HF drugs Flashcards
Which pt population is at increased risk for hyperkalemia?
diabetics & elderly
Potassium supplements should not be used with aldosterone antagonist when the serum potassium is…
> 3.5mEq/L
When should potassium levels be checked when using an aldosterone antagonist?
- 3 days after starting therapy then1 week later & at least monthly for the 1st 3 months of therapy
Before an aldosterone antagonist can be started, the renal clearance should be checked. what are the Ideal SCr levels for a man & woman?
Male: < 2.5mg/dL
female: <2mg/dL
Unlike ACEIs, BB & aldosterone antagonist, digoxin has no effect on what outcome?
Digoxin has no effect on mortality.
Digoxin affects this outcome of HF
It is ONLY for symptomatic benefit
What is the MOA of digoxin?
Digoxin inhibits the Na-K-ATPase pump which causes increased INTRAcellular calcium –> positive inotropic effects (increased contractility)
What happens at low doses vs. high doses of Lanoxin (digoxin)
Low doses: there is decreased sympathetic output w/o (+)inotropy
High doses: positive inotropic effect
What are the side effects of digoxin?
Heart: arrhhythmias, bradycardia, heart block
GI: abdominal pain, Nausea, vomiting, anorexia
neurologi: fatigue, visual disturbance, disorientation, confusion
What are the Therapeutic ranges for digoxin
HF: 0.5-1ng/ml
A. Fib: 0.8-2ng/ml
Digoxin is the drug of choice after failure of BB or CCB in what condition?
LV systolic dysfunction
What are the initial signs & symptoms of digoxin toxicity?
Nausea, comiting, diarrhea, bradycardia, dizziness, lightheadedness, fatigue
prolonged digoxin toxicity has symptoms of
vision changes (green/yello halos)
hallucinations
palpitations
At what levels do many pts experience digoxin toxicity
concentrations >2ng/ml normally, but in the elderly & pts with HYPOkalemia or HYPOmagnesemia toxicity can be seen with lower doses.
What medications need to be decreased by half when used in combination with digoxin?
Quinidine
verapamil
amiodarone
Which medications increase the concentration of digoxin?
Verapamil, Amiodarone, Quinidine
1c antiarrythmics (Propafenone, Flecanide)
Macrolides (erythromycins & clarythromycin)
Azols (itraconazole & ketoconazole)
Spironolactone
Cyclosporin
What medications decrease digoxin levels
Kaolin-pectin
Antacids, cholestryamine & colestipol (bind)
Metoclopramide
Digoxin is cleared significantly by the liver?
FALSE, digoxin is cleared mainly by the kidneys and dose adjustment in renal failure is REQUIRED
What is an appropriate starting dose of digoxin when used in the elderly or pts with low body mass?
0.125mg/day or every other day is appropriate
When is a loading dose of digoxin needed?
A loading dose of 0.25mg q2h with a max of 1.5mg is needed in the treatment of A. Fib.
NONE is needed in HF
A nurse has a patient on digoxin for HF & A. Fib. She knows that a dig level needs to be drawn on the pt, but is not sure when. What do you tell her?
Blood samples for dig levels should be drawn at least 6 hours, but preferably 12hrs AFTER the last dose of dig was given
The combination of hydrazine & isosorbide (BiDil) has what effect of HF outcomes
reduced mortality (but not more than ACEIs)
When can hydrazine & isosorbide (BiDil) be used in HF when
- pts that CAN’T use an ACEI or ARB due to intolerance, hypotension or renal insufficiency
- pts experience peristent HF symptoms despite therapy with ACEI + BB
- in addition to ACEI + BB + diuretic + digoxin in AF with HF
What are the most common side effects of hydrazine & isosorbide (BiDil)
HA
dizziness
GI complaints
When are BB indicated for use in HF
All STABLE pt with: a) current or hx of HF + reduced LVEF b) in combo with ACEIs & loops
Though BB have been shown too reduce symptoms, improve clinical outcome and decrease hospitalization & death; caution should be used when initiating & increasing dosage because BB can cause this?
increase in fluid retention = worsening HF when starting or increasing the dose
BB side effects of _____ & _____ that occur in the first weeks of therapy usually resolve
Fatigue & weakness
BB cause bradycardia which leads to the other BB side effects of
dizziness, lightheadedness, or blurred vision
Norvasc (amiodarone) & NDHP CCB increase these BB SE
bradycardiaheart blockhypotention
Metoprolol (Torpolol-XL) & carvediliol (Coreg) are 2D6 substrates and their hepatic metabolism is inhibited by
Quinidinefluoxetineparoxetineother 2D6 inhibitors
Which of the HF BB is metabolized by the Kidney & is adjustment for renal failure needed?
Bisoprolol & yes renal adjustment is needed
A diabetic patient with HF is currenlty being manage with oral anti-diabetics. Which class may not be effective if the patient is on a BB?
Sulfonylureas
When are diuretics used in HF & which type is preferred?
Diuretics are used ONLY in pts with signs & symptoms of volume overload with loop diuretics are preferred
Which electrolytes are depleted by loop diuretics
potassium (hypokalemia) &magnesium (hypmagnesemia)
Which diuretics should be given on an empty stomach & why?
Lasix (furosemide) & Bumex (bumetanide) are best taken on an empty stomach because food decrease their absorption
A pt presents to the emergency room with ADHF. their current oral medications include: Lasix(furosemide) 10mg, Prinivil(lisinopril) 5mg and Lanoxin(digoxin) 0.25mg. Which of these medication should be kept?
All of the medications should be kept; however PO furosemide should be switched to either IV Lasix or another loop diuretic due to decreased absorption PO lasix in ADHF.
What is the indication for ACEIs in HF
ACEIs are indicated for all pt with current or past HF symptoms + reduced LVEF
What are the positive effects/outcomes of ACEIs on HF
ACEIs:1. improve HF symptoms2. reduce hospitalizations & death3. slow the progression of HF
What are the side effects of ACEIs?
Renal isufficinceyAngioedemaHyperkalemiaRashCoughTaste disturbancehypotention & thus dizziness
Which ACEI, induced toxicities are increased by cyclosporine(Neoral) & tacrolimus(Prograf, Protopic)
nephrotoxicity & hyperkalemia
Which ARBs are indicated for HF & when should they be used?
Candisartan (Atacand) & Valsartan (Diovan) are indicated for HF in pts that are intolerant to ACEIs
When are aldosterone antagonists used in HF?
They are to be added to standard therapy in pts with moderate-severe HF & reduced LVEF or NYHA class 2 pts currently on BB + ACEI therapy & LVEF <35%
What effects to aldosterone antagonists have on HF outcomes
They reduce the risk of death & hospitalization
Name all vasodilators
Nipride (nitroprusside)
Nitro-Bid, Nitrostat (nithroglycerin)
Natrecor (nesiritide)
What is the MOA of Natrecor (nesiritide)
Natecore(nesiritide) is a B-type natriuretic peptide that cases an increase in diureses as well as arterial and venous dilation
Nipride(nitroprusside) causes dilation of?
arterials & ventricals
What is the dilatory effect of Nitro-Bid/Nitrostat (nitroglycerin)
low doses = venous dilation &
high doses = arterial dilation
What are the side effects specific to Nipride?
myocardial ischemia
cyanide & thiocyanate toxicity
Which of the vasodilators used in ADHF has the side effect of hemodynamic effect tolerance?
Nitroglycerin
Vasodilators Nipride &Nitrostate cause which SE
hypotension, HA & tachycardia
A pt taking Natrecor/ nesiritide is more likely to experience hypotension, HA if they are also taking what medication for HF or HTN?
a diuretic
What is the generic name for Nipride
Nitroprusside
What is the generic name for Natrecor
nesiritide
What are the brand names for nitroglycerin
Nitro-Bid & Nitrostat
What class do Intropin/dopamine, Doburex/dobutamine & Primacor/Milrinone fall into?
Inotropic agents
What is the MOA of Intropin
Dose dependent dopamine, Beta and alpha1 agonist
What dose of Intropin/dopamine stimulates dopamine receptors & what effect dose it have in the body?
0-3mcg/kg/min stimulates dopamine = improved urine output
What dose of Intropin/dopamine stimulates Beta receptors & what effect dose it have in the body?
3-10mcg/kg/min stimulates Beta1 &2 receptors = increased CO
What dose of Intropin/dopamine stimulates alpha1 receptors & what effect dose it have in the body?
> 10mcg/kg/min stimulates aplha-1 receptors = increased BP
When should dopamine be used?
ONLY in pts with marked systemic hypotension or cardiogenic shock
In what type of pt would Doutrex/dobutamine NOT be of benefit?
Dobutamine should NOT be used to increase BP in hypotensive pts because it has only weak agonistic effects on alpha1= little BP increase.
What is the MOA of Primacor/milrinone
Milrinone/Primacor inhibits Phosphodiesterase III = positive inotropic & vasodilating effects
What is the MOA of Dobutrex/Dobutamine
B1 & B2 agonist with WEAK alpha1 agonist activity that causes increases in CO & vasodilates
What are the side effects of Primacor/milrinone
Arrhythmias
hypotention
HA
When is the use of milrinone/Primacor indicated
- An alternative to dopamine/Intropin & dobutamine/Dobutrex when the pt is not responding
- Pt currently on BB, since the inotropic effects of Primacor are via a different pathway
Which Inotrope & vasodilator must be adjusted or monitored in renal failure?
Inotrope- Primacor/milrinone = adjust
Vasodilator- Natrecor/nesiritide = monitor
When are Inotropes indicated for use?
ONLY in hypoperfused pts, b/c they can increase the risk of death
