Exam 2 lecture 3

Question 1

BB drug nmes with brand names

Answer 1

Bisoprolol- zebeta
Carvedilol- coreg
metoprolol succinate- toprol

Question 2

Initial and final doses of BB

Answer 2

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

Question 3

how to titrate doses for BB

Answer 3

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

Question 4

BB monitoring

Answer 4

BP and HR

Question 5

what does systolic HF mean

Answer 5

HFrEF

Question 6

COnsensus panel for use o BB

Answer 6

Stage B- All patients in stage B should be on B blocker
Stage C- All patients in stage C should be on BB

Question 7

What happens to aldosterone in HF?

Answer 7

It is elevated

Question 8

What does aldosterone do in HF?

Answer 8

SNS activation
PSNS inhibition
cardiac and vascular remodelling

Question 9

What are the 2 MRAs? How are they different?

Answer 9

Spironolactone is non selective
eplerenone is selective

spironolactone causes gynecomastia
Eplerenone is selective with lower affinity for androgen (no anti androgen effect)

Question 10

how do MRAs affect K, Mg, Na retention, and sympathetic stimulation

Answer 10

reduce K and Mg losses
reduce Na retention
reduce sympathetic stimulatio

Question 11

Eplerenone dosing

Answer 11

CrCl>50- initial- 25 mg daily
maintainence- 50 mg daily

CrCl- 30-49- initial- 25 mg every other day
maintenance- 25 mg daily

Question 12

Spironolactone dosing

Answer 12

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

Question 13

when to avoid MRAs

Answer 13

SeCr>2.5 for men and 2.0 for women
CrCl<30
K+>5

Question 14

Do we just skip MRAs if K>5 or if CrCl<30?

Answer 14

No. we wait for it to get to normal and try again

Question 15

What to avoid if taking MRAs

Answer 15

Avoid use of K+ sparring diuretics
Avoid NSAIDs

Question 16

consensus for recommendations for MRAs

Answer 16

stage B- avoid
Stage C- Use, but make sure CrCl>30, K<5

Question 17

effect of SGLT2 on preload and afterload

Answer 17

Reduces both preload and afterload

Question 18

Do SGLT2 decrease CV death? hospitalization?

Answer 18

decreases both

Question 19

which NYHA is SGLT2 used in

Answer 19

NYHA II-IV

Question 20

dosing of SGLT2 i

Answer 20

dapagliflozin and empagliflozin 10 mg QD

Question 21

adverse effects of SGLT2I

Answer 21

ketoacidosis in DM
hypoglycemia
infection rise
volume depletion

Question 22

which drugs need CrCl of >30

Answer 22

ACE/ARB/ARNI
spironolactone
SGLT2i

Question 23

important parameters before starting SGLT2 i

Answer 23

SBP>100
eGFR>20T

Question 24

monitoring parameters for SGLT2i

Answer 24

SeCr and SeK
DM monitoring
hypotension

Question 25

when to reduce SGLT2i dose or discontinue

Answer 25

Secr>by 30 % within 4 weeks ketone development

Question 26

ARNI/ARB/ACE important clinical parameters to initiate? When to follow up? what are the clinical parameters to follow up on?

Answer 26

SBP>100 SeK<5.4 eGFR>30 Follow up within 2-4 weeks of initiation and titration

Question 27

when to discontinue RAASi

Answer 27

symptomatic hypotension SeCr increased by 30% within 4 wks SeK>5.4

Question 28

important clinical parameters to initiate BB

Answer 28

SBP>100 HR>60

Question 29

BB monitoring parameters

Answer 29

HR BB

Question 30

when to dx BB

Answer 30

HR<50 hypotension

Question 31

important parameters to initiate MRA

Answer 31

SBP>100 SeK<5.4 eGFR>30

Question 32

follow up times and parameters for MRA

Answer 32

2-4 weeks hypotension SeCr SeK

Question 33

When to reduce or dx MR doses

Answer 33

hypotension SeCr increase by 30% within 4 wks SeK>5.4

Question 34

What are the drugs to initiate in stage C/D HF

Answer 34

ACE/ARB/ARNI BB SGLT2i MRA (diuretic as needed)

Question 35

When are hydral nitrates used in HF?

Answer 35

in NYHA III-IV african american pts

Question 36

ISDN/hydralazine drug name

Answer 36

BilDil

Question 37

does ISDN/hydralazine reduce mortality

Answer 37

Yes

Question 38

is ISDN/hydralazine arteral dilator, venous dilator or balanced dilator?

Answer 38

balanced

Question 39

adverse effects of ISDN/hydralazine

Answer 39

h/a, N/V. flushing, lupus like syndrome

Question 40

doses of ISDN/hydralazine

Answer 40

starting- 20/37.5 TID target- 40/75 mg TID

Question 41

consensus recommendation for ISDN/hydralazine

Answer 41

stage- no recommendation stage C- black pts with NYHA III and IV receiving ARNI, BB, MRA and diuretic as add on)

Question 42

lisinopril dose equivalent drugs

Answer 42

150 captopril QD= 20 enalapril QD=20 lisinopril QD

Question 43

does ivabredine reduce mortality? hospitalization?

Answer 43

reduces hospitalization. not mortality.

Question 44

what are the specific indications of ivabredine

Answer 44

symptomatic HF EF<40 (HFrEF) in normal sinus rhythm HR>70 on max tolerated BB dose

Question 45

Digoxin MOA

Answer 45

2 fold MOA blocks Na/K ATPase increase in vagal activity

Question 46

What does digoxin blocking Na/K ATPase do?

Answer 46

Ca2+ increase and increases contraction

Question 47

What does digoxin increase in vagal activity lead to?

Answer 47

reduce AV conduction reduce HR

Question 48

what is digoxin used for?

Answer 48

used to slow HR in pts who have A-fib and HF

Question 49

does digoxin reduce mortality? hospitalization?

Answer 49

reduces hospitalization

Question 50

Digoxin dosing

Answer 50

0.125-0.25 mg QD

Question 51

goal serum concentration of digoxin

Answer 51

0.5-0.9 ng/ml

Question 52

when to lower digoxin dose

Answer 52

>70 yo impaired renal function low weight

Question 53

drug interactions with digoxin (and how much the dose changes by)

Answer 53

Amiodarone (doubles digoxin dose) Quinidine and verapamil (80% increase) itra/ktz (50-100% increase)

Question 54

use of PUFA (omega 3 polyunsaturated fatty acid) in HF

Answer 54

reduce risk in HF (II-IV) patients use as adjunct

Question 55

long term ASA is used in

Answer 55

HF, CAD, ASCVD

Question 56

CCB use in HF? what to use what not to use?

Answer 56

Never use diltiazem, verapamil and nifedipine. Felodipine and amlodipine should be used.

Question 57

most common cause of HFpEF

Answer 57

HTN

Question 58

for HFpEF which drugs reduce hospitalization? mortality?

Answer 58

digoxin has no effect on mortality or hospitalization ACE/ARBs do not reduce mortality, they reduce hospitalization.