Heart Failure Flashcards
Angiotensin Receptor Neprilysin Inhibitor
Neprilysin: enzymes that break down natriuretic peptides
Valsartan/Sacubitril
- Valsartan=ARB
- Sacubitril=neprillysin inhibitor
Additional counseling point:
Allow at least 36 hours of “wash out” when switching from ACE-i to reduce risk of angioedema
Metoprolol succinate (XL)
BETA BLOCKER
Adrenergic blockade: Beta 1 selective
Target dose: 200mg daily
Counseling points/Monitoring parameters:
- Start low and titrate slowly
- Titrate to max tolerated/target dose
- Educate patient worsening of HF symptoms is normal 1-2 weeks of drug initiation/dose increase. Symptoms will resolve afterward
Use selective beta-blocker in patients with severe asthma
Bisoprolol
BETA BLOCKER
Adrenergic blockade: Beta-1 selective
Target dose: 10mg daily
Counseling points/Monitoring parameters:
- Start low and titrate slowly
- Titrate to max tolerated/target dose
- Educate patient worsening of HF symptoms is normal 1-2 weeks of drug initiation/dose increase. Symptoms will resolve afterward
Use selective beta-blocker in patients with severe asthma
Carvidelol
BETA BLOCKER
Adrenergic blockade: Beta-1, Beta-2, Alpha-1
Target dose: 20-50mg twice daily (40-100mg per day)
Counseling points/Monitoring parameters:
- Start low and titrate slowly
- Titrate to max tolerated/target dose
- Educate patient worsening of HF symptoms is normal 1-2 weeks of drug initiation/dose increase. Symptoms will resolve afterward
Use selective beta-blocker in patients with severe asthma
Inotropes
Added in very severe heart failure
Route: IV
Digoxin: PO/IV
3 agents:
Digoxin
Dobutamine
Milrinone
Digoxin
PATHO
Cardiac glycoside
Narrow therapeutic range
When used for heart failure:
- Improve cardiac output
- Improve symptoms
- Does not improve mortality
Last-line therapy
Digoxin
Route: Oral/IV
Dosing: loading dose, maintenance dose
Monitoring: narrow therapeutic index, DRUG LEVELS=0.5-0.8 mcg/mL
Mechanism of action:
Inhibits Na/K/ATPase pump
Increases intracellular Ca concentrations
Increases force of contractions
Role of potassium: competes with digoxin for binding to Na/K/ATPase
- if K levels are low, higher digoxin binding
- if K levels are high, lower digoxin binding
Physiologic effects:
Increased cardiac output
Suppresses renin release in the kidneys–> decreases activation of the RAAS pathway
Alters electrical activity in the heart–>increases vagal responses
Pharmacokinetics:
- Well absorbed and distributed into tissues
- High levels reached in cardiac tissues
- Long half-life
Digoxin Adverse effects
Cardiac dysrhythmias Predisposing factors: -Hypokalemia -Elevated digoxin levels -Heart disease
Management of dysrhythmias
- discontinue digoxin, thiazide and loop diuretics
- Monitor and ensure normal potassium levels
- consider use of reversal agent Digifab*
GI symptoms: Nausea, vomiting, anorexia
Fatigue
Visual Disturbances:
- Blurred vision
- Yellow-tinged vision
- Halos
Dobutamine
Route: IV
Mechanism of action:
- Beta 1 and 2 activation
- Increase force of contraction
- Increase heart rate
Place in therapy: acute decompensated HF
Adverse effects/monitoring parameters:
- Arrhythmias
- BP and HR monitoring
Milrinone
Route: IV
Mechanism of action:
- Phosphodiesterase-3 inhibitor
- increases cyclic AMP→ ↑ myocardial contractility
- Vasodilation
Place in therapy:
-Acute decompensated HF
Adverse effects/Monitoring parameters:
- Arrhythmias
- Hypotension
Drug therapy based on HF stage
Stage A: No symptoms/structural damage. Treat risk factors.
Drugs: ACE-i/ARB
Stage B: No symptoms, BUT has structural damage. Drugs: ACE-i/ARB + Beta Blockers
Stage C: Symptoms + structural heart damage. *Devices used
Drugs: ACE-i/ARB+ARNI, Beta Blockers + Diuretics, +/- Digoxin or Aldosterone Antagonist
Stage D: Refractory HF requiring specialized intervention
Devices used
Drugs: ACE-i/ARB/ARNI, Beta Blockers, Diuretics, +/- Digoxin or Aldosterone Antagonist + Inotropes
Drug therapies for HF
Diuretics (Thiazide, Loop, K-sparing)
- First-line for patients with fluid overload
- Loops are most effective
Beta-Blockers (Metoprolol XL, Carvedilol, Bisoprolol)
- Protect heart from excessive stimulation by sympathetic NS
- START low dose & titrate (to max dose)
- Only 3 FDA-approved meds for HF
Inhibitors of RAAS (Angiotensin converting enzyme inhibitor/Angiotensin II receptor blocker/Angiotensin receptor-neprilysin inhibitor, Direct renin inhibitor, Aldosterone antagonists)
- Prevent cardiac remodeling
- Prevent fluid rentetnion from aldosterone release
