Heart Failure Drugs (12c) Flashcards
What group of people are not as benefitted by the use of ACE inhibitors?
Afro-Americans
All patients with _____ _____ _____ should be started on ACE inhibitors
Left Ventricular Dysfunction
What is an important thing to know about the use of ACEIs in patients with heart failure?
They improve the symptoms and survival
What are the ACEIs
Captopril Lisinopril Fosinopril
What is the site of action of the ACEIs?
Renal Renin-Angiotensin
The MOA of ACEIs
Inhibit conversion of Angiotensin I into Angiotensin II, lowering arteriolar resistance and increasing venous capacity, cardiac output and volume Also Lower renovascular resistance
The ACEIs reduce _______ and ________
after load and preload
By reducing Afterload, the ACEIs are enhancing what?
Stroke volume and ejection fraction
By reducing preload, the ACEs decrease what specifically?
Pulmonary and systemic congestion and edema
What are the target doses of the ACEI drugs?
Enalopril - 20mg BID Captopril 50mg TID Lisinopril 40 mg QD
How often can you increase the dose of ACEs (as long as the patient remains stable)?
Every 2 weeks
What are the major ADR for ACEIs and are therefore contraindicated?
Cough Angiogenic Edema!!!
What labs should be monitored on patients on ACEIs?
- Creatinine and K+ within 2 wks of initiation and after increased dose - Then in 3-4 wks if stable - Then 1x to 2x per year unless Cr changes
What are contraindications to ACEIs?
Pregnancy (Teratrogenic) Renal Artery stenosis
What is responsible for the cough caused by ACEIs?
Increased Bradykinin
What drugs can you not use with ACEIs?
ARBs Aliskirin
What do you need to watch for when starting ACEIs?
first dose hypotension
What are the indications of ACEIs?
HTN
HF
Left Ventricular dysfunction after MI Diabetic nephropathy
What is the Angiotensin Receptor Blocker that we will prescribe?
Losartan
What is the site of action of ARBs?
Smooth muscle cells of blood vessels
What is the MOA of ARBs?
Blocks Angiotensin 1 and Angiotensin 2 receptors, relaxing smooth muscle cells and dilating blood vessels which ini turn causes decreased BP
When do you use ARBs over ACEIs?
In patients who can’t tolerate ARBs
Afro-americans
Can you take ARBs and ACEIs together?
NO!!
What are adverse side effects of ARBs?
Diarrhea
Muscle cramps
Dizziness
Cough (although not as much as ACEIs)
Increased K+
Impotence
Contraindications of ARBs
Pregnancy
Severe renal disease
Elevated K+
What is losartan used for?
HTN
diabetic nephropathy in T2DM
Stroke risk reduction in HTN
LVH
Losartan blocks which angiotensin with a greater affinity?
Angiotensin 1 (1000x greater)
What drugs should you not use with ARBs?
Direct renin inhibitors
ACEI
Aliskerin
Losartan increases the excretion of what compound?
Uric Acid! Additive benefit for gout pts
What are the Vasodilator drugs used for Heart Failure?
Dihydropyridine Ca++ channel blockers Hydralazine/Isosorbide Dinitrate
What is important to remember about amlodipine in regards to HF?
That is is not used directly for HF, but it is used in HF patients for treatment of angina and HTN
Can you use Non-dihydropyradines for HF?
NO!! They decrease cardiac contractability
What is the site of action for the DCCBs?
Vascular smooth muscle
What is the MOA for the DCCBs?
Blocks Ca++ channel, decreasing/preventing contraction resulting in vascular relaxation and decreased Total peripheral resistance - Vasodilation of the coronary arteries
What are some adverse effects of CCBs? (only at high doses)
- Increased mortality in patients post-MI - High doses increase risk of AMI
Indications for Amlodipine?
Angina
HTN
Can be used in Patients with HF with HTN/angina
What is a major contraindication for Amlodipine?
Recent AMI
What does amlodipine do?
Vasodilates coronary arteries
The combination drug used for HF is what?
BiDil - hydralazine + Isosorbide dinitrate
What is the site of action for BiDil?
Vascular smooth muscle
What does BiDil do specifically in Heart failure?
It reduces the after load and strongly reduces the peripheral resistance
What group of people is BiDil highly recommened in?
Afro-americans
What are some adverse effects caused by BiDil?
Elicits a reflex sympathetic stimulation of heart
Loss of appetite
Diarrhea/HA
What are the contraindations to Hydralazine?
CAD
Mitral Valve Rheumatic HD
What can Hydralazine cause?
Lupus!
What drug is the DOC for tx of hypertensive emergency in preganc women?
Hydralazine
What is the MOA of Hydralazine?
Diract acting arteriolar vasodilators
What are the indications for the use of BiDil?
Adjunctive tx of HF, esp in afroamericans
What type of agent is Digoxin?
Positive Inotropic agents: Cardiac Glycosides
Cardiac glycosides have a propensity to cause _______ changes
EKG
Prolonged PR interval
Inverted T wave
ST segment Depression
Shortened QT interval
What is the MOA of digoxin?
Inhibits Na/K ATPase pump in myocardial cells promoting influx Ca++ leading to increased contractility
Also, direct suppressor of AV node decreases ventricular rate
The cardiac glycososides increase _______ tone, resulting in slowed HR
Vagal
True or false: carciac glycosides should be used for the initial tx of acute HF
False!
What may happen as a result of using Cardiac glycosides, specifically as a result of increasing intracellular calcium
Arrhythmias, specifically PVCs
Can you use Beta blockers with digoxin?
You can, but you should try to avoid it if possible
What are some side effects of using digoxin?
Delirium
Visual disturbances
AV Block/EKG changes
Toxic psychosis
What is an interesting fact about the glycosides regarding how long they have been used and where they originate from?
3000 years!
Milkweed, Lily of valley, foxglove, Oleander
What is Digoxin indicated for?
Mild to Moderate HF
Afib control
Digoxin causes an influx in what Ion, leading to increased contractility?
Ca++
Why should Digoxin be avoidedin the elderly?
Can have a proarrhythmic effect
The positive Ionotropic Agents that are B agonisits includes what drug?
Dobutamine
When do you use Dobutamine?
NOT recommended in acute HF, but it is still used in critical situations
Gives End stage HF patients improved Quality of life while awaiting transplant
What are the adverse effects of Dobutamine?
Cardiac arrhythmia
Precipitate angina in patients with CAD
What is Dobutamine used for?
Short term managment of cardiac decompensation
What is the MOA of Dobutamine?
Stimualtes B1 adrenergic receptors increasing cardiac contracility and HR
Little impact on B2/alpha receptors
Dobutamine should not be used in patients who have a history of what type of allergery?
Sulfa
How do you administer Dobutamine?
IV
What is the Positive Ionotropic Agent PDE inhibitor?
Milrinone
What is the MOA of Milrinone
Incrases cAMP in heart and vascular muscle, positive inotrope and vasodilator
Why do you use Milrinone?
For Refractory HF to improve quality of life in end stage disease
Milrinone is contraindicated when?
AMI
Severe obstructive/pulmonic valv disease
How do you administer Milrinone?
IV
What are side effects of Milrinone?
Hypotension
Arrhythmias
Nesiritide is what class of drug?
B-type naturetic peptide (BNP)
When do you use Nesiritide
Acutely decompensated HF with dyspnea at rest or with minimal activity
What is the MOA of Nesiritide
Increases intracell GMP in vasc smooth muscle cells and endothilium causing smooth muscle relaxation and reducing Pulm cap wedge pressure and systemic arterial pressure
Side effects of nesiritide include…?
Hypotension, increased serum creatinin, arrhythmias
What is the direct renin inhibitor drug
Aliskiren
How does aliskerin work?
It directly inhibits renin, lowering BP
(blocks conversion of angiotesinogen to angiotensin 1, reducing conversion to angiotesin II, producing arteriolar vasodilartion
In what patients should you not use Aliskirin?
DM or Renal disease
Why do you prescribe aliskirin?
For the Tx of hypertension
Ivabradine is used for what?
HF in patients with EF of <35% who are on max tolerated Bblocker dose/unable to take Bblocker
Off label for angina
Ivabradine is contraindicated in which patients?
Severe hepatic disease
What do you need to monitor occurance for in patients who take Ivabradine?
Visual changes - May see peripheral floaters
What is Ivabradine contraindicated in?
Acute Decomensated HF
SSS
Low BP
Low HR
Pacemaker
Hepatic impairment
