Heart failure meds Flashcards
What reductions bring about heart failure?
Reduction in ventricular filling
Reduction in myocardial contractility
What is reduction of ventricular filling also known as?
Diastolic dysfunction
What is reduction of myocardial contractility also known as?
Systolic dysfunction
With what model do we describe heart failure?
Neurohormonal model
What hormones are involved with the neurohormone activation?
Norepinephrine
Angiotensin II
Aldosterone
Proinflammatory cytokines
How do we target pharmacotherapy for HF?
We try to antagonize the neurohormonal activation
Give the shorthand for diastolic dysfucntion with preserved AND reduced ejection fraction
HFpEF
HFrEF
What type of HF pts are most commonly involved in HF drug trials?
Pts with HFrEF
Describe pts classified in NYHA functional classification 1
Pt w/ cardiac disease but w/o limitations of physical activity
Describe pts classified in NYHA functional classification 2
Pts w/ cardiac disease w/ slight limitations of physical activity
Describe pts classified in NYHA functional classification 3
Pts w/ cardiac disease w/ marked limitations of physical activity
Describe pts classified in NYHA functional classification 4
Pts w/ cardiac disease w/ inability to carry on physical activity w/o discomfort
Do sx of NYHA HF
classification stay the same always?
No, they can change
What is the first stage of the ACC/AHA HF stage?
At risk stage
What is the second ACC/AHA HF stage?
Pts with structural heart disease
What is the third ACC/AHA HF stage?
Pt with structural heart disease and current or previous sx
What is the fourth ACC/AHA HF stage?
Refractory HF
Do ACC/AHA HF stages changes?
No, they are consistent with the progressive nature of HF
What is the primary dysfunction that has been addressed in pharmacotherapy trials?
Systolic dysfunction
List two newer agents being used for systolic dysfunction
Ivabradine
Sacubitril/valsartan
When are diuretics indicated for HF pts?
In any pt w/ evidence or history of fluid retention
Is there a potential for chronic diuretic use for HF pts?
Yes
How do we monitor the effects of diuretics for HF pts?
Daily morning weight measurements
Are thiazide diuretics weak or strong for HF?
Weak, use with something else
What thiazide is added to loops for diuretic resistance?
Metolazone
What is the doseage of metolazone?
2.4-10 mg once daily PLUS loop
What is the most potent diuretic for HF?
Loop
What is the ceiling effect of loop diuretics?
Hit a highest dose, still not totally effective
Give this more frequently, instead of increasing dose
When is torsemide preferred?
In pts with persistent fluid retention despite high doses of other loops
Give the relationship of IV dosing of Lasix, torsemide, and bumetanide
40 mg Lasix = 20 mg torsemid = 1 mg bumetanide
What is the cornerstone of HF pharmacotherapy?
ACE inhibitors
When are ACE inhibitors first line therapy for HF
Systolic HF
What is the reduction in mortality if HF pt is on an ACEI?
20-30%
What do you use with an ACEI unless contraindicated?
Beta blocker
When do you add beta blockers to ACEi?
After titrating ACEI to max dose (or even before)
What do you have to monitor when a pt is on an ACEI?
Serum K+ and renal function
What is a risk of abrupt withdrawal of ACEI?
Decompensation
What are some AEs of ACEIs?
Hypotension
Functional renal insufficency
Cough
Angioedema
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
How do you deal with the ACEI cough?
Switch to an ARB
What % of pts on ACEIs develop angioedema? What does this mean?
<1%
Must avoid ACEIs for lifetime
When are beta blockers indicated for HF pts?
For use in ALL stable HF pts unless intolerant or contraindicated
When should you use a diuretic with your beta blocker?
For current or recent fluid retention
Whats the biggest reason you should give your HF pts beta blockers?
They decrease mortality!
Give some examples of beta blockers used for HF
Bisoprolol
Carvedilol
Metoprolol succinate (not tartrate)
What is the MOA of carvedilol?
Blocks beta 1 and 2 and alpha 1 receptors
nonselective
When might carvedilol be preferred?
In pts w/ poorly controlled BP due to alpha and beta 1 blockade
When should you avoid carvedilol?
In asthmatic pts
Because beta 2 agonists are part of their tx
How do you start beta blockers?
Low doses with gradual dose titration
If you get AEs, should you keep increasing the BB dose?
No, wait until AEs have disappeared
Do you continue long term BB tx even if sx dont improve?
Yes
What may happen if you withdraw BB abruptly? How do you deal with that?
Acute decompensation
Taper if d/cing
Is there one BB that is better than others
Nope. Great class effect
What are the major AEs of BB?
Fluid retention
Fatiuge
Bradycardia
Hypotension
What are the minor AEs of BB?
Bronchospasm
Worsening glucose tolerance (won’t mask sweating)
Sexual dysfunction in males
What is the MOA of ARBs?
Inhibit AT-II at its receptor
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
What dont you use ARBs with?
ACEI
Can angioedema still occur with ARBS?
Yes, just way less
When do you start BBs with ARBs?
Before reaching max dose like w/ ACEIs
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
What are two examples of ARAs?
Spironolactone
Eplerenone
What do you discontinue after starting an ARA?
K+ supplements
When do you stop ARAs?
During diarrhea, dehydration, or interruptions of diuretic therapy
What are some AEs of spironolactone?
Gynecomastia
Hyperkalemia (monitor K+ closely)
What are some AEs of epleronone?
Hyperkalemia
Gynecomastia
What do you do with epleronone if serum K+ > 6 mEq/L?
Discontinue
What do you do with epleronone if serum K+ > 5.5 mEq/L
Discontinue or lower dose
What id digoxin?
Only orally active positive cardiac inotrope
Does digoxin improve mortality?
No
What dose digoxin do?
Improves LVEF Quality of life Exercise tolerance HF sx
Should you give a loading dose of digoxin for HF like you do with afib?
No
What is the target plasma level of digoxin?
What do higher levels mean?
0.5-1.0 ng/mL
Higher moretality
What does digoxin toxicity occur earlier with?
Hypokalemia
Hypomagnesemia
Hypothyroidism
When do you get your first digoxin plasma level?
3-5 days after starting therapy
When do you check digoxin levels after changing dosage?
5-7 days
When do you check digoxin levels after a general dose?
6-8 hours after (want a trough level)
What are some AEs of digoxin?
Cardiac arrythmias
GI sx
Neurological complaints (visual disturbances, altered color perception)
What is hydralazine?
An arterial vasodilator
AKA afterload reducer
What is isosorbide dinitrate?
Potent venous dilator
AKA preload reducer
Which population is hydralazine/isosorbide dinitrate useful in?
African Americans w/ HF
When do you start h/isdn for African Americans
On all African Americans on optimum ACEI and BB therapy unless contraindicated
When do you start h/isdn for non-African Americans?
On those intolerant to or contraindicated to ACEIs or ARBs
What is the MOA of ivabradine?
Decreases HR by inhibiting If pacemaker current in SA node
What is the benefit of ivabradine?
Reduces risk of hospitalization for worsening HF
What is a new class of HF drugs? (Includes sacubitril/valsartan)
Angiotensin recepter-neprilysin inhibitor (ARNI)
How significantly did ARNI entresto lower CV mortality?
By 20%
