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Pharmacology 2 > Heart failure > Flashcards

Heart failure Flashcards

1
Q

Difference between Systolic (HFrEF) and diastolic (HFpEF) heart failure

A
  • If you have systolic heart failure (reduced EF), it means your heart does not contract effectively with each heartbeat. LVEF <40%
  • If you have diastolic heart failure (preserved EF), it means your heart isn’t able to relax normally between beats. Both types of left-sided heart failure can lead to right-sided heart failure. LVEF >50%
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2
Q

Rationale for drug use
Heart failure

A

Provide symptom relief and improve exercise tolerance.

Prevent hospitalisation and deterioration in left ventricular function.

Reduce mortality.

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3
Q

Non pharmacological treatment
Heart failure

A

Exercise
diet

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4
Q

Drugs for heart failure management

A

Standard treatment of HFrEF consists of quadruple therapy with:

ACE inhibitor (or sartan or sacubitril with valsartan)
beta-blocker
aldosterone antagonist (Eplerenone, Spironolactone)
sodium-glucose co‑transporter 2 inhibitor.
Doubutamine
Digoxin

Loop diuretics can be used to relieve symptoms of heart failure

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5
Q

Indication
Dobutamine

A

Inotropic support in acute heart failure, cardiogenic and septic shock

Pharmacological stress testing of myocardial function

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6
Q

Indication
Digoxin

A

AF and atrial flutter
Heart failure

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7
Q

ACE inhibitor means …

A

Angiotensin converting enzyme inhibitor

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8
Q

MOA
ACE inhibitor

A
  • block angiotensin I conversion to angiotensin II
  • inhibit breakdown of bradykinin (contribute to vasodilation)
  • reduce sodium retention
  • reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)

ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP

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9
Q

Indication
ACE inhibitors

A

Hypertension

Chronic heart failure with reduced ejection fraction as part of standard treatment

Diabetic nephropathy

Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)

Post MI

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10
Q

Adverse reactions
ACE inhibitors

A
  • hypotension
  • headache
  • dizziness
  • cough (dry / non productive)
  • hyperkalaemia
  • fatigue
  • nausea
  • renal impairment
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11
Q

Practice points

A

*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*

When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

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12
Q

Drug class and indication

Captopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)

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13
Q

Drug Class and indication

Enalapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction

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14
Q

Drug class and indication

Enalapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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15
Q

Drug class and indication

Fosinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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16
Q

Drug class and indication

Fosinopril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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17
Q

Drug class and indication

Lisinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment

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18
Q

Drug class and indication

Perindopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure

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19
Q

Drug class and indication

Perindopril with amlodipine

A

ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease

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20
Q

Drug class and indication

Perindopril with indapamide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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21
Q

Drug class and indication

Quinapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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22
Q

Drug class and indication

Quinapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* hypertension

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23
Q

Drug class and indication

Ramipril

A

ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors

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24
Q

Drug class and indication

Ramipril with felodipine

A

ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension

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25
Q

Drug class and indication

Trandolapril

A

ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction

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26
Q

Generic names of ACE inhibitors

A

Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril

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27
Q

Drug interactions
ACE inhibitor

A

Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).

Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.

ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.

Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.

Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.

ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.

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28
Q

SARTANs a.k.a. …

A

angiotensin receptor agonists (ARA)

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29
Q

MOA
sartans / ARA

A

Competitively block binding of angiotensin II to type 1 angiotensin (AT1) receptors. They reduce angiotensin II-induced vasoconstriction, sodium reabsorption and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.

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30
Q

Indication
sartans / ARAs

A
  • Hypertension
  • Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
31
Q

Adverse effects
sartans

A

dizziness, headache, hyperkalaemia

32
Q

Precautions / contradictions
sartans / ARAs

A

Peripheral vascular disease or atherosclerosis—patients may be more likely to have renal artery stenosis.

Volume or sodium depletion—Monitor combination w/ diuretics (both affect sodium and BP)

Black African or Caribbean descent

Treatment with drugs that can increase potassium concentration,

33
Q

Practice points
sartans / ARAs

A
  • stop K+ and K+ sparing diuretics
  • review use of NSAIDs
  • check renal function
  • used when ACE inhibitors are not tolerated for HTN and chronic heart failure

You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.

when starting a sartan:
stop potassium supplements and potassium-sparing diuretics
in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan
review use of NSAIDs (including selective COX‑2 inhibitors)
start with a low dose
check renal function and electrolytes before starting a sartan and review after 1–2 weeks
unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they:
cause less cough than ACE inhibitors
may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence)
maximum antihypertensive effect occurs about 4–6 weeks after starting treatment
encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

34
Q

Drug class and indication

Candesartan

A

sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors

35
Q

Drug class and indication

Candesartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

36
Q

Drug class and indication

Eprosartan

A

sartan / ARA
Hypertension

37
Q

Drug class and indication

Eprosartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

38
Q

Drug class and indication

Irbesartan

A

sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)

39
Q

Drug class and indication

Irbesartan with hydrochlorothiazide

A

sartan /ARA + thiazide diuretic
Hypertension

40
Q

Drug class and indication

Losartan

A

sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)

41
Q

Drug class and indication

Olmesartan

A

sartan / ARA
Hypertension

42
Q

Drug class and indication

Olmesartan with amlodipine

A

sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension

43
Q

Drug class and interaction

Olmesartan with amlodipine and hydrochlorothiazide

A

sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic
Hypertension

44
Q

Drug class and interaction

Olmesartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

45
Q

Drug class and indication

Telmisartan

A

sartan / ARA
* Hypertension
* Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA

46
Q

Drug class and indication

Telmisartan with amlodipine

A

sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension

47
Q

Drug class and indication

Telmisartan with hydrochlorothiazide

A

sartan / ARA + thiazide diuretic
Hypertension

48
Q

Drug class and indication

Valsartan

A

Sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
* Left ventricular failure/dysfunction after MI, when clinically stable

49
Q

Drug class and indication

Valsartan with hydrochlorothiazide

A

Sartan / ARA + Thiazide diuretic
Hypertension

50
Q

Generic names of Sartans / ARA

A

Candesartan
Candesartan with hydrochlorothiazide
Eprosartan
Eprosartan with hydrochlorothiazide
Irbesartan
Irbesartan with hydrochlorothiazide
Losartan
Olmesartan
Olmesartan with amlodipine
Olmesartan with amlodipine and hydrochlorothiazide
Olmesartan with hydrochlorothiazide
Telmisartan
Telmisartan with amlodipine
Telmisartan with hydrochlorothiazide
Valsartan
Valsartan with hydrochlorothiazide

51
Q

Tripple Whammy

A

NSAID + Sartan + ACE

Sounds like satan ate enough said

52
Q

Suffix:

Beta-blocker

A

lol

53
Q

Drug class

lol

A

Beta-blockers

54
Q

Indication
Beta-blocker

A

Hypertension
Angina
Tachyarrhythmias
MI
Chronic heart failure with reduced ejection fraction as part of standard treatment
Prevention of migraine

55
Q

MOA
Beta-blocker

A

Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.

Beta-blockers reduce heart rate, BP and cardiac contractility; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.

56
Q

Precautions / adverse effects
Beta-blockers

A

Shock (cardiogenic and hypovolaemic)—contraindicated.

Hyperthyroidism—beta-blockers may mask clinical signs, eg tachycardia.

Phaeochromocytoma—beta-blockers may aggravate hypertension; an alpha-blocker should be given first.

History of anaphylactic reactions—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis.

Myasthenic symptoms—may worsen.

CARDIACContraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure.
Respiratory contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD

Myasthenic symptoms (muscle weakness)

57
Q

Adverse effects
Beta-blockers

A
  • bradycardia,
  • hypotension,
  • orthostatic hypotension
  • bronchospasm,
  • dyspnoea,
  • fatigue, dizziness
  • Mask Hypoglycemia

Can mask signs of hypoglycemia in diabetics

58
Q

Counselling / practice points
Beta-blockers

A

Counselling
This medicine may cause dizziness or tiredness
Do not stop taking this medicine suddenly

Practice points
beta-blockers are not usually recommended first line for uncomplicated essential hypertension; they are associated with reduced protection against stroke in the elderly
**when stopping treatment, reduce dosage gradually

59
Q

Drug class and indication

Atenolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI

60
Q

Drug class and indication

Bisoprolol

A

Beta-blocker
Chronic heart failure with reduced ejection fraction as part of standard treatment

61
Q

Drug class and Indication

Carvedilol

A

Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment

62
Q

Drug class and indication

Labetalol

A

Beta-blocker
Hypertension
Hypertensive emergency

63
Q

Drug class and Indication

Metoprolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Prevention of migraine
Chronic heart failure with reduced ejection fraction as part of standard treatment

64
Q

Drug class and Indication

Nebivolol

A

Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment

65
Q

Drug class and indication

Propranolol

A

Beta-blocker
Hypertension
Angina
Tachyarrhythmias
Tetralogy of Fallot, seek specialist advice
MI
Prevention of migraine
Essential tremor
Phaeochromocytoma (with an alpha-blocker)

66
Q

Generic drug names
Beta-blockers

A

Atenolol
Bisoprolol
Carvedilol
Esmolol
Labetalol
Metoprolol
Nebivolol
Propranolol
Sotalol

67
Q

Indication
Loop diuretic

A

Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome

68
Q

MOA
Loop diuretic

A

Inhibit reabsorption of sodium and chloride in the ascending limb of the loop of Henle. This site accounts for retention of approximately 20% of filtered sodium; therefore, these are potent diuretics.

Produce a rapid and intense diuresis and have a short duration of action (4–6 hours). They are effective over a wide dose range with a dose-related response.

69
Q

Precautions
Loop Diuretics

A

Allergy to the specific loop diuretic—contraindicated (see Comparative information below).

Prostatic obstruction—loop diuretics may precipitate acute urinary retention.

Gout—may be aggravated by diuretic-induced hyperuricaemia. If a regular loop diuretic is started after the target serum urate level has been reached, measure serum urate levels every 2–5 weeks and adjust dose of urate-lowering drugs if necessary.

Treatment with ototoxic drugs—increases risk of ototoxicity with loop diuretics; use combinations carefully, especially in renal impairment.

70
Q

Adverse effects
Loop diuretics

A

electrolyte disturbances (eg hyponatraemia, hypokalaemia, hypomagnesaemia, hypochloraemia, hypocalcaemia), dehydration, metabolic alkalosis, increased creatinine concentration, hyperuricaemia, gout, dizziness, orthostatic hypotension, fainting

71
Q

Nursing considerations
Loop diuretic

A

Furosemide is the only loop diuretic available in oral and IV formulations.

Bumetanide may be used in patients allergic to furosemide (eg rash) but risk of cross-reactivity cannot be excluded.

Can cause hypotension which can cause dizziness

in case of heart failure:
1. Start with low dose
2. combine with ACE inhibitor

This medicine is usually taken once daily in the morning. If you are taking it twice a day, take the first dose in the morning and the second dose at lunchtime.

You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy.
role of loop diuretics in hypertension is limited to management of excess salt and water retention inadequately controlled by other antihypertensive treatment

**Heart failure
**start with a low dose then adjust according to clinical response; use the lowest effective maintenance dose
combine with an ACE inhibitor
if hypotension occurs decrease dose of diuretic before that of the ACE inhibitor
usually given once daily in the morning although there may be a better clinical response if the drug is given twice daily (second dose is usually given at midday; diuresis may interfere with sleep if given after 6 pm)
higher doses are necessary in refractory heart failure:
a trial of IV furosemide may be more effective than increasing oral doses
increase diuretic effect by adding a thiazide diuretic; use small, intermittent thiazide doses with careful monitoring, seek specialist advice
monitor weight and electrolytes
hypokalaemia is less likely when diuretics are used with ACE inhibitors or sartans than when used alone

72
Q

Drug class and indication

Bumetanide

A

Loop diuretic
Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome

Given if furosemide is not tolerated

73
Q

Drug class and indication

Furosemide

A

Loop diuretic
Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome

Pharmacology 2 (41 decks)

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