Heart Failure Drugs

Question 1

What drugs may precipitate or exacerbate HF?

Answer 1

The following should be avoided (if possible) in HF patients:

NSAIDS
Alcohol 
Calcium Channel Blocker
High dose Beta Blockers
Some Anti-arrhythmic Drugs

Question 2

What are the agents of choice in HF?

Answer 2

Angiotensin-converting enzymes (ACE) inhibitors

Question 3

Describe the MOA of ACEi

Answer 3

• Block the enzyme that cleaves angiotensin I to form angiotensin II (angiotensin II=vasoconstrictor)
• Decrease the secretion of aldosterone which decreases sodium and water retention
• diminish rage of bradykinin inactivation

ACEi decrease vascular resistance, venous tone, and blood pressure decreasing preload and after load and increasing cardiac output

Question 4

What patient education might you provide to a patient taken an ACEi?

Answer 4

ACEis should be taken on an empty stomach-presence of food may decrease absorption

SE: postural hypotension, renal insufficiency, hyperkalemia, angioedema, persistant dry cough

Should not be used in pregnancy-toxic to fetus

Question 5

When might ARBs be used for HF?

Answer 5

Substitute for patients who cannot tolerate ACEi d/t severe cough or angioedema

Question 6

What role do Beta blockers play in HF? What beta blocker is commonly used?

Answer 6

improved systolic function and reverse cardiac remodeling

metoprolol is a B1-selective antagonist

Beta blockers are recommended in all patients with heart disease except those at high risk with no symptoms and those in ACUTE HF (decompensating)

patients w/HF and HTN will benefit from Beta blocker

Question 7

What symptoms do patients with HF experience?

Answer 7

dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and dependent edema

Question 8

What might you need to know before giving a patient a thiazide + digoxin?

Answer 8

this combination can lead to severe hypokalemia and therefore arrhythmia! If you must give both, ADD K+ sparing diuretic, such as spironolactone, which will reduce risk of hypokalema! BOOM!

Question 9

When might an ACEi be considered for monotherapy in HF?

Answer 9

patients with mild dyspnea on exertion who do not show signs or symptoms of volume overload (edema).

Question 10

What needs to be taken into consideration when placing a patient on a thiazide diuretic for HF?

Answer 10

Renal function! Thiazides are weak diuretics and lose efficacy if patient creatinine clearance is less than 50 mL/min.

Loop diuretics are used for patient with renal insufficiency and are the most commonly used in patients with HF

Question 11

What combination of drugs should be used in African American patients with HF?

Answer 11

Hydralazine (decreases afterload) and isosorbide dinitrate (decreases preload)

This combination may also be used in patients who are intolerant of ACEi or Beta Blockers, or if an additional vasodilator response is required

Question 12

Which class of drugs should be avoided in HF?

Answer 12

Calcium Channel Blockers!

Question 13

When is digoxin indicated?

Answer 13

Patients with severe left ventricular systolic dysfunction after initiation of ACEi and diuretic therapy

Major indication: HF with Atrial Fibrillation

Question 14

When should digoxin NOT be used in HF?

Answer 14

patients with diastolic or right-sided HF

Question 15

Let’s talk AE with Digoxin…

Answer 15

TOXICITY which may cause V-tach

Decreased serum potassium can predispose patient to digoxin toxicity

Monitor Digoxin levels in patients with renal insufficiency

Question 16

A 58 year old man is admitted to the hospital with acute heart failure and pulmonary edema.  Which one of the following drugs would be most useful in treating the pulmonary edema?
A. Digoxin
B. Dobutamine
C. Furosemide
D. Minoxidil
E. Spironolactone

Answer 16

C. Furosemide has the ability to dilate vessels in the context of acute heart failure. It also mobilizes the edematous fluid and promotes excreation.

Question 17

Which drugs can interact with digoxin and increase risk of toxicity?

Answer 17

Amiodarone, Erythromycin, Quinidine, Tetracycline, Verapamil

Question 18

What Beta Adrenergic Agonist is given by IV infusion and is primarily used in the treatment of acute HF in a hospital setting.

Answer 18

Dobutamine-causes positive inotropic effects and vasodilation

Question 19

What aldosterone antagonist should be reserved for the most advanced cases of HF?

Answer 19

Spironolactone-direct antagonist of aldosterone-prevents salt retention, myocardial hypertrophy, and hypokalemia.

Question 20

SE of Spironolactone and Patient Education?

Answer 20

Promotes potassium retention-patients should not be taking potassium supplements.

gastritis, peptic ulcer, gynecomastia, decreased libido, and menstrual irregularities

Question 21

Order of Therapy for HF

Answer 21

loop diuretics are often introduced first for relief of signs/symptoms of volume overload

ACEi (or ARBs if ACEi not tolerated) are then added. Beta blocker is initiated after patient is stable on ACEi.

Digoxin is initiated in patients who continue to have symptoms of HF despite the multiple drug therapy