Heart Failure Flashcards
What does it mean when someone has heart failure?
- Heart is not able to supply oxygen rich blood to the body, due to left ventricle not filling or ejecting
What are the 2 classifications of Heart Failure?
- Ischemic [MI] or Non-Ischemic [Uncontrolled HTN]
What are some of the more common symptoms of Heart Failure?
- Fluid Overload [SOB or Edema]
why we give diuretics
What is one thing that we can do to help with the diagnosis of Heart Failure?
- Echocardiography [Echo] –> helps show the LVEF
- EF < 40 = HFrEF
What are the Stages of the ACC/AHA for HF?
- A: Risk of HF w/o symptoms [HTN, ASCVD, Diabetes]
- B: Structural Heart Disease w/o symptoms
- C: Structural Heart Disease w/ symptoms [SOB, Fatigue, reduced exercise ability]
- D: Advanced Heart Disease [severe symptoms or recurrent hospitalizations]
What are the stages of NYHF in HF and where do they link up with the ACC/AHA stages>
- Class I: NO Limitations [Stage A & B]
- Class II: Slight Limitations, ordinary physical activity [Stage B]
- Class III: Marked Limitations, minimal exertion [Stage B]
- Class IV: Unable to do anything without HF symptoms or Symptoms at rest [Class C & D]
What is cardiac output
- Volume of blood that is pumped by the heart in one minute
- CO = HR x SV
What is the compensatory mechanism for HFrEF?
- HFrEF is low cardiac output by activating neurohormonal pathway to increase blood volume or contraction force
- Increase CO = Cardiac Remodeling
What are the main pathways that lead to the Compensatory mechanisms in HFrEF?
- Activates RAAS, SNS, and Vasopression
What is important to know about RAAS and Vasopression Activation with HF?
- Ang II causes Vasoconstriction [releases aldosterone from adrenal & Vasopressin from pituitary]
- Aldosterone = Na and H20 retention
- Vasopression = Vasoconstriction & H20 Retention
What is important to know about SNS activation with HF?
- Norepi increases HR, Contractility, Vasoconstriction
What is some important Lifestyle Management for HF?
- Monitor and Document body wieght
- Notify if weight increase by 2-4 lbs
- AVOID excessive sodium [< 1500]
- Restrict fluid on Stage D
- Stops smoking… Limit Alcohol
What are some natural products that could be used in HF?
- Omega 3: Decrease mortality
- Hawthorn & Coenzyme Q10: Improve HF symtpoms
What are some drugs that can worsen HF by causing Fluid Retention, Edema, Increase BP or Negative Inotropic Effects?
- DDP-4: Alogliptin, Saxagliptin
- Immunosuppressants: TNF inhibitors, interferons
- Non-DHP CCBs: Diltiazem, Verapamil
- Antiarrhythmics: Class I, Dronedarone, Amiodarone, Dofetilide
- Thiazolidinediones
- Itraxonazole
- Oncology Drugs
- NSAIDS
Drug Information NATION
What are the 4 drugs classes for HFrEF that decrease morbidity and mortality?
- RAAS Inhibitor [ARNI, ACEi, ARB]
- Beta Blocker
- Aldosterone Receptor Antagonist
- SGLT-2 Inhibtors
These should all be titrated to target doses
What are some of the additional treatment options that can be used as add-on therapy in HF?
- Loop Diuretics
- Hydralazine & Nitrate [BiDil]
- Ivabradine
- Digoxin
- Vericigant
What are the RAAS inhibitors that are used in HF and what is important to know about then?
- ARNI, ACE, ARB
- Decrease Cardiac Remodeling = Decrease Morbidity and Moralaity
- Titrate to target doses
What is the MOA for ARNIs?
- ARB: Blocks Ang II from binding = decrease in vasopression and aldosterone
- Neprilysin: Stops degradation of vasodilaitory peptides
What is the ARNI that is used and what is the target dose for it?
- Sacubitril/Valsartan [Entresto]
- Target Dose = 97/103mg BID
What are the boxed warning for Entresto?
- Injury or death to fetus; stop ASAP if pregnant
What are the contraindications for Entresto?
- DO NOT use with or within 36h of ACEi
- DO NOT use if Hx of Angioedema
What are teh warnings for Entresto?
- Angioedema, Hyperkalemia, Renel Impairment, Hypotension
What is the main side effect for Entresto?
- Dry cough
What are some things that we should monitor with Entresto?
- BP, K, Renal Function, S/Sx of HF
what are the ACEi that are used in Heart Failure?
- Enalapril [Vasotec]
- Lisinopril [Zestril]
- Quinapril [Accupril]
- Ramipril [Altase]
What are the target doses for the ACEi in Heart Failure?
- Enalapril: 10-20mg PO BID
- Lisinopril: 20-40mg Daily
- Quinapril: 20mg BID
- Ramipril: 10mg Daily
What are the ARBs that are used in Heart Failure?
- Losartan [Cozaar]
- Valsartan [Diovan]
What are the target doses of ARBs in Heart Failure?
- Losartan: 50-150mg Daily
- Valsartan: 160mg BID
What are the boxed warnings for ACEi or ARBs in Heart Failure?
- Injury or Death to fetus; DISCONTINUE ASAP
What are the contraindications for ACEi or ARBs in Heart Failure?
- DO NOT use with Hx of Angioedema
- DO NOT use within 36h of entresto [ARBs you can]
What are some of the warnings for the ACEi or ARBs in Heart Failure?
- Angioedema [less with ARBs], Hyperkalemia, Renal Impairment, Hypotension
What are the side effects for ACEi and ARBs in Heart Failure?
- Cough [less with ARBs]
What are some of the drug interactions for ANRIs, ACEi, and ARBs?
- HYPERKALEMIA
- DO NOT use more than one at the same time
- 36h washout with ACE and ARNI
- Could decrease lithium clearacne and increase toxicity
What is the MOA for the Beta Blockers In Heart Failure?
- Antagonize cateacholamines at Beta 1, 2 and Alpha 2 = Decrease in vasoconstriction
- Decreases Mortality and Morbidity
What are the Beta Blockers that are used in Heart Failure?
- Metoprolol Succ [Toprol XL]
- Bisprolol
- Carvediolol [Coreg, Cpreg XL]
M & B are Beta 1 and C are Nonselective
What are the Target doses for the Beta Blockers in Heart Failure?
Metoprolol: 200mg daily
Bisoprolol: 10mg daily
Carvedilol: 25 - 50mg daily [depends on weight]
What is the boxed warnings for the Beta Blockers in Heart Failure?
- DO NOT stop taking abruptly; taper over 1-2 weeks
What are the warnings for the Beta Blockers in Heart Failure?
- Caution in Diabetes; masks hypoglycemia
- Caution in Asthma/COPD; broncospams
- Caution with Raynauds
What are some of the side effects for the Beta Blockers in Heart Failure?
- Bradycardia, hypotension, fatigue, dizziness, depression, impotence
What are the drug interactions for the Beta Blockers in Heart Failure?
- Mask Hypoglycemic Events
- Caution with other drugs that decrease HR [Digoxin, Verapimil, Diltiazem, Amiodraone]
What is the MOA for the Aldosterone Receptor Antagonists in Heart Failure?
- Compete with Aldosterone Receptors in the Distal/Collecting Duct; decreasing Na, H20, Cardaic Remodeling
1st Line
What are the Aldosterone Receptor Antagonist that are used in Heart Failure?
- Spironolactone [Aldactone]
- Eplerenone [Inspra]
What is the Target dose for Spironolactone in Heart Faliure?
- 25 - 50mg daily
What are the Contraindications for the Aldosterone Receptor Antagonists in Heart Failure?
- DO NOT use with hyperkalemia, renal impairment, Addisons Disease
What are the warnings for the Aldosterone Receptor Antagonist in Heart Failure?
- DO NOT use when K > 5
What are the side effects for the Aldosterone Receptor Antagonist in Heart Failure?
- Hyperkalemia, Increase SCr, Dizziness
- Spiro: Gynocomastia, Breast Tenderness, Impotence
What are some of the Drug interactions for the Aldosterone Receptor Antagonists in Heart Failure?
- Risk of Hyperkalemia
- DO NOT use ACE + ARB/ARNI + ARA
What is the MOA for the SGLT-2 in Heart Failure?
- NOT SURE… but may decrease Na reabsorption, Diruesis, Pre-load/Afterlod
What are the SGLT-2 that are used in Heart Failure?
- Dapagliflozin [Farxiga] 10mg daily
- Empagliflozine [Jardiance] 10mg daily
What is the MOA for the Loop Diuretics that are used in Heart Failure?
- Block Na & Cl reabsorption in ascending loop of henle [increasing excreation of Na, K, Cl, Mg, Cl, H20] = decrease in fluid volume
- DO NOT help with survival
Whta are the Loop Diuretics that are used in Heart Failure?
- Furosemide [Lasix]
- Bumetanide [Bumex]
- Torsemide
What are the warnings for the Loop Diuretics in Heart Failure?
- Sulfa Allergy
- Ototoxicity [more with ethacrynic acid]
- Acute kidney injury [becuase of fluid loss]
What are some of the side effects for the Loop Diuretics in Heart Failure?
- Decreased K, Mg, Cl, Ca
- Increased HCO3, UA, BG, TGs, TC
- Orthostatic hypotension, photosensitivity
What are some of the important monitoring for Loop Diuretic in Heart Failure?
- Renal function, fluid status, BP, Electrolytes, S/Sx of HF
What is the Dosing Equivalents of the Loop Diuretics in Heart Failure?
- Furo 40mg = Tors 20mg = Bumeta 1mg = Etha Acid 50mg
- Furosemide IV:PO = 1:2
What are some of the drug interactions with the loop diurectics in Heart Failure?
- Avoid NSAIDS
- Could change Lithium levels = toxicity
What is the MOA for Hydralazine/Nirtate [BiDil] in Heart Failure?
- Hydralazine: arterial vasodilator = decrease afterload
- Nitrates: increase NO = decrease preload
When should BiDil [Hydralazine/Nitrates] be used during Heart Failure?
- When ARNI, ACE, or ARB are not tolerated
- In Black Patients
What are the Warnings to know about the Hydralazine component in Heart Failure?
- Drug Induced Lupus Erythematosus [DILE]
What are the side effects of the Hydralazine componenet in Heart Failure?
- Peripheral Edema, Headache, Flushing, Palpatiation, Reflex Tachycardia
What are the contraindictions of the Nitrate component in Heart Failure?
- DO NOT use with PDE-5 Inhibitor [Severe hypotension]
What are that side effects of the Nitrate component in Heart Failure?
- Hypotension, Headachem Dizziness, Tachyphylaxis
What is the MOA of Ivabradine in Heart Failure?
- “Hyperpolarization Activated Cyclic Nucleotide Gated Channel Blocker”
- Block If in the SA node = decreased HR
When shouild Ivabradine be used in Heart Failure?
- When patient is getting GDMT, and resting HR > 70
GDMT = Beta Blockers, ARNI/ACE/ARB, SGLT2, ARA [At max or target dose]
What are the Warnings for Ivabradine in Heart Failure?
- Can cause Bradycardia
- Increased risk of AFib
What are the side effects of Ivabradine in Heart Failure?
- Bradycardia, Hypertension
What ist eh MOA of Digoxin in Heart Failure?
- Inhibits Na-K-ATPase Pump; causing positive inotropic effect [increase CO] and negative chronotropic effect [decrease HR]
- DOES NOT help with survival but may help with hospitalization
What is the important to know about the dosing for digoxin in Heart Failure?
- Typical Dose: 0.125 - 0.25mg PO Daily
- CrCl < 60 = decreased dose
- PO -> IV = decreased dose by 20-25%
- Therapeutci Range: 0.5-0.9
What are some of the important things to monitor for Digoxin in Heart Failure?
- Eletrolytes, Renal function, Hr
What are some of the toxicites of Digoxin in Heart Failure?
- N/V, Loss of Appetite, Blurred/Double Vision, Greenish-Yellow Halos, Life Threatening Arrhythmias
- Increase risk of Hypokalemia, Hypomagnesemia, Hypercalcmia
What is the antidote for Digoxin?
- Digifab
What are some of the drug interactions for Digoxin in Heart Failure>
- P-gp & 3A4 = Reduce dose by 50% when starting amiodarone & caution with drugs that decrease HR [BB, Clonidine, Non-DHP, Amiodarione]
What is the MOA of Vericiguat in Heart Failure?
- Solube guanylate cyclase stimulator that increases cyclic GMP = smooth mucsle relaxation and vasodilation
What are the contraindications for Vericiguat in Heart Failure?
- DO NOT use with Riociguat [same class]
What are the side effects for Vericiguat in Heart Failure?
- Hypotension
- Anemia, Dyspepsia
What are the drug interctions for Vericiguat in Heart Failure?
- PDE-5 Inhibitor = Hypotension effects
- Those taking Long acting nitrates [Hypotension]
Why is it important to maintain Potassium level, Especially in those that have Heart Failure?
- reduce Arrhythmia risks
When should Potassium be check and what else should be checked with it
- K should be checked after a change in ARNI, ACE, ARB, ARA
- Also check Mg
What is the most commonly used supplement when potassium levels are wack in Heart Failure?
- Potassium Choride [Tablet or Capsule]
- IV Potassium Chloride is a high alert med
What is the 10% oral solution of Potassium?
- 20mEq/15ml
