Heart Failure Flashcards
the equation for cardiac output
CO = SV x HR
HF patients should limit sodium intake to ______ unless they also have HTN then they should limit it to _________.
2 grams/day
1.5 grams/day
how often should HF patients monitor their weight?
every morning before eating and after peeing
when should apatient be concerned when their weight increases?
if within 24 hours they gain 3 pounds or more than 5 pounds in 1 week. They need to see the doctor for decompensation
What pain medication should be avoided Heart failure?
NSAIDs due to risk of renal insufficiency and fluid retention, should asof avoid ephedrine because of increased morbidty and mortality
What 2 vaccines are recommended with CHF?
pneumococcal and annual influenza
What drugs can worsen heart failure?
Verapamil/diltiazem, class 1 anti-arrhythmic, NSAIDs, Triptan migraine drugs, thiazolinediones, excessive alcohol
what ejection franction defines systolic heart failure (ventricles failiing)?
systolic = < 40%, diastolic > 40%
What are the 2 mainstays of therapy for HF if not contraindicated?
ACE + BB
what other classes are added to therapy to the mainstay therapy in HF when needed?
ARBS
aldosertone antagonists
Hydralazine + a nitrate , sometimes digoxin
Pts with congestive heart failue will also need what?
diuretic - probably loop
Some pts may receive both ACE and ARB. Whats the problem with this?
both can increase K
Pts on ACE or ARB should not be using Ms. _____?
Dash - salt substitutes - have more K
ARBs block the AT II receptors on the ___________________-
smooth muscle wall of the vessel
candesartan - brand, dosing
Atacand - target dose: 32 mg/day
DIovan dosing?
Target dose: 160 mg BID (Di=2 = BID)
Eplerenone is a selective aldosterone blocker therefore it __________________-
has less side effects than spironolactone
What are the contraindications for K sparing diuretics?
K+ > 5.0 meq/L
Scr > 2.5 mg/dL
CrCl < 30
what are the 3 most commonly used ACEs for HF? Starting dose and target dose?
Lisinopril 5mg po daily , target: 20 daily
Ramipril 2.5mg daily , t: 10 mg dailiy
Enalaprilat 5 mg t: 10 BID
when should you DC/ Ace’s arbs?
Pregnancy, angioedema, cough for ace, hyperkalemia
two most commo n RBs for HF, doses and target doses?
losartan 25mg daily to target 150mg daily
valsartan 40mg bid to 160mg bid
A triple combo of ACE + ARB + aldosterone antagonist is not recommended because of _____________
high risk of hyperkalemia
What BB should be avoided in heart failure?
ISA Beta Blockers - CAPP - carteolol, acebutolol, penbutolol, pindolol
bisoprolol - brand and HF dosing
Zebeta - target dose: 10 mg/d
counseling pearl for coreg
take with food, all forms
hydralazine is a direct ________ vasodilator which reduces ________.
arterial , afterload
Nitrates are ________ vasodilators which reduce ________.
venous, preload
Hydralazine and nitrates are used in what HF pt group?
those that cannot tolerate ACE / ARB therapy b/c of renal insuff., angioedema, or hyperkalemia
when should nitrates be used alone in tx for HF?
Never! hydralazine is used to improve efficacy and reduce nitrate tolerance
what are side effects of hydralazine?
lupus like syndrome - (report fever, joint/muscle ache, fatigue)
reflex tachycardia
what is the role of aldoserterone receptor antagonists in HF?
tx for class 3 or class 4 hf in addition to standard therapy
aldactone
spirionolactone
spironolactone dose and targed dose for HF
12.5 daily goal: 25 daily
contraindiation to sprionolactone
Clcreatienin <30ml/in, hyperkalemia, cyp 34 INHIBITORS
spironolactone side effects?
hyperkalemia, increase SCr, gynecomastia, tenderness, impotence, hirusutism
BBW spironolactone
risk of tumors based on rat models
inspra
eplerenone
how can u reduce the riks of hyperkalemia with potassium sparing diuretics
dont start if potassium is > 5, patient has clcr <30, dont use with NSAIDs
two most commone beta blockers used for hf with doses and target doses?
metoprolol succinate (XL) 12.5 daily t: 200 daily
carvedilol start IR 3.125 bid or cr 10mg daily
t: IR: 25 bid or 50 bid if > 85, ER: 80mg daily
coreg conversion factor
ir 25mg bid = CR 80mg daily
MOA hydralzaine
arterial vasodilator which decreases after load
MOA of nitrates in HF?
venous vasodilators wihich decrease the preload
what combination of therapy is indicated for AF Am patients w/ class II / IV hf
African Am who are symptomatic despite ACE and BB optimiation : the comb rec is BiDil
Bidil
isosorbide dinitrate and hydralazine
SE of bidily?
Lupus- lik sysndrome : report fever, joint-muscle aches, -Has, reflex tach, dizziness
can you used just hydralazine by itself for therapy w/ hF?
no you must use it with nirtates because using hydralazine with nitrates reduces tolerance of nitrates
what is a major contrainidation of isosorbide mononitrate?
PDE-5 inhibtoors
imdur
isosoribide mononitrate
monoket
isosorbide mononitrate
what is the role of diuretics in HF?
used for symptomatic treatment of fludi overload. Try to avoid side effects, can incerase the dose, swith to IV or add metolzaone for better control
Lasix
furosemide
hydralazine - brand
Apresoline
what are some side effects of isosorbide mononitrate?
HA, dizziness, tachyphylaxis (need 10-12 hour nitrate free interval)
dose equivalencey of furosemide, bumetanide, torsemide
bumetinide 1mg
torsemide 20mg
furosmeide 40mg
major side effects of loop diuretics
hypokalemia,
dec NA, CA, Cl, MG, Ca
orthostatic Hypo
what main side effect is important to monitor at high doses of loop diuretics esp ethacryrnic acid?
cuases ototoxicity esp at high doses or rapid IV administration
furosemid IV PO conversion
IV 1 PO 2x the dos e of IV
in what setting can AMG + Loops be dangerous?
in patients w/ impaired renal function, increase risk of ototoxicty so avoid this combo. (unless it is a life threatening situation
What is digoxins role in HF?
symptom improvement, increase exercise tolerance, increase QOL
Digoxin acts as a ____________inotrope and ___________chronotrope.
inotrope (increase contractility and cardiac output) positve
chronotrope (decrease HR) negative
what is the most commone digoxin dose? What thereapuetic range?
0.125 mg daily, 0.5 to 0.9 ng/mL
decrease the dose of digoxin by _____% when going from oral to IV
20-25%
what is the antidote for digoxin?
digibind or digiFab
what are the signs of digoxin toxicity?
first - NV, loss of appetitie, bradycardia
others - blurred or “yellow” vision, abd pain, confusion, delirium,
hypokalemia, hypercalcemia and digoxin, whats the scoop?
HYPOkalemia and HYPERcalcemia may increase risk of digoxin toxicity
What is a good marker to help identify whether a person is having an acute exacerbation of HF?
BNP : B-type natriuretic peptide
and Pro-BNP
For an acute exacerbation of HF, what agents to use?
if fluid overload: IV loop diuretics, can ad metolazone 30 min before loop
If congestive sx: can add IV vasodilators-nitroglycerin, nitorpursside or nesiritide. Make sure patient not hypotensive
If los bp or sx of low CO (low perfusion) : inotropig drugs dobutamine or milrione to be used
nitroprusside acts where? Brand name? storage?
is an arterial and venous vasodilator = more pronounced effects on blood pressure
Nipride
protect from light
nesiritide brand name
Natrecor
what does a blue colored solution of nitroprusside indicate?
the drug has degraded to cyanide - do not use
what can you do if you cannot take coreg po easily ?
sprinkle the capsule beads over applesauce and eat right away
MOA of nitroglycerin?
venous dilator
mOA of nesiritide?
it is BNP causese smooth muscle cell relaxation, dec arterial BP
MOA of nitroprusside?
Venous and arterial vasodialtor : stronger effect of nBP
Contraindiation of Nitroglycerin?
SBP < 90mmgHG,
PDE5 inhibitos,
Increased intracranial pressure
what is advantage of nesiritide?
no developemnt of tolerance to increasing dose
nitroglycerin side effects?
hyotension, HA, dizzy, tachycardia, tachyphylaxis
ci for nitorpursside?
same as nitroglycerin
CI for nesiritide?
SBP < 90 mm HG
Nonpharm rec for HF?
[-monitor weight daily
-sodium restriction
-avoid alcohol, smoking, drugs
-avoid NSAIDS
-compliance is KEY
why must coreg be taken with food?
delays absorption so less dizziness
counseling for digoxin
makes heart beat stronger and more regularly
keep normal hydration cuz can affect levels
N, V, D, loss of appetiet, seeing halos, blurred vission, feeling like passing out: call doctor right away
