Heart Failure Flashcards by Maya Chilbert

Which beta-blockers decrease mortality in HFrEF?

Carvedilol, metoprolol succinate (XL), Bisoprolol

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BB AEs

Bradycardia, bronchospasm (esp non-selective BB)

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BB management in HF exacerbation

Do not initiate while in a heart failure exacerbation
Reduce dose if patient experiencing an exacerbation (try not to discontinue if possible)

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Bisoprolol: Specificity, starting, and target dose

Specificity: B1 selective
Starting dose: 2.5 mg daily
Target dose: 10 mg daily

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Metoprolol succinate: Specificity, starting, and target dose

Specificity: B1 selective
Starting dose: 12.5-25 mg daily
Target dose: 200 mg daily

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Carvedilol: Specificity, starting, and target dose

Specificity: alpha 1, B1, B2
Starting dose: 3.125 mg - 6.25 mg twice daily
Target dose: 25 mg twice daily (if > 85 kg: 50 mg twice daily)

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BB decrease mortality in HFrEF (T/F)

TRUE

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Preferred agent in HFrEF: ACEI/ARB/ARNI?

ARNI

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Sacubitril/valsartan brand name

Entresto

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Sacubitril MOA

Blocks breakdown of B-type natriuretic peptide → vasodilation and natriuresis

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ARNI washout

ACEI: 36 hours
ARB: NONE

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ACEi/ARB/ARNI decrease mortality in HFrEF (T/F)

TRUE

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MRA MOA

Competitive antagonists of the mineralocorticoid receptor → decreasing sodium reabsorption and increasing potassium reabsorption

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What is the eGFR or SCr or K+ requirement for initiating an MRA?

GFR>30, SCr<2.5 (male), SCr<2 (females), K<5

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MRA Monitoring (HF)

Electrolytes and renal function 2-3 days after initiation, then again 7 days after initiation/titration. Then check monthly for 3 months and every 3 months afterwards

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Selective MRA

Eplerenone

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Spironolactone AE

HyperK, gynecomastia, breast tenderness, impotence

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Spironolactone: Starting and target dose

12.5-25mg daily, 25-50 mg daily

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MRAs decrease mortality in HFrEF (T/F)

TRUE

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SGLT2 inhibitor MOA

Osmotic diuresis via glucose excretion, likely improvement in cardiac metabolism

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SGLT2i AE

Dehydration, UTI, hypoglycemia (if they also have diabetes)

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Dapagliflozin brand name

Farxiga

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Dapagliflozin dose

10 mg

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eGFR must be above ___ for dapagliflozin initiation

30 mL/min/1.73m²

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Empagliflozin brand name

Jardiance

Empagliflozin dose

10 mg (only titrate up to 25 mg for glycemic control)

eGFR must be above ___ for empagliflozin initiation

20 mL/min/1.73 m²

Indication for hydralazine/isosorbide

NYHA III-IV African American patients on titrated GDMT with ACEI/ARB/ARNI, BB, MRA, and SGLT2i OR Patients who can't tolerate an ACEI/ARB/ARNI

Hydralazine: starting and target dose

25 mg TID, 75 mg TID

Hydralazine AE

Reflex tachycardia, peripheral edema, palpitations, DILE

Isosorbide dinitrate: starting and target dose

20 mg TID, 40 mg TID

Isosorbide dinitrate AE

Headache

BiDil: starting and target dose

1 tablet BID, 2 tablets BID 1 tablet = 37.5 mg hydralazine, 20 mg isosorbide dinitrate

Signs and symptoms of congestion

Weight gain, SOB, orthopnea, paroxysmal nocturnal dyspnea, pleural effusion, crackles/rales, S3, S4, peripheral edema, BNP, JVD

Loop diuretics should be initiated when:

WET (warm/wet, cold/wet). Determine a patient is wet via signs of congestion

Typical loop diuretic starting dose

20-40mg furosemide PO / equivalent

Furosemide brand name

Lasix

Torsemide brand name

Demadex

Bumetanide brand name

Bumex

Ethacrynic acid brand name

Edecrin

Loop diuretic monitoring

BP, BUN, SCr, electrolytes, fluid/volume status

Loop diuretic AEs

hypokalemia hyponatremia hypovolemia hypocalcemia hypotension

Loop diuretic equivalents

Furosemide: 20mg IV or 40mg PO Torsemide: 20mg IV and PO Bumetanide: 1mg IV and PO

Loop diuretics decrease mortality in HFrEF (T/F)

FALSE

Ivabradine brand name

Corlanor

Ivabradine MOA

Impacts the funny channel in the AE node causing a reduced heart rate

Ivabradine indication

Resting HR 70 bpm or greater, on maximally tolerated BB, sinus rhythm, symptomatic

Ivabradine DDI

Major substrate of CYP3A4

Ivabradine decreases mortality in HFrEF (T/F)

FALSE

How does Vericiguat increase smooth muscle relaxation and vasodilation?

It increases sensitivity of sGC (soluble guanylate cyclase) to NO (nitric oxide) and directly stimulates sGC. These ultimately increases cGMP, which causes smooth muscle relaxation and vasodilation.

Vericiguat brand name

Verquvo

Vericiguat monitoring

Negative pregnancy test before initiation BP for hypotension

Vericiguat decreases mortality in HFrEF (T/F)

FALSE

Digoxin MOA

Inhibition of the sodium/potassium ATPase pump in myocardial cells results in a transient increase of intracellular sodium, which in turn promotes calcium influx via the sodium calcium exchange pump leading to increased contractility.

Digoxin DDI

P-glycoprotein inducers/inhibitors and CYP3A4 inducers/inhibitors

Digoxin monitoring

HR and rhythm, serum concentrations

Digoxin target concentrations (HF)

trough goal: 0.5-0.9 ng/mL

Digoxin AE

Arrhythmias, heart block, GI side effects, neurologic side effects

Digoxin decreases mortality in HFrEF (T/F)

FALSE

Signs and symptoms of hypoperfusion

Tachycardia, fatigue, cyanosis, cold extremities, organ dysfunction, increased SCr, increaed LFTs, confusion, altered mental status

IV Nitroglycerin MOA

Dilates veins and arteries, but more venodilation at lower doses. Increasing dose leads to more arterial dilation

IV Nitroglycerin AEs

Headache, hypotension

IV Nitroprusside MOA

Works via direct action and causes NO release \> dilates arteries and veins. Much greater impact on BP than IV Nitroglycerin at low doses

Nitroprusside Monitoring

BP and for Cyanide/Thiocyanate toxicity (especially with renal or hepatic dysfunction (normally if on 3mcg/kg/min for over 3 days))

Nitroprusside AEs

Hypotension and Cyanide/Thiocyanate toxicity

IV NTG/Nitroprusside Use in ADHF (classification and vs inotropes)

COLD (Class III & IV (cold/dry & cold/wet)) AND BP is ‘okay’ and can tolerate some lowering

Inotropic agents (2)

Dobutamine Milrinone

Dobutamine MOA

Stimulates B1 in the heart → increased contractility and HR (inotropy, chronotropy) Stimulates B2 in vasculature → vasodilation

Dobutamine AE

Arrhythmia, potential hypotension

Milrinone MOA

Selective PDE-3 inhibitor → vasodilation, inotropy

Milrinone AE

Hypotension, potential arrhythmia

ADHF Class IV (Cold/Wet): Which to address first?

Perfusion! Warm them up first (vasodilation/inotropes/pressors) then use diuretics "Warm them up to dry them out"

Which drugs should be avoided in HFrEF?

Non-DHP CCB Class IC Antiarrhythmics, dronedarone TZDs DPP-4s - saxagliptin, alogliptin NSAIDs