heart failure medications Flashcards
What is heart failure?
Heart cannot pump enough blood to meet the body’s needs for blood and oxygen (i.e. supply ≠ demand)
What is the goal of therapy?
Manage co-morbidities, lifestyle modifications, reduce mortality, reduce hospitalizations, symptom improvement, non-curative
lowering afterload
use vasodilators
ACE inhibitors
target MAP
50-60 mmhg
treatment for preload and afterload reduction
ACE inhibitor
ARB
ARNI**
ISDN/Hydalazine
sympathetic reduction
Beta blocker
Ivabradine
beta blocker
very efficient way to lower the heart rate, can cause bradycardia if given high doses, can put them in cardiogenic shock, heart will stop
dont use beta blocker on ECMO patients
Ivabradine
slows down heart rate without blocking beta receptors
volume reduction
Loop diuretic
Mineralocorticoid receptor antagonists
SGLT-2 inhibitor
Increase contractility
Digoxin –>has minor potential to act as a minor inotrope while slowing down your heart
ACE inhibitors
Captopril
Enalapril
Lisinopril
Ramipril
side effect of ACE inhibitors is the COUGH
usually give ARBS instead of ACEi
ARBS
Candesartan
Losartan
Valsartan
Mechanism of action:
Absorption:orally bioavailable
Metabolism:hepatic
Elimination:primarily feces
(ARNI) Angiotensin Receptor-Neprilysin Inhibitor
Mechanism of action
oral medication
Sacubitril/valsartan
Sacubitril: prodrug that inhibits neprilysin (neutral endopeptidase) leading to increased levels of peptides, including natriuretic peptides; induces vasodilation and natriuresis
Valsartan: direct antagonist of the angiotensin II (AT2) receptors; antagonizes AT1-induced vasoconstriction, aldosterone release, catecholamine release, arginine vasopressin release, water intake, and hypertrophic responses
two drugs that cause vasodilation through two different mechanisms
BETA BLOCKERS
only three we use during heart failure
selective beta 1 blockers
Metoprolol –> ONLY SLOWS DOWN HEART RATE
Bisoprolol
nonselective beta-blockers
–> Carvedilol –> drops pressure and heart rate
labetalol is best used for aortic dissection –> NOT HEART FAILURE
Sacubitril/Valsartan pharmacokinetics
Absorption:orally bioavailable
Metabolism:converted to active metabolite by esterases (sacubitril); minimally metabolized (valsartan)
Elimination:primarily urine (sacubitril); primarily feces (valsartan)
valsartan is VERY POTENT VASODILATOR
beta blocker mechanism of action
Absorption:orally active; some are available IV (esmolol, metoprolol, propranolol, labetalol)
Onset: oral agents can take several weeks to see full effects
Metabolism:
Propranolol undergoes extensive and highly variable first-pass metabolism
beta blocker pearls
aldosterone antagonist
spironolactone (most common one we use)
Eplerenone
Absorption:orally active
Metabolism: rapid and extensive; hepatic to multiple metabolites
Elimination: urine (primarily as metabolites) and bile (secondary)
SGLT inhibitors
Dapagliflozin
Empagliflozin
inhibition of proximal renal tubules –>
block reabsorption of filtered glucose –> increasing urinary glucose excretion (osmotic diuresis)
causes reduction in preload and afterload
“diuretic for your glucose”
pulls glucose from your blood and you pee it out
SGLT-2 inhibitors Pearls
Contraindications:
Type 1 diabetes (increased risk of diabetes ketoacidosis)
Known hypersensitivity to drug
Pregnancy/lactation
Dialysis
Precautions
Dapagliflozin (eGFR < 25 mL/min/1.73 m2)
Empagliflozin (eGFR < 20 mL/min/1.73 m2)
Volume depletion:
Euglycemic ketoacidosis
Increased risk of mycotic genital infections, UTI, and necrotizing fasciitis of perineum
Hydralazine and Isosorbide Dinitrate
African american pts have less renin
Hydralazine: direct arterial vasodilator decreased SVR (afterload)
Nitrates: NO donor venous vasodilation decreased preload
dont use as commonly as other emds
Ivabradine
use only for SINUS RHYTHM
Selectively inhibits If current (“funny current”) in SA node
↓ HR with no affect on blood pressure
It skews your action potential to go around and that slows down your action potential that slows down your heart rate
Use it for reduced heart failure EJ less than 55%
Diuretics
LOOP DIURETICS are the most potent and remove the MOST VOLUME
Thiazide diuretics –> used for pts with high blood pressure –> BLOOD PRESSURE CONTROL
Loop diuretics
Furosemide
Bumetanide
Torsemide
thiazide diuretics
Chlorothiazide
Hydrochlorothiazide –> SHORTEST HALF LIFE
Metolazone –> LONGEST HALF LIFE
digoxin
slows down heart rate and has a minor inotropic potential –> helps with patients that have AFIBB
digoxin pearls
has a NARROW THERAPEUTIC INDEX
meds to avoid in heart failure
NSAIDs
Nasal decongestants with pseudoephedrine/ephedrine
Alka-seltzer (sodium bicarbonate)
HFrEF
Thiazolidinedione (rosiglitazone, pioglitazone)
Most antiarrhythmic drugs (exceptions: dofetilide/amiodarone)
Calcium channel blockers (non-dihydropyridines verapamil/diltiazem)
