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therapeutics 2 > Heart Failure Study Deck > Flashcards

Heart Failure Study Deck Flashcards

1
Q

what is the definition of heart failure

A

abnormality of myocardial function leading to failure of heart to pump blood

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2
Q

what are the two main types of HF

A

HFrEF and HFpEF

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3
Q

what are the causes of HFrEF

A

systolic definition
decreased contractility
most closely related to CAD

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4
Q

what are the causes of HFpEF

A

diastolic dysfunction
impairment w/ventricular relaxation and filling
most closely related to HTN

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5
Q

what are the 3 categories of drug induced HF

A

negative inotropes
direct cardiac toxins
fluid and sodium retention

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6
Q

what is the definition of asymptomatic rEF

A

no HF symptoms w/ EF < 40%

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7
Q

what is the definition of HFrEF

A

HF symptoms w/ EF < 40%

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8
Q

what is the definition of HFimpEF

A

previous s/sxs of rEF but now improved

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9
Q

what is the definition of HFmrEF

A

HF symptoms w/ EF 41-49%

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10
Q

what is the definition of HFpEF

A

HF symptoms w/ EF > 50%

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11
Q

what are the main clinical presentations of HF

A

shortness of breath
swollen/tender abdomen
swelling of feet/legs
cough/sputum
chronic fatigue
increase urination at night
difficulty sleeping
confusion/impaired memory

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12
Q

major s/sxs of pulmonary congestions

A

exertional dyspnea
paroxysmal nocturnal dyspnea
pulmonary edema
orthopnea
rales breathing
bendopnea

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13
Q

major s/sxs of systemic congestion

A

peripheral edema (gravity dependent areas)
jugular venous distention
hepatojugular reflux
hepatomegaly ascites

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14
Q

Initial Labs for HF

A

-CBC, electrolytes, BUN, TFTs
-electrocardiogram
-chest x-ray

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15
Q

How to evaluate LV function and EF

A

-echocardiogram
-nuclear testing (MUGA)
-cardiac catheterization
-MRI and CT

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16
Q

NYHA FC I

A

cardiac disease w/o limitations of physical activity

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17
Q

NYHA FC II

A

cardiac disease + slight limitations of physical activity

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18
Q

NYHA FC III

A

cardiac disease + limitations of physical activity

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19
Q

NYHA FC IV

A

cardiac disease + inability to carry on activity w/o discomfort

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20
Q

AHA staging A

A

high risk of developing HF. no identified abnormalities or symptoms of HF

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21
Q

AHA stage B

A

structural heart disease but no s/sx of HF

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22
Q

AHA stage C

A

HF symptoms current or prior

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23
Q

AHA stage D

A

Advanced heart disease + symptoms HF at rest

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24
Q

what are the goals of therapy for HF

A
  1. slow disease progression
  2. reduce sxs and increase QOL. reduce hospitalizations
  3. reduce mortality
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25
Q

sodium monitoring in HF

A

-intake should be 2-3 gram/day
-avoid salty foods

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26
Q

alcohol monitoring in HF

A

-patients should abstain from alcohol
-no more than 2 drinks/day for men and 1/drink/day for women

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27
Q

fluid monitoring in HF

A

-restrict to <2 L/day in patients with hyponatremia
-diuretics difficult in maintaining fluid volume

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28
Q

staged based drug therapy A

A

ACE-i / ARB

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29
Q

stage based drug therapy B

A

ACE-i / ARB
Beta blockers

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30
Q

stage based drug therapy C/D

A

ARNi or ACE/ARB
Beta Blocker
MRA
SGLT2i
Diuretics as needed

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31
Q

Additional therapies for C

A

ISDN/hydralazine
Ivabradine
Digoxin

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32
Q

what effects do diuretics have in HF disease

A

dont reduce disease just symptoms
no impact on mortality

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33
Q

How potent are loops

A

potent. block Na and Cl absorption in ascending limb

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34
Q

What drug class blocks loop

A

NSAIDs. Avoid combination

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35
Q

Loop initiation

A

start low then double and titrate
adjust off weight and symptoms
overload and reduce weight 1-2 pounds/day
BUN/Cr ratio not >20:1

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36
Q

Loop monitoring

A

1-2 weeks after start get labs
fluid intake and outtake
BP
serum electrolytes

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37
Q

what is the potassium goal in HF

A

> 4

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38
Q

what is the magnesium goal in HF

A

> 2

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39
Q

IV equivalent dosing for loops

A

furosemide 40mg =
bumetanide 1mg =
torsemide 20mg =
ethacrynic acid 50mg

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40
Q

Adverse Effects of loops

A

hypomagnesia
hypokalemia
volume depletion
hyponatremia
increase uric acid
increase calcium

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41
Q

What are the RAS inhibitors

A

ARNi
ACEi
ARB

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42
Q

what is the main actions of RAS inhibitors in HF

A

stop cell hypertrophy, cell death, fibrosis, and arrhythmias

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43
Q

what HF patients should use ACEi

A

benefit occurs in all HF and all severity
must be used in all HF w/o contraindication

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44
Q

what is the mechanism of action of ACEi in general

A

block conversion of angiotensin I to angiotensin II

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45
Q

what is the mechanism of action of ACEi in HF

A

reduced vasoconstriction
improve cardiac hemodynamics
inhibit hypertrophy

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46
Q

ACEi dosing principles in HF

A

titrate slowly to target dose
start low and double every 1-4 weeks

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47
Q

when should dosing in ACEi be cautioned in HF

A

volume depletion
SBP <80
K>5
SCr > 3
lower the dose and monitor closely

48
Q

Enalapril (vasotec) initial dosing

A

2.5mg-5mg BID

49
Q

Enalapril (vasotec) target dosing

A

10mg BID

50
Q

Captopril (capoten) initial dosing

A

6.25-12.5mg TID

51
Q

Captopril (capoten) target dosing

A

50mg TID

52
Q

Lisinopril (Prinivil, Zestril) initial dosing

A

2.5-5mg QD

53
Q

Lisinopril (Prinivil, Zestril) target dosing

A

20-40mg QD

54
Q

Absolute CI of ACEi

A

pregnancy
PMH of angioedema
Bilateral Renal Arterial Stenosis
PMH of intolerance due to hypotension
decreased renal function
hyperkalemia
cough

55
Q

Adverse effects of ACEi

A

Hypotension
renal insufficiency
hyperkalemia
cough
angioedema

56
Q

Monitoring for ACEi and ARB

A

volume status
renal function and K levels
blood pressure

57
Q

How often should labs be done with ACEi and ARB

A

1-2 weeks after initiation then every 3-6 months

58
Q

what is the acceptable amount SCr may increase with ACEi and ARB

A

less than or equal to 30%

59
Q

when are ARBs used in HF

A

in place of ACEi

60
Q

mechanism of action of ARBs

A

block angiotensin II at the AT1 receptor

61
Q

Losartan (Cozaar) initial dosing

A

25-50mg daily

62
Q

Losartan (Cozaar) target dosing

A

150mg daily

63
Q

Valsartan (Diovan) initial dosing

A

20-40mg BID

63
Q

Valsartan (Diovan) target dosing

A

160 mg BID

64
Q

Candesartan (Atacand) initial dosing

A

4mg QD

65
Q

Candesartan (Atacand) target dosing

A

24mg QD

66
Q

when to use ARB in place of ACEi

A

unable to take ACEi due to cough
ACEi induced angioedema

67
Q

ARNi mechanism of action

A

dual NP and RAAS. more beneficial effects

68
Q

how does ARNi work in HF

A

reduce risk of CV death/hospitalization for HFrEF patients with NYHA class II-IV

69
Q

High-Dose ACEi/ARB to initial ARNi dose

A

S49/V51mg BID

70
Q

High-Dose ACEi/ARB to max ARNi dose

A

97/103mg BID

71
Q

Low to medium dose ACEi or ARB or naive to ARNi dose

A

24/26 BID

72
Q

ARNi adverse effects

A

hypotension
increase in SCr and K+
angioedema (rare)
CI with pregnancy
expensive

73
Q

ARNi contraindications

A

within 36hr of ACEi use
pregnancy
hepatic impairment
hypersensitivity to ACEi/ARB

74
Q

Stage B recommendations for RAS inhibitors

A

ACEi or ARB

75
Q

Stage C recommendations for RAS inhibitors

A

1st: ARNi
2nd: ACEi if arni not possible
3rd: ARB if ACEi intolerant or arni not possible

or replace ace/arb with ARNi

76
Q

what are the main actions of beta blockers in HF

A

reverse remodeling
decrease cardiac hypertrophy and cell death
decrease HR and vasoconstriction

77
Q

what beta blockers can be used in HF

A

bisoprolol (Zebeta)
Carvedilol (Coreg)
Carvedilol ( Coreg CR)
Metoprolol Succinate (Toprol XL)

78
Q

initial dose of bisoprolol (zebeta)

A

1.25mg daily

79
Q

target dose of bisoprolol (zebeta)

A

10mg daily

80
Q

initial dose of Carvedilol (Coreg)

A

3.125mg BID

81
Q

target dose of Carvedilol (Coreg)

A

25-50mg BID

82
Q

initial dose of metoprolol succ (toprol xl)

A

12.5mg-25mg daily

83
Q

target dose of metoprolol succ (toprol xl)

A

200mg daily

84
Q

monitoring for BB in HF

A

BP, HR
not lower than 50bpm
edema and fluid retention
fatigue or weakness

85
Q

what are the recommendations for BB in HF stage B

A

all patients should be on beta blocker

86
Q

what are the recommendations for BB in HF stage C

A

all patients should be on beta blocker

87
Q

what are the main actions of MRAs in HF

A

decrease electrolyte loss
decrease sodium retention
decrease sympathetic stimulation
block direct fibrotic action on myocardium

88
Q

initial dose of eplerenone with normal crcl

A

25mg qd

89
Q

target dose of eplerenone with normal crcl

A

50mg qd

90
Q

initial dose of eplerenone with crcl 30-49

A

25mg every other day

91
Q

target dose of eplerenone with crcl 30-49

A

25mg qd

92
Q

initial dose of spironolactone with normal crcl

A

12.5mg

93
Q

target dose of spironolactone with normal crcl

A

25mg qd

94
Q

initial dose of spirionolactone with crcl 30-49

A

12.5mg every other day

95
Q

target dose of spironolactone with crcl 30-49

A

25mg every other day

96
Q

dosing principles of MRAs in HF

A

added to RASi and BB therapy
avoid if SCr > 2.5 or 2
avoid if K>5
concomitant use with k sparing diuretics should be avoided
avoid NSAID use

97
Q

monitoring for MRAs in HF

A

renal effects and k within 3 days - 1wk of initiation then every 3 months
counsel on avoiding salt substitutes and sources of potassiumk

98
Q

what are the recommendations for MRAs in HF stage B

A

not recommended

99
Q

what are the recommendations for MRAs in HF stage c

A

NYHA II-IV
HFrEF
eGFR >30
K< 5
d/c if K cannot be mainted

100
Q

what are the main actions of SGLT-2is in HF

A

decrease the risk of CV death or hospitalization for HFrEF class ii-iv

101
Q

dosing for SGLT2is in HF

A

dapagliflozin 10mg qd or
empagliflozin 10mg qd

102
Q

adverse effects/monitoring of SGLT2-is

A

volume depletion
ketoacidosis
hypoglycemia
infection risk

103
Q

recommendations for SGLT2-is in HF

A

symptomatic chronic HFrEF w/wo DM to reduce hospitalizations and CV mortality
as long as renal function is good

104
Q

how should ISDN/Hydralazine be used in HF

A

treatment for HF in black patients as adjunct to GDMT at optimal dose

105
Q

ISDN/Hydralazine initial dose

A

25mg hydralazine TID
20mg ISDN TID
20/37.5mg TID (combo)

106
Q

ISDN/Hydralazine target dose

A

75mg hydralazine TID
40mg ISDN TID
40/75mg TID (combo)

107
Q

adverse effects of ISDN/Hydralazine

A

lupus like syndrome, headache, nvd, hypotension

108
Q

ivabradine dosing

A

2.5mg BID then increase by 2.5 up to 7.5mg BID

109
Q

when to use digoxin in HF

A

HF + Afib
patients w/ symptomatic HFrEF despite optimized GDMT or can’t tolerate GDMT

110
Q

digoxin dosing

A

empically
0.125-0.25mg qd

111
Q

what is the goal serum for digoxin

A

0.5-0.9 ng/ml
lower doses when greater than 70 years old

112
Q

DDIs with digioxin

A

amiodarone
quinidine
verapamil
itra/KTZ

113
Q

what is the main goal in HFpEF

A

control the BP

114
Q

what drugs are used for symptom relief in HFpEF

A

diuretics
used for volume overload

115
Q

what drugs are used to decrease hospitalizations and CV mortality in HFpEF

A

SGLT-2i

116
Q

do you use RASi or MRAs in HFpEF

A

can be considered
may decrease hospitalizations for selected patients

therapeutics 2 (24 decks)

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