Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PharmD > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What are the quadruple therapy agents used to treat heart failure with reduced ejection fraction?

A
  1. ARNI or ACE/ARB
  2. Beta blocker
  3. Mineralocorticoid receptor antagonist (MRA)
  4. SGLT2i
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Quadruple therapy should be started ______ and titrated to _________ or _________ __________ doses .
Goal is to optimize doses in ____ - ____ months.

A

early
target or maximally tolerated
3-6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What does ARNI stand for?

A

Angiotensin receptor/neprilysin inhibitor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the ARNI combo we use for heart failure?

A

Valsartan/Sacubitril (Entresto)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

The ARNI vs enalapril trial was of great success. What were the trial entry criteria?

A
  1. Asymptomatic LV dysfunction
    or
  2. Severe HFrEF
    or
  3. New HFrEF
    or
  4. Cannot tolerate the equivalent of enalapril 10mg BID
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are two reasons why ACEi is often used instead of ARNI?

A

Cost and if patients doesn’t fit trial criteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How quickly do you titrate ACEi to target doses?

A

Titrate every 7-14 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

a) What parameters do you need to monitor before starting ACEi?
b) Which parameter can you expect to change following initiation?

A

a) Serum creatinine, potassium, and BP
b) Serum creatinine (up to 30% increase is expected and acceptable)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do you manage a SCr increase greater than 30% following initiation of ACEi?

A

Check for other causes of worsening renal function. A common reason with HF is hypovolemia from excessive diuresis.

If no other cause is found, reduce dose or discontinue ACEi.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What parameters have ACEi been shown to improve?

A
  1. Improve symptoms
  2. Reduce risk of hospitalization
  3. MI and death in patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are four side effects to monitor for after starting ACEi?

A

cough, angioedema, hyperkalemia, renal dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which of those side effects can be mediated by switching to an ARB?

A

Cough or angioedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why does ACEi cause hyperkalemia?

A
  1. ACEi blocks the conversion of angiotensin I to angiotensin II
  2. Angiotensin II stimulates release of aldosterone
  3. Aldosterone acts on kidney to promote sodium reabsorption and potassium excretion
    ∴ ACEi decreases angiotensin II, aldosterone, and therefore potassium excretion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How does ACEi decrease blood pressure?

A
  1. ACEi blocks conversion of angiotensin I to angiotensin II
  2. Angiotensin II is a vasoconstrictor
  3. Angiotensin II also stimulates release of aldosterone which promotes sodium reabsorption
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How does ACEi cause angioedema?

A
  1. ACE (angiotensin converting enzyme) usually breaks down bradykinin
  2. Bradykinin increases vascular permeability and vasodilation.
  3. ACEi increases bradykinin and leads to capillary leakage and fluid buildup
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How does ACEi cause dry cough?

A
  1. ACEi leads to more bradykinin and substance P
  2. These both promote the production of prostaglandins, which may exacerbate the cough reflex
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How does ACEi help with heart failure?

A
  1. ACEi blocks conversion of angiotensin I to II.
  2. Angiotensin II causes vasoconstriction
  3. This also leads to less aldosterone and less sodium retention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the dosing for ACEi for HF?
(enalapril, lisinopril, perindopril, ramipril, trandolapril)

A

Enalapril (I= 1.25-2.5mg BID, T= 10 mg BID)
Lisinopril (I= 2.5-5mg QD, T= 20-35mg QD)
Perindopril (I= 2mg QD, T= 8mg QD)
Ramipril (I=1.25-2.5mg BID, T= 5mg BID)
Trandolapril (I= 1mg QD, T= 4mg QD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

If starting an ARNI, should we use BNP or NT-proBNP to monitor clinical outcomes?

A

NT-proBNP
Neprilysin inhibition leads to accumulation of NP which makes BNP inaccurate.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

How does the ARNI combo affect the bioavailability of valsartan?

A

Sacubitril enhances bioavailability of valsartan.

Valsartan 51mg potentiates to 80mg.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

As per current Canadian HF guidelines, when do we recommend Entresto over ACEi/ARB?

A
  1. Patient with HFrEF who remain symptomatic despite treatment
    or
  2. Newly diagnosed HFrEF admitted to hospital
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the washout period when switching between ARNI and ACEI?

A

36 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How often should dose be titrated with ARNI?

A

Titrate every 2-4 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is dosing schedule of Entresto?

A

Initial: 51/49mg BID
Target: 103/97 mg BID

26/24mg BID is an option for those at risk of hypotension or not at target dose for ACEi/ARB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What parameters have beta blockers been shown to improve?

A
  1. Improve symptoms
  2. Reduce the risk of hospitalization
  3. Death in patients
26
Q

Which beta blockers are used in HF?

A

First line= bisoprolol, carvedilol
Second line= metoprolol tartrate, as data is extrapolated from metoprolol succinate (unavailable in Canada)

*There has been more mortality and hospital admission with metoprolol tartrate (controversial point though)

27
Q

What are the target doses of the beta blockers?

A

Bisoprolol (I=1.25mg QD, T= 10mg QD)
Carvedilol (I= 3.125mg QD, T= 25mg BID)
Metoprolol (I= 6.25mg BID, T= 100mg BID)

28
Q

How quickly do you titrate beta blockers?

A

Titrate every 2-4 weeks

29
Q

When should we not initiate or increase doses of beta blockers in heart failure?

A

When patient is acutely decompensated (negative inotropic effect can worsen HF) or if bradycardic

30
Q

What’s an important counselling point for new starts of beta blockers?

A

May feel temporarily worse during initiation and up-titration but will benefit from long term reductions in HF outcomes

31
Q

Can you stop beta blockers abruptly?

A

No, rebound tachycardia

32
Q

What parameters have mineralocorticoid receptor antagonists been shown to improve?

A

Reduce mortality and morbidity

33
Q

What are the two MRA options?

A

Spironolactone and eplerenone

34
Q

When should we not use MRA?

A

Baseline potassium >5 mmol/L or CrCl <30 mL/min

35
Q

What are the monitoring parameters after starting MRA?

A

SCr and potassium on day 3 and 7. Monthly for 3 months and then every 3 months.

36
Q

When differentiates eplerenone from spironolactone?

A

Eplerenone does not have anti-androgen effects, so no gynecomastia, impotence, or irregular menstruation.

37
Q

Does eplerenone have a similar risk of hyperkalemia and renal dysfunction as spironolactone?

A

Yes, so no point in using it as substitutes for those reasons

38
Q

What are the two SGLT2i we use for HF?

A

Empagliflozin and dapagliflozin

39
Q

What parameters have SGLT2i been shown to improve?

A

Decrease morbidity and mortality

40
Q

When is SGLT2i contraindicated?

A

Type 1 diabetes, allergy, history of euglycemic ketoacidosis

41
Q

What are monitoring parameters following SGLT2i initiation?

A

Fluid status (may cause mild volume depletion)
and renal function (a drop in eGFR <15% is ok)

42
Q

When is ivabradine used in heart failure?

A

HF with LVEF ≤35%, NYHA II-III, sinus rhythm, HR ≥77 despite being on optimal beta blocker doses
OR
beta blockers not tolerated

43
Q

When should ivabradine be avoided?

A

If patient has afib

44
Q

Does ivabradine affect mortality?

A

Yes, it reduces the risk of mortality

45
Q

When is digoxin used in heart failure?

A

For patient with persistent symptoms despite optimal therapy with quadruple agents.

46
Q

Does digoxin affect mortality?

A

No

47
Q

What is usual dosing range for digoxin and serum concentration target?

A

0.0625-0.25mg
0.6-1.2nmol/L

48
Q

What are signs of digoxin toxicity?

A

Confusion, loss of appetite, nausea, vomiting, diarrhea, or vision problems

49
Q

When do we use nitrates/hydralazine combo in heart failure?

A

In HF patients who do not tolerate ACEi/ARB or ARNI (renal dysfunction or hyperkalemia)
OR
+add on therapy in Black patients

50
Q

What is the nitrate/hydralazine combo we use in heart failure?

A

ISDN/hydralazine

51
Q

Does ISDN/hydralazine affect mortality?

A

Yes but only as a combo. Nitrates alone is only good for symptom relief

52
Q

When is vericiguat used in heart failure?

A

May be considered in high risk patients hospitalized for HF. Not approved in Canada yet.

53
Q

What is omega-3’s rule in heart failure?

A

Omega 3 polyunsaturated fatty acid (n-3-PUFA) at low dose (1g/day) may be considered in mild to moderate HF.

*3g/day or more is associated with excessive bleeding

54
Q

Where does calcium channel blockers come into heart failure?

A

Avoid non-DHP CCBs like verapamil and diltiazem because of their negative inotropic effects.
Avoid nifedipine and felodipine due to lack of data.
Amlodipine is safe for patients with persistent angina despite beta blockers and nitrates or uncontrolled hypertension despite use of ACEi, MRA, beta blocker, and diuretic.
Caution amlodipine in those with fluid retention.

55
Q

Do CCBs affect mortality?

A

No

56
Q

What’s the role of antiarrhythmics in heart failure?

A

Only use amiodarone and may be considered to maintain sinus rhythm in those with afib.

57
Q

Should patients start statins for heart failure?

A

No. However, it is reasonable to continue them if patient is already receiving them.

58
Q

What’s the treatment approach for HFpEF?

A

Treatment does not reduce mortality, so the focus is to control risk factors like hypertension, DM, and ventricular rate in afib).

59
Q

What drugs are used for HFpEF?

A

SGTL2i are the only class of medications that have shown improvement in HFpEF.
In Canada, empagliflozin is indicated for HFpEF.

60
Q

Pregnancy Considerations for HF:
Diuretics
ACEi/ARBs or ARNI
MRAs
Beta blockers
SGLT2i
Ivabradine
Digoxin
Nitrate/Hydralazine

A

Diuretics= furosemide ok but watch for dehydration
ACEi/ARBs or ARNI = avoid
MRAs= avoid
Beta blockers= metoprolol preferred
SGLT2i=avoid
Ivabradine= avoid
Digoxin= safe but may need higher doses
Nitrate/Hydralazine= ok

61
Q

Breastfeeding Considerations in HF:
Diuretics
ACEi/ARBs or ARNI
MRAs
Beta blockers
SGLT2i
Ivabradine
Digoxin
Nitrate/Hydralazine

A

Diuretics= furosemide has limited data
ACEi/ARBs or ARNI= safe
MRAs= spironolactone ok
Beta blockers= metoprolol preferred
SGLT2i= avoid
Ivabradine= avoid
Digoxin= ?
Nitrate/Hydralazine=?

PharmD (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions