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Therapeutics 3 Kappa Epsilon > Exam 2 - Sowinski (CHF) > Flashcards

Exam 2 - Sowinski (CHF) Flashcards

1
Q

2 types of CHF

A 
HFrEF (systolic dysfunction)
or HFpEF (diastolic dysfunction)
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2
Q

definition of HFrEF:

A

HF symptoms with EF < 35 - 40%

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3
Q

definition of HFpEF:

A

HF symptoms with EF > 50%

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4
Q

main 4 compensatory responses

A

increased preload
vasoconstriction
tachycardia/increased contractility (SNS activation)
Ventricular hypertrophy/remodeling

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5
Q

why is increased preload bad (aka what is its detrimental effect as part of compensation)

A

it causes pulmonary/systemic congestion and edema

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6
Q

why is vasoconstriction bad (aka what is its detrimental effect as part of compensation)

A

increased afterload AND decreased SV AND

further activates compensatory responses

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7
Q

why is tachycardia/increased contractility bad (aka what is its detrimental effect as part of compensation)

A

shortened diastolic filling time
ventricular arrhythmias
increased risk of myocardial cell death

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8
Q

why is ventricular hypertrophy/remodeling bad (aka what is its detrimental effect as part of compensation)

A

diastolic/systolic function
Risk of myocardial cell death/ischemia
risk of arrhythmia/fibrosis

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9
Q

3 main categories for drug-induced heart failue

A

Drugs that cause…

  1. Decreased contractility
  2. Direct Cardiac Toxins
  3. Na+/H2O retention
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10
Q

What are some drugs that will may cause drug induced HF via decreased contractility

A

Beta blockers
CCBs (verap/diltiazem)
Antiarrhythmics

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11
Q

What are some drugs that will may cause drug induced HF by being a direct cardiac toxin

A

Amphetamine/Cocaine/Ethanol

  • nib drugs (Imatinib, Lapatinib, Sunitinib)
  • rubin drugs
  • zumab drugs
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12
Q

What are some drugs that will may cause drug induced HF via Na+/H2O Retention

A 
Glucocorticoids
Androgens
Estrogens
NSAIDs/COX-2-Inhibitors
Rosiglitazone/Pioglitazone
Sodium Containing Drugs
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13
Q

Classic HF Symptoms

A
  • SOB and Chronic lack of Energy!!
  • Swelling of feet/legs
  • Difficultly sleeping due to breathing problems
  • Swollen/tender abdomen w/ loss of appetite
  • Cough with FROTHY sputum (??)
  • Increased urination at night
  • Confusion and/or impaired memory
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14
Q

______ Ventricular failure is more related to signs/symptoms of Systemic venous congestion

A

RIGHT

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15
Q

______ Ventricular failure is more related to signs/symptoms of pulmonary congestion

A

LEFT

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16
Q

what are the symptoms of Left Ventricle Failure

A

since Left..pulmonary congestion happens….therefore.

  • DOE
  • Tachypnea
  • Orthopnea
  • Cough
  • Hemoptysis
  • PND (paroxysmal nocturnal dyspnea)
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17
Q

what are signs of Left Ventricle Failure

A 
Rales
S3 gallop
pulmonary edema
pleural effusion
Cheyne-Stokes Respiration
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18
Q

what are the symptoms of right Ventricle Failure

A 
since right..systemic venous congestion...aka lots of fluid overload
Abdominal pain
Anorexia
nausea
bloating
constipation
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19
Q

what are the signs of right Ventricle Failure

A 
peripheral edema
JVD (jugular venous distension)
HJR (hepatojugular relfex)
Hepatomegaly
Ascites
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20
Q

what is rales

A

when listening to lungs can hear fluid —- sounds like rattling

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21
Q

what is orthopnea

A

having trouble breathing while laying down

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22
Q

what is PND

A

Paroxysmal Nocturnal dyspnea

pt wakes up in middle of night and feels like they are drowning

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23
Q

what is cardiomegaly

A

abnormal heart enlargement

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24
Q

what is JVD

A

jugular venous distension

can see jugular vein pulsating

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25
Q

what are initial lab assessments done for HF

A

Hematology/Biochem (CBC, Serum electrolytes, BUN, CR, Thyroid function tests)

ECG (check for arrhythmias!!)
Chest X-Ray
BNP or NT-proBNP

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26
Q

what is a diagnostic value BNP in HF

A

> 100 pg/mL

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27
Q

what is a diagnostic value NT-proBNP in HF

A

> 300 pg/mL

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28
Q

How does NYHA classify HF patients

A

Classes I - IV and based on symptoms

IV - is like hella bad/pt can’t get out of bed without having symptoms

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29
Q

How does AHA classify HF pts

A

by STAGES A,B,C,D
A is at risk
D - is worst

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30
Q

AHA Classifications:

What is Stage A

A

pt is at high risk of developing HF (ex: pt has HTN, CAD, DM, Dyslipidemia) NO symptoms

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31
Q

AHA Classifications:

What is Stage B

A

pt has structural heart disease but NO signs/symptoms of HF

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32
Q

AHA Classifications:

What is Stage C

A

current or prior HF symptoms with underlying struc. heart disease

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33
Q

AHA Classifications:

What is Stage D

A

has advanced struc. heart disease and marked Sxs of HF

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34
Q

Definition of Asymptomatic rEF

A

No HF symptoms with EF < 40%

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35
Q

Definition of HFrEF

A

HF symptoms with EF < 40%

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36
Q

what classes/stages are known as Asymptomatic rEF

A

Stage B (AHA)
or
NYHA Funct. Class I

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37
Q

what classes/stages are known as HFrEF

A

Stage C/D (AHA)
or
NYHA Funct. Class II - IV

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38
Q

HF Pts: Sodium Intake Guidelines

A

2 - 3 gms/day (aka 4 - 6 gms of NaCl)

may have to do <2 g/day if severe HF

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39
Q

HF pts: Alcohol Intake Guidelines

A

if have HF due to EtOH – then avoid completely

if not EtOH induced — NMT 2 drinks/day (men) or 1 drink/day (women)

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40
Q

HF Pts: when do you fluid restrict? how how do you fluid restrict?

A 
if hyponatremia (Na < 130 mEq/L);
< 2 L/day
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41
Q

Managing HF:

Reduce Intravascular Volume by using ______

A

diruetics

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42
Q

Managing HF:

Increase myocardial contractility by using ______

A

positive inotropes

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43
Q

Managing HF:

Decrease ventricular afterload by using _______

A

ACEIs and Vasodilators

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44
Q

Managing HF:

Block Neurohormones by using what things?

A 
Beta blockers
ACEIs
ARBs
Spironolactone
ARNIs
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45
Q

If Pt is Stage A HF — how do you treat it?

A

Just Control Risk Factors
aka smoking cessation!!
treat any other diseases (DM, HTN, Dyslipidemia, CAD)

if PT has DM or coronary/cerebral, peripheral vascular disease then but them on an ACEI/ARB

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46
Q

If Pt is Stage B HF — how do you treat it?

A

ACEI/ARB
and Beta-Blockers
(no diuretics because no symptoms)

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47
Q

If Pt is Stage C HF — how do you treat it?

A

everyone is on ACEI/ARB, Beta blocker, and diuretic

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48
Q

T or F: Diuretics decrease hospitalization AND mortality

A

FALSE. reduces ONLY hospitalization

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49
Q

T or F: Even if HF pt does not have symptoms they should be on a diuretic

A

false! no symptoms = no diuretic

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50
Q

long term benefits of diuretics

A

reduce daily symptoms and improve quality to exercise

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51
Q

short term benefits of diuretics

A

reduce fluid retention by…

decrease edema/pulmonary congestion/JVD

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52
Q

Diuretics:

They reduce _____load AND reduce _______ pressure

A

PREload; cardiac filling

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53
Q

if a pt is fluid overloaded, diuretics should be used to reduce weight by ______ (how much?)

A

1 - 2 pounds/day

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54
Q

Patients need to report any weight gain of _______

A

3 - 5 lbs/week

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55
Q

____tension and (increase or decrease) SCr or BUN/Cr Ratio is indicative of volume depletion

A

HYPOtension

INCREASE

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56
Q

What is a loop diuretic’s “additional benefit”

A

they enhance release of renal prostaglandin

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57
Q

which loop diuretic has erratic bioavailability and which one could replace it

A

furosemide - erratic

replace w/ torsemide

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58
Q

which thiazide diuretic is erratically absorbed

A

MTZ (metazolone)

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59
Q

initial dose of torsemide

A

10 - 20 mg QD

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60
Q

initial dose of furosemide

A

20 - 40 mg QD or BID

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61
Q

goal dose for furosemide

A

20 - 160 mg QD or BID

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62
Q

goal dose for torsemide

A

10 - 80 mg QD

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63
Q

which loop diuretic has the longest duration of action

A

Torsemide

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64
Q

Main ADEs of diuretics

A

Hypokalemia
Hypomagnesemia
Volume depletion
Decrease in renal function

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65
Q

Monitoring Parameters for Diuretics

A 
Fluid intake/urinary output
Body weight
blood pressure
Serum Electrolytes (K+/Mg2+)
Renal function
S/Sx of systemic or pulmonary congestion (JVD etc..)
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66
Q

When using diuretics, K+ and Mg2+ can be low…. you should replace K+ if it is < _____ and replace Mg2+ if it is < ______

A

K: < 4
Mg: < 2

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67
Q

what drugs are known as neurohormonal blockers

A 
ACEI/ARBs
Beta Blockers
ARNI
MRA (aldosterone antagonists! - mineralcorticoid receptor antag.)
ISDN/Hydralazine
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68
Q

what drug combo therapies have been proven to be most effective in HF (the chart about RCTs and the hazard ratio not crossing 1..)

A
  • ARNI + BB + MRA

- ACEI + BB + MRA

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69
Q

ACEI Mechanism:

Bradykinin leads to vaso_____

A

dilation!

why when ACEI prevents break down of bradykinin thats good….

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70
Q

Angiotensin II leads to vaso______

A

constriction

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71
Q

what are some reasons that a patient would be on a lower than normal ACEI dose

A 
if CKD (CrCl < 30 mL/min)
Hypotension -- if symptomatic! (ok if low BP (to some extent...))
72
Q

what are the 4 ACEIs used for HF

A

Lisinopril
Enalapril
Captopril
Ramipril

73
Q

which ACEI for HF is once a day?

A

Lisinopril

74
Q

which ACEI for HF is twice a day?

A

Ramipril and Enalapril

75
Q

which ACEI for HF is three times a day?

76
Q

For dosing of ACEI in HF:

start low and double the dose how often?

A

every 2 weeks!!

Q1 - 4 wks…

77
Q 
For dosing of ACEI in HF:
lower doses and more monitoring are required with...
SCr > \_\_\_\_\_\_
and/or
CrCl < \_\_\_\_\_
A

SCr > 3

ClCr < 30

78
Q

For dosing of ACEI in HF:
Use with caution if pt…
what 4 things

A

SBP < 80 mmHg
Volume Depleted
Serum K > 5
SCr > 3

79
Q

Absolute contraindications for ACEI?

A

Pregnancy
Hx of Angioedema or Hypersensitivity
Bilateral Renal Artery Stenosis
Hx of well documented intolerance (dat cough)

80
Q

ADEIs of ACEI

A 
functional renal insufficency
hypotension
Hyperkalemia
skin rash
dysguesia (metallic taste in mouth)
Cough
Angioedema
81
Q

Monitoring for ACEIs

How to Monitor Renal Function and K+?

A

1) prior to therapy
2) 1 - 2 weeks after each increase in dose
3) 3- 6 mos intervals

82
Q

T or F: It is ok to keep a patient on an ACEI even if their SCr has increased?

A

T and F…. it is ok unless the SCr increases more than 20%

83
Q

Sacubitril/Valsartan is indicated for who?

A

HFrEF pts with NYHA Class II-IV

Must have K+ < 5.2
Must have eGFR > 30

84
Q

ADEs of Sacubitril/Valsartan

A

just like ACEI/ARB…
Hypotension
Elevations in SCr and K+
(possibly rare) Angioedema

85
Q

Contraindications for Sacubitril/Valsartan

A

within 36 hours of ACEI
if had angioedema with ACEI or ARB before
Pregnancy/Lactation
Severe Hepatic Liver impairment
known hypersensitivity to either ARB or ACEI

86
Q

what are the 3 beta blockers that are ok to use in HF

A

carvedilol (regular or CR)
Metoprolol
Bisoprolol

87
Q

Beta blockers are known to have what “special” property…

A

Reverse Remodeling! (genetic makeup changes)

88
Q

2 pathways that beta blockers are beneficial for HF pts

A

Overall blocking cardiac NE.. but the 2 pathways are…

blocking Beta-AR pathway desensitization
AND
decreasing myocyte toxicity from NE

89
Q

what patients should start a beta blocker

A

STABEL and EUVOLEMIC

90
Q

if patient is in hospital for HF exacerbation— when do you start a beta blocker (near beginning or end of stay?)

A

END!

want them more stable before you start it…)

91
Q

how do you titrate beta blockers

A

double the dose every 2 weeks and monitor closely!!

92
Q

aim for the target dose of beta blockers with in ______ weeks or …..

A

8 - 12 weeks
OR
high of a dose as tolerated

93
Q

initial dose for bisoprolol

A

1.25 mg QD

94
Q

initial dose for Carvedilol (reg AND CR)

A

reg: 3.215 mg BID

CR: 10 mg QD

95
Q

initial dose of Metoprolol XL

A

12.5 - 25 mg QD

96
Q

goal HR for beta blockers in HF?

A

there isn’t one!!

97
Q

goal dose for bisoprolol

98
Q

goal dose for carvedilol (reg and CR)

A

reg: 25 mg BID

CR: 80 mg QD

99
Q

goal dose of Metoprolol XL

100
Q

if patient is on a beta blocker and the start to experience…
Fluid retention/Worsening HF
What do you do?

A

don’t stop drug…

intensify diuretic therapy

101
Q

if patient is on a beta blocker and the start to experience…
Bradycardia/Heart block
What do you do?

A

reduce beta blocker dose

usually asymptomatic and do not need to treat though

102
Q

if patient is on a beta blocker and the start to experience…
Hypotension
What do you do?

A

separate from ACEI to decrease risk
may reduce ACEI or diuretic dose to compensate
if also signs of hypoperfusion (aka low BP) - decrease the dose

103
Q

benefits for Aldosterone Receptor Antagonists

A
  • decrease K/Mg losses = protect against arrhythmia
    decrease Na+ retention
    Decrease sympathetic simulation
    blocks direct fibrotic action on myocardium
104
Q

Spironolactone or Eplerenone?

is a substrate of CYP3A4

A

Eplerenone

105
Q

Spironolactone or Eplerenone?

has ADEs of gynecomastia, impotence, menstrual irregularities

A

Sprionolactone

106
Q

For aldosterone antagonists, the CrCl cut offs are?

A

> 50
30 - 49
and < 30 - do not use

107
Q

Spironolactone: if CrCl is > 50
what is initial dose
and maintenance

A

initial: 12.5 - 25 mg QD
Main: 25 mg QD

108
Q

Spironolactone: if CrCl is 30 - 49
what is initial dose
and maintenance

A

initial: 12.5 mg QD or every other day

12. 5 - 25 mg QD

109
Q

Spironolactone: if CrCl is < 30
what is initial dose
and maintenance

A

do not use under 30!!!!

110
Q

Eplerenone: if CrCl is > 50
what is initial dose
and maintenance

A

initial: 25 mg QD
Main: 50 mg QD

111
Q

Eplerenone: if CrCl is 30 - 49
what is initial dose
and maintenance

A

initial: 25 mg q other day
main: 25 mg QD

112
Q

Eplerenone: if CrCl is < 30
what is initial dose
and maintenance

A

do not use!!

113
Q

Avoid Aldosterone antagonists if….?

A 
SCr > 2.5 (men) or > 2 (women)
or
CrCl < 30 mL/min
or
K+ > 5
or hx of severe hyperkalemia/recent worsening renal function
114
Q

Monitoring of Aldosterone Antagonists:

After any change, addition, diseases or acute illness that may affect K+? when to monitor again

A

3 days - 1 wk

115
Q 
Monitoring of Aldosterone Antagonists:
Normal monitoring (when no changes etc)
116
Q

why is ISDN/Hydralazine of benefit?

A

reduces both preload AND after load because of hella vasodilation
(study to show efficacy in African American patients)

117
Q

why is ISDN/Hydralazine problematic?

A

Side effects for dayz!
Reflex tachycardia, hypotension, HA, flushing…
lupus-like syndrome/fluid retention/myocardial ischemia

118
Q

Hydralazine is a dilator of artieries or veins?

119
Q

ISDN is a dilator of artieries or veins?

120
Q

ISDN:
Initial
Target
Max dose

A

initial: 20 mg TID/QD
Target: 40 mg TID/QD
Max: 80 mg TID

121
Q

Hydralazine:
Initial
Target
Max dose

A

Initial: 25 mg TID/QD
Target: 75 mg TID
Max dose: 100 mg TID

122
Q

Ivabrandine is indicated for what pts?

A
  • symptomatic HF
  • EF < 35%
  • in NSR (normal sinus rhythm)
  • rHR >/= 70 in MAX TOLERATED beta blocker
123
Q

Dosing for Ivabradine

A

start: 2.5 mg BID
adjust q 2 wks
Max: 7.5 mg BID

124
Q

Adjusting dose for Ivabradine

what are the HR cutoffs

A

> 60
50 - 60
< 50

125
Q

Adjusting dose for Ivabradine

pts HR is 60 BPM - what do you do?

A

increase dose by 2.5 mg (given BID)

Max is 7.5 mg BID tho!

126
Q

Adjusting dose for Ivabradine

pts HR is in 50 - 60 range - what do you do?

A

maintain dose

127
Q

Adjusting dose for Ivabradine

pts HR is < 50 - what do you do?

A

decrease dose by 2.5 mg (BID)

if already at 2.5, d/c the drug!

128
Q

ADEs of Ivabradine

A

Fetal toxicity
A. Fib
Bradycardia/Conduction disturbances

129
Q

Ivabradine - drug interactions?

A

it is a CYP3A substrate

Ketoconazole, Diltiazem, Verapamil, grapefruit juice is concern!!

130
Q

if a HF has persistent HTN (even with ACEI, beta blocker, and diuretic (for Sx) – what do you give them

A
  • ISDN/Hydralazine
    OR
    Amlodipine/Felodipine
131
Q

if a HF has Concomitant Angina – what do you give them

A

amlodipine/felodipine

132
Q

T or F: Digoxin can reduce mortality

A

False! only reduces hospitalizations

133
Q

Target goal of Serum Digoxin Concentrations

A

< 1

0.5 - 1 is acceptable range

134
Q

T or F: do not do a loading dose of Digoxin in a pt with HF

A

True!!! (as long as they are in NSR (normal sinus rhythm) do NOT do a loading dose)

135
Q

Dosing for Digoxin

A
  1. 125 mg - .25 mg QD

0. 125 mg is normal dose to get into appropriate goal range of 0.5 - 0.9

136
Q

What patients would more than likely get a lower dose of digoxin

A

> 70 y.o
decreased renal function
low weight

137
Q

NON-CARDIAC ADEs of Digoxin:

A
  • Anorexia, N/V
  • Visual disturbances (halos, photophobia, altered color) (remember Van-Gogh crap)
  • Fatigue, weakness, dizziness, confusion, psychosis
138
Q

Cardiac ADEs of Digoxin

A

AV block
PVCs, VT, VF!!
Sinus Bradycardia

139
Q

what is used to treat digoxin toxicity

140
Q

what things may predispose someone to digoxin toxicity

A 
Electrolyte disturbances (hypoK+/Mg2+, hyperCa2+)
older pt
Alkalosis
Hypoxia
Renal Dysfxn
Hypothyroidism
Drug interactions! (Verap and Amiod!!)
141
Q

what electrolyte imbalances increase a pts risk for dig toxicity

A

hypokalemia
hypomagnesemia
hypercalcemia

142
Q

T or F: all HF pts need to receive anti-platelet therapy

A

False!

Should get it only if the have IHD, CAD, or ASCVD along with their HF

143
Q

T or F: all HF pts need anti-coag therapy

A

false!!! (only if they have a reason to be on it… like A. Fib.)

144
Q

Definition of ADHF

A

Acute Decompensated Heart Failue =
HF exacerbation =
pts with new or worsening HF signs/sx

145
Q

Definition of Cardiogenic Shock:

A

Hypotension with Low CO

146
Q

Definition of Hypotension

A

SBP < 90 mmHg

MAP (mean arterial pressure) < 70 mmHG

147
Q

T or F: ADHF includes both HFrEF and HFpEF

148
Q

ADHF is mainly of worsening HF cases or new cases?

A

worsening (~70%)

149
Q

what are the 4 main reasons for why ADHF can happen

A

CV causes
Metabolic causes
Toxins/Drugs
Drug non-adherence/Dietary indiscretion

150
Q

What are CV causes that can lead to ADHF

A 
ischemia
arrhythmia
valvular disease
uncontrolled HTN
pulmonary embolism
progressive HF
151
Q

what are metabolic causes that lead to ADHF

A

infection
anemia
thyroid disorders
renal insufficiency

152
Q

what are some toxins/drugs that can lead to ADHF

A

negative inotropes, cardiotoxins, Na+/water retention

153
Q

what is the main way that hospitals distinguish the SOB b/w Pulmonary embolism/pneumonia or heart failure

A

BNP and Nt-proBNP levels

154
Q

what are the important “easy” things of a physical examination in ADHF that dictate treatment

A

warm/cold
and
dry/wet

155
Q

For ADHF Classifications: What is subset I

A

warm/dry NORMAL

156
Q

For ADHF Classifications: What is subset II

A

warm/wet - pulmonary congestion

157
Q

For ADHF Classifications: What is subset III

A

cool/dry - hypoperfusion

158
Q

For ADHF Classifications: What is subset IV

A

cool/wet

pulmonary congestion AND hypoperfusion

159
Q

For ADHF Classifications:

Cardiac Index is a way to measure _______

A

contractility

160
Q

For ADHF Classifications:

PCWP is a way to measure

A

Pre-Load! or LV-End diastolic end pressure

161
Q

For ADHF Classifications:

Having a LOW PCWP means what?

A

there is PULMONARY CONGESTION (wet)

162
Q

For ADHF Classifications:

having a low cardiac index means what?

A

there is hypoperfusion (Cool)

163
Q

if pt comes in and has ADHF..

if they are Warm and Wet - what do you do?

A

IV diuretics!

maybe a venous vasodilator - like morphine..

164
Q

if pt comes in and has ADHF..

if they are warm and dry - what do you do?

A

optimize chronic therapy

165
Q

if pt comes in and has ADHF..

if the pt is cold and dry what do you do?

A

have to look at PCWP:
if <15 - give IV fluids until PCWP reaches b/w 15 - 18

if < 15 and SBP is < 90 - give IV dopamine

if SBP is > 90 - IV inotrope or arterial vasodilator is good.

166
Q

if pt comes in and has ADHF..

if pt comes in Cold and wet - what do you do?

A

if SBP < 90 - IV dopamine

if SBP > 90: inotrope or arterial/venous vasodilator

167
Q

Dosing Diuretics For Hospitalized Pts:

Initial dose is done by IV…. how to pick a dose?

A

go with whatever they are taking at home!

*if furosemide 40 mg at home – do 20 mg (b/c bioavailability is wack)

168
Q

ways to overcome loop diuretic resistance?

A 
Na+/Water restriction
increase dose (not just frequency)
do a continuous infusion
Add thiazide
169
Q

what are vasodilators are mentioned for ADHF

A 
Nitroprusside*
Nitroglycerin
Nesiritide
Morphine*
Enalaprilat
Hydralazine
170
Q

what positive inotropes are mentioned for ADHF

A

Dobutamine, Milrinone, Dopamine

171
Q

what is milrinones MOA

A

PDEI — will increase cardiac indx
(since PDE inhibitor- good to use when pt is on beta blocker…effect wont be blunted by the beta blocker already present)

172
Q

Dopamine’s dosing leads to different effects… what are the different effects

A

Low Dose: renal vasculature dilator
Med. Dose: increase myocardial contractility/inotrope
High Dose: Aterial vasoconstriction - increase BP

173
Q

When dopamine is at a low dose – what is its effect

A

renal vasculature dilator

174
Q

When dopamine is at a medium dose – what is its effect

A

increase myocardial contractility/inotrope

175
Q

When dopamine is at a high dose – what is its effect

A

increase arterial vasoconstrition – increase BP

176
Q

if someone comes in for ADHF — never been on diuretic but they need a diuretic - how do you dose it?

A

start with 40 mg IV — see how they respond
good to check renal function too!
if they have shitty kidneys — increase the dose!!

Therapeutics 3 Kappa Epsilon (20 decks)

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