Exam 2 lecture 2 Flashcards
potential pharmacologic strategies for HF
reduce intravascular volume
increase myocardial contractility
reduce ventricular afterload
neurohormonal blockade
drugs that can reduce intravascular volume
diuretics and SGLT2i
Drugs that increase myocardial contractility
positive inotropes
reduce ventricular afterload
ACEIs, vasodilators
GDMT for stage A
ACE/ARB
GDMT for stage B
ACE/ARB
B Blocker
GDMT for stage C
ARNI (preferred)/ACE/ARB
BB
MRA
SGLT2i
loop diuretic if volume overloaded
some pts going to be on ivabradine, digoxin, ISDN/hydralazine
What are the only BB we can use for stage C
metoprolol succinate, bisoprolol, carvedilol
Know dose and brand name of metoprolol succinate, bisoprolol and carvedilol
do diuretics reduce mortality
NO
place of diuretics in HF
all HF pts with s/s of fluid retention (symptomatic) should be managed with diuretics. They reduce hospitalizations. They improve QOL
should pts who do not have symptoms of volume overload receive diuretics
no
short term benefits and long term benefits of diuretics
short term- reduce fluid retention, lower edema, preload and JVD
long term- reduce symptoms and improve ability to exercise
MOA of diuretics
reduce Na and H20 excretion by reducing Na reabsorption at various sites in nephron
90-95% of Na is filtered at
glomerulus
70% of Na reabsorption is at
PCT
20-25% of Na reabsorbed at
ALH
Most potent group of diuretics? MOA?
Loop diuretics. Block Na and Cl- reabsorption in ALH
loop diuretics additional benefits
enhance renal release of prostaglandins (increase renal blood flow and enhance venous capacity)
what is the advantage of torsemide over furosemide
Furosemide has erratic bioavailability, torsemide may have an advantage in some pts
Name loop diuretics
furosemide
torsemide
bumetanide
ethacrynic acid
Furosemide dose and bioavailability
20-40 mg- 50% bioavailability
Bumetanide dose and bioavailability
0.5-1 mg - 80-100% bioavailability
Torsemide dose and bioavailability
10-20 mg- 80-100% bioavailability
ethacrynic acid bioavailability
100%
What are the IV equivalent of the different loop diuretics
Furosemide 40mg =Bumetanide 1mg =Torsemide 20 mg= Ethacrynic acid 50 mg
how do thiazides work?
block Na and Cl reabsorption
When can we use thiazide drugs?
Mild HF with small amounts of fluid retention
higher doses necessary when GFR is below 30
thiazide drugs
HCTZ, metalizone, chlorthalidone, CTZ, indapemide
K sparring diuretics drugs? how do they work?
spironolactone and eplerenone.
work by blocking aldosterone
rules for diuretic initiation
initiate at lowest dose and double
if fluid overloaded, reduce weight 1-2 lbs/day
when should patients report weight gain
3-5 lbs/week
what are some factors that may be indicative of volume depletion
BUN/Cr, increase in SeCr, hypotension
is hypocalcemia caused by thiazides or loop diuretics?
What about hypercalcemia
hypercalcemia- thiazides
hypocalcemia-loop diuretics
How do you assess volume depletion in a patient
Increase in serum creatinine, increase in BUN and/Cr ratio and hypotension
What BUN/Cr ratio shows dehydration
BYN/Cr>20
What happen to hemoglobin and hematocrit in dehydration
increase
monitoring diuretics
1-2 weeks after initiation and increase
BP
serum creatinine
replace K if < or =4 and if mg< or = 2
renal function
Lasix (furosemide) acts on what part of kindey
ALH
Which stage of HF to use diuretics in
Stage C
(use at lowest possible dose to maintain euvolemia)
should not be used in stage B unless HTN and reduced EF
what are the RAAS inhibitor drugs
ARNI, ACEI, ARB
does ACEi reduce mortality? hospitalization? symptoms? does it slow progression?
yes to all
How do ACEi work?
block conversion of angiotensin I to angiotensin II
Also blocks bradykinin (may cause cough)
Are ACEi venous or arterial dilators?
Both (balanced vasodilator)
Why do ACEi work?
Inhibition of cardiac hypertrophy, reduces remodelling
starting doses for ACEi
Enalapril- 2.5-5mg BID
Captopril- 6.25-12.5mmg TID
lisinopril- 2.5-5 mg QD
ACE i target doses
Enalapril- 10 mg BID
captopril- 50 mg TID targeted
lisinopril- 20-40 mg QD
ACEi brand and generic names
Enalapril- vasotec
captopril- capoten
lisinopril- prinivil, zestril)
What is the important doses to remember for ACEi conversion
20 mg enalapril/day=150 mg captopril/day=20 mg lisinopril/day
Why are ACE inhibitors under used and under dosed
CKD
Hypotension
ACE inhibitor dose increase
Start low and double dose every 1-4 weeks. Caution if volume depleted.
when are lower dose and monitoring are required for ACEi
serum creatinine>3 and/or CrCl<30
Absolute contraindications of ACEi
pregnancy
history of angioedema
monitoring for ACEi
renal function and K+
BP
SCr
What is an acceptable rise in SCr for ACEi
30%
adverse effects of ACEi
hypotension
cough
angioedema
hyperkalemia
Captopril may cause skin rash and dysgausea
How do ARBs work
Blocks effects of angiotensin II at the AT1 receptor
What does blocking AT1 receptor lead to?
decrease in
myocardial fibrosis
norepinephrine
vasoconstriction
PAi/Endothelin
ACEi drug names with bran and starting and target doses
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
when to give ARB instead of ACE
if unable to take ACEi due to cough.
Ace-i induced angioedema
ARNI MOA and drug name
has a dual effect on the RAAS system and NP system (AT1 receptor blockade and inhibition of degradation of BNP
sacubitril/valsartan (entresto)
entresto dose equivalence to valsartan
26=40
51=80
103=160
adverse effects of entresto
hypotension
angioedema
costs 600/month (expensive)
LCZ696 (valsartan/sacubitril) vs enalapril compare common adverse effects
Hypotension more common in LCZ696
elevates Scr, SeK, cough more in enalapril
rules when switching from ACE or ARB to ARNI
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
How to dose entresto when switching from high dose ACE/ARB
S 49/ V 51 mg BID
titrate to 97/103 mg BID
when to use lower dose entresto
ACE/ARB naive
low to medium dose ACE/ARB
eGFR<30
Age>75
moderate hepatic impairement
What dose to start for non high dose entresto
24/26 mg BID
precaution to take when switching from ACE to ARNI
do not give dose within 36 hours of last dose
contraindications of entresto
Any ACE/ARB
pregnancy
if pt had angioedema with ACE/ARB
within 36 hrs of ACE use
when and how to use ARNI/ACE/ARB
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
Can we use ARNI for stage B
no
If patient is on an ACE/ARB for stage C is it beneficial to switch to ARNI or not
switch it as it is more beneficial
entresto Contraindications
hyperkalemia
angioedema
SBP<100
We can add amlodipine in HF. T/F
false
Do BB reduce hospitalization? mortality?
Both reduces
What are the only BB we can use for HF
carvedilol, metoprolol succinate and bisoprolol
mechanism for why BB is good in HF
reverse remodeling
patient selection for BB
Pt has to be stable (no signs of edema)
symptomatic pts should receive diuretics also
if recent hx of asthma avoid until controlled
