Heart Failure Drugs Flashcards
drugs for HFrEF
ARNI
Beta Blocker
MRA
SGLT2 Inhibitor
1st line therapy in de novo RASi-naïve patients
ARNI (sacubitril/valsartan)
If a patient is being switched from an ACEi to an ARNI, they require _______ to decrease the risk of angioedema
a 36 hour wash out period
contraindication for ARNI
Avoid using in patients with symptomatic hypotension (SBP ≤ 100 mmHg); eGFR < 30 mL/min; hyperkalemia (K > 5.4); or symptomatic hypotension
Avoid using ARNI in patient with history of angioedema
Monitor ___ for ARNI
Monitor serum electrolytes (for hyperkalemia) & creatinine (renal function
Angiotensin Converting Enzyme Inhibitor (ACEI)
MOA
Inhibit the production of angiotensin II
Decrease afterload & preload
Increase SV
Decrease activation of SNS
Inhibit degradation of bradykinin (vasodilator)
Monitor for ACEI
Monitor serum electrolytes (potassium) and creatinine
Angiotensin Receptor Blocker (ARB) indication
can be used if ACEi intolerant
ACEI side effects
cough
pregnancy and breastfeeding considerations
ARNI, ACEi, ARB are all contraindicated during pregnancy
Enalapril is the preferred ACEi during breastfeeding
ARNI contraindicated during breastfeeding
If ARB has to be used during breastfeeding, use
candasartan and valsartan due to shorter half life
beta blockers MOA
Reduce myocardial workload and oxygen demand (decrease HR and BP/SVR); ↑ SV, ↓ PCWP —— negative inotropic effect
adverse effects of beta blockers
Hypotension (orthostatic hypotension)
Dizziness
Bradycardia, AV block
Fatigue
Carvedilol
Nonselective beta-blocker & alpha adrenergic blocking activity
Bisoprolol
More cardioselective β-1 blockage; Used in reactive airway disease such as COPD
MRAs (Mineralocorticoid Receptor Antagonist)
MOA
spironolactone; eplerenone
* Block the detrimental effects of aldosterone on the heart; Increase Na and water
excretion while conserving potassium
* Maintain serum potassium levels (particularly in patients who are on diuretic therapy)
MRAs can increase _______
MRAs can increase potassium and creatinine
Hold/reduce dose if K > 5.6 mmol/L or evidence of worsening renal dysfunction (↑baseline Cr by 30%)
Avoid using if eGFR < 30 mL/min
SGLT2 Inhibitors MOA
Diuretic effect, reduction in preload
- Antihypertensive effect, reduction in afterload
- Weight loss
- Improved endothelial function
- Cardiac metabolism, calcium homeostasis in myocardium - Induce autophagy
SGLT2 contraindication
Allergy or known intolerance to SLGT2 Inhibitors
* CKD eGFR < 25 mL/min
T1DM
adverse effects of SGLT2 inhibitors
History of severe hypoglycemia (DM), DKA
Hypotension (SBP< 95 mmHg)
Volume depletion
Active genital mycotic infection
examples of SGLT2 inhibitors
Dapagliflozin
Empagliflozin
Ivabradine
MOA and therapeutic use
inhibits a depolarizing current in the sinus node; negative chronotropic effect on SA node
NSR (normal sinus rhythm) with a resting heart rate of ≥ 70 bpm
adjunctive therapy for a patient who is on maximally tolerated beta- blocker dose or who is intolerant to beta-blockers
Contraindications for Ivabradin
Resting HR < 70 bpm prior to initiation of therapy
* ADHF (Acute decompensated heart failure)
* Prolonged QT interval
* Hypotension
* Atrial fibrillation; Heart Block
* Advanced liver disease
* Pregnancy
* Severe renal impairment eGFR < 15
Hydralazine, ISDN
MOA and therapeutic use
HFrEF, NYHA III-IV as additional therapy or if cannot tolerate ACEi/ARB/ARNI due to CKD
- Hydralazine arterial vasodilator (reduces afterload/BP)
- ISDN venodilator (reduces preload/myocardial oxygen demand)
Digoxin therapeutic use
Used in patients with HFrEF, NYHA FC III-IV, and
persistent symptoms despite GDMT
* Control of ventricular rate in patients in atrial fibrillation
Loop Diuretic (Furosemide) MOA
relieve symptoms of congestion/fluid retention
Inhibit Na/K/Cl co-transporter at thick portion of ascending loop of Henle (this is where 1/3 of filtered Na is reabsorbed)
* Inhibit Na and water reabsorption
Adverse effect of Loop diuretics
- Electrolyte abnormalities (hypokalemia, hyponatremia, hypomagnesaemia)
- Hypotension
- Renal dysfunction
- Ototoxicity (high doses)
Oral sGC Stimulator: Vericiguat
MOA
Enhances cyclic guanylate monophosphate (GMP) production + endogenous sGC sensitivity to NO
Dehydrating Illness > 24 hours
(fever, vomiting, diarrhea)
Temporarily hold medications: SADMANS
S: Sulfonylureas
A: ARNI or ACEI
D: Diuretics (Lasix, MRA, Metolazone) M: Metformin
A: ARBs
N: NSAIDs
S: SGLT2 Inhibitors
avoid ____ in HF because
Increased risk of HF exacerbation
NSAIDs inhibit prostaglandin synthesis
Impair renal function – decrease renal blood flow and GFR Increase retention of sodium & water