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Therapeutics 2 > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Describe: NYHA Functional Classification I

A

no limitation on physical activity

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2
Q

Describe: NYHA Functional Classification II

A

slight limitation of physical activity; comfortable at rest, but ordinary activity results in symptoms of HF

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3
Q

Describe: NYHA Functional Classification III

A

marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes symptoms of HF

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4
Q

Describe: NYHA Functional Classification IV

A

unable to carry on any physical activity without symptoms of HF or even symptoms of HF at rest

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5
Q

Define: HFrEF

A

LVEF of 40% or less

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6
Q

Define: HFpEF

A

LVEF of 50% or greater

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7
Q

What are the goals of therapy for HF treatment?

A

-reduced mortality
-prevent or minimize hospitalizations
-slow progression of disease
-relieve or reduce symptoms
-improve quality of life

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8
Q

What are the precipitating and exacerbating factors of heart failure?

A

-nonadherence with medical regimen, sodium and/or fluid retention
-acute myocardial infarction
-uncorrected high blood pressure
-recent addition of negative inotrope
-medications
-excessive alcohol or illicit drug use
-pulmonary embolus
-endocrine abnormalities
-infection

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9
Q

What medication should be avoided in heart failure?

A

-NSAIDs, COX-2 inhibitors
-thiazolidinediones
-saxagliptin and alogliptin
-antiarrhythmics
-NON dihydropyridine calcium channel blockers (CCBs) (diltiazem and verapamil)

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10
Q

What can be done to control the risk factors of heart failure?

A

-control BP
-diabetes control with SGLT2i can prevent HF hospitalizations
-adherence to healthy lifestyle (no smoking, physical activity, healthy diet)
-ASCVD (including MI) -> ACEI/ARB, beta blocker, statin

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11
Q

What is the first step of treatment for a patient with established diagnosis of HFrEF?

A
  1. ARNI (preferred) or ACEI or ARB
  2. beta blocker
  3. mineralocorticoid receptor antagonist (MRA)
  4. SGLT2 inhibitor
  5. possible diuretic (as needed)
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12
Q

What drug is an Angiotensin receptor-neprilysin Inhibitor (ARNi) approved for patients with heart failure?

A

sucubitril (ARNi)/valsartan (ARB) (ENTRESTO)

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13
Q

What is the indication for sucubitril/valsartan (ENTRESTO)?

A

reduce the risk of CV death and hospitalization for patients with heart failure (HF)

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14
Q

What is the starting dose for sacubitril/valsartan (ENTRESTO)?

A

49mg/51mg po BID with or without food

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15
Q

What is the target dose of sacubitril/valsartan (ENTRESTO)?

A

97mg/103mg BID

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16
Q

If a patient is not currently taking an ACEI/ARB or is taking a low dose they should initially take _______ of sucubitril/valsartan (ENTRESTO).

A

24mg/26mg

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17
Q

If a patient has severe renal impairment (eGFR <30 mL/min/1.73m2) they should initially take _______ of sucubitril/valsartan (ENTRESTO).

A

24mg/26mg

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18
Q

If a patient has moderate hepatic impairment they should initially take _______ of sucubitril/valsartan (ENTRESTO).

A

24mg/26mg

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19
Q

If a patient is over the age of 75 years old they should initially take _______ of sucubitril/valsartan (ENTRESTO).

A

24mg/26mg

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20
Q

What are the contraindications of ARNi/ARB (sucubitril/valsartan) use?

A

-history of angioedema with ACEI or ARB
-concomitant use or use of an ACEI within 36h (WASHOUT PERIOD REQUIRED) note this is not needed for an ARB
-severe hepatic impairment (not recommended)

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21
Q

What are the warnings/precautions of ARNi/ARB (sucubitril/valsartan) use?

A

-fetal toxicity (due to ARB)
-angioedema
-hypotension
-impaired renal function, hyperkalemia (high potassium, K+)

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22
Q

What are the adverse effects of ARNI/ARB (sucubitril/valsartan)?

A

-angioedema
-hypotension
-increased serum creatine
-hyperkalemia
-dizziness

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23
Q

What are the monitoring parameters of ARNI/ARB (sucubitril/valsartan)?

A

-blood pressure
-renal function
-potassium (K+)

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24
Q

What drugs are Angiotensin Converting Enzyme Inhibitor (ACEI)?

A

-pril
-LISINOPRIL
-captopril
-enalapril

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25
Q

What is the starting dose for Lisinopril?

A

2.5-5mg po daily

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26
Q

What is the target dose for Lisinopril?

A

20-40mg po daily

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27
Q

What are the recommended monitoring parameters after Angiotensin COnverting Enzyme Inhibitor (ACEI) INITIATION?

A

assess BP, renal function and potassium (K+) 1-2 weeks after therapy initiation and dosage changes, then periodically (3 months, 6 months, or annually- depends on patient)

28
Q

What are the adverse effects of ACEI?

A

-hypotension
-increased serum creatine
-increase potassium (K+)
-cough!
-angioedema

29
Q

What are the contraindications/precautions for ACEI?

A

-angioedema
-pregnancy
-bilateral renal artery stenosis
-symptomatic hypotension
-hyperkalemia (K+ > 5)
-increased serum creatine
-cough

30
Q

What is the indication of ACEI in heart failure patients?

A

HFrEF when ARNi is not feasible in combination with beta blockers

31
Q

What drugs are Angiotensin Receptor Blockers (ARBs)?

A

-artan
-losartan
-valsartan
-candesartan
note these are the 3 ARBs in treatment guidelines for HF

32
Q

What are the adverse effects of Angiotensin Receptor Blockers (ARBs)?

A

-angioedema
-hyperkalemia (high potassium)
-renal insufficient
-hypotension
risks higher when combined with other inhibitors of renin angiotensin-aldosterone system

33
Q

What is the indication of ARBs in heart failure patients?

A

HFrEF with ACEI intolerance when ARNi is not feasible

34
Q

What is the starting dose for Losartan?

A

25-50mg po daily

35
Q

What is the target dose for Losartan?

A

50-150mg po daily

36
Q

What is the starting dose of Valsartan?

A

20-40mg po daily

37
Q

What is the target dose for Valsartan?

A

160mg po BID

38
Q

What drugs are Beta Blockers?

A

-metoprolol succinate (XL): selective beta1 receptor blocker
-carvedilol: block alpha1, beta1, and beta2
-bisoprolol: selective beta1 receptor blocker
note these are beta blockers that have evidence in HF

39
Q

What is the starting dose of Metoprolol succinate?

A

12.5-25mg po daily

40
Q

What is the target dose of Metoprolol succinate?

A

200mg po daily

41
Q

What is the starting dose of Carvedilol?

A

3.125mg po BID

42
Q

What is the target dose of Carvedilol?

A

-85kg or less: 25mg po BID
-more than 85kg: 50mg po BID

43
Q

What are the contraindications of Beta Blockers?

A

-acute, decompensated HF
-reactive airway disease
-second or third degree AV block
-sick sinus syndrome
-cardiogenic shock
-severe bradycardia (< 55bpm)
-severe, symptomatic hypotension

44
Q

What are the risks of treating a patient with Beta Blockers?

A

-fluid retention and worsening HF (monitor weight!)
-fatigue, but HF also does this…
-bradycardia and heart block
-hypotension

45
Q

What is the indication of Beta Blockers for patients with heart failure?

A

all patients with current or prior symptoms of HFrEF UNLESS contraindicated

46
Q

Describe: RAAS Blockade

A

ARNi or ACEI or ARB + BETA-BLOCKER

47
Q

What is the benefit of using diuretics for heart failure treatment?

A

rapidly provides symptomatic benefit by directly interfering with sodium retention in HF

48
Q

What is the preferred diuretic in HF patients?

A

loop diuretics

49
Q

What drugs are Loop Diuretics?

A

-furosemide
-torsemide
-bumetanide

50
Q

What must be monitored in a patient with HF taking Loop Diuretics?

A

ins and outs, weight

51
Q

What is the indication for Loop Diuretics for a patient with HF?

A

pt with fluid retention

52
Q

What drugs are Mineralocorticoid Receptor Antagonists (MRAs)?

A

-spironolactone
-eplernone

53
Q

Patients at risk for ______________ require close monitoring while on Mineralocorticoid Receptor Antagonists (MRAs).

A

renal dysfunction or hyperkalemia

54
Q

What are the contraindications for Mineralocorticoid Receptor Antagonists (MRA)?

A

-eGFR 30ml/min/1.73m2 or less
-K+ 5mEq/L or greater

55
Q

What is the indication of Mineralocorticoid Receptor Antagonists (MRAs) in patients with HF?

A

HFrEF unless contraindicated- must monitor renal function and potassium closely

56
Q

What is the indication for Sodium-Glucose Cotransporter Inhibitor (SGLT2i)

A

symptomatic HFrEF to reduce hospitalization for HF and death in pt regardless of type 2 diabetes diagnosis

57
Q

What drugs are SGLT2i?

A

dapagliflozin and empagliflozin

58
Q

What is the dosing of Dapagliflozin?

A

10mg po daily

59
Q

eGFR must be _______ before initiation of Dapagliflozin.

A

at least 25mL/min/1.73m2

60
Q

What are the four pillars for survival in a patient with HF?

A

-ARNi
-beta blocker
-MRA
-SGLT2i

61
Q

What is the indication of Nitrates/Hydralazine?

A

african americans with HFrEF who are receiving optimal medical therapy

62
Q

What are the risks of Nitrates/Hydralazine treatment?

A

-adherence difficult
-side effects: headache, GI, hypotension

63
Q

What is the indication of Ivabradine (Corlanor)?

A

pt with stable, symptomatic chronic HF with EF < 35% who are in sinus rhythm with resting HR > 70 bpm and who are on maximum tolerated doses of beta blocker or are contraindicated to beta blockers

64
Q

What is the indication of Digoxin?

A

potential use in Afib with HF, but is considered last line

65
Q

What drugs are NOT indicated for HF because they have not been shown to reduce hospitalization or mortality?

A

-calcium channel blockers (verapamil and diltiazem may make HF worse and amlodipine has no evidence to reduce outcomes)
-antiarrhythmics

66
Q

What is the indication of Vericiguat?

A

high-risk patients with HFrEF with recent or worsening HF already on optimized therapy

67
Q

What are the goals of treatment for a patient with HFpEF?

A

-alleviate congestion (diuretics)
-manage precipitating factors (hypertension, high HR, Afib, myocardial ischemia)

Therapeutics 2 (13 decks)

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