Exam 2 lecture 2 Flashcards by Matti Daniel

potential pharmacologic strategies for HF

reduce intravascular volume
increase myocardial contractility
reduce ventricular afterload
neurohormonal blockade

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drugs that can reduce intravascular volume

diuretics and SGLT2i

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Drugs that increase myocardial contractility

positive inotropes

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reduce ventricular afterload

ACEIs, vasodilators

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GDMT for stage A

ACE/ARB

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GDMT for stage B

ACE/ARB
B Blocker

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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

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What are the only BB we can use for stage C

metoprolol succinate, bisoprolol, carvedilol

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

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do diuretics reduce mortality

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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

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

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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

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MOA of diuretics

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

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90-95% of Na is filtered at

glomerulus

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70% of Na reabsorption is at

PCT

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20-25% of Na reabsorbed at

ALH

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Most potent group of diuretics? MOA?

Loop diuretics. Block Na and Cl- reabsorption in ALH

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loop diuretics additional benefits

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

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what is the advantage of torsemide over furosemide

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

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Name loop diuretics

furosemide
torsemide
bumetanide
ethacrynic acid

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Furosemide dose and bioavailability

20-40 mg- 50% bioavailability

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Bumetanide dose and bioavailability

0.5-1 mg - 80-100% bioavailability

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Torsemide dose and bioavailability

10-20 mg- 80-100% bioavailability

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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

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