Heart Failure Flashcards

Question

ACEi and ARBS actions

Answer 1

* Prevent conversion of AI to AII and lower circulating AII. * antagonize deleterious actions of AII on the heart, BV and Kidneys * Cause veno and arterial dilation to decrease mean arterial BP. * Reduce levels of aldosterone (act as an indirect diuretic) * Increase stroke volume and cardiac output for a given preload * reduce ventricular end-diastolic pressure and volume * Increase bradykinin (ACEI) * improve myocardial energy metabolism

Answer 2

direct effects on preload and afterload and improved survival

Answer 3

* hypotension * Cough ~15-20% of patients (bradykinin acting on stretch receptors in the throat). * **_Hyperkalemia_** because they reduce aldosterone, which normally mediates Na+ absorption and K+ excretion * Proteinuria and angioedema

Answer 4

* Hypotension * Recommended for patients with cough from ACEI. * Less angioedema Than ACEI.

Answer 5

ACEI or ARB

Answer 6

decrease incidences and prolong survival also improve symptoms

Answer 7

FALSE - low doses and titrate to the highest tolerated dose targeting max daily

Answer 8

yes, if the patient has fluid retention

Answer 9

loop of henle aka loop diuretics \> thiazides

Answer 10

increased catecholamine neurotransmitter release, which increase HR and force and maintain CO

Answer 11

chronic sympathetic stimulation

Answer 12

administration at very low doses initially then gradually increased over 8 week intervals

Answer 13

lower HR, reduce O2 consumption, fibrosis, arrhythmias, cell death

Answer 14

B blockers; diastole

Answer 15

* **NON-selective** B blocker with NO intrinsic sympathomimetic activity and alpha-1 adrenergic receptor blocker * scavenger of O2 free radicals → role in myocardial necrosis * metabolizes by CYP2D6, but half life of the drug is 7h, allowing twice a daily dosing

Answer 16

* with continuous use, Carvedilol increases S.V. decreases intracardiac and pulmonary vascular pressure * decreases heart rate. * prevents progressive enlargement of the left ventricle. * Reduces incidence of diabetes mellitus.

Answer 17

* B blocker * zero-order prolonged release formulation

Answer 18

metoprolol once a day dosing, less hypotension because alpha 1 (orthostatic hypotension), more selective B1 blockade (reduce risk of bronchospasm)

Answer 19

* metabolism dependent on polymorphic CYP2D6 * CYP2D6 poor metabolizers

Answer 20

long-half life and give once daily

Answer 21

* May aggravate heart failure * they are administered at low doses that are built slowly. (START LOW AND GO SLOW). * Like other β-blockers, may aggravate bronchospasm and precipitate asthma.

Answer 22

* All patients with symptomatic heart failure and * all patients with left ventricular dysfunction (stage B, NYHA I) * after myocardial infarction

Answer 23

in new-onset or acutely decompensated heart failure. If patients are hospitalized with acute decompensation

Answer 24

Use of ß-blockers such as bisoprolol, carvedilol, or extended-release metoprolol succinate in addition to ACEI consistently leads to a 30-40% reduction in hospitalization and mortality

Answer 25

* Aldosterone, as the second major actor of the RAAS, **promotes Na+ and fluid retention, loss of K+ and Mg2+ , and myocardial and vascular fibrosis and damage.** * MRAs are K+-sparing diuretics but gained more importance in the treatment of heart failure for their additional efficacy in suppressing the consequences of neurohumoral activation. * Aldosterone plasma levels decrease under therapy with ACEIs or ARBs, but quickly increase again, a phenomenon called ***_aldosterone escape_***.

Answer 26

MRAs act as antagonists of nuclear receptors of aldosterone.

Answer 27

hyperkalemia

Answer 28

eplenorone

Answer 29

Do not use if the GFR is less than 30 mL/min (creatinine ~ 2 mg/dL).

Answer 30

carry higher risk of hyperkalemia

Answer 31

* Atrial Natriuretic peptide (ANP) * Brain Natriuretic peptide (BNP) * C-Type Natriuretic peptide (CNP) (endothelial and renal origin) * Urodilatin (found in urine, paracrine regulator of Na+ transport)

Answer 32

* an atrial peptide produced in response to stretch. * It binds to NP receptor-A (NPR), activates GC and increases cGMP.

Answer 33

* BNP is produced by the ventricle * BNP also binds to NPR-A and acts like ANP

Answer 34

CNP binds to NPR-B in vascular smooth muscle cells and mediates relaxation.

Answer 35

sacubitril

Answer 36

* recommended over an ACEI or ARB in patients with NYHA class II or III HF * ARB-NI combination (ARNI) * A combination of an ARB “Valsartan” and sacubitril (an inhibitor of the peptidase neprilysin * Entresto combines inhibition of the RAAS with activation of a beneficial axis of neurohumoral activation, the natriuretic peptides

Answer 37

* ARNI promote the beneficial effects natriuresis, diuresis, and vasodilation of arterial and venous blood vessels. * ARNI also inhibit thrombosis, fibrosis, cardiac myocyte hypertrophy, and renin release. * They augment ANP/BNP levels by inhibiting their degradation, which is a better pharmacological principle than giving the agonist BNP (neseritide).

Answer 38

* Hypotension, renal insufficiency, and hyperkalemia can occur. * BP and serum K+ should be monitored

Answer 39

Patients with a history of angioedema should not take an ARNI.

Answer 40

* contraindicated for use with or within 36 hours after the last dose of an ACE inhibitor. * Concurrent use of potassium-sparing diuretics is contraindicated. * NSAIDs might worsen renal function when taken with EntrestoTM. * Contraindicated in Pregnancy (ARB)

Answer 41

activate soluble guanylyl cyclase by mimicking the activity of nitric oxide (NO)

Answer 42

* Increase concentration of cyclic GMP in vascular smooth muscles relaxes smooth muscles in peripheral veins * increase venous capacitance * Improve exercise capacity * Reduce pulmonary and systemic vascular resistance

Answer 43

nitrate tolerance and hypotension

Answer 44

* Potent soluble guanylate cyclase STIMULATOR. * Reduces afterload by increasing cyclic GMP leading to smooth muscle relaxation and vasodilation of veins/arteries. * Intended for use in adults with symptomatic chronic HF and EF \<45% who are receiving standard therapy without further symptom improvement * Contraindicated in pregnancy * Should not be taken with PDE5 inhibitors (e.g. Viagra) Hypotension.

Answer 45

relaxes arteriolar smooth muscles

Answer 46

* Reduces systemic and vascular resistance reduces R and L ventricular afterload * Increases stroke volume and reduces stress during ventricular systole. * Has no effect on venous capacitance, used with a nitrovasodilator for HFrEF patients. * A fixed combination of Hyd 37.5 mg and 20 mg of isosorbide dinitrate is sold as Bidil™ (it is the first race-based drug in the US, because it is marketed exclusively for CHF in African Americans).

Answer 47

used in a combination with a diuretic, isosorbide mono- or dinitrate and occasionally with a ACE inhibitor

Answer 48

* Digoxin binds to and inhibits the -subunit of the sarcolemmal Na+-K+- ATPase. * Inhibition of the ATPase leads to an increase in intracellular Na+ concentration which in turn activate Na+/Ca++ exchange leading to increased intracellular Ca++ concentration. * Increased Ca++ ions are reabsorbed by the S.R. Therefore, the Conc. of Ca++ in the S.R. increases * Consequently increased amounts of Ca++ are released by the S.R. after depolarization. * Summary: Digitalis glycosides increase the release of calcium during systole and there by increase FORCE

Answer 49

* Increase the velocity of cardiac muscle shortening. * Increased stroke volume is generated for a given preload. * These changes are caused by the increase availability of Ca++ ions during systole

Answer 50

* Direct: Inhibit Na-K-ATPase in neuronal cells. Stimulate parasympathetic and inhibit sympathetic discharges. * Indirect: improve the pattern of fluctuating sympathetic discharges because digitalis sensitizes pressure sensitive baroreceptor cells.

Answer 51

* Prolong the effective refractory period and decrease conduction velocity the AV node. * increase in vagal tone impedes transmission through the AV node.

Answer 52

NO. decreases symptoms of heart failure, increases exercise tolerance, decreases the rate of hospitalization half life 26-45 hours

Answer 53

impaired kidney function

Answer 54

* Narrow margin of safety (monitor digoxin serum levels). * Hypokalemia – hypokalemia enhances digitalis toxicity by promoting glycoside binding to the Na+-K+-ATPase pump and by inhibiting the turnover of the Na+ pump. * Hypokalemia decreases the margin of safety of digitalis glycosides.

Answer 55

* Extracardiac CNS: visual problems, fatigue, G.I. Anorexia, nausea and vomiting * Cardiac Electrophysiological, including suppression of AV conduction, ectopic beats in AV and ventricle. EKG reveals a prolonged PR interval

Answer 56

* **Administration of K+:** potassium stimulates sodium pump activity, reduces glycoside binding to the Na+-K+-ATPase and alters membrane conductance to cations. * **Anticardiac glycoside immunotherapy (Digibind™)** Digibind™ is a purified preparation of Fab fragments from sheep anti-digoxin antisera. 1 vial neutralizes 0.6 mg digoxin

Answer 57

* used short term * activates cardiac ß1-adrenergic receptors (cardiotonic) and dopamine receptors in the kidney to produce renal vasodilatation.

Answer 58

hospitals ## Footnote preferentially dilates renal blood vessels, promoting renal blood flow and maintenance of GFR in patients with shock

Answer 59

maintenance of B.P. in cardiogenic, hemorrhagic or other types of shock

Answer 60

Ca2+; systole

Answer 61

It has a wider spectrum than dopamine and stimulates both β1- and β2-adrenergic receptors and also both alpha1- and alpha2-adrenergic receptors.

Answer 62

* Positive inotropic effects due to activation of β1-AR * Does not increase renal blood flow selectively like dopamine * Dobutamine acts as a vasodilator and reduces vascular resistance

Answer 63

superior to Dopamine in patients with advanced heart failure who do not improve with oral vasodilators.

Answer 64

Cyclic AMP is degraded to AMP by “phosphodiesterases”. Therefore, by inhibiting the PDE, cAMP is preserved to produce its effects on contractility

Answer 65

* Inhibitors cyclic GMP-inhibited cyclic AMP PDE (type III). * Milrinone is 10 times more potent, has a shorter half-life and is **more selective** for type III PDE than Amrinone. * agent of choice among PDE inhibitors. * Used for short-term only because long-term use of these drugs often causes intolerable side effects and increased death among heart failure patients.

Answer 66

* inhibits cardiac pacemaker current (If), a mixed sodium-potassium inward current (funny current). * slows firing in the SA node, and ultimately reduces heart rate. * Its cardiac effects are specific to the SA node with no BP effects.

Answer 67

2nd line for symptomatic HF

Answer 68

mild and infrequent. but include luminous phenomena (phosphenes) or visual brightness because ivabradine partially inhibits the retinal current (Ih), which has properties similar to that of cardiac

Answer 69

* inhibit the sodium-glucose co-transporter in the proximal convoluted tubule. * used to lower blood glucose levels in patients with type II diabetes, by increasing the urinary excretion of glucose.