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Heart failure meds Flashcards

1
Q

What reductions bring about heart failure?

A

Reduction in ventricular filling

Reduction in myocardial contractility

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2
Q

What is reduction of ventricular filling also known as?

A

Diastolic dysfunction

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3
Q

What is reduction of myocardial contractility also known as?

A

Systolic dysfunction

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4
Q

With what model do we describe heart failure?

A

Neurohormonal model

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5
Q

What hormones are involved with the neurohormone activation?

A

Norepinephrine
Angiotensin II
Aldosterone
Proinflammatory cytokines

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6
Q

How do we target pharmacotherapy for HF?

A

We try to antagonize the neurohormonal activation

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7
Q

Give the shorthand for diastolic dysfucntion with preserved AND reduced ejection fraction

A

HFpEF

HFrEF

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8
Q

What type of HF pts are most commonly involved in HF drug trials?

A

Pts with HFrEF

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9
Q

Describe pts classified in NYHA functional classification 1

A

Pt w/ cardiac disease but w/o limitations of physical activity

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10
Q

Describe pts classified in NYHA functional classification 2

A

Pts w/ cardiac disease w/ slight limitations of physical activity

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11
Q

Describe pts classified in NYHA functional classification 3

A

Pts w/ cardiac disease w/ marked limitations of physical activity

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12
Q

Describe pts classified in NYHA functional classification 4

A

Pts w/ cardiac disease w/ inability to carry on physical activity w/o discomfort

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13
Q

Do sx of NYHA HF

classification stay the same always?

A

No, they can change

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14
Q

What is the first stage of the ACC/AHA HF stage?

A

At risk stage

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15
Q

What is the second ACC/AHA HF stage?

A

Pts with structural heart disease

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16
Q

What is the third ACC/AHA HF stage?

A

Pt with structural heart disease and current or previous sx

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17
Q

What is the fourth ACC/AHA HF stage?

A

Refractory HF

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18
Q

Do ACC/AHA HF stages changes?

A

No, they are consistent with the progressive nature of HF

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19
Q

What is the primary dysfunction that has been addressed in pharmacotherapy trials?

A

Systolic dysfunction

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20
Q

List two newer agents being used for systolic dysfunction

A

Ivabradine

Sacubitril/valsartan

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21
Q

When are diuretics indicated for HF pts?

A

In any pt w/ evidence or history of fluid retention

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22
Q

Is there a potential for chronic diuretic use for HF pts?

A

Yes

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23
Q

How do we monitor the effects of diuretics for HF pts?

A

Daily morning weight measurements

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24
Q

Are thiazide diuretics weak or strong for HF?

A

Weak, use with something else

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25
What thiazide is added to loops for diuretic resistance?
Metolazone
26
What is the doseage of metolazone?
2.4-10 mg once daily PLUS loop
27
What is the most potent diuretic for HF?
Loop
28
What is the ceiling effect of loop diuretics?
Hit a highest dose, still not totally effective | Give this more frequently, instead of increasing dose
29
When is torsemide preferred?
In pts with persistent fluid retention despite high doses of other loops
30
Give the relationship of IV dosing of Lasix, torsemide, and bumetanide
40 mg Lasix = 20 mg torsemid = 1 mg bumetanide
31
What is the cornerstone of HF pharmacotherapy?
ACE inhibitors
32
When are ACE inhibitors first line therapy for HF
Systolic HF
33
What is the reduction in mortality if HF pt is on an ACEI?
20-30%
34
What do you use with an ACEI unless contraindicated?
Beta blocker
35
When do you add beta blockers to ACEi?
After titrating ACEI to max dose (or even before)
36
What do you have to monitor when a pt is on an ACEI?
Serum K+ and renal function
37
What is a risk of abrupt withdrawal of ACEI?
Decompensation
38
What are some AEs of ACEIs?
Hypotension Functional renal insufficency Cough Angioedema
39
How do you avoid hypotension with ACEIs?
Spread doses of other vasoactive meds out OR start on captopril, titrate to max, then switch the ACEI with once daily dosing
40
How do you deal with the ACEI cough?
Switch to an ARB
41
What % of pts on ACEIs develop angioedema? What does this mean?
<1% | Must avoid ACEIs for lifetime
42
When are beta blockers indicated for HF pts?
For use in ALL stable HF pts unless intolerant or contraindicated
43
When should you use a diuretic with your beta blocker?
For current or recent fluid retention
44
Whats the biggest reason you should give your HF pts beta blockers?
They decrease mortality!
45
Give some examples of beta blockers used for HF
Bisoprolol Carvedilol Metoprolol succinate (not tartrate)
46
What is the MOA of carvedilol?
Blocks beta 1 and 2 and alpha 1 receptors | *nonselective*
47
When might carvedilol be preferred?
In pts w/ poorly controlled BP due to alpha and beta 1 blockade
48
When should you avoid carvedilol?
In asthmatic pts | Because beta 2 agonists are part of their tx
49
How do you start beta blockers?
Low doses with gradual dose titration
50
If you get AEs, should you keep increasing the BB dose?
No, wait until AEs have disappeared
51
Do you continue long term BB tx even if sx dont improve?
Yes
52
What may happen if you withdraw BB abruptly? How do you deal with that?
Acute decompensation | Taper if d/cing
53
Is there one BB that is better than others
Nope. Great class effect
54
What are the major AEs of BB?
Fluid retention Fatiuge Bradycardia Hypotension
55
What are the minor AEs of BB?
Bronchospasm Worsening glucose tolerance (won't mask sweating) Sexual dysfunction in males
56
What is the MOA of ARBs?
Inhibit AT-II at its receptor
57
What is something ARBs dont do that ACEIs do? What does that mean
Dont inhibit bradykinin metabolism (no increase in bradykinin) Means less cough and angioedema
58
What dont you use ARBs with?
ACEI
59
Can angioedema still occur with ARBS?
Yes, just way less
60
When do you start BBs with ARBs?
Before reaching max dose like w/ ACEIs
61
What are the serum requirements for starting aldosterone receptor antagonists (ARAs)?
SCr <2.5 mg/dL (M) or < 2.0 (F) CrCl > 30 mL/min Serum K+ < 5.0 mEq/L
62
What are two examples of ARAs?
Spironolactone | Eplerenone
63
What do you discontinue after starting an ARA?
K+ supplements
64
When do you stop ARAs?
During diarrhea, dehydration, or interruptions of diuretic therapy
65
What are some AEs of spironolactone?
Gynecomastia | Hyperkalemia (monitor K+ closely)
66
What are some AEs of epleronone?
Hyperkalemia | Gynecomastia
67
What do you do with epleronone if serum K+ > 6 mEq/L?
Discontinue
68
What do you do with epleronone if serum K+ > 5.5 mEq/L
Discontinue or lower dose
69
What id digoxin?
Only orally active positive cardiac inotrope
70
Does digoxin improve mortality?
No
71
What dose digoxin do?
``` Improves LVEF Quality of life Exercise tolerance HF sx ```
72
Should you give a loading dose of digoxin for HF like you do with afib?
No
73
What is the target plasma level of digoxin? | What do higher levels mean?
0.5-1.0 ng/mL | Higher moretality
74
What does digoxin toxicity occur earlier with?
Hypokalemia Hypomagnesemia Hypothyroidism
75
When do you get your first digoxin plasma level?
3-5 days after starting therapy
76
When do you check digoxin levels after changing dosage?
5-7 days
77
When do you check digoxin levels after a general dose?
6-8 hours after (want a trough level)
78
What are some AEs of digoxin?
Cardiac arrythmias GI sx Neurological complaints (visual disturbances, altered color perception)
79
What is hydralazine?
An arterial vasodilator | AKA afterload reducer
80
What is isosorbide dinitrate?
Potent venous dilator | AKA preload reducer
81
Which population is hydralazine/isosorbide dinitrate useful in?
African Americans w/ HF
82
When do you start h/isdn for African Americans
On all African Americans on optimum ACEI and BB therapy unless contraindicated
83
When do you start h/isdn for non-African Americans?
On those intolerant to or contraindicated to ACEIs or ARBs
84
What is the MOA of ivabradine?
Decreases HR by inhibiting If pacemaker current in SA node
85
What is the benefit of ivabradine?
Reduces risk of hospitalization for worsening HF
86
``` What is a new class of HF drugs? (Includes sacubitril/valsartan) ```
Angiotensin recepter-neprilysin inhibitor (ARNI)
87
How significantly did ARNI entresto lower CV mortality?
By 20%

Pharm (32 decks)

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