Heart Failure

Question 1

What are the 4 functional classifications of HF

Answer 1

I: asymptomatic
II: symptomatic with moderate exertion
III: symptom with minimal exertion
IV symptomatic at reset despite therapy

Question 2

What are the ejection fraction levels

Answer 2

reduced: <40%
mildly reduced 41-49%
preserved >50
improved: previous <40 now >40

Question 3

What are the best treatment options for HFrEF

Answer 3

ARNIs, ACEIs, ARBs (only select one), β blockers, SGLT2Is, mineralocorticoid receptor antagonists (MRA)

Question 4

What are the sodium-glucose cotransporter 2 inhibitors

Answer 4

“liflozin”

dapaglifozin, empaglifozin

Question 5

What are the 4 pillars of survival for HFrEF therapies? This reduced all cause mortality by up to 72%

Answer 5

ARNI, βb, MRA, SGLT2i

arni is preferred over ACEIs and ARBs

Question 6

ARNI MOA?

Answer 6

Sacubitril breaks down ANP and BNP-> decrease vasodilation

Valsartan hits Angiotensin1 receptor-> vasoconstriction

Question 7

When are ANP and BNP released

Answer 7

in response to stretch and volume overload

Question 8

Cough is an adverse effect of ____

Answer 8

ACE inhibitors. This is due to bradykinin blockage.

give ARBs instead.

Question 9

Should you switch a patient who is stable on an ACEI or ARB to and ARNI?

Answer 9

you can, as long as no history of angioedema.

CV mortality affected

Question 10

When are ARBs preferred over ACEIs and ARNIs in HFpEF

Answer 10

intolerant to the cough or angio edema

Question 11

When are ACEIs ok over ARBs

Answer 11

alterations in renal function or serum potassium. they all have these adverse effects

Question 12

ARNI can be started after __ hours after last dose of ACE inhibitor

Answer 12

36 hours

Question 13

AEs of RAAS drugs

Answer 13

hypotension, worsening renal fxn, hyper K+, cough, angioedema

Question 14

What are contraindications of RAAS drugs

Answer 14

pregnancy, hypotension, AKI, renal artery stenosis, hyper K+

Question 15

Β blockers hit (sympathetic system)
β1-> ?
α1 peripheral-> ?

Answer 15

β1: decrease tachycardia, raise CO

α1: decrease BP, raise CO

Question 16

Potential adverse effects of β blockers

Answer 16

metabolic alterations (glucose intolerance, masked hypoglycemia, lipid change TG up, HDL down), bronchospasm, bradycardia, exercise intolerance

Question 17

Caution using β blocker when

Answer 17

there is preexisting lung dx. start when patients are stable and euvolemic

Question 18

What are contraindication for β blockers

Answer 18

cariogenic shock, decompensated HF

bradycardia>1st degree AV block without pacemaker

Question 19

MRAs block what pathway

Answer 19

Angiotensin II to aldosterone

Question 20

You can give MRA for HFrEF if

Answer 20

eGFR>30mL/min/1.53m2 and serum K is <5.0mEq/L

Question 21

Potential adverse effects for MRAs

Answer 21

steroid effects of gynecomastia, menstrual irregularities (spirono only)
hyper K, hypotension

Question 22

Contraindications of MRAs

Answer 22

Hyperkalemia (if not <5.5mEq/L, discontinue), renal failure, anuria, adrenal insufficient, routine with ACE and ARB-> risk of hyper K

Question 23

What happens if serum potassium is >5.5?

Answer 23

risk of arrythmias

Question 24

What is MOA of SGLT2i

Answer 24

reduce glucose reabsorption at kidney and release glucose in urine

Question 25

What are the SGLT2i cardioprotective effects?

Answer 25

decrease cardiac remodeling, inflammation, sympathetic NS, BP Cause diuresis, natriuresis, erthyropoiesis, improved cardiac energy metabolism

Question 26

SGLT2i's are indicated for HFrEF stage _?

Answer 26

C EF<40%, use with other GDMT give regardless of diabetes

Question 27

What must the eGFR be for the two SGLT2i's (dapaliflozin and empagliflozin)

Answer 27

>30 for dapa | >20 for empa

Question 28

What population is hydralazine/isosorbide dinitrate used in?

Answer 28

African Americans and individuals who cannot tolerate RAAS drugs from hyperK+

Question 29

hydralazine/isosorbide dinitrate MOA

Answer 29

hemodynamic effects. nitrates are vasodilators-> reduce venous return-> reduce preload hydralazine is an arteriole dilator, reduce afterload

Question 30

When would diuretics be used in HFrEF patients

Answer 30

stage C-D with fluid retention. treat congestive symptoms (JVP, pulmonary congestion, peripheral edema). want to minimize electrolyte abormalities.

Question 31

Loop diuretics MOA

Answer 31

Inhibit Na+ reabsorption in the ascending loop of henle

Question 32

Thiazide and thiazide-like MOA

Answer 32

inhibit Na+ reabsorption in the DCT (resistance on high dose loop diuretics)

Question 33

Diuretic monitoring

Answer 33

urine output, daily weights, symptoms of congestsion

Question 34

What to watch for when taking an diuretic

Answer 34

electrolyte wasting, serum creatinine, BUN, ototoxicity, myalgia, BP, heart rate

Question 35

what could be used for treatment in HFmrEF

Answer 35

a ok: diuretics less great: SGLT2i's meh: RAAS, MRA, β blockers

Question 36

what could be used for treatment in HFpEF

Answer 36

a ok: diuretics less great: SGLT2i's meh: ARB, MRA, β blockers

Question 37

What drugs are we avoiding, especially in HFrEF

Answer 37

NSAIDs, class 1 and 3 antiarrhytmics (flecainide and propafenone and class III dronedarone) Non-DHP CCB Thiazolidinediones