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PHAR 253 - Therapeutics (2) > Heart Failure / Arrythmias > Flashcards

Heart Failure / Arrythmias Flashcards

1
Q

How many new canadians are diagnosed with HF every yea?

A

100,000

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2
Q

What is the mortality rate of HF after 5 years?

A

50%

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3
Q

True or false: HF has the same mortality rate of certain cancers?

A

False-higher

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4
Q

What is stroke volume and what three parameters affect it?

A

SV= volume of blood ejected per heartbeat

dependent on preload, stretch(contractibility), and afterload

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5
Q

What is the relationship between stretch and force?(Frank-Sterling law)

A

the greater the stretch the greater the force of contraction

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6
Q

What will the body do to maintain cardiac output?

A

NorE, angiotensin 2, aldosterone, vasopressin, inflammatory

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7
Q

How can the heart remodel to maintain cardiac output?

A

the Left ventricle will grow bigger to get better force BUT this allows for less blood to actually enter the ventricle

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8
Q

What are the common causes of heart failure?

A

tachycardia, valve disease, CAD, LVH

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9
Q

What is the definition of heart failure?

A

Sx/signs= LV hypertrophy, low pressure and dysfunction
AND also need one of increased natriuretic peptides, evidence of pulmonary congestion

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10
Q

What are common sx of HF?

A

SOB
orthopnea
fatigue
WEIGHT GAIN
ankle swelling
nightime SOB, cough, bloating

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11
Q

What are some specific signs of HF?

A

third heart sound, pulmonary edema, , elevated jugular pressure

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12
Q

What levels of proBNP and BNP is high enough to diagnose HF?

A

Pro= >125
BNP>50

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13
Q

What does BNP do in the body?

A

excrete sodium and water and dilate vessels

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14
Q

What other conditions raise BNP?

A

A fib

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15
Q

What condition can lower BNP?

A

obesity

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16
Q

A patient is asymptomatic and has raised BNP. Will he be diagnosed with HF?

A

NO

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17
Q

How much of a BNP drop do we need to discharge a patient?

A

> 30%

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18
Q

What is the EDS criteria for entresto?

A

BNP levels too high

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19
Q

How can we test to see systemic and pulmonary congestion in HF?

A

x-ray, heart catheterization, measure pressure in those areas, ECHO

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20
Q

A patient comes in and is wondering what a ECHO is for as they have been recently diagnosed with HF. What do you tell them?

A

give info on size of heart, pumping capacity, locate damage,

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21
Q

WHat is a normal ejection fraction?

A

50-70%

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22
Q

A patient comes in and reports they have been diagnosed with HF-pEF. What would their ejection fraction be?

A

> 50%

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23
Q

What is generally wrong with the heart if preserved ejection fraction?

A

heart is stiff/problem with ventricle relaxing

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24
Q

Which people are more likely to get HF-pEF?

A

women, old

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25
Q

I am a patient with HF-mEF. what is my ejection fraction?

A

40-49%

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26
Q

What ejection fraction is clinical HF-rEF?

A

<40%

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27
Q

What is generally wrong with the heart if HF-rEF?

A

problem with contractility.

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28
Q

In some patients they can get HF with improved EF. Where did they start and where are they now with ejection fraction?

A

was at <40% now at >40 with at least 10% increase

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29
Q

What are the classes of HF?

A

1= no limitation
2=slight limitation
3=marked limitation
4- sx at rest

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30
Q

What is the four pillar approach to HF?(<40%)

A

ARNI/ARB/ACE
Beta blocker
MRA
SGLT2i

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31
Q

What is the RAAS system and what drugs inhibit this?

A

RAAS makes angiotensin 2 to make aldosterone to retain salt and water.
MRA and ACE stop it

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32
Q

Why does ACEi have cough?

A

bradykinin increase

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33
Q

What is the benefit of an ACE?ARB?

A

lower preload and afterload= lowers mortality and hospitalizations

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34
Q

What difference in dosing for ACE occurs in HF rather than HTN?

A

BID dosing

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35
Q

Which ACE inhibitor is recommended in HF?

A

any of them

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36
Q

At what GFR can we not use ACE?

A

30 ml

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37
Q

What what K level is ACE an issue?

A

> 5.2

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38
Q

WHat drug interaction with ACE is an issue?

A

trimethoprim, high K stuff

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39
Q

What side effects are we concerned about with ACE?

A

cough, hypotension, angioedema, high K

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40
Q

When would we use an ARB for HF?

A

if cough is an issue

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41
Q

Any statistical difference between ACE and ARB ?

A

No

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42
Q

How is ARB dosed in HF?

A

BID

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43
Q

What is an ARNI and where does it act?

A

sacubatril and valsartan
sacubatril stops BNP breakdown= pee out and dilate

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44
Q

What benefit does ARNI do for patients with HF?

A

lower hospitalizations and decreased mortality

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45
Q

Compared to ACE, what adverse effects do entreso have?

A

more hypotension, less kidney injure and cough

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46
Q

When to we switch to an ARNI from an ACE?

A

if still symptomatic on ACE

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47
Q

If we are switching from an ACE to an ARNI what must we do?

A

wait 36 hours-56

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48
Q

What is the issue with entreso?

A

priceyyyyy

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49
Q

What is EDS criteria for Entreso?

A

symptomatic, <40%, not stable on ACE, or super high BNP

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50
Q

What is the monitoring for entreso?

A

kindly function and K+

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51
Q

How much is target entreso dose?

A

200mg BID

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52
Q

What is the benefit of a beta blocker for heart failure?

A

lowers mortality and hospitalizations

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53
Q

What is target dose for beta blockers?

A

Carvedilol= 25 BID
Bis=10
metoprolol=200

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54
Q

Who can’t get a beta blocker?

A

av block, HR<50, uncontrolled asthma,

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55
Q

What is a weird side effect of beta blockers?

A

HF sx may get worse before better

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56
Q

What beta blockers is generally better for HF?

A

Carvedilol-BUT non specific

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57
Q

A patient also needs an MRA for HF why?

A

neurohormonal benefit (RAAS)

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58
Q

What MRA’s are available for HF?

A

spironolactone-25-50
eplerenone= 50mg

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59
Q

What contraindications for MRA’s and what drug interaction are we worried about?

A

> 6 of K
digoxin with spironolactone

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60
Q

What monitoring must be done for MRA?

A

K
renal function

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61
Q

Why is eplerenone better than spironolactone?

A

only acts on aldosterone
spirinolactone= ED, man boobs

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62
Q

At what point of GFR should you not use spironolactone for HF?

A

<30 ml/min GFR

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63
Q

True or false: We use MRA for the benefit of blood pressure lowering.

A

False- for neural hormonal

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64
Q

How does SGLTi help with HF?

A

lots of stuff, lowers preload, afterload,

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65
Q

True or false empagliflozin lowers mortality.

A

False only dapagliflozin

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66
Q

Does SGLTi lower volume?

A

Not statisically

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67
Q

Will the SGLTi help with A1C if diabetic and heart failure?

A
  • yes but loses that ability if low kidney function
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68
Q

What side effects can occur with SGLTi?

A

genital infections, UTI, DKA

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69
Q

At what renal disease can you not use SGLTi?

A

empa=<20
Dapa<25

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70
Q

A patient that is on quadruple, optimized therapy, no a fib, and has a high heart rate. >70 bpm What should be added?

A

ivabradine

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71
Q

How does ivarbradine work?

A

works on SA node and lets heart fill with blood by lowering HR

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72
Q

A patient has a heart rate of 89 bpm but is in a fib, can we give ivabradine?

A

No

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73
Q

True or false: Ivabradine lowers mortality.

A

no, only hospitalizations

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74
Q

What is target dose for ivabradine?

A

7.5 mg BID

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75
Q

What drugs are we worried about interactions with ivabradine?

A

ketoconazole, clarithromycin, amiodaron, digoxin, simvastatin

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76
Q

S/e of ivabradine?

A

a fib, light flashes

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77
Q

When is it a good idea to add digoxin?

A

in HF-rEF in sinus with mod sx and FOR SURE in HFrEF and chronic AF

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78
Q

Does digoxin lower mortality in HF?

A

no

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79
Q

What is the mechanism of action of digoxinin heart failure?

A

increase parasympathetic and increases heart contractility

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80
Q

What DI are there with digoxin?

A

amiodarone, b blockers, ccb

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81
Q

What s/e of digoxin?

A

a fib, anorexia, dizzy

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82
Q

Which is better ivabradine and digoxin?

A

equal for reducing hospitalization
iva= less interactions and dose adjustments
dig= more data

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83
Q

If vericuguat was given to patient with HF, what can we assume happened?

A

recent hospitalized (last 6 months) due to decompressed HF

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84
Q

How does vericiguat work?

A

increases NO work

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85
Q

Is it okay to be on a boner pill and vericiguat?

A

FUCK no

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86
Q

When to use hydralazine-nitrates for HF?

A

Black on optimal with sx or can’t handle AC/ARB/ANRI

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87
Q

What is the MOA of hydralazine and nitrates?

A

vasodilator and heart ability to pump
nitrates= low in HF that’s why they get them

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88
Q

If giving nitrate for HF what mist we ensure?

A

12 hour free interval

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89
Q

For HF-pEF patient what drugs should they use?

A

treat comorbidities= HTN, DM,
candesartan + spirinolactone+SGLT2i= lower hospitalizations
entresto= only for US-Not sig

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90
Q

For HF-mEF patients what drugs should they be on?

A

all four but no mortality reduction

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91
Q

What is percent error on ECHO for ejection fraction?

A

10%

92
Q

If you were in HF-rEF but since became improve (>50%) what should you do for medications?

A

CONTINUE QUAD therapy

93
Q

What is the benefit of adding a diuretic for HF?

A

lower preload by removing water and sodium and edema lowering
lower hospitalizations

94
Q

Where do loop diuretics act?

A

ascending limb

95
Q

If you have a very low renal function do you need to adjust furosemide dosing?

A

no

96
Q

What are the loop diuretics and what are their optimal dosing?

A

furosemide-20-40 OD or BID
butemanide-10
ethacrynic acid=200BID

97
Q

If a patient has a sulfa allergy do we need to take them off furosemide?

A

prob not but if needed go to ethacrynic acid

98
Q

Im a patient on furosemide. What is the process for weighing myself?

A

wake, void, weigh nude/minimal clothing

99
Q

Im a patient on furosemide. I have been weighing myself and this morning I noticed an increase of weight of 3 lbs. What should I do?

A

need to go for an assessment

100
Q

Is it acceptable to combine loop and thiazide? if so what thiazide?

A

yes-metolazone

101
Q

What can happen with chronic loop diuretics use?

A

rebound Na retention= resistance

102
Q

If using a diuretic and digoxin what are we concerned about?

A

toxicity with digoxin if hypokalemia

103
Q

How much fluid should you take in a day if in HF?

A

2 l/day

103
Q

How much salt should you have in a day If in HF?

A

2-3 g /day

104
Q

What drugs can exacerbate HF?

A

high sodium drugs
cancer
change fluid-CS, NSAIDs, CCB,

104
Q

To overcome the issue of NSAIDS with heart failure can you increase the dose for a shorter duration?

A

NO- dose dependent

105
Q

Is it wise to use alternative medicine for HF?

A

NO

106
Q

What is the percentage of people that are not on optimized therapy for HF?

A

2/3

107
Q

How much does risk reduce for HF with pharmacists being involved on the healthcare team?

A

30%- for hospitalizations

108
Q

What benefit does adding a pharmacist on team for HF?

A

more optimized therapy= less hospitalizations

109
Q

When would we know that cough is caused by congestion vs drug?

A

drug= dry persistent cough
congestion= productive cough, usually nocturnal or othopnea only

110
Q

What form of edema suggests HF?

A

BILATERAL

111
Q

How can patients improve their ankle edema?

A

raise legs for 1 hour prior to bed time

112
Q

If the patient is hypovolemic what might we do for them?

A

tell them to drink 1.5-2 l of fluids a day, decrease dose (hold for 2 days or decrease furosemide by 1/2 for 2-3 days

113
Q

If hypervolemic, what might we do for them?

A

lower fluids, lower salt

114
Q

What medications can exacerbate HF?

A

Sodium, NSAIDS, CS, estrogens, recent initiation of beta blocker

115
Q

If we increased a patients furosemide dose 2 times what is the next step if not euvolemic?

A

add metolazone

116
Q

When should you take a diuretic?

A

morning BUT not after midafternoon

117
Q

What is target HR for HF patients?

A

50-60 bpm

118
Q

If a patient with heart failure is experiencing hypotension what should we do?

A

can reduce diuretic, CCB, or switch from carvedilol because it reduces blood pressure much more

119
Q

If a patient with heart failure is experiencing bradycardia what do you do?

A

take at night, lower dose, titrate

120
Q

If a patient with heart failure is experiencing issues with potassium what do you do?

A

if high= lower diet, no NSAIDs,
low= increase ACE, start MRA

121
Q

What heart failure Meds are a part of SADMANS

A

ACE, ARB, ARNI
MRA
SGLT2
Diuretics

122
Q

What are foods high in potassium?

A

potatoes, tomatoes, bananas

123
Q

What percent lose of GFR is acceptable from a drug?

A

30%

124
Q

What is the difference between atrial fibrillation vs flutter?

A

fibrillation= multiple loci so they quiver
flutter=still contract but way too fast, AV node isn’t filtering

125
Q

How much of the ejection fraction is due to the atrial kick?

A

20%

126
Q

True or false AF is life threatening and must be treated as soon as possible.

A

False= just associated with risk of other conditions

127
Q

What change to the ECG will happen with A fib?

A

no p wave

128
Q

How fast is atrial rate in a fib?

A

350-600

129
Q

How fast is ventricular rate in a fib

A

120-180= reduced because its not filling enoughh

130
Q

Over the age of 60 what is prevalence of AF? what about 80 years?

A

60-5%
80- 10%

131
Q

What is your increased risk of thromboembolic events and stroke if having a fib?

A

thrombi-1.5-4 x
stroke-3-5 fold

132
Q

What are sx of a fib?

A

chest pain, palpitations, fatigue, dyspnea

133
Q

What is the difference between valvular and non-valvular a fib?

A

valvular= valve disease, repair, or prothetic
non valve= none of it

134
Q

What anticoagulant for valvular a fib?

A

warfarin

135
Q

What is lone atrial fibrillation?

A

no clinical or ECG findings of CVD, pulmonary disease, no enlargement, or under the age of 60

136
Q

What is paroxysmal a fib?

A

can last for 7 days

137
Q

What is persistent a fib?

A

last for 1 year

138
Q

What is longstanding persistent a fib?

A

greater than 1 year

139
Q

What type of a fib does triggers usually cause?

A

paroxysmal

140
Q

What type of a fib does substrates cause?

A

permanent

141
Q

What are some possible substrates for a fib?

A

remodelling, HTN, obesity, sleep apnea

142
Q

What are some possible triggers

A

stimulants, alcohol, no sleep, stress

143
Q

What percentage of unknown causes of strokes do asymptomatic a fib cause?

A

10%

144
Q

What is the CHADS2 score?

A

C-recent CHF=1 point
H- HTN=1 point
A- Age>75= 1 point
D- diabetes= 1 point
S2= history of stroke=2 points

145
Q

If I had a CHADS2 score of 4 what is my risk?

A

8%
each point is about 2 % risk

146
Q

WHat parameters indicate OAC for a fib?

A

> 65
or if had stroke, HTN,HF, DM, hyperthyroid

147
Q

What parameters indicate anti platelet for a fib?

A

if CAD

148
Q

How much does warfarin reduce risk of stroke?

A

66%

149
Q

Which anticoagulant is preferred for a fib?

A

DOAC

150
Q

What population gets better benefit from DOACs for a fib?

A

> 85

151
Q

If you have obesity why is your risk of stroke and bleed?

A

lower stroke
but higher bleed

152
Q

At what BMI is warfarin needed?

A

> 50

153
Q

What BMI is it indicated for caution with apixaban and edoxaban

A

40-49

154
Q

What is usually dose of dabigatran for a fib?

A

150 mg BID

155
Q

What is usually dose of rivaroxaban for a fib?

A

20 mg daily

156
Q

What is usually dose of apixaban for a fib?

A

5 mg BID

157
Q

What is usually dose of edoxaban for a fib?

A

60mg daily

158
Q

At what renal function do you need to stop using MOST of the anticoags?

A

<30 ml/min

159
Q

What drug can you give to more renal disease(30-40) for anticoagulation without adjustment?

A

apixaban- need 2 out of renal disease, >80, or underweight to change dose

160
Q

What drug needs food for better bioavailability?

A

rivaroxaban

161
Q

Which DOACs are we concerned with CYP interactions

A

apixaban and rivaroxaban

162
Q

What is the antidote for dabigatran

A

idarucizumab

163
Q

What is antidote for other DOACS?

A

Andexanet

164
Q

How much does bleed risk increase with triply therapy?

A

double

165
Q

If paroxysmal AF what do we do?

A

if low recurrance= ADD prn
high= ADD scheduled and maybe catheter ablation

166
Q

When is rate controlled method preferred in a fib?

A

if permanent

167
Q

What do we use for reducing rate in a fib patients?

A

B blocker s or Non-CCB (amlodipine, nifedipine, felodipine)

168
Q

If still no heart rate control for a fib after Beta blocker

A

digoxin if >40% EF
can use amiodarone or digoxin at <40%

168
Q

When would we prefer beta blocker in a fib?

A

<40% EF

169
Q

When can you do rhythm control for a fib?

A

recent diagnose= 1 year, lots of recurrence, hard to rate control

170
Q

When do you have to anticoagulate before doing rhythm control?

A

if in a fib for 24-48 hours
need anticoagulant for 3 weeks before than 4 weeks after

171
Q

How can we speed up the timeline to see if we can do rhythm control?

A

do a TEE to see if clot in heart

172
Q

Who are most likely to maintain normal sinus rhythm?

A

short AF, recent, HF, angina, hypotension

173
Q

WHat are the two ways of doing cardio version?

A

drugs or electrical

174
Q

Which way to cardiovert is better?

A

electrical= more effective

174
Q

What drugs can cardiovert?

A

amiodarone
good= ibutelide, procainamide, flecainide

175
Q

Side effects of the drugs that can cardiovert?

A

pro arrhythmia, left ventricular depression

176
Q

If cardioverting what drug MUST be used as well (not necessarily anticoagulant)

A

B blockers
Non-CCB

177
Q

What initiates heart beat?

A

SA node

178
Q

What is the path of electrical impulses in the heart?

A

SA node- AV node- Bundle of his- Bundle branches- Purkinje fibers

179
Q

If the SA node fails what then makes the heart beat?

A

AV node

180
Q

What ions are high in the cell and what ions are high outside?

A

In=potassium
Out= sodium and calcium

181
Q

Explain the steps to forming an action potential?

A

Na channels open and it comes in
at peak then it closes and K and Ca channels open
then steep repolarization after a while as just k channels are open

182
Q

What is the absolute refractory period?

A

time when it cannot be re-excited

183
Q

What is the relative refractory period?

A

time after absolute refractory period but needs higher voltage to initiate another impulse

184
Q

What does the p wave represent?

A

atrial depolarization

185
Q

When does atrial repolarization happen?

A

in QRS

186
Q

What does QRS complex mean?

A

ventricles depolarize

187
Q

What does t wave represent?

A

ventricle repolarization

188
Q

What are the two causes of arrhythmias?

A

generational=automaticty
Conduction= re-entral

189
Q

What is needed for re entry arrhythmias?

A

2 pathways for impulse
one is blocked
slow conduction in the other

190
Q

Which group of class 1 antiarrhythmic drugs is the most potent?

A

Class 1 C

191
Q

What are the class 1A antiarrythmics?

A

procainamide
quinidine

192
Q

What are the class 1B antiarrythmics?

A

Lidcaine

193
Q

What are the class 1C antiarrythmics?

A

flecanide
propafenone

194
Q

What are the class 2 antiarrythmics?

A

B blockers

195
Q

What are the class 3 antiarrythmics?

A

amiodarone, sotalol

196
Q

How do the class 3 antiarrythmics work?

A

block potassium channels= prolong refractory period

197
Q

What are the class 4 antiarrythmics?

A

CCB= verapamil, diltiazem

198
Q

How does digoxin work for antiarrythmias?

A

stop Na K pump

199
Q

At what heart rate will you become symptomatic?

A

<50

200
Q

What can cause irreversible AV block?

A

heart attack

201
Q

How do we treat AV block?

A

pacemaker

202
Q

What is sick sinus syndrome?

A

pauses, dropped beat = SLOW heart rate

203
Q

What is SVT?

A

re-entry tachy
narrow QRS, no p waves

204
Q

What do we do for SVT?

A

1st= vagal maneuvers
2nd= adenosine’s blocker

205
Q

What is a form of SVT that we have learned?

A

A fib

206
Q

What is PVC and what do we do for it?

A

asymptomatic usually from MI
do nothing

207
Q

What is VT and what do we do for it?

A

worse than PVC
cardiovert
procainamide, amiodarone, lidocaine if stable

208
Q

What is the most effective drug for prevention of VT recurrences?

A

amiodarone

209
Q

Which population usually get VT?

A

MI, drug overdose

210
Q

What is TDP?

A

life threatening with long QT

211
Q

How do we treat TDP?

A

Mag sulfate or cardiovert

212
Q

If Vt what is ALWAYS given?

A

b blocker

213
Q

What instrument can help prevent VT?

A

ICD= sense arrhythmias, correct it and send info to doctor

214
Q

If they have an ICD can they stop their meds?

A

NO

215
Q

What monitoring is required for amiodarone?

A

ECHO
Derm- examination
AST/ALT
Neurologic
Eyes
Pulmonary tests

216
Q

What weird skin thing can amiodarone cause?

A

blue/grey skin/ UV insensitivity

217
Q

Which type of drugs has a higher incidence of TDP?

A

potassium channel blockers= sotalol

218
Q

What is the definition of Qtc prolonged for both men and women?

A

men=470
women=480

219
Q

At what QTc prolongation do we need to be concerned?

A

> 500

220
Q

What score can we use to see risk of QTc prolongation?

A

Tisdale risk score

221
Q

What are some possible risk factors for QTc prolongation?

A

> 68
female
loop diuretic
low K
prolongation
MI
HF
1 prolongation drug
2 prolongation drug
sepsis

222
Q

Are smart watches true detectors of arrhythmias?

A

no but getting better

PHAR 253 - Therapeutics (2) (8 decks)

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