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Therapeutics > Exam 2 lecture 2 > Flashcards

Exam 2 lecture 2 Flashcards

1
Q

potential pharmacologic strategies for HF

A

reduce intravascular volume
increase myocardial contractility
reduce ventricular afterload
neurohormonal blockade

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2
Q

drugs that can reduce intravascular volume

A

diuretics and SGLT2i

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3
Q

Drugs that increase myocardial contractility

A

positive inotropes

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4
Q

reduce ventricular afterload

A

ACEIs, vasodilators

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5
Q

GDMT for stage A

A

ACE/ARB

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6
Q

GDMT for stage B

A

ACE/ARB
B Blocker

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7
Q

GDMT for stage C

A

ARNI (preferred)/ACE/ARB
BB
MRA
SGLT2i

loop diuretic if volume overloaded

some pts going to be on ivabradine, digoxin, ISDN/hydralazine

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8
Q

What are the only BB we can use for stage C

A

metoprolol succinate, bisoprolol, carvedilol

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9
Q

Know dose and brand name of metoprolol succinate, bisoprolol and carvedilol

A
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10
Q

do diuretics reduce mortality

A

NO

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11
Q

place of diuretics in HF

A

all HF pts with s/s of fluid retention (symptomatic) should be managed with diuretics. They reduce hospitalizations. They improve QOL

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12
Q

should pts who do not have symptoms of volume overload receive diuretics

A

no

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13
Q

short term benefits and long term benefits of diuretics

A

short term- reduce fluid retention, lower edema, preload and JVD

long term- reduce symptoms and improve ability to exercise

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14
Q

MOA of diuretics

A

reduce Na and H20 excretion by reducing Na reabsorption at various sites in nephron

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15
Q

90-95% of Na is filtered at

A

glomerulus

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16
Q

70% of Na reabsorption is at

A

PCT

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17
Q

20-25% of Na reabsorbed at

A

ALH

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18
Q

Most potent group of diuretics? MOA?

A

Loop diuretics. Block Na and Cl- reabsorption in ALH

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19
Q

loop diuretics additional benefits

A

enhance renal release of prostaglandins (increase renal blood flow and enhance venous capacity)

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20
Q

what is the advantage of torsemide over furosemide

A

Furosemide has erratic bioavailability, torsemide may have an advantage in some pts

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21
Q

Name loop diuretics

A

furosemide
torsemide
bumetanide
ethacrynic acid

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22
Q

Furosemide dose and bioavailability

A

20-40 mg- 50% bioavailability

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23
Q

Bumetanide dose and bioavailability

A

0.5-1 mg - 80-100% bioavailability

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24
Q

Torsemide dose and bioavailability

A

10-20 mg- 80-100% bioavailability

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25
Q

ethacrynic acid bioavailability

A

100%

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26
Q

What are the IV equivalent of the different loop diuretics

A

Furosemide 40mg =Bumetanide 1mg =Torsemide 20 mg= Ethacrynic acid 50 mg

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27
Q

how do thiazides work?

A

block Na and Cl reabsorption

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28
Q

When can we use thiazide drugs?

A

Mild HF with small amounts of fluid retention
higher doses necessary when GFR is below 30

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29
Q

thiazide drugs

A

HCTZ, metalizone, chlorthalidone, CTZ, indapemide

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30
Q

K sparring diuretics drugs? how do they work?

A

spironolactone and eplerenone.
work by blocking aldosterone

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31
Q

rules for diuretic initiation

A

initiate at lowest dose and double
if fluid overloaded, reduce weight 1-2 lbs/day

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32
Q

when should patients report weight gain

A

3-5 lbs/week

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33
Q

what are some factors that may be indicative of volume depletion

A

BUN/Cr, increase in SeCr, hypotension

34
Q

is hypocalcemia caused by thiazides or loop diuretics?
What about hypercalcemia

A

hypercalcemia- thiazides
hypocalcemia-loop diuretics

35
Q

How do you assess volume depletion in a patient

A

Increase in serum creatinine, increase in BUN and/Cr ratio and hypotension

36
Q

What BUN/Cr ratio shows dehydration

A

BYN/Cr>20

37
Q

What happen to hemoglobin and hematocrit in dehydration

A

increase

38
Q

monitoring diuretics

A

1-2 weeks after initiation and increase

BP
serum creatinine
replace K if < or =4 and if mg< or = 2
renal function

39
Q

Lasix (furosemide) acts on what part of kindey

A

ALH

40
Q

Which stage of HF to use diuretics in

A

Stage C
(use at lowest possible dose to maintain euvolemia)

should not be used in stage B unless HTN and reduced EF

41
Q

what are the RAAS inhibitor drugs

A

ARNI, ACEI, ARB

42
Q

does ACEi reduce mortality? hospitalization? symptoms? does it slow progression?

A

yes to all

43
Q

How do ACEi work?

A

block conversion of angiotensin I to angiotensin II
Also blocks bradykinin (may cause cough)

44
Q

Are ACEi venous or arterial dilators?

A

Both (balanced vasodilator)

45
Q

Why do ACEi work?

A

Inhibition of cardiac hypertrophy, reduces remodelling

46
Q

starting doses for ACEi

A

Enalapril- 2.5-5mg BID
Captopril- 6.25-12.5mmg TID
lisinopril- 2.5-5 mg QD

47
Q

ACE i target doses

A

Enalapril- 10 mg BID
captopril- 50 mg TID targeted
lisinopril- 20-40 mg QD

48
Q

ACEi brand and generic names

A

Enalapril- vasotec
captopril- capoten
lisinopril- prinivil, zestril)

49
Q

What is the important doses to remember for ACEi conversion

A

20 mg enalapril/day=150 mg captopril/day=20 mg lisinopril/day

50
Q

Why are ACE inhibitors under used and under dosed

A

CKD
Hypotension

51
Q

ACE inhibitor dose increase

A

Start low and double dose every 1-4 weeks. Caution if volume depleted.

52
Q

when are lower dose and monitoring are required for ACEi

A

serum creatinine>3 and/or CrCl<30

53
Q

Absolute contraindications of ACEi

A

pregnancy
history of angioedema

54
Q

monitoring for ACEi

A

renal function and K+
BP
SCr

55
Q

What is an acceptable rise in SCr for ACEi

A

30%

56
Q

adverse effects of ACEi

A

hypotension
cough
angioedema
hyperkalemia
Captopril may cause skin rash and dysgausea

57
Q

How do ARBs work

A

Blocks effects of angiotensin II at the AT1 receptor

58
Q

What does blocking AT1 receptor lead to?

A

decrease in
myocardial fibrosis
norepinephrine
vasoconstriction
PAi/Endothelin

59
Q

ACEi drug names with bran and starting and target doses

A

Losartan- Cozaar
Valsartan-diovan
Candesartan- atacand

initial
Losartan- 25-50 QD
Valsartan- 20-40 BID
Candesartan- 4 mg QD

target
losartan- 150 QD
valsartan- 160 BID
candesartan- 32 mg QD

60
Q

when to give ARB instead of ACE

A

if unable to take ACEi due to cough.
Ace-i induced angioedema

61
Q

ARNI MOA and drug name

A

has a dual effect on the RAAS system and NP system (AT1 receptor blockade and inhibition of degradation of BNP

sacubitril/valsartan (entresto)

62
Q

entresto dose equivalence to valsartan

A

26=40
51=80
103=160

63
Q

adverse effects of entresto

A

hypotension
angioedema
costs 600/month (expensive)

64
Q

LCZ696 (valsartan/sacubitril) vs enalapril compare common adverse effects

A

Hypotension more common in LCZ696
elevates Scr, SeK, cough more in enalapril

65
Q

rules when switching from ACE or ARB to ARNI

A

if we have a patient on a high dose ACE inhibitor (>10 mg enalapril or equivalent) start on a high dose

if we have a patient on 160 mg total daily valsartan or equivalent, start on a higher dose

66
Q

How to dose entresto when switching from high dose ACE/ARB

A

S 49/ V 51 mg BID
titrate to 97/103 mg BID

67
Q

when to use lower dose entresto

A

ACE/ARB naive
low to medium dose ACE/ARB
eGFR<30
Age>75
moderate hepatic impairement

68
Q

What dose to start for non high dose entresto

A

24/26 mg BID

69
Q

precaution to take when switching from ACE to ARNI

A

do not give dose within 36 hours of last dose

70
Q

contraindications of entresto

A

Any ACE/ARB
pregnancy
if pt had angioedema with ACE/ARB
within 36 hrs of ACE use

71
Q

when and how to use ARNI/ACE/ARB

A

stage B- ACE 1st choice (ARB if intolerant to ACE).
ARNI not indicated in stage B

Stage C- ARNI is the drug of choice, if CI use ACE, then ARB

72
Q

Can we use ARNI for stage B

A

no

73
Q

If patient is on an ACE/ARB for stage C is it beneficial to switch to ARNI or not

A

switch it as it is more beneficial

74
Q

entresto Contraindications

A

hyperkalemia
angioedema
SBP<100

75
Q

We can add amlodipine in HF. T/F

A

false

76
Q

Do BB reduce hospitalization? mortality?

A

Both reduces

77
Q

What are the only BB we can use for HF

A

carvedilol, metoprolol succinate and bisoprolol

78
Q

mechanism for why BB is good in HF

A

reverse remodeling

79
Q

patient selection for BB

A

Pt has to be stable (no signs of edema)
symptomatic pts should receive diuretics also

if recent hx of asthma avoid until controlled

80
Q
A

Therapeutics (38 decks)

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