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Therapeutics Module 3 > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is heart failure?

A

any cardiac structural or functional disorder leading to inadequate cardiac output &/or elevated ventricular filling pressures

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2
Q

What does Heart failure do?

A

impairs the ability of the ventricle to fill (diastolic) with or eject (systolic) blood

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3
Q

What does reduced cardiac output mean for Heart failure?

A
  • unable to meet metabolic demands of
    the body
  • only able to maintain cardiac output with abnormally high cardiac pressures
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4
Q

Pulmonary or systemic congestion with heart failure occurs at?

A

Rest or with stress

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5
Q

What is the pathophysiology of HF?

A

Cardiac output is ↓ in heart failure

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6
Q

What is SV?

A

Stroke volume is the volume of blood ejected per heartbeat, which is dependent on preload, afterload, and contractility
Cardiac output (CO) = heart rate (HR) x stroke volume (SV)

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7
Q

What is stroke volume?

A
  • the volume of blood ejected per heartbeat
  • dependent on preload, afterload, and contractility
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8
Q

What is the frank starling law?

A

ability of the heart to alter the force of contraction based on changes in preload

if the heart is over stretched, it loses its ability to return force

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9
Q

What does myocardial injury mean?

A

compensatory responses in an attempt to maintain cardiac output

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10
Q

What is the myocardial injury intended for?

A

intended to be short-term to maintain BP & renal perfusion, but with the persistent decline in cardiac output in HF, results in long-term activation of the compensatory mechanisms

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11
Q

What are HF symptoms?

A

shortness of breath, fatigue, edema

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12
Q

Pharmacotherapy targeting the above can slow progression, and reduce the risk of morbidity & mortality in

A

Hf-rEF

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13
Q

Frank starling law in summary?

A

if the heart is over stretched, it loses its
ability to return force

THink of the spring model where we over stretch the heart too much what happens?

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14
Q

What is structural heart disease/

A

left ventricular hypertrophy, valvular heart disease

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15
Q

What is abnormal cardiac function?

A

reduced left or right ventricular systolic function, increase filling pressures, abnormal diastolic dysfunction

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16
Q

What is Natriuretic peptide?

A

synthesized & released from the ventricle in response to pressure or volume overload

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17
Q

What does Elevated plasma concentrations of ProBNP do?

A
  • increase natriuresis, diuresis & attenuate renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system activation
  • can be used to help diagnosis and monitor heart failure
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18
Q

What enzyme converts BNP?

A

Neprilysin

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19
Q

Should np-BNP be used independant of diagnosing HF?

A

should not be used independent of signs, symptoms & other diagnostic information (e.g. cardiac imaging)

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20
Q

What is BNP vs NTproBNP

A
  • similar – either can be used; dependent on your local lab
  • absolute values & thresholds are NOT interchangeable
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21
Q

Is chronic HF the same as congestive heart failure?

A

NO

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22
Q

What is Acute / decompensated HF?

A

gradual or rapid change in HF signs & symptoms, resulting in the need for urgent therapy

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23
Q

What is Advanced HF?

A

frequent decompensations, mechanical devices, transplantation, palliative therapies

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24
Q

What is considered normal ejection fraction?

A

50-70%

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25
Q

What is considered borderline ejection fraction?

A

41-49

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26
Q

What is considered Reduced ejection fraction?

A

<40

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27
Q

When does LVEF <40 usually occur?

A
  • systolic
    dysfunction
  • problems with the
    heart pump / ventricular contractility
  • usually after an acute CAD event
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28
Q

What is HF with improved EF?

A
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29
Q

What is considered symptomatic HF?

A

NYHA class II to IV

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30
Q

Majority of HF trials enrollees are?

A

NYHA class II to III

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31
Q

What are the 4 categories of HFrEF indicated standard therapies?

A
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32
Q

What medications fall under the ARNI or ACEi/ARB category?

A

captopril enalapril lisinopril ramipril trandolapril

candesartan valsartan

sacubitril / valsartan

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33
Q

What beta blockers are indicated for HF?

A

bisoprolol carvedilol metoprolol

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34
Q

What MRA medications are indicated for HF?

A

Eplerenone
Spironolactone

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35
Q

Which SGLT2 inhibitors are indicated for HF?

A

Dapagliflozin
Empagliflozin

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36
Q

What is the benefit of quadruple therapy>

A

Decrease risk of mortality and decrease risk of HF hospitalization

Improve HF symptoms

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37
Q

Where do ACEi work?

A
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38
Q

What is the target dose of enalapril?

A

10mg BID

20mg BID in NYHA IV

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39
Q

What is the target dose of Lisinopril?

A

20-35mg daily

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40
Q

What is the target dose of perindopril?

A

4-8mg daily

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41
Q

What is the target dose of ramipril?

A

5mg BID

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42
Q

What is the target dose of trandalopril?

A

4mg daily

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43
Q

How quickly do we increase doses of Ace inibitors?

A

1-3 weeks

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44
Q

What are the contraindications of using ACEi?

A
  • bilateral renal artery stenosis or unilateral if only 1 kidney
  • history of angioedema
  • pregnancy
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45
Q

What is angioedema?

A

welling that is similar to hives, but the swelling is under the skin instead of on the surface

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46
Q

When are ACEi cautioned?

A
  • K+ greater than 5.2mmol/L, SCr greater than 220umol/L or eGFR less than
    30mL/min
  • SBP less than 90mmHg or symptomatic hypotension
  • moderate to severe aortic stenosis
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47
Q

What is an issue with ACEi in terms of Drug interactions?

A

Increased risk of hyperkalemia

Lithium toxicity

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48
Q

What adverse reactions need to be monitored while on ACEi?

A
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49
Q

What are the leading causes of angioedema in terms drug therapy?

A

ACEi

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50
Q

Where do RAAS inhibitors work?

A
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51
Q

What is the place in therapy for using an ARB?

A
  • Use an ARB if ACEi intolerance
  • cough(10-20%)
  • Angioedema <1%
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52
Q

What is the Acei vs ARB arguement?

A
  • more evidence with ACEi
  • no significant difference in rates of hypotension, hyperkalemia or renal dysfunction
    *do NOT combine an ACEi and ARB,due to↑risk of hypotension,hyperkalemia, & renal dysfunction
  • Entresto contains an ARB (valsartan)
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53
Q

What is the target dose of candesartan?

A

32mg daily

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54
Q

What is the target dose of valsartan?

A

160mg BID

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55
Q

Where does the ARNI Sacubitril work?

A
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56
Q

What is entresto?

A

Combo produt of ARNI and ARB

57
Q

MOA of ENTRESTO?

A
58
Q

What are the AE of ENTRESTO?

A

More symptomatic hypotension

More angioedema (Non stat significant)

Less SCr elevation cough and discontinuations though

59
Q

What are the CI of ENTRESTO?

A
  • concurrent ACEi use (36-hour washout period ACEi ,ARNI) * wash-out period not required with an ARB
  • history of ACEi or ARB angioedema
60
Q

What should be cautioned with entresto?

A

Recent symptomatic hypotension

61
Q

What is the target dose of ARNI?

A

200mg BID

62
Q

How quickly do we double dose or ENTRESTO?

A

3 to 6 weeks

63
Q

What are the three beta-blockers used in HF?

A

bisoprolol
carvedilol
metoprolol

64
Q

What do Beta Blockers do?

A

Reduce the risk of mortality and risk of HF hospitalizations

Improve HF symptoms

65
Q

What is the MOA of Beta Blockers

A
  • block norepinephrine at the beta-adrenergic receptors
  • improves myocardial function by prolonging ventricular filling time, resulting in a more productive heartbeat
66
Q

What is the target dose of carvedilol

A

25mg BID

50mg BID >85 kg

67
Q

What is the target dose of bisoprolol?

A

10mg daily

68
Q

What is the target dose of metoprolol?

A

200mg Daily

69
Q

Which formulation of metoprolol is preferred?

A

Long acting formulation preferred

70
Q

How quickly are beta blockers titrated?

A

2-4 weeks

71
Q

What is the contraindications of the usage of Beta blockers/

A
  • in the absence of a pacemaker: 2nd or 3rd degree AV block or HR <50bpm
  • PR interval greater than 0.24 seconds
  • severe / uncontrolled asthma
    (stable COPD is not a contraindication)
  • severe peripheral artery disease
72
Q

Which BP/HR are beta blockers cautioned in?

A

<90 mmHG SBP or <50bpm

73
Q

What are the DI of Beta blockers/

A
  • risk of bradycardia / AV block with verapamil, diltiazem, amiodarone, digoxin
  • risk of hypertensive crisis with clonidine
  • risk of reduced B-blocker efficacy with phenobarbital
74
Q

Should beta blockers be stopped abruptly?

A

No taper over 1 to 2 weeks

75
Q

Which beta blockers are cardio selective? (Indicated for HF Too)

A

bisoprolol, metoprolol

76
Q

Which beta blockers are non-cardioselective (HF indicated)

A

carvedilol

77
Q

What are the Mineral receptor antagonist?

A

Eplerenone
Spironolactone

78
Q

What is the MOA of MRA?

A
79
Q

What are the target doses of MRA Spironolactone

A

25-50mg daily

80
Q

What are the target doses of MRA eplerenone?

A

50mg daily

81
Q

What is the benefit due to neurohormonal activity of RAAS?

A
  • weak natriuretic agent
  • minimal impact on blood pressure… unless BP elevated (HF vs resistant HTN)
82
Q

What are the drug interactions of spironolactone?

A

increases digoxin serum concentrations

83
Q

What are the drug interactions of Eplerenone?

A

Caution with strong CYP 3A4 inhibitors

Caution using maximum 25mg daily with moderate CYP 3A4 inhibitors

84
Q

What are the adverse events that may occur while on MRA?

A

Hyperkalemia
Gynecomastia (Man boobs)
ED
Menstrual irregularities

85
Q

What is MRA used for?

A
  • used in HF for neurohormonal benefit (RAAS inhibition)
  • loop diuretics (e.g. furosemide) are used for congestion / fluid overload in HF
86
Q

What are the two SGLT2 inhibitors discussed in class for HF?

A

dapagliflozin empagliflozin

87
Q

What does SGLT2 inhibitors do?

A

Decrease risk of mortality and HF hospitalizaiton

Decrease risk of renal outocmes

88
Q

When is the AIC lowering effects of SGLT2 inhibitors diminished?

A

CKD

  • minor at eGFR 30-45mL/min
  • absent at an eGFR <30mL/min
89
Q

CI of SGLT2 inhibitors

A
  • severe renal or hepatic dysfunction * dapagliflozin
    CrCl<25mL/min

*empagliflozin
CrCl<20mL/min

90
Q

What are the DI of SGLT2 inhibitors?

A

Diuretics

91
Q

What do we monitor with respect to SGLT2 inhibitors?

A

VOlume status

SCR at 14-30 days, (WE WILL SEE 15-20 reduction in eGFR at the beginning which is acceptable)

A1C in T2DM

92
Q

What is dapagliflozin indicated for?

A

HFref

93
Q

What is Empagliflozin indicated for?

A

HF

94
Q

Which SGLT2 is cheaper?

A

Dapagliflozin because of generic availability..

BUT not officially indicated!

95
Q

Which SGLT2 inhibitor decreases mortality?

A

Dapagliflozin only

96
Q

Review this table for a minute

A
97
Q

Take some time to review this table

A
98
Q

What is ivabradine?

A

LANCORA (TM) is a medication that slows the diastolic depolarizaiton by blocking sodium channels.

99
Q

What does ivabradine do?

A

Lowers HR

100
Q

What place odes Ivabradine have?

A
  • Symptomatic HF-rEF despite guideline directed therapy, in sinus rhythm and a raised resting heart rate, & HF hospitalization within 12 months
101
Q

What are the benefits of Ivabradine?

A

reduces the risk of HF hospitalizations, but not mortality

102
Q

What is the target dose of Ivabradine?

A

7.5mg BID

103
Q

What is Ivabradine CI in?

A

3rd degree AV block, sick sinus syndrome, pacemaker dependence, prolonged QT interval, unstable CV conditions, severe renal or hepatic dysfunction

Cyp 3A4 inhibitors

Moderate Cyp 3A4 inhibitors that reduce HR

104
Q

What are the adverse effects of ivabradine?

A

Afib
Transient flashes of light

105
Q

What do we monitor for while using Ivabradine?

A

Heart rate!

106
Q

What type of coverage is their available?

A

HF LVEF <35%, >77 beats per minute

107
Q

What is Digoxin place in therapy?

A

HF-rEFinsinusrhythmwhocontinuetohavemoderate to severe symptoms, despite appropriate doses of guideline directed medical therapy to relieve symptoms & reduce hospitalizations

108
Q

What are the benefits of Digoxin?

A

reduces the risk of HF hospitalizations, but not mortality

109
Q

What is the MOA of Digoxin?

A

positive inotropic effect (Strengthens contractions)

110
Q

What is Digoxin CI in?

A

Ventricular fibrillation

111
Q

What is Digoxin cautioned in?

A

acute MI, AV block, bradycardia, renal or thyroid dysfunction, hypokalemia

112
Q

What are the AE of digoxin?

A

Toxicity

113
Q

What is monitored with Digoxin?

A

HR
SCr (Caution if CrCl <30ml/min)
Potassium (Low levels)

114
Q

What is the target dose of Digoxin

A

Dose: 0.0625mg to 0.25mg po once daily

115
Q

Who should we consider lower levels of digoxin in?

A

Elderly, females, renal impairment

116
Q

What will ivabradine and Digoxin both do?

A
  • lower raised resting heart rates in HF patients
  • reduce the risk of HF hospitalizations, but not mortality
117
Q

What is the issue with ivabradine as compared to digoxin/

A

has less real-world experience, cannot be used in AF patients, is more
expensive

118
Q

If we want to reduce HF hospitalization which drug would be want to consider?

A

Vericiguat

119
Q

If HR is above 70bpm what should we consider?

A

Ivabradine

120
Q

What is the place of therapy of Vericiguate?

A
121
Q

What is the benefit of Vericiguate?

A
  • reduces the risk of HF hospitalizations, but not mortality
122
Q

CI of Vericiguate

A

FDA: concomitant use of other sGC stimulators, pregnancy

123
Q

What is the target dose of Vericiguat?

A

10mg daily

124
Q

What is the MOA of Vericiguat?

A

It increases sGC activity which

125
Q

Vericiguat increase sGC activity to improve

A

Myocardial and vascular function

126
Q

What is the MOA of Hydralazine and nitraes?

A

Reduces afterload on Left ventricle, enhances hearts ability to pump

Nitrates reduce preload

127
Q

When should patients be recommended to start H-ISDN?

A

recommend that H-ISDN be considered in patients with HFrEF who are unable to tolerate an ACEi, ARB, or ARNI

128
Q

CI of Hydralazine?

A

Acute dissecting aortic anuerysm

129
Q

What needs to be monitored when on Hydralazine?

A

BP and HR

130
Q

Isosorbide Dinitrate monitoring?

A

BP and HR

131
Q

What is the target dose of Vericiguat?

A

10mg daily

132
Q

What is the target dose of hydralazine/isosorbide dinitrate?

A

75-100mg TID

40mg TID

133
Q

In those with HfPref what do we do?

A

Identify & treat comorbid conditions that
might exacerbate HF e.g. HTN, DM, AF

use loop diuretics to control symptoms of congestion & peripheral edema

134
Q

In individuals with EF >40% what should we do? Hfmref

A
135
Q

WHat is the treatment for patients with HfPef LVEF >50%

A
136
Q

What are our loop diuretics?

A

Furosemide, Bumetanide, Ethacrynic acid

137
Q

How do we assess loop diuretics usage?

A
  • If weight ↑ 2lbs in one-two days or 5lbs over a week

→ call healthcare provider for assessment

138
Q

Review the next table with respect to a summary that describes monitoring of drugs

A
139
Q
A

Therapeutics Module 3 (6 decks)

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