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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
sodium monitoring in HF
-intake should be 2-3 gram/day -avoid salty foods
26
alcohol monitoring in HF
-patients should abstain from alcohol -no more than 2 drinks/day for men and 1/drink/day for women
27
fluid monitoring in HF
-restrict to <2 L/day in patients with hyponatremia -diuretics difficult in maintaining fluid volume
28
staged based drug therapy A
ACE-i / ARB
29
stage based drug therapy B
ACE-i / ARB Beta blockers
30
stage based drug therapy C/D
ARNi or ACE/ARB Beta Blocker MRA SGLT2i Diuretics as needed
31
Additional therapies for C
ISDN/hydralazine Ivabradine Digoxin
32
what effects do diuretics have in HF disease
dont reduce disease just symptoms no impact on mortality
33
How potent are loops
potent. block Na and Cl absorption in ascending limb
34
What drug class blocks loop
NSAIDs. Avoid combination
35
Loop initiation
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
36
Loop monitoring
1-2 weeks after start get labs fluid intake and outtake BP serum electrolytes
37
what is the potassium goal in HF
>4
38
what is the magnesium goal in HF
>2
39
IV equivalent dosing for loops
furosemide 40mg = bumetanide 1mg = torsemide 20mg = ethacrynic acid 50mg
40
Adverse Effects of loops
hypomagnesia hypokalemia volume depletion hyponatremia increase uric acid increase calcium
41
What are the RAS inhibitors
ARNi ACEi ARB
42
what is the main actions of RAS inhibitors in HF
stop cell hypertrophy, cell death, fibrosis, and arrhythmias
43
what HF patients should use ACEi
benefit occurs in all HF and all severity must be used in all HF w/o contraindication
44
what is the mechanism of action of ACEi in general
block conversion of angiotensin I to angiotensin II
45
what is the mechanism of action of ACEi in HF
reduced vasoconstriction improve cardiac hemodynamics inhibit hypertrophy
46
ACEi dosing principles in HF
titrate slowly to target dose start low and double every 1-4 weeks
47
when should dosing in ACEi be cautioned in HF
volume depletion SBP <80 K>5 SCr > 3 *lower the dose and monitor closely*
48
Enalapril (vasotec) initial dosing
2.5mg-5mg BID
49
Enalapril (vasotec) target dosing
10mg BID
50
Captopril (capoten) initial dosing
6.25-12.5mg TID
51
Captopril (capoten) target dosing
50mg TID
52
Lisinopril (Prinivil, Zestril) initial dosing
2.5-5mg QD
53
Lisinopril (Prinivil, Zestril) target dosing
20-40mg QD
54
Absolute CI of ACEi
pregnancy PMH of angioedema Bilateral Renal Arterial Stenosis PMH of intolerance due to hypotension decreased renal function hyperkalemia cough
55
Adverse effects of ACEi
Hypotension renal insufficiency hyperkalemia cough angioedema
56
Monitoring for ACEi and ARB
volume status renal function and K levels blood pressure
57
How often should labs be done with ACEi and ARB
1-2 weeks after initiation then every 3-6 months
58
what is the acceptable amount SCr may increase with ACEi and ARB
less than or equal to 30%
59
when are ARBs used in HF
in place of ACEi
60
mechanism of action of ARBs
block angiotensin II at the AT1 receptor
61
Losartan (Cozaar) initial dosing
25-50mg daily
62
Losartan (Cozaar) target dosing
150mg daily
63
Valsartan (Diovan) initial dosing
20-40mg BID
63
Valsartan (Diovan) target dosing
160 mg BID
64
Candesartan (Atacand) initial dosing
4mg QD
65
Candesartan (Atacand) target dosing
24mg QD
66
when to use ARB in place of ACEi
unable to take ACEi due to cough ACEi induced angioedema
67
ARNi mechanism of action
dual NP and RAAS. more beneficial effects
68
how does ARNi work in HF
reduce risk of CV death/hospitalization for HFrEF patients with NYHA class II-IV
69
High-Dose ACEi/ARB to initial ARNi dose
S49/V51mg BID
70
High-Dose ACEi/ARB to max ARNi dose
97/103mg BID
71
Low to medium dose ACEi or ARB or naive to ARNi dose
24/26 BID
72
ARNi adverse effects
hypotension increase in SCr and K+ angioedema (rare) CI with pregnancy expensive
73
ARNi contraindications
within 36hr of ACEi use pregnancy hepatic impairment hypersensitivity to ACEi/ARB
74
Stage B recommendations for RAS inhibitors
ACEi or ARB
75
Stage C recommendations for RAS inhibitors
1st: ARNi 2nd: ACEi if arni not possible 3rd: ARB if ACEi intolerant or arni not possible or replace ace/arb with ARNi
76
what are the main actions of beta blockers in HF
reverse remodeling decrease cardiac hypertrophy and cell death decrease HR and vasoconstriction
77
what beta blockers can be used in HF
bisoprolol (Zebeta) Carvedilol (Coreg) Carvedilol ( Coreg CR) Metoprolol Succinate (Toprol XL)
78
initial dose of bisoprolol (zebeta)
1.25mg daily
79
target dose of bisoprolol (zebeta)
10mg daily
80
initial dose of Carvedilol (Coreg)
3.125mg BID
81
target dose of Carvedilol (Coreg)
25-50mg BID
82
initial dose of metoprolol succ (toprol xl)
12.5mg-25mg daily
83
target dose of metoprolol succ (toprol xl)
200mg daily
84
monitoring for BB in HF
BP, HR not lower than 50bpm edema and fluid retention fatigue or weakness
85
what are the recommendations for BB in HF stage B
all patients should be on beta blocker
86
what are the recommendations for BB in HF stage C
all patients should be on beta blocker
87
what are the main actions of MRAs in HF
decrease electrolyte loss decrease sodium retention decrease sympathetic stimulation block direct fibrotic action on myocardium
88
initial dose of eplerenone with normal crcl
25mg qd
89
target dose of eplerenone with normal crcl
50mg qd
90
initial dose of eplerenone with crcl 30-49
25mg every other day
91
target dose of eplerenone with crcl 30-49
25mg qd
92
initial dose of spironolactone with normal crcl
12.5mg
93
target dose of spironolactone with normal crcl
25mg qd
94
initial dose of spirionolactone with crcl 30-49
12.5mg every other day
95
target dose of spironolactone with crcl 30-49
25mg every other day
96
dosing principles of MRAs in HF
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
monitoring for MRAs in HF
renal effects and k within 3 days - 1wk of initiation then every 3 months counsel on avoiding salt substitutes and sources of potassiumk
98
what are the recommendations for MRAs in HF stage B
not recommended
99
what are the recommendations for MRAs in HF stage c
NYHA II-IV HFrEF eGFR >30 K< 5 *d/c if K cannot be mainted*
100
what are the main actions of SGLT-2is in HF
decrease the risk of CV death or hospitalization for HFrEF class ii-iv
101
dosing for SGLT2is in HF
dapagliflozin 10mg qd or empagliflozin 10mg qd
102
adverse effects/monitoring of SGLT2-is
volume depletion ketoacidosis hypoglycemia infection risk
103
recommendations for SGLT2-is in HF
symptomatic chronic HFrEF w/wo DM to reduce hospitalizations and CV mortality *as long as renal function is good*
104
how should ISDN/Hydralazine be used in HF
treatment for HF in black patients as adjunct to GDMT at optimal dose
105
ISDN/Hydralazine initial dose
25mg hydralazine TID 20mg ISDN TID 20/37.5mg TID (combo)
106
ISDN/Hydralazine target dose
75mg hydralazine TID 40mg ISDN TID 40/75mg TID (combo)
107
adverse effects of ISDN/Hydralazine
lupus like syndrome, headache, nvd, hypotension
108
ivabradine dosing
2.5mg BID then increase by 2.5 up to 7.5mg BID
109
when to use digoxin in HF
HF + Afib patients w/ symptomatic HFrEF despite optimized GDMT or can't tolerate GDMT
110
digoxin dosing
empically 0.125-0.25mg qd
111
what is the goal serum for digoxin
0.5-0.9 ng/ml lower doses when greater than 70 years old
112
DDIs with digioxin
amiodarone quinidine verapamil itra/KTZ
113
what is the main goal in HFpEF
control the BP
114
what drugs are used for symptom relief in HFpEF
diuretics used for volume overload
115
what drugs are used to decrease hospitalizations and CV mortality in HFpEF
SGLT-2i
116
do you use RASi or MRAs in HFpEF
can be considered may decrease hospitalizations for selected patients

therapeutics 2 (24 decks)

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