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Pharm > Heart failure meds > Flashcards

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
Q

What thiazide is added to loops for diuretic resistance?

A

Metolazone

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26
Q

What is the doseage of metolazone?

A

2.4-10 mg once daily PLUS loop

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27
Q

What is the most potent diuretic for HF?

A

Loop

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28
Q

What is the ceiling effect of loop diuretics?

A

Hit a highest dose, still not totally effective

Give this more frequently, instead of increasing dose

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29
Q

When is torsemide preferred?

A

In pts with persistent fluid retention despite high doses of other loops

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30
Q

Give the relationship of IV dosing of Lasix, torsemide, and bumetanide

A

40 mg Lasix = 20 mg torsemid = 1 mg bumetanide

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31
Q

What is the cornerstone of HF pharmacotherapy?

A

ACE inhibitors

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32
Q

When are ACE inhibitors first line therapy for HF

A

Systolic HF

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33
Q

What is the reduction in mortality if HF pt is on an ACEI?

A

20-30%

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34
Q

What do you use with an ACEI unless contraindicated?

A

Beta blocker

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35
Q

When do you add beta blockers to ACEi?

A

After titrating ACEI to max dose (or even before)

36
Q

What do you have to monitor when a pt is on an ACEI?

A

Serum K+ and renal function

37
Q

What is a risk of abrupt withdrawal of ACEI?

A

Decompensation

38
Q

What are some AEs of ACEIs?

A

Hypotension
Functional renal insufficency
Cough
Angioedema

39
Q

How do you avoid hypotension with ACEIs?

A

Spread doses of other vasoactive meds out
OR
start on captopril, titrate to max, then switch the ACEI with once daily dosing

40
Q

How do you deal with the ACEI cough?

A

Switch to an ARB

41
Q

What % of pts on ACEIs develop angioedema? What does this mean?

A

<1%

Must avoid ACEIs for lifetime

42
Q

When are beta blockers indicated for HF pts?

A

For use in ALL stable HF pts unless intolerant or contraindicated

43
Q

When should you use a diuretic with your beta blocker?

A

For current or recent fluid retention

44
Q

Whats the biggest reason you should give your HF pts beta blockers?

A

They decrease mortality!

45
Q

Give some examples of beta blockers used for HF

A

Bisoprolol
Carvedilol
Metoprolol succinate (not tartrate)

46
Q

What is the MOA of carvedilol?

A

Blocks beta 1 and 2 and alpha 1 receptors

nonselective

47
Q

When might carvedilol be preferred?

A

In pts w/ poorly controlled BP due to alpha and beta 1 blockade

48
Q

When should you avoid carvedilol?

A

In asthmatic pts

Because beta 2 agonists are part of their tx

49
Q

How do you start beta blockers?

A

Low doses with gradual dose titration

50
Q

If you get AEs, should you keep increasing the BB dose?

A

No, wait until AEs have disappeared

51
Q

Do you continue long term BB tx even if sx dont improve?

52
Q

What may happen if you withdraw BB abruptly? How do you deal with that?

A

Acute decompensation

Taper if d/cing

53
Q

Is there one BB that is better than others

A

Nope. Great class effect

54
Q

What are the major AEs of BB?

A

Fluid retention
Fatiuge
Bradycardia
Hypotension

55
Q

What are the minor AEs of BB?

A

Bronchospasm
Worsening glucose tolerance (won’t mask sweating)
Sexual dysfunction in males

56
Q

What is the MOA of ARBs?

A

Inhibit AT-II at its receptor

57
Q

What is something ARBs dont do that ACEIs do? What does that mean

A

Dont inhibit bradykinin metabolism (no increase in bradykinin)
Means less cough and angioedema

58
Q

What dont you use ARBs with?

59
Q

Can angioedema still occur with ARBS?

A

Yes, just way less

60
Q

When do you start BBs with ARBs?

A

Before reaching max dose like w/ ACEIs

61
Q

What are the serum requirements for starting aldosterone receptor antagonists (ARAs)?

A

SCr <2.5 mg/dL (M) or < 2.0 (F)
CrCl > 30 mL/min
Serum K+ < 5.0 mEq/L

62
Q

What are two examples of ARAs?

A

Spironolactone

Eplerenone

63
Q

What do you discontinue after starting an ARA?

A

K+ supplements

64
Q

When do you stop ARAs?

A

During diarrhea, dehydration, or interruptions of diuretic therapy

65
Q

What are some AEs of spironolactone?

A

Gynecomastia

Hyperkalemia (monitor K+ closely)

66
Q

What are some AEs of epleronone?

A

Hyperkalemia

Gynecomastia

67
Q

What do you do with epleronone if serum K+ > 6 mEq/L?

A

Discontinue

68
Q

What do you do with epleronone if serum K+ > 5.5 mEq/L

A

Discontinue or lower dose

69
Q

What id digoxin?

A

Only orally active positive cardiac inotrope

70
Q

Does digoxin improve mortality?

71
Q

What dose digoxin do?

A 
Improves
LVEF
Quality of life
Exercise tolerance
HF sx
72
Q

Should you give a loading dose of digoxin for HF like you do with afib?

73
Q

What is the target plasma level of digoxin?

What do higher levels mean?

A

0.5-1.0 ng/mL

Higher moretality

74
Q

What does digoxin toxicity occur earlier with?

A

Hypokalemia
Hypomagnesemia
Hypothyroidism

75
Q

When do you get your first digoxin plasma level?

A

3-5 days after starting therapy

76
Q

When do you check digoxin levels after changing dosage?

77
Q

When do you check digoxin levels after a general dose?

A

6-8 hours after (want a trough level)

78
Q

What are some AEs of digoxin?

A

Cardiac arrythmias
GI sx
Neurological complaints (visual disturbances, altered color perception)

79
Q

What is hydralazine?

A

An arterial vasodilator

AKA afterload reducer

80
Q

What is isosorbide dinitrate?

A

Potent venous dilator

AKA preload reducer

81
Q

Which population is hydralazine/isosorbide dinitrate useful in?

A

African Americans w/ HF

82
Q

When do you start h/isdn for African Americans

A

On all African Americans on optimum ACEI and BB therapy unless contraindicated

83
Q

When do you start h/isdn for non-African Americans?

A

On those intolerant to or contraindicated to ACEIs or ARBs

84
Q

What is the MOA of ivabradine?

A

Decreases HR by inhibiting If pacemaker current in SA node

85
Q

What is the benefit of ivabradine?

A

Reduces risk of hospitalization for worsening HF

86
Q 
What is a new class of HF drugs?
(Includes sacubitril/valsartan)
A

Angiotensin recepter-neprilysin inhibitor (ARNI)

87
Q

How significantly did ARNI entresto lower CV mortality?

Pharm (32 decks)

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