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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
Caution for Spironolactone
Renal impairment SCr ≤2.5 male, ≤2 female | Potassium ≤5
26
Spironolactone vs Eplerenone | Which is more potent
Spironolactone
27
Spironolactone vs Eplerenone differences in MOA
Spironolactone: nonselective antagonist on mineralocorticoid and progesterone, androgen receptors Eplerenone: Selective antagonist on mineralocorticoid receptor in kidney, heart, vessels
28
Spironolactone ADE
Gynecomastia | Increase K
29
Eplerenone ADE
Increase K
30
Spironolactone and Eplerenone caution
Hyperkalemia and CKD
31
Dapa and Empagliflozin reducing glucose reabsorption effects
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
32
eGFR for Dapa
>30
33
eGFR for Empa
>20
34
____ diuretics are the gold standard
Loop diuretics
35
____ may be added to loop diuretics for "diuretic resistance"
Thiazide (hydrochlorothaizide, metolazone)
36
Furosemide: Bumetanide: Torsemide Equivalent PO dosing
40mg F:1mg B: 20mg T
37
Furosemide: Bumetanide: Torsemide | Bioavailability
40-70% vs 70-90% vs 85-95%
38
Furosemide: Bumetanide: Torsemide: Duration of action
4-6hrs vs 6-8hrs vs 12-16hrs
39
Metolazone Dosing
2.5mg to 10mg once or twice a WEEK
40
Advantages of metolazone compared to other thiazides
Effectives even if GFR <30
41
Sequential Nephron Blockade
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)
42
Treating Diuretic Resistance
``` 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 ```
42
Loop diuretic considerations
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
Preferred add-on for AA pts
Oral nitrates and hydralazine (isosorbide dinitrate + hydralazine)
44
Ivabradine recommendation
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
MOA of Ivabradine
Only works at the SA node by blocking the lf current; slows HR only and doe snot provide adrenergic blockade
46
Digoxin: MOA
Neurohormonal modulator; increases parasympathetic and baroreceptor sensitivity Weak inotrope based on inhibiting NA-K ATPase Decreases HR via vagal effects; role in AFib
47
Digoxin Cautions
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
Vericiguat Drug Class
Guanylyl cyclase stimulator
49
Vericiguat MOA
Binds directly to soluble guanylyl cyclase increasing cyclic guanosine monophosphate inducing vasodilation, decreases in cardiac remodeling/fibrosis, and improving endothelial function
50
Vericiguat pt population
NYHA II to IV on GDMT still exp elevated BNP (≥300) or NT pro-BNP ≥1000
51
Vericiguat caution
Combo with nitrate and/or PDE5i (hypotension risk )
52
Signs of congestion/volume overload
``` Orthopnea/PND SOB Distended internal jugular vein S3 heart sound Pulmonary rales Resting tachycardia Peripheral edema ```
53
Signs of Low perfusion
``` Worsening renal function (Increased SCr) Confusion Hypotension (Low MAP) tachycardia Metabolic acidosis Cyanosis Cold or cool extremities ```
54
Mean Arterial Pressure (MAP) Equation
(DBPx2 + SBP) / 3
55
MAP should be > ___
>65
56
___ is helpful to assess severity of AHF
Cardiac index
57
What is cardiac index ?
An assessment of CO based on pt's size CI = CO / body surface area
58
What is normal range of CI
2.5-4 L/min/m2
59
Poor perfusion/NOT good CI is ___
≤2.2 L/min/m2
60
BNP <100ng/L means
probably not AHF
61
BNP > 400ng/L means
probably AHF exacerbation
62
BNP can be falsely ELEVATED in ___
CKD, AF, pulmonary HTN
63
BNP can be falsely LOW in
obese pts, HFpeF
64
___ responsible for breaking down NPs into inactive fragments (except NT-proBNP)
Neprilysin
65
Inhibiting neprilysin increases ____ conc
BNP, bradykinin, and substance P
66
Inhibiting neprilysin also breaks down ___
Angiotensin II
67
Pharmacologic Management: Wet
Diuresis Vasodilation (nitroglycerin>nitroprusside) Fluid restriction Sodium restriction Compression devices to help move fluids from tissues into vasculature
68
Pharmacologic Management: Cold
Inotropes Inodilator Pressors Mechanical devices
69
Loop diuretic conversions PO vs IV | Furosemide: Bumetanide: Torsemide
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
Diuretic considerations preventing Adverse effects
``` Hypokalemia Hypomagnesemia Uric acid Resistance Reflex increase in neurohormones ```
71
Furosemide brand name
Lasix
72
Bumetanide brand name
Bumex
73
Torsemide brand name
Demadex
74
Nitroglycerin MOA
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
Nitroprusside MOA
Direct relaxation of smooth muscle by activating guanylate cyclase Balanced venodilator and arteriodilator
76
Nitroglycerin vasodilation effects
Reduce preload and pulmonary congestion | May lower systemic afterload, increase stroke volume and CO at higher doses
77
Nitroprusside vasodilation effects
Reduction of afterload and preload | Increase CO
78
Role of vasodilators
No clear mortality or rehospitalization benefit | Relieves symptoms of dyspnea
79
Inotropes examples
Dobutamine | Milrinone
80
Dobutamine MOA
Inotrope | Stimulates B1 and B2 receptors
81
Milrinone MOA
INO-dilator | Acts on PDE3 in cardiac and vascular tissue
82
When to choose dobutamine
Hypotension and renal insufficiency
83
When to choose milrinone
Increased pulmonary artery pressure | Need for beta blockade (arrhythmia -- on a BB)
84
Which inotrope causes hypotension
Milrinone
85
Which inotrope reduces PAP and afterload
Milrinone
86
Which inotrope has minimal effect on MAP
Dobutamine
87
Which inotrope increases CO (CI)
Both dobutamine and milrinone
88
What is cardiogenic shock?
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
Treating cardiogenic shock
Maintain MAP | Initial treatment = Pressors
90
Which receptors does epinephrine work on
Alpha, B1, B2
91
Which receptors does phenylephrine work on?
Alpha
92
Which receptors does vasopressin work on
V1 receptor
93
Epinephrine effect on SBP, CO, SVR
Increase SBP, CO, SVR
94
NE effcct on SBP, CO, SVR
SBP, SVR
95
Phenylephrine effect on SBP, CO, SVR
SBP, SVR
96
Dopamine effect on SBP, CO, SVR
CO and SVR
97
Vasopressin effect on SBP, CO, SVR
SBP, SVR
98
Which pressors may cause hyperglycemia
Epinephrine | NE
99
____ is associated with lower mortality than dopamine and a lower risk of arrhythmias
NE
100
___ is less arrythmogenic than NE or EPI
Phenylephrine
101
Phenylephrine: avoid in pts with low ___
CO
102
T/F: Phenylephrine may cause reflex bradycardia
Treu
103
Dopamine: avoid doses ____ in HFA
≥15mcg/kg/min
104
Dopamine may cause ___
Arrhythmias, myocardial ischemia, and hyperglycemia
105
Vasopressin has no outcomes data in ___
cardiogenic shock

CDM 2 (8 decks)

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