once or twice a WEEK

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40
Q

Advantages of metolazone compared to other thiazides

A

Effectives even if GFR <30

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41
Q

Sequential Nephron Blockade

A

Give thiazide-like diuretic at the same time or 30min prior to loop diuretic (Metolazone most commonly used)

Duration 12-72hrs (prolonged in pts with renal dysfunction)

Accumulation of doses can lead to over diuresis

Be cautious with high dose metolazone in the elderly (rec 2.5mg twice or three times weekly)

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42
Q

Treating Diuretic Resistance

A 
Switch to different loop diuretic 
Increase dose 
Lower sodium intake <2g/day 
Fluid restriction 1.5-2L/day 
Minimize DDI (NSAIDs) 
IV admin (bolus or infusion)
Sequential nephron blockade
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42
Q

Loop diuretic considerations

A

Sulfa allergy (ethacrynic acid preferred or bumetanide (sulfa but lower risk)
Dosing: titrate to I + O and body weight
Initial goal: lose 500ml to 1L a day
Split daily dose for max effect
Monitor renal function, K, Na, Mg
Monitor gout attacks
Monitor urine freq and color

43
Q

Preferred add-on for AA pts

A

Oral nitrates and hydralazine (isosorbide dinitrate + hydralazine)

44
Q

Ivabradine recommendation

A

To reduce hospitalizations in pts with stable HF, EF ≤35%, HR >70bpm on max tolerated BB

Usually COPD and hypotension pts that cannot tolerate max BB

45
Q

MOA of Ivabradine

A

Only works at the SA node by blocking the lf current; slows HR only and doe snot provide adrenergic blockade

46
Q

Digoxin: MOA

A

Neurohormonal modulator; increases parasympathetic and baroreceptor sensitivity
Weak inotrope based on inhibiting NA-K ATPase

Decreases HR via vagal effects; role in AFib

47
Q

Digoxin Cautions

A

Dose as per renal fxn and age
0.125mg daily/ every other day for >70yo, impaired renal fxn, or low BMI

Target serum conc: 0.5-0.9ng/mL

48
Q

Vericiguat Drug Class

A

Guanylyl cyclase stimulator

49
Q

Vericiguat MOA

A

Binds directly to soluble guanylyl cyclase increasing cyclic guanosine monophosphate inducing vasodilation, decreases in cardiac remodeling/fibrosis, and improving endothelial function

50
Q

Vericiguat pt population

A

NYHA II to IV on GDMT still exp elevated BNP (≥300) or NT pro-BNP ≥1000

51
Q

Vericiguat caution

A

Combo with nitrate and/or PDE5i (hypotension risk )

52
Q

Signs of congestion/volume overload

A 
Orthopnea/PND
SOB 
Distended internal jugular vein 
S3 heart sound
Pulmonary rales
Resting tachycardia
Peripheral edema
53
Q

Signs of Low perfusion

A 
Worsening renal function (Increased SCr)
Confusion
Hypotension (Low MAP) 
tachycardia
Metabolic acidosis 
Cyanosis
Cold or cool extremities
54
Q

Mean Arterial Pressure (MAP) Equation

A

(DBPx2 + SBP) / 3

55
Q

MAP should be > ___

A

> 65

56
Q

___ is helpful to assess severity of AHF

A

Cardiac index

57
Q

What is cardiac index ?

A

An assessment of CO based on pt’s size

CI = CO / body surface area

58
Q

What is normal range of CI

A

2.5-4 L/min/m2

59
Q

Poor perfusion/NOT good CI is ___

A

≤2.2 L/min/m2

60
Q

BNP <100ng/L means

A

probably not AHF

61
Q

BNP > 400ng/L means

A

probably AHF exacerbation

62
Q

BNP can be falsely ELEVATED in ___

A

CKD, AF, pulmonary HTN

63
Q

BNP can be falsely LOW in

A

obese pts, HFpeF

64
Q

___ responsible for breaking down NPs into inactive fragments (except NT-proBNP)

A

Neprilysin

65
Q

Inhibiting neprilysin increases ____ conc

A

BNP, bradykinin, and substance P

66
Q

Inhibiting neprilysin also breaks down ___

A

Angiotensin II

67
Q

Pharmacologic Management: Wet

A

Diuresis
Vasodilation (nitroglycerin>nitroprusside)

Fluid restriction
Sodium restriction
Compression devices to help move fluids from tissues into vasculature

68
Q

Pharmacologic Management: Cold

A

Inotropes

Inodilator
Pressors
Mechanical devices

69
Q

Loop diuretic conversions PO vs IV

Furosemide: Bumetanide: Torsemide

A

PO: 40mg F: 1mg B: 20mg T
PO to IV: 40mg F PO: 20mg F IV // 1mg B PO: 1mg B IV

**typically double the dose, assess response in 2 hrs (urine output 500cc or 250cc if CrCl <30)

70
Q

Diuretic considerations preventing Adverse effects

A 
Hypokalemia 
Hypomagnesemia 
Uric acid
Resistance
Reflex increase in neurohormones
71
Q

Furosemide brand name

A

Lasix

72
Q

Bumetanide brand name

A

Bumex

73
Q

Torsemide brand name

A

Demadex

74
Q

Nitroglycerin MOA

A

Biotransformed into nitrogen oxides and mimics the effects of nitric oxide, activating intracellular soluble guanylate cyclic GMP levels

Primarily venodilator (arteriodilator at higher doses)

75
Q

Nitroprusside MOA

A

Direct relaxation of smooth muscle by activating guanylate cyclase

Balanced venodilator and arteriodilator

76
Q

Nitroglycerin vasodilation effects

A

Reduce preload and pulmonary congestion

May lower systemic afterload, increase stroke volume and CO at higher doses

77
Q

Nitroprusside vasodilation effects

A

Reduction of afterload and preload

Increase CO

78
Q

Role of vasodilators

A

No clear mortality or rehospitalization benefit

Relieves symptoms of dyspnea

79
Q

Inotropes examples

A

Dobutamine

Milrinone

80
Q

Dobutamine MOA

A

Inotrope

Stimulates B1 and B2 receptors

81
Q

Milrinone MOA

A

INO-dilator

Acts on PDE3 in cardiac and vascular tissue

82
Q

When to choose dobutamine

A

Hypotension and renal insufficiency

83
Q

When to choose milrinone

A

Increased pulmonary artery pressure

Need for beta blockade (arrhythmia – on a BB)

84
Q

Which inotrope causes hypotension

A

Milrinone

85
Q

Which inotrope reduces PAP and afterload

A

Milrinone

86
Q

Which inotrope has minimal effect on MAP

A

Dobutamine

87
Q

Which inotrope increases CO (CI)

A

Both dobutamine and milrinone

88
Q

What is cardiogenic shock?

A

persistent hypotension and tissue hypoperfusion due to cardiac dysfunction in the presence of adequate vascular volume

SBP <90 for >30 min
Low CI <2.2
Elevated PCWP >15mmHg

Oliguria, cool extremities, poor mentation

89
Q

Treating cardiogenic shock

A

Maintain MAP

Initial treatment = Pressors

90
Q

Which receptors does epinephrine work on

A

Alpha, B1, B2

91
Q

Which receptors does phenylephrine work on?

A

Alpha

92
Q

Which receptors does vasopressin work on

A

V1 receptor

93
Q

Epinephrine effect on SBP, CO, SVR

A

Increase SBP, CO, SVR

94
Q

NE effcct on SBP, CO, SVR

A

SBP, SVR

95
Q

Phenylephrine effect on SBP, CO, SVR

A

SBP, SVR

96
Q

Dopamine effect on SBP, CO, SVR

A

CO and SVR

97
Q

Vasopressin effect on SBP, CO, SVR

A

SBP, SVR

98
Q

Which pressors may cause hyperglycemia

A

Epinephrine

NE

99
Q

____ is associated with lower mortality than dopamine and a lower risk of arrhythmias

A

NE

100
Q

___ is less arrythmogenic than NE or EPI

A

Phenylephrine

101
Q

Phenylephrine: avoid in pts with low ___

A

CO

102
Q

T/F: Phenylephrine may cause reflex bradycardia

A

Treu

103
Q

Dopamine: avoid doses ____ in HFA

A

≥15mcg/kg/min

104
Q

Dopamine may cause ___

A

Arrhythmias, myocardial ischemia, and hyperglycemia

105
Q

Vasopressin has no outcomes data in ___

A

cardiogenic shock

CDM 2 (8 decks)

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