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C/R > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is heart failure

A

What is it ?

a decrease in cardiac output (amount of blood being ejected from the heart). Heart cant meet the demands of the body

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2
Q

1 cause of heart failure

A

MI

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3
Q

how is HF diagnosed

A

echo of heart

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4
Q

classification of HF based on EF

A

NORMAL ef 50-70%
HFrEF : ef< 40%
HFpEF: EF> 50% but less starting volume
HFmrEF: EF 40-50

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5
Q

clinical presentations of hypoperfuion

A

a. tachycardia
b.fatigue
c. cyanosis
d. cold extremities
e. organ dysfunction
I. increased SCr (AKI)
II. increased LFTs
III. Confusion/ AMS

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6
Q

clinical representations of congestion

A

a. Weight gain
b. SOB
c. Orthopnea
d. Paroxysmal nocturnal dyspnea
e. pleural effusion
f. Crackles/ rales
g. S3 and S4 heart sounds
h. pitting edema
I. increased B-type natriuretic Peptide (BNP)
J. Jugular venous distention

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7
Q

what is the first line treatments for HF

A

ARNI or ACE/ARB w. BB

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8
Q

what is the pharmacologic treatment approach to HF

A

initiate as many mortality benefiting drugs as the pt can tolerate and titrate up over time. start low and go slow

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9
Q

Sarcubatril/ Valsartan

what is the brand name

A

entresto

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10
Q

Sacubitril/Valsartan (Entresto)

Class:

Indication:

Mechanism of Action: Valsartan (ARB):

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy:

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:

A

Sacubitril/Valsartan (Entresto)

Class: ARNI-Neprilysin Inhibitor/ ARB

Indication: reduce risk of CV death and hospitalizations for HF in patients with chronic HF.

Mechanism of Action: Valsartan (ARB): blocks angiotensin II activity at the angiotensin receptor on vascular smooth muscle.
Sacubitril (Neprilysin Inhibitor): inhibits neprilysin (responsible for breakdown of BNP), blocks breakdown of BNP. ARB and sacubatril used together because Neprilysin inhibitor also prevents breakdown of angiotensin II, up regulating RAAS system effects. so valsartan is added to minimize those effects

Effects of mechanism of Action: causes natriuresis (excretion of sodium) and vasodilation.

Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), , angioedma, hypotension.

Absolute Contraindications: pregnancy, 36 hours of an ACE inhibitor (b/c ACE and Neprolysin inhibitor both increase bradykinin, greatly increases the risk of angioedema) bilateral renal stenosis

Pregnancy: DO NOT USE

Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L

Drug-Drug Interactions (DDIs):ACE inhibitors : must have 36-hour wash out period). NSAIDS (can cause acute kidney injury), Potassium supplements (can cause hyperkalemia), other RAAS drugs (can cause AKI and Hyperkalemia), Lithium (increase lithium concentrations).

Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.

Pearls:
.1 do not use in combo with RAAS drugs
2. protect the myocardium from remodeling/ hypertrophy in patients with heart failure

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11
Q

Angiotensin converting enzyme inhibitors (ACEi)

examples:

Class: Ace inhibitors

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy:

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls: 1

A

Angiotensin converting enzyme inhibitors (ACEi)

examples: end in -PRIL. Lisinopril (Privinil/Zestril), Enalapril (Vasotec), Quinapril (Accupril)

Class: Ace inhibitors

Indication: Adjunctive therapy to reduce signs and symptoms of Heart Failure

Mechanism of Action:Prevents conversion of angiotensin 1 to angiotensin II by way of the angiotensin converting enzyme. this prevents actions such as vasoconstriction, sympathetic activation, and aldosterone release.

Effects of mechanism of Action: decreased vasoconstriction and decreased aldosterone( corticosteroid that stimulates absorption of sodium by the kidneys) release.

Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), dry cough( because of bradykinin), angioedma, orthostatic hypotension.

Absolute Contraindications:pregnancy, history of angioedema, 36 hours of an angiotensin receptor/ neprilysin inhibitor[ARNI-sacubritil/valsartan], bilateral renal stenosis

Pregnancy: DO NOT USE

Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L

Drug-Drug Interactions (DDIs): NSAIDS (can cause acute kidney injury), Potassium supplements (can cause hyperkalemia), other RAAS drugs (can cause AKI and Hyperkalemia, Lithium (increase lithium concentrations). Quinalipril contains magnesium: avoid with fluoroquinones and tetracyclines.

Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.

Pearls: 1.drug of choice in its with diabetes, heart failure, post MI, stroke, and/ or CKD due to target organ protection

  1. do not use in combo with RAAS drugs
  2. protect the myocardium from remodeling/ hypertrophy in patients with heart failure
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12
Q

Angiotensin Receptor blockers (ARBs)

examples:

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy:

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:
Pearls:

A

Angiotensin Receptor blockers (ARBs)

examples: end in -SARTAN. i.e Irbesartan (Avapro), Losartan (Cozaar), Valsartan (Diovan)

Class: ARBS

Indication: Adunctive therapy to reduce signs and symptoms of heart failure

Mechanism of Action: blocks angiotensin II activity at the angiotensin receptor on vascular smooth muscle

Effects of mechanism of Action: decreased vasoconstriction and decreased aldosterone( mineralocorticoid that stimulates sodium reabsorption by way of the kidneys) release.

Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), orthostatic hypotension, hypotension. Olmesartan: can cause spur-like enteropathy (severe diarrhea with profound weightloss)

Absolute Contraindications:pregnancy, bilateral renal stenosis

Pregnancy: DO NOT USE

Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L
history of angioedema (angioedema may be less likely to occur in ARBS over ACEI, but risk cannot be ruled out)

Drug-Drug Interactions (DDIs):

Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.

Pearls: 1.drug of choice in its with diabetes, heart failure, post MI, stroke, and/ or CKD due to target organ protection

  1. do not use in combo with RAAS drugs
  2. protect the myocardium from remodeling/ hypertrophy in patients with heart failure
  3. no washout period required when transitioning to a neprilysin inhibitor
  4. Less dry cough/ angioedema due to lack of peripheral effects of angioedema
  5. Olmesartan can cause spur-like enteropathy (severe diarrhea with profound weight loss.
  6. comes available (with HCTZ, CCBs)
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13
Q

Beta Blockers

examples:

Class: Beta blockers

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:
Pregnancy: —

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:–

Pearls:

A

Beta Blockers

examples: in general, end in -OLOL. * have mortality benefit in HF (Metoprolol Succinate (Toprol xl) Carvedilol(Coreg), Bisoprolol (Zebeta)

Class: Beta blockers

Indication: treatment of stable, symptomatic HF to reduce the mortality plus hospitalization

Mechanism of Action: inhibiting Beta 1 +/- Beta 2 receptors.
contains subclasses:
Cardio-selective Beta blockers:More selective for beta 1 receptors then beta 2 (metoprolol, Bisoprolol)
Cardio-selective and vasodilatory: block beta 1 only
intrinsic sympathomimetic activity (ISA): exhibit low level agonist activity at the beta adrenergic receptor site while simultaneously acting as a receptor antagonist.
Combined alpha and beta blockade: Carvedilol

Effects of mechanism of Action: decreased heart rate and myocardial contractility. (variable based on beta blocker subclass

Adverse Effects: Bradycardia, heart block, worsening heart failure, bronchospasm fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence.

Absolute Contraindications: severe bradycardia

Pregnancy: —

Warning/ Precautions: Use with cautioning patients with bronchospastic diseases (COPD, asthma). use with caution in patients with diabetes

Drug-Drug Interactions (DDIs): Use with caution with other drugs that cause bradycardia

Monitoring Parameters:–

Pearls:

  1. Beta blockers with mortality benefit in HF. Metoprolol succinate, Carvedilol, Bisoprolol
  2. do not initiate in heart failure exacerbation
  3. lower dose if patient experiencing exacerbation (try not to D/C due to rebound hypertension)
  4. MUST BE TAPERED upon D/C. can cause rebound hypertension
  5. can mask symptoms of hypoglycemia in patients with diabetes.( i.e palpitations, shakiness, anxiety)
  6. enhance hypoglycemic effects of insulin and sulfonylureas
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14
Q

which beta blockers have mortality benefit in patient with HF

A

metoprolol succinate, carvedilol, bisiprolol

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15
Q

entrsto

starting dose
target dose

A

SD: 24/26 mg-49/51 mg twice daily

97/103 twice daily

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16
Q

LISINOPRIL
brand name
SD:
TD:

A

ZeSTRIL/PRIVINIL
sd: 2.5-5 mg daily
TD: 20-40 mg daily

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17
Q

enalopril
BRAND NAME
SD:
TD:

A

vasotec
sd: 2.5-5 mg twice daily
TD:10-20 mg twice daily

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18
Q

Losartan
brand name:
SD:
td:

A

cozaar

sd: 25-50 mg dally
td: 150 mg daily

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19
Q

Valsartan
brand name
sd
td

A

diovan

sd: 40 mg twice daily
td: 160 mg twice daily

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20
Q

metoprolol succinate
brand name
sd
td

A

toprol XL

sd: 12.5-25 mg daily
td: 200 mg daily

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21
Q

bisoprolol
brand name
sd
td

A

zebeta

sd: 2.5 mg daily
td: 10 mg daily

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22
Q

carvedilol
brand name
sd
td

A

coreg
sd: 3.125 mg -6.25 mg twice daily
td: 25 mg twice daily
>85 kg: 50 mg BID

23
Q

Mineralcorticoid receptor antagonists

examples:

Class: Mineralcorticoid receptor antagonists

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters:

Pearls:

A

Mineralcorticoid receptor antagonists

examples:Sprinolactone (non selective) , Eplerenone (selective)

Class: Mineralcorticoid receptor antagonists

Indication: To increase survival, manage edema, and reduce need for hospitalization in patients with heart failure with reduced ejection fraction and NYHA class II-IV, normally in conjunction with other heart failure therapies

Mechanism of Action: competitive antagonists of the mineralocorticoid receptor

Effects of mechanism of Action: decreased sodium reabsorption and increasing potassium reabsorption

Adverse Effects: hyperkalemia, dehydration, hyponatremia.

spironolactone: gynecomastia, breast tenderness, impotence (inability of a man to get an erection and/or orgasm)
eplerenone: increased triglycerides

Absolute Contraindications: hyperkalemia, anuria, CrCl < 30 mL/min (different than <50mL/min in HTN)

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters: HF: monitor electrolytes (especially K+) and renal function at 2-3 days following initiation, and then 7 days after initiation/ titration. Then check monthly for 3 months and then every 3 months afterwards (this is different than monitoring 2-6 weeks after initiation or titration of therapy.

Pearls:

  1. preferred in primary aldosteronism and resistant hypertension
  2. minimally efficacious BP control when used as mono therapy.
  3. used in combo with loops and thiazides to combat potassium loss
24
Q

sprinolactone
sd
td

A

sd: 25 mg daily
td: 50 mg daily

25
Q

eplerenone sd:

td:

A

sd: 12.5-25 mg daily
td: 25-50 mg daily

26
Q

SGLT-2 Inhibitors

examples:

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters:

Pearls:

A

SGLT-2 Inhibitors

examples: Dapagliflozin, Empagliflozin

Class: SGLT-2 inhibitors

Indication: to reduce the risk of CV death and hospitalization for heart failure, with or without diabetes

Mechanism of Action: inhibiting sodium glucose co transporter 2 (SGLT-2) in the proximal renal tubules, SGLT-2 inhibitors reduce reabsorption of filtered glucose and sodium from the tubular lumen and lowers the renal threshold for glucose

Effects of mechanism of Action: decreased sodium and glucose reabsorption, and increases sodium delivery to proximal tubule, which decreased cardiac preload/ afterload, down regulate sympathetic activity, and decrease intraglomerular pressure

Adverse Effects:Dehydration, genetic mycotic infections/ UTI, hypoglycemia, euglycemic ketoacidosis

Absolute Contraindications: Dapagliflozin: eGFR <30 mL/min
Epagliflozin: eGFR <20 mL/ min

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters: Volume status, in patients with diabetes: blood glucose and ketones

Pearls:
may require adjustment to loop diuretic doses
1. no titration needed if no diagnosis of diabetes

27
Q

dapagliflozin
sd
td:

A

sd: 10 mg daily
td: 10 mg daily

28
Q

empagliflozin
sd:
td:

A

sd: 10 mg daily
td: 10 mg daily

29
Q

Loop Diuretics

examples:

Class: Loop diuretic

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy:–

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:
1.

A

Loop Diuretics

examples:Furosemide (Lasix), Butanemide (Bumex), Torsemide (Demadex)

Class: Loop diuretic

Indication: management of edema associated with Heart Failure, reduces morbidity of heart failure

Mechanism of Action:inhibits sodium, chloride, and potassium reabsorption in the thick ascending limb of the nephron

Effects of mechanism of Action: decreased blood volume, cardiac output, and peripheral vascular resistance.

Adverse Effects:hypokalemia,hyponatremia, HYPOcalcemia, hyperuricemia, hypochloremia, metabolic acidosis, ototoxicity, hyperglycemia, hypertryglyceridemia, orthostatic hypotension

Absolute Contraindications:Severe kidney dysfunction (anuria)
Pregnancy:

Warning/ Precautions: use precaution in patients with gout

Drug-Drug Interactions (DDIs): Aminoglycosides, ACEi/ ARBS (hypotension)’ Lithium toxicity

Monitoring Parameters: Blood Pressure, BUN SCr, Serum electrolytes; Fluid status

Pearls:
1. all loops (excepts Ethacrynic acid) have sulfa moieties:
able to still be used in sulfa allergies, unless allergic to loop specifically

30
Q

loop diuretic dosing

A

iv po
Furosemide 20 40
butanemide 1 1
torsemide 20 20

31
Q

how to go about loop dosing in hf

A

double home dose and give as iv,
goal urine output is 100 m/L for 6/hours
overall goal output is 1-2 L negative

32
Q

HYDRALAZINE

Class: direct vasodilators

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters: –

Pearls:–

A

HYDRALAZINE

Class: direct vasodilators

Indication: additional therapy to optimal guideline directed medical therapy for self identified african american patients with persistent NYHA class III-IV HFrEF who are also on ARNI/BB/MRA/SGLT-2 inhibitor

Mechanism of Action:direct vasodilation

Effects of mechanism of Action: decreased systemic vascular resistance

Adverse Effects: Hydralazine: reflex tachycardia, peripheral edema, palpitations, DILE

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions:—-

Monitoring Parameters: –

Pearls:–

33
Q

hydralazine
sd
td

A

sd: 25 mg TID
td: 75 mg TID

34
Q

Long acting nitrates

examples:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Pregnancy: —

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): –

Monitoring Parameters:

Pearls:
1

A

Long acting nitrates

examples: PO isosorbide dinitrate, isosorbide mononitrate (Transdermal patch)
Class: Beta blockers

Indication: As additional therapy for persistent NYHA class III-IV HF with reduced ejection fraction despite optimal guideline.

Mechanism of Action:form free radical nitric oxide. this activates cyclic GMP
(cGMP) leading to smooth muscle relaxation.

Effects of mechanism of Action:peripheral dilation of veins and arteries, more so veins.overall decreases O2 demand.

Adverse Effects: headache, hypotension,
Absolute Contraindications:

Pregnancy: —

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): –

Monitoring Parameters:BP, HR

Pearls:

  1. isosorbide dinitrate is approved for HFrEF in combination with hydralazine. Combo product BiDil (20 mg isosorbide dinitrate/37.5 mg hydralazine) TID.
  2. can have lack of efficacy after consistent exposure (tachyphylaxis) (tolerance)
  3. provide 10-14 your nitrate free period
35
Q

isosorbide dinitrate
sd:
td:

A

sd: 25 mg TID
td: 40 mg TID

36
Q

when do you initiate vaso/venodilators such as hydralazine/nitrates?

A

to persistently symptomatic black patients on ARNI/BB/MRA/SGLT2 inhibitors, bp must be high enough to tolerate additional lowering

37
Q

Ivabridine (Corlanor)

Class: Cardiovascular agent

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions:—-

Interactions:

Monitoring Parameters:

Pearls:

A

Ivabridine (Corlanor)

Class: Cardiovascular agent

Indication: to reduce risk of hospitalization in adult with stable, symptomatic HF with left ventricular ejection fraction = 35% who are in sinus rhythm with resting heart rate of >70 bpm despite being on a maximally tolerated beta blocker.

Mechanism of Action:selective and specific inhibition of the hyperpolarization-activated cyclic nucleotide - gated HCN channels (f-channels) within the sinoatrial node (SA node) of cardiac tissue resulting in disruption of the If ion current flow prolonging diastolic depolarization, slowing muring in the SA node, and ultimately reducing heart rate

Effects of mechanism of Action: reduce heart rate

Adverse Effects: bradycardia, atrial fibrillation

Absolute Contraindications:Severe hepatic impairment, acute decompensated heart failure, clinically significant hypotension, sick sinus syndrome, sinoatrial block, or third degree AV block

Pregnancy: –

Warning/ Precautions:—-

Interactions: major CYP3A4 substrate

Monitoring Parameters: monitor heart rate and rhythm

Pearls: complicated dosing algorithm in the guidelines

38
Q

Vericiguat (Verquvo)

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action: i

Adverse Effects:hypotension

Absolute Contraindications:

Pregnancy:

Warning/ Precautions:–

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:
1.

A

Vericiguat (Verquvo)

Class: Soluble Guanylate Cyclase (sGC) stimulator

Indication:

Mechanism of Action:enhances production of cyclic GMP (cGMP) by directly stimulating soluble guanylate cyclase independent of nitric oxide (NO) and enhances sGC sensitivity to endogenous NO, thereby increasing cGMP production

Effects of mechanism of Action: increased levels of cGMP lead to smooth muscle relaxation and vasodilation

Adverse Effects:hypotension

Absolute Contraindications: PREGNANCY, use with PDE5 inhibitors
Pregnancy: DO NOT USE

Warning/ Precautions:–

Drug-Drug Interactions (DDIs): use with pde5 inhibitors

Monitoring Parameters: Blood Pressure, negative pregnancy test prior to initiation

Pearls:
1.complicated dosing algorithm based on BP in VICTORIA trial

39
Q

Digoxin

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:–

Pregnancy: -

Warning/ Precautions:

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:

A

Digoxin

Class: cardiac glycoside

Indication: treatment of mild to moderate heart failure in adults

Mechanism of Action:inhibition of sodium potassium ATPase pump in the myocardial cells results in a transient increase of intracellular sodium, which in turn promotes calcium influx via the socdium-calcium exchange pump leading to increased contractility

Effects of mechanism of Action: increased contractility of the heart

Adverse Effects: arhythmia, heart block, GI side effects (anorexia, , nausea and vomiting), neurologic side effects: visual disturbances, disorientation, confusion)

Absolute Contraindications:–

Pregnancy: -

Warning/ Precautions:

Drug-Drug Interactions (DDIs): Major substrate of P-glycoprotein, minor substrate of CYP3A4.

Monitoring Parameters: Heart rate and rhythm,
Serum concentrations: ideally a trough, goal 0.5-0.9 ng/mL

Pearls:

  1. on the Beers Criteria list (not safe for people over the age of 65)
  2. while target concentration is 0.5-0.9 ng/mL, patients can still develop toxicity in this range
40
Q

which HF treatment drugs are mortality and morbidity decreasing agents

A 
ARNI
ACE/ARBS
beta blockers
MRA's
SGLT-2 inhibitors
vaso/veno dilators
41
Q

which HF drugs re morbidity decreasing agents

A

loop diuretics
ivabridine
digoxin
soluble guanylate cyclase inhibitor (vericiguat)

42
Q

What is acute decompensated HF

A

What is it?
clinical syndrome of new or worsening signs and symptoms of heart failure, often leading to hospitalization or a visit to the emergency department

43
Q

classifications of acute decompensated heart failure

A

Classifications of Acute Decompensated Heart Failure

Class I. Warm and Dry
Class II. Warm and Wet
Class III. Cold and dry
Class IV. Cold and Wet

44
Q

Class I.Warm and dry

what do you do

A

warm and dry is the goal. no treatment for those needed

45
Q

class II. Warm and wet
what do u do?
what can you use?
what is the goal?

A

warm: goal. do nothing about that
wet: congested: DRY THEM OUT.
use loop diuretics. 1.5-2.5x home dose as iv.
if no home dose loop, start with 40 IV or equivalent
GOAL: 1-2 L negativ a day.
dose is working if there is at least 100 mL urine output in 6 hours

46
Q

class III. Cold and dry
what do you do?
what can you use?
what is the goal?

A

cold. want to perfuse them
IF HEMODYNAMICALLY STABLE, use..
ACE/ARBS/ARNI, hydralazine, IV vasodilators like…
IV nitroglycerin, IV nitroprusside,

if low bp, can use milrinone or dobutamine

47
Q

in acute decompensated HF

NTG

Nitroglycerin

Class:

Indication: .

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs):

Monitoring Parameters: –

Pearls:

A

NTG

Nitroglycerin

Class: nitrates

Indication: . IV: vasodilator in acute decompensated heart failure

Mechanism of Action: forms free radical nitric oxide, which activates cyclic GMP (cGMP), which causes smooth muscle relaxation. .

Effects of mechanism of Action: produces vasodilator effect on peripheral arteries and veins but more so on veins. overall reduces demand of oxygen to relieve angina.

Adverse Effects: Headache

Absolute Contraindications:recent use with phosphodiesterase inhibitor . Sildenafil/ Avanafil: 24 hr, Tadalafil: 48 hr, concurrent use with soluble guanylate cyclase stimulators (veriguat, riociguat)

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): can cause profound hypotension with recent use of PDE inhibitors like sildenafil, Avanafil, and Tadalafil

Monitoring Parameters: –

Pearls:
give as continuous IV infusion

48
Q

Nitroprusside

Class:

Indication: .

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): –

Monitoring Parameters:

Pearls:

A

Nitroprusside

Class: vasodilator

Indication: . IV: vasodilator in acute decompensated heart failure

Mechanism of Action: causes peripheral vasodilation by direct action on venous and arterial smooth muscle and release of nitric oxide, this reducing peripheral resistance; with increased cardiac output and after load.

Effects of mechanism of Action: produces vasodilator effect on peripheral arteries

Adverse Effects: Hypotension, cyanide and thiocyanate toxicity (by arterial blood gas or levels)

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): –

Monitoring Parameters: blood pressure, cyanide and thiocyanate toxicity (particularly if on for >3 days at > 3mcg/kg/min)

Pearls:
give as continuous IV infusion

49
Q

Milrinone

Class:

Indication: .

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:

A

Milrinone

Class: inotrope, phosphodiesterase 3 inhibitor

Indication: . use for patient in acute decompensated heart failure with reduced cardiac output. (when patient is cold (hypo perfused) and no hemodynamically stable. need to raise bp)

Mechanism of Action: selective PDE3 inhibitor in cardiac and vascular tissue

Effects of mechanism of Action: results in vasodilation and inotropic effects

Adverse Effects: increased or decreased BP, increased HR, arryhthmias

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): Anagrelide: category X. increases aryhtmia potential in combo with other anti arrhythmic agents

Monitoring Parameters: BP, HR, ECG, for arrhythmia

Pearls:

  1. moderate risk of arryhthmia, high risk of hypotension
  2. give as continuous IV infusion
  3. renal eliminated (more renal dysfunction-> more drug exposure and hypotension)
50
Q

Dobutamine

Class:
Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs):

Monitoring Parameters:
Pearls:
1

A

Dobutamine

Class: Adrenergic agonist agent, inotrope

Indication: . short term management of patients with cardiac decompensation to reperfuse. (when patient is cold (hypo perfused) and Low BP. need to raise bp)

Mechanism of Action: stimulate myocardial beta 1 adrenergic receptors resulting in increased contractility of the heart
stimulate beta 2 and alpha 1 in vasculature, resulting in vasodilation

Effects of mechanism of Action: increases ionotropic properties (increased contractility) produces vasodilator effect on peripheral arteries

Adverse Effects: increased or decreased BP, increased HR, arryhthmias

Absolute Contraindications:–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): increased arrythmogenic potential in combo with other anti arrhythmic agents

Monitoring Parameters: BP, HR, ECG, for arrhythmia

Pearls:

  1. high risk o arryhthmia, moderate-low risk of hypotension
  2. give as continuous IV infusion
51
Q

cold and wet
what to do?
what to use?

A

warm them up, and then dry them out.
warm. if hemodynamically stable, can use ace/arb/arni/ hydralazine, IV nitroglycerin, iv nitroprusside
if low bp. use inotropes like milrinone or dobutamine.
if hemodynamically unstable, can use vasopressors like norepinephrine, epinephrine, dobutamine

wet. MUST warm them up before drying them out. need to make sure kidneys ar perfused properly before giving loops.
then give loops as directed with wet. 1.5-2.5 x home dose or start with furosemide 40 IV if no home dose. goal is to be 1-2 L negative

52
Q

Vasopressors

Class: Vasopressors
Examples:

Indication: .

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:r–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs):

Monitoring Parameters:

Pearls:

A

Vasopressors

Class: Vasopressors
Examples: Norepinephrine, epinephrine, Dopamine

Indication: . IV: vasodilator in acute decompensated heart failure. (used when pt is cold and wet. in cold when the patient is hemodynamically unstable)

Mechanism of Action: generally alpha/beta agonists to increase iontropy and chronotropy and vasoconstriction

Effects of mechanism of Action: increase ionotropy/chronotropy and cause vasoconstriction

Adverse Effects: increased BP, increased HR, arrhythmia, extravasation (leakage of injected drugs from blood vessels causing damage to the surrounding tissues

Absolute Contraindications:r–

Pregnancy: –

Warning/ Precautions: –

Drug-Drug Interactions (DDIs): increases arrythmogenic potential in combo with other pro-arrhythmic agents

Monitoring Parameters: BP, HR, ECG for arrythmias

Pearls:
norepinephrine is given as the first line agent for cariogenic shock
dopamine increases fatal arrhythmia and mortality in cardigenic shock (AVOID)
give as continuous IV infusion

53
Q

What is HFpEF

A

What is it?
the left ventricule doesn’t fill properly, but does contract, so the same percentage of blood leaves the ventricle, but from a smaller starting volume

54
Q

approved meds for HFpEF

A
  1. sacubatril/ valsartan (entresto)

2. SGLT-2 inhibitors only empagliflozin right now

C/R (12 decks)

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