Exam 2 lecture 3 Flashcards
BB drug nmes with brand names
Bisoprolol- zebeta
Carvedilol- coreg
metoprolol succinate- toprol
Initial and final doses of BB
bisoprolol- initial- 1.25 mg QD, target- 10 mg QD
carvedilol- initial-3.125 mg BID, target- 25-50 BID
ER- initial 10 mg, target 80 mg QD
metoprolol- initial- 12.5-25 mg QD, target- 200 mg QD
how to titrate doses for BB
Carvedilol- 3.125 mg BID for 2 weeks
Coreg- 10 mg QD for 2 weeks
Metoprolol- 12.5-25 mg QD for 2 weeks
double dose every 2 weeks and monitor vital signs and symptoms
aim target dose in 8-12 weeks or highest tolerated dose
carvedilol<85 kg - 25 mg BID
>85- 50 mg BID
Coreg- 80 mg QD
Metoprolol- 200 mg QD
BB monitoring
BP and HR
what does systolic HF mean
HFrEF
COnsensus panel for use o BB
Stage B- All patients in stage B should be on B blocker
Stage C- All patients in stage C should be on BB
What happens to aldosterone in HF?
It is elevated
What does aldosterone do in HF?
SNS activation
PSNS inhibition
cardiac and vascular remodelling
What are the 2 MRAs? How are they different?
Spironolactone is non selective
eplerenone is selective
spironolactone causes gynecomastia
Eplerenone is selective with lower affinity for androgen (no anti androgen effect)
how do MRAs affect K, Mg, Na retention, and sympathetic stimulation
reduce K and Mg losses
reduce Na retention
reduce sympathetic stimulatio
Eplerenone dosing
CrCl>50- initial- 25 mg daily
maintainence- 50 mg daily
CrCl- 30-49- initial- 25 mg every other day
maintenance- 25 mg daily
Spironolactone dosing
CrCl>50- initial- 12.5-25 QD
maintenace- 25 mg QD
CrCl 30-49- initial- 12.5-25 QD every other day
maintenance- 12.5-25 QD
when to avoid MRAs
SeCr>2.5 for men and 2.0 for women
CrCl<30
K+>5
Do we just skip MRAs if K>5 or if CrCl<30?
No. we wait for it to get to normal and try again
What to avoid if taking MRAs
Avoid use of K+ sparring diuretics
Avoid NSAIDs
consensus for recommendations for MRAs
stage B- avoid
Stage C- Use, but make sure CrCl>30, K<5
effect of SGLT2 on preload and afterload
Reduces both preload and afterload
Do SGLT2 decrease CV death? hospitalization?
decreases both
which NYHA is SGLT2 used in
NYHA II-IV
dosing of SGLT2 i
dapagliflozin and empagliflozin 10 mg QD
adverse effects of SGLT2I
ketoacidosis in DM
hypoglycemia
infection rise
volume depletion
which drugs need CrCl of >30
ACE/ARB/ARNI
spironolactone
SGLT2i
important parameters before starting SGLT2 i
SBP>100
eGFR>20T
monitoring parameters for SGLT2i
SeCr and SeK
DM monitoring
hypotension
when to reduce SGLT2i dose or discontinue
Secr>by 30 % within 4 weeks
ketone development
ARNI/ARB/ACE important clinical parameters to initiate?
When to follow up? what are the clinical parameters to follow up on?
SBP>100
SeK<5.4
eGFR>30
Follow up within 2-4 weeks of initiation and titration
when to discontinue RAASi
symptomatic hypotension
SeCr increased by 30% within 4 wks
SeK>5.4
important clinical parameters to initiate BB
SBP>100
HR>60
BB monitoring parameters
HR
BB
when to dx BB
HR<50
hypotension
important parameters to initiate MRA
SBP>100
SeK<5.4
eGFR>30
follow up times and parameters for MRA
2-4 weeks
hypotension
SeCr
SeK
When to reduce or dx MR doses
hypotension
SeCr increase by 30% within 4 wks
SeK>5.4
What are the drugs to initiate in stage C/D HF
ACE/ARB/ARNI
BB
SGLT2i
MRA
(diuretic as needed)
When are hydral nitrates used in HF?
in NYHA III-IV african american pts
ISDN/hydralazine drug name
BilDil
does ISDN/hydralazine reduce mortality
Yes
is ISDN/hydralazine arteral dilator, venous dilator or balanced dilator?
balanced
adverse effects of ISDN/hydralazine
h/a, N/V. flushing, lupus like syndrome
doses of ISDN/hydralazine
starting- 20/37.5 TID
target- 40/75 mg TID
consensus recommendation for ISDN/hydralazine
stage- no recommendation
stage C- black pts with NYHA III and IV receiving ARNI, BB, MRA and diuretic as add on)
lisinopril dose equivalent drugs
150 captopril QD= 20 enalapril QD=20 lisinopril QD
does ivabredine reduce mortality? hospitalization?
reduces hospitalization. not mortality.
what are the specific indications of ivabredine
symptomatic HF
EF<40 (HFrEF) in normal sinus rhythm
HR>70
on max tolerated BB dose
Digoxin MOA
2 fold MOA
blocks Na/K ATPase
increase in vagal activity
What does digoxin blocking Na/K ATPase do?
Ca2+ increase and increases contraction
What does digoxin increase in vagal activity lead to?
reduce AV conduction
reduce HR
what is digoxin used for?
used to slow HR in pts who have A-fib and HF
does digoxin reduce mortality? hospitalization?
reduces hospitalization
Digoxin dosing
0.125-0.25 mg QD
goal serum concentration of digoxin
0.5-0.9 ng/ml
when to lower digoxin dose
> 70 yo
impaired renal function
low weight
drug interactions with digoxin (and how much the dose changes by)
Amiodarone (doubles digoxin dose)
Quinidine and verapamil (80% increase)
itra/ktz (50-100% increase)
use of PUFA (omega 3 polyunsaturated fatty acid) in HF
reduce risk in HF (II-IV) patients
use as adjunct
long term ASA is used in
HF, CAD, ASCVD
CCB use in HF? what to use what not to use?
Never use diltiazem, verapamil and nifedipine.
Felodipine and amlodipine should be used.
most common cause of HFpEF
HTN
for HFpEF which drugs reduce hospitalization? mortality?
digoxin has no effect on mortality or hospitalization
ACE/ARBs do not reduce mortality, they reduce hospitalization.
