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Year 1: Patho/Pharm > Heart Failure PHARM > Flashcards

Heart Failure PHARM Flashcards

1
Q

Quadruple therapy

A
  1. ARNI
    - angiotensin receptor / neprilysin inhibitor
    Ex. valsartan/sacubitril
  2. beta blocker
    - OLOL
  3. SGLT2 inhibitor
    SOdium glucose transporter 2 inhibitor
    Ex. GLIFLOZIN
  4. MRA
    mineralcorticoid receptor antagonist
    Ex. spironolactone
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2
Q

ARNI
Example

A

Angiotensin receptor neprilysin inhibitor

  1. valsartan with 2. sacubitril
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3
Q

ARNI
MOA

A

Angiotensin receptor blocker
- Valsartan
- blocks angiotensin II receptors
- Prevens 1. vasoconstriction (vasodilation)
2. prevents release of aldosterone (prevents reuptake sodium, water)
- prevents activation SNS
- prevents remodelling

Sacubitril
- neprilysin inhibitor
- Neprylysin cleaves natriuretic peptides (diuresis, sodium loss), bradykinin (vasodilation, vascular permeability), angiotensin I and II (vasoconstriction, aldosterone release, sodium and water reabsorption)

NET EFFECT
1. block RAAS (vasodilation, decrease SNS activation, remodelling, decrease sodium and water reabsorption)
2. increase bradykinin and natriuretic peptides (increase fluid and sodium loss, increase vasodilation)

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4
Q

Benefits
ARNI

A
  1. decrease all cause mortality
  2. decrease VS mortality
  3. decrease hospitalizations HF
  4. decrease HF symptoms
  5. nephroprotective

benefit > ACEi and ARB alone

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5
Q

Rules for prescribing
ARNIs

A

washout 36 hours if ACEi D/C

can start right away if on ARB

start low go slow, work up
blood work 1 week after start, increase dose

Can increase dose every 2-4 weeks

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6
Q

Blood work monitoring
ARNI

A
  1. electrolytes (sodium, potassium)
  2. creatinine (kidney function)
  3. GFR (> 30mL/min)
  4. Blood pressure (> 100mmHg)
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7
Q

SE ARNI

A
  1. ARB SE
    - Hyperkalemia
    - Hypotension
    - cough and angioedema (cross reactivity with ACEi 8%)
    - teratogenic
  2. neprilysin inhibitors SE
    - build up bradykinin (cough, angioedema)
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8
Q

Contraindications
ARNI

A
  1. angioedema
  2. ACEi (cannot prescribe within 36 hours)
  3. Hypotension < 100mmHg
  4. GFR < 30ml/min
    - loss of the RAAS to maintain afferent arteriole GFR results in kidney failure?
    - do not clear the drug (dangerous)
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9
Q

Angiotensin Converting Enzyme Inhibitors
Indications HF

A

Post MI with HTN and HF

HFrEF < / = 40% (who do not tolerate ARNI)

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10
Q

ACE inhibitor
MOA

A
  1. block ACE prevent formation angiotensin II
  2. prevents vasoconstriction, lowering afterload
  3. prevents aldosterone, and sodium and water retention, decreasing preload
  4. prevents SNS activation, lowering afterload and preload (vasoconstriction arteries, veins)
  5. prevents breakdown of bradykinin (vasodilation)

INCREASES STROKE VOLUME OF THE HEART IN HEART FAILURE

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11
Q

ACE inhibhitor
SE

A
  1. first dose hypotension
  2. hypotension
  3. hyperkalemia
  4. neutropenia
  5. teratogenic
  6. kidney failure (contraindicated bilateral renal stenosis)
  7. cough and angioedema (10/100)
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12
Q

ACE inhibitor
Examples

A

RamIPRIL
PerindoPRIL

reduce all cause moratlity
reduce CV death
reduce hospitalization
reduce HF symptoms

ARNI more effective than ACEi

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13
Q

Rules for prescribing
ACEi

A
  1. start low go slow
  2. titrate every 1-2 weeks
  3. repeat blood work
    - potassium
    - creatinine (kidney function)
    - GFR
    - BP
  4. monitor for symptomatic hypotension (likely in HF, low CO = low BP)
    - stop and reduce dose if BP < 90mmHg
  5. Low potassium diet
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14
Q

Contraindications
ACEi

A

potassium supplements, salts (hyperkalemia)

hypotension (lower dose if < 90mmHg)

pregnancy

angioedema

D/C potassium sparing diruetics for 2-3 days before starting (to prevent hyperkalemia)

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15
Q

Angiotensin Receptor Blockers (ARBs)
Examples

A

ValSARTAN
CandeSARTAN

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16
Q

ARB
MOA

A

Block angiotensin II receptors
prevent vasoconstriction (lower afterload)
prevent aldosterone release (prevent fluid and sodium retention) decrease preload
prevention remodelling
prevention SNS activation (preload, afterload)

17
Q

ARB
SE

A
  • teratogenic
  • hypotension
  • hyperkalemia
  • cough and angioedemaA
18
Q

ARB
Contraindications

A

ACEi

pregnancy

Hypotension < 90mmHg

hyperkalemia

Caution: digoxin, lithium (toxicity)

19
Q

ARB
prescribing considerations

A

work up every 1-2 weeks

blood work
- potassium
- creatnine clearance, GFR
- BP (> 90mmHg)

20
Q

Beta blockers
Examples

A

OLOL

Carvedilol (third generation)
metoprolol (second generation)
bisoprolol

21
Q

Beta blocker
MOA

A

block G protein activation
prevent cAMP signal
prevents opening calcium channels

decrease HR, conduction, contractility
decrease workload of heart and demand for oxygen

  1. increase stroke volume
  2. increase LVEF over 6-12 months
  3. decreaase mortality, hospitalization, increase QOL
22
Q

Benefits beta blockers

A
  1. increase stroke volume
  2. increase LVEF
  3. decrease mortality, hospitalization, QOL
23
Q

Indications for starting beta blocker

A
  1. NYHA class I and II
    - asymptomatic
    - symptomatic with exertion beyond normal

*others
started with cardiologist
can worsen heart failure

24
Q

SE
Beta blockers

A
  1. heart blocks
  2. bradycardia
  3. worsening heart failure
  4. orthostatic hypotension
  5. contrainidcated older people > 60 years
25
Q

Prescribing considerations
beta blockers

A
  1. monitor HR
  2. monitor BP
  3. ECG performed before prescribing (check for arrhythmias, heart blocks)
  4. hypoglycemia, impaired awareness hypoglycemia
  5. bronchoconstriction
  6. impairment anaphylaxis epipen
  7. insomnia, depression, nightmares
  8. sexual dysfunction
26
Q

Prescribing considerations

A

Caution:
diabetics, anaphylaxis, depression, AV blocks, dysrhtyhmias, heart failure, older age

Blood monitoring
- Creatinine
- liver function
- ECG
- BP and HR

Titrate up
- 2-4 weeks (ARNI same schedule)
- start low go slow

27
Q

INdications
carvedilol vs. bisoprolol / metoprolol

A

class II cardioselective
- target heart
- will not exacerbate / bronchoconstriction in R sided heart failure

Class III
- blocks beta 1, beta 2 and alpha 1
- decreases preload, afterload and also heart rate, conduciton, contracitlity…

28
Q

Mineralcorticoid receptor antagonists (MRA)
Examples

A

Spironolactone
eplerenone

29
Q

MRA
Mechanism of action

A

Blocks aldosterone receptor on principle cell in distal tubule
prevents Na/K pump synthesis (3-5 days lifespan of cell)
Na and water excreted (decrease preload)
K reabsorbed (risk hyperkalemia)

Blocks remodelling cardiac

MINIMAL EFFECT ON BP….
MOA for HF is cardiac remodelling decrease

30
Q

Benefits of MRA

A
  1. Decrease mortality
  2. decrease aldosterone cardiac remodelling
31
Q

SE MRA

A

bind to androgenic receptors
- gynecomastia
- hirsituism
- deep voice
- sexual dysfunction, impotence
- teratogenic

hyperkalemia

kidney disease

32
Q

Prescribing considerations

A

Hold/decrease dose
K > 5.5
Cr > 30% baseline

D/C if GFR < 30ml/min

Monitoring
- potassium
- creatinine
- GFR

33
Q

Prescribing consideration
RAAS inhibitors

A

HFrEF < / = 40%

  1. ARNI or ACEi or ARB
  2. MRA

Hold/lower dose if Cr > 30%
Hold/lower dose if K+ > 5.5
Hold/lower dose if BP < 100mmHg

Start low , go slow
Monitor BW at initiation, 1 week following, and any dose change (Q2 weeks)

K+
Cr
Blood pressure

Common SE
- Cough, angioedema
- hypotension
- hyperkalcemia
- renal failure
- teratogenic

Year 1: Patho/Pharm (45 decks)

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