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Cardiopulm II E1 > HF Medications > Flashcards

HF Medications Flashcards

Brand/Generic Drug classes MOA AE Indication

1
Q

What is the treatment algorithm for stage A HFrEF?

A

Control conditions that contribute to HF: HTN, hyperlipidemia, obesity, diabetes

Avoid: tobacco use, cardiotoxic agents

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2
Q

What is the treatment algorithm for stage B HFrEF?

A

NYHA Class I: Start off with an ACE-I or ARB AND BB to prevent symptomatic HF

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3
Q

What is the treatment algorithm for stage C HFrEF?

A
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4
Q 
B-Adrenergic Blockers
MOA: 
Dosing: 
When to use:
Benefits (2)
Monitor (4)
C/I (3)
A

MOA: blocks effect of NE on the heart

Dosing: patient must be asymptomatic, stable, and dry (negative inotropic effects), titrate up, double every 2 weeks, even if HR is <70bpm if symptomatic

When to use: AHA/ACC Stage B or higher, NYHA Functional Class 1 or higher

Benefits: decreased mortality, slows ventricular remodeling

Monitor: HR, BP, signs of congestion, dizziness

C/I: cardiogenic shock, 2nd/3rd degree heart block, severe reactive airway disease (asthma, active bronchospasm)

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5
Q

What are the starting doses of B-Adrenergic Blockers for HF? (3 drugs)

A
  1. Metoprolol succinate (12.5 - 25mg QD) to target dose of 200mg QD
  2. Carvedilol (3.125 mg BID) to 25mg BID if patient is less than 85 kg and 50mg BID if 85 or above
  3. Bisoprolol (1.25mg QD) to a target dose of 10mg QD
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6
Q 
ACE-I
MOA: 
Dosing: 
When to use:
Benefits 
Monitor (3)
C/I (3)
A

MOA: reduces production of angiotensin II and aldosterone which reduces pre and after load, increases bradykinins which increases vasodilatory prostaglandins

Dosing: start low and titrate every 2 weeks to max tolerated dose

When to use: AHA/ACC Stage B or above, NYHA Functional Class 1 or above

Benefit: decreased mortality, prevents ventricular remodeling, *improves functional class

Monitor: 2 weeks after initiation and dose increase: SrCr, K+, BP, cough, angioedema

C/I: hx of angioedema, current hyperkalemia (K is above 5), pregnancy

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7
Q

What are the starting doses for ACE-I?

A

Captopril, Enalapril, Lisinopril, Ramipril

Lisinopril (2.5-5mg QD) to target dose of 20-40 mg QD

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8
Q 
ARBs
MOA
Dosing
When to use
Benefits 
Monitor (3)
C/I (3)
A

MOA: inhibits effects of angiotensin II (decreases afterload and preload)

Dosing: start low and titrated every 1-2 weeks to target dose

When to use: AHA/ACC Stage B or above if can’t tolerate ARB, NYHA Functional Class 1 or above if can’t tolerate ARB

Benefits: decreases mortality in patients not taking ACE-I, improves exercise tolerance

Monitor: 2 weeks after initiation and dose increase: SrCl, K+, BP
C/I: Hx of angioedema, hyperkalemia, pregnancy

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9
Q

What are the 3 ARBs used for HF?

Doses and target doses?

A
  1. Losartan (25-50mg QD) to target dose of 150mg QD
  2. Valsartan (40mg BID) to target dose of 160mg BID
  3. Candesartan (4-8mg QD) to 32mg QD
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10
Q

When are you able to use ARBS over ACE-I? (2)

A

When the patient has:
1. angioedema
2. cough
from an ACE-I, you can use ARB.

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11
Q

How do you know to add an ACE-I/ARB or BB first?

A
  1. ACE/ARB: better when patient is “wet”
  2. BB: better when patient is “dry” DO NOT START WITH SIGNS OF DECOMPENSATION (SOB, DIZZINESS, PALPITATIONS, FLUID OVERLOAD)
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12
Q

What is the treatment algorithm for stage C patients with Class II-IV HF?

A

ARNI is preferred over an ACE-I or ARB.
Add loop for volume overload.

If NYHA Class II or above:

  • CrCl is less than 30 or K is less than 5: add MRA
  • Adequate drug-specific eGFR: Add SGLT2 inhibitor
  • HR 70 or above on max BB: add ivabradine (NYHA class II-III)
  • Intolerance to ACE-I or ARB: switch to ISDN/Hyd

If NYHA class III or above: black ancestry > add ISDN/Hyd

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13
Q

What is Entresto?

MOA
Indication
Benefits
Dose 
C/I (5)
Monitoring (5)
A

Sacubitril/Valsartan

MOA: inhibits neprilysin to increase peptides to specifically natriuretic peptide, no increase in NT-proBNP

Indication: Stage C or above, NYHA II-IV, use instead of ACE-I or ARB

Benefits: decreased mortality, less cough AE, but higher risk of hypotension than ACE-I, make sure patient is NOT volume depleted when initiation, dec. loop diuretic

Dose: Target dose of 97/103 BID

C.I: within 36 hours of ACE-I use, hx of angioedema, pregnancy, use of aliskiren in DM, hepatic renal impairment (Child-Pugh C)

Monitoring: BP (volume depletion SBP is <100 mmHg), SCr, K+, angioedema, cough

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14
Q

Do loop diuretics have an effect on mortality?

A

No, use in patients with fluid retention to decrease sx, pulmonary congestion/JVD> edema, and improve cardiac function and exercise tolerance and ADLs

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15
Q

What are the doses for the 3 loop diuretics used in HF?

A

Furosemide (20-40mg QD or BID) to target dose of 600mg QD
Bumetanide (0.5-1mg QD or BID) to target dose of 10mg QD
Torsemide (10-20mg QD) to target dose of 200mg QD

Furosemide 40mg > bumetanide 1mg > torsemide 20mg

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16
Q

What are the goals of loop diuretics in HF?

A

Decrease volume. Titrate to achieve dry weight over days to weeks:

  • 1-2 lbs of weight loss per day
  • in an acute exacerbation: goal is to be 1L negative
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17
Q

What should you monitor for loop diuretics?

A

CHF symptom relief, fluid retention, SCr, electrolytes, daily weight, signs of volume depletion (hypotension, dizziness, decreased urine output, increased BUN/SCr)

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18
Q

How do you convert loop diuretics from PO to IV?

A

IV to PO Conversion: 1:2

Patient takes 20mg furosemide at home.
How much should be take at the hospital PO? 40mg
How much should be take if IV? 20mg

Home & IV dosing is the same!

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19
Q 
Thiazides
MOA
Indication
Benefits
Dose 
C/I (5)
Monitoring (4)
A

MOA: inhibits NaCl in distal convoluted tubule leading to decreased sodium and chloride reabsorption, increased diuresis

Indication: Add thiazide, once or twice daily, to loop diuretics in patients with persistent fluid retention despite high dose loop diuretic therapy; chronic use discouraged!

Benefits: volume depletion
Dose: titrate within days or weeks to relieve congestion
C/I: ?
Monitoring: hypokalemia, hyponatremia, volume depletion, worsening renal function

20
Q

What thiazide diuretics can be used in patients with compromised renal function?

A

Metolazone

Indapamide

21
Q

What are the 4 thiazide diuretic doses?

A
  1. Chlorthalidone (12.5-25mg QD) to target dose of 100mg QD
  2. Hydrochlorothiazide (25mg QD) to target dose of 200mg QD
  3. Metolazone (2.5mg QD) to target dose of 20mg QD
  4. Indapamide (2.5mg QD) to target dose of 5mg QD
22
Q 
Aldosterone Antagonists
MOA
Indication
Benefits
Dose 
C/I 
Monitoring
A

MOA: blockers effects of aldosterone in kidneys

Indication: symptomatic stage C, NYHA Class II-IV, K is less than 5, SCR 2.5 or less in males, SCr 2 or less in females

Benefits: reduced mortality

Dose: increase every 2 weeks until maximum tolerated or target dose achieved

Monitoring: SCr and K at baseline, 2-3 after initiation, 1 week after initiation, monthly for 3 months, and then every 3 months [BUN/Scr, gynecomastia)

C/I: Avoid if SCr > 2.5 mg/dL in men and > 2 mg/dL in women (or eGFR <30 mL/min/1.73 m2) or K+ > 5 mEq/L

23
Q

What are the 2 aldosterone antagonists used for HF? Doses & notable facts?

A
  1. Eplerenone (25mg QD) to target dose of 50mg QD
  2. Spironolactone (12.5-25mg QD) to 25-50mg QD

Do not use eplerenone with: verapamil, fluconazole, clarithromycin, ketoconazole

Spironolactone: 30% reduction in all cause mortality
Eplerenone: 37% reduction in CV death

24
Q 
Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors
MOA
Indication
Benefits
Dose 
C/I 
Monitoring/ADR
A

MOA: inhibit glucose reabsorption in proximal tubule via inhibition of SGLT2 cotransporter

Indication: NYHA class II_IV with/w/o diabetes, •eGFR > 30 mL/min/1.73 m2 for Dapagliflozin before initiation
•eGFR > 20 mL/min/1.73 m2 for Empagliflozin before initiation

Benefits: reduced mortality, hospitalizations, preload, afterload, hypertrophy and remodeling

Dose: *Dosing is different for Type 2 Diabetes Mellitus without ASCVD or HF

C/I: type 1 diabetes, known hypersensitivity of drug, lactation, dialysis

Caution: pregnancy, ketoacidosis, AKI

Monitoring/ADR: UTI/Yeast infection, increased thirst/urine output, hypotension, euglycemic DKA, transient decrease of eGFR 2-4 weeks after initiation (~ 4-6 mL/min/1.73 m2 decrease)

25
Q

What are the 2 SGLT2 inhibitors used for HF?

A
  1. Dapagliflozin (Farxiga) starting with 10mg daily to 10mg daily as target
  2. Empagliflozin (Jardiance) starting with 10mg daily with 10mg daily as a target

*Dosing is different for Type 2 Diabetes Mellitus without ASCVD or HF

26
Q

What is Corlanor?

A

Ivabradine

27
Q 
Ivabradine
MOA
Indication
Benefits
Dose 
C/I 
Monitoring
A

MOA: selective inhibitor of the If current (controls spontaneous activity of SA node) prolongs duration of diastole, slows HR

Indication: NYHA II-III, on MAX BB, NSR, HR 70 or over, **LVEF 35%

Benefits: NONE on contractility or BP, lowered hospitalization

Dose: age dependent, if under 75, 5mg BID with meals, if over 75, 2.5 BID with meals, max dose is 7.5mg BID

C/I: HFpEF, angina, hepatic impairment (CP-C), acute decompesated HF, BP <90/50, sick sinus rhythm, SA block, **persistent AFib or Aflutter (paroxymal OK), atrial pacemaker dependence

Monitoring: HTN, HR prior to initiation, increase dose, or decrease dose, BP, EKG

DDI: like everything, cannot use in those with pacemakers set to 60 bpm or above

28
Q

Ivabradine Titration Algorithm

A

Starting: age dependent, if under 75, 5mg BID with meals, if over 75, 2.5 BID with meals, max dose is 7.5mg BID

If HR over 60, increase dose by 2.5mg BID
If HR 50-60, continue current dose
If HR under 50bpm or s/x of bradycardia: decrease by 2.5mg BID or d/c if that’s the dose already

MAX DOSE: 7.5mg BID

29
Q 
Hyralazine/Isosorbide
MOA
Indication
Benefits
Dose 
C/I 
Monitoring
SE
A

MOA: hydralazine (vasodilation of arterioles, decreasing afterload), isosorbide (stimulates NO leading to vasodilation, decreasing preload)

Indication: NYHA III-IV (BiDil so not class 2), African Americans with s/x despite ARNI, BB< aldosterone antagonist, SGLT2-I

Benefits: decreased mortality in African American patients

Dose: titrate up to max tolerable target dose every 2 weeks

C/I

Monitoring: HR and BP

SE:
H: HA, GI upset, flushing, SLE (lupus) sx
I: HA,. orthostasis, hypotension

30
Q

Hydralazine/Isosorbide Dosing

A

Hydrazaline (25mg TID) to target of 75mg TID
Isosorbide (20mg TID) to target 40mg TID
Fixed combo (37.5mg/20mg TID) to 75/40mg TID***

  • Because of compliance, try using long acting, once-daily isosorbide mononitrate
31
Q 
Digoxin
MOA
Indication
Benefits
Dose 
C/I 
Monitoring (3) w/ 1 important thang 
SE
A

MOA: inhibits Na+/K+ ATPase pump on cardiac cells, A.Fib(rate control), HF(increased contractility)

Indication: HFrEF to control rate in those with low BP

Benefits: reduces hospitalizations, NO EFFECT ON MORTALITY

Dose: 0.125* to 0.25mg QD, lower is better for those over 70 or those with impaired renal function or low lean body mass, can dose every other day; no loading dose for HF

C/I:

Monitoring: BUN/SCr, K+ and Mg+, Digoxin levels - **target in HF 0.5-1ng/mL

IMP: trough – must wait until steady state is reached after 5-7 days, must wait until distribution phase is reached 8 hours after PO dose administered

SE: digoxin toxicity, cardiac 1, 2, 3, AV block, atrial tachycardia, fibrillation, ventricular arrhythmias, sinus bradycardia

32
Q

What DDI would you decrease the dose of digoxin?

Increase?

A

D: amiodarone, erythromycin, ketoconazole, spironolactone, verapamil, quinidine

not diuretics though

I: antacids, cholestyramine

33
Q

What is the BP goal of HFrEF and HFpEF?

A

<130/80

34
Q

What drugs do you use for HFpEF?

A

ACE-I (improves NYHA class), ARB, digoxin, BB, non-dhp CCB

Aldosterone receptor antagonists: with EF 45% or above, elevated BNP levels or HD readmission within 1 year

ARNI: maybe EF with 40-57%

No to: PDE-5i/nitrates

35
Q

What are some ways to manage HF nonpharmacologically?

A
  1. Lose weight, encourage smoking cessation, minimize alcohol
  2. Limit Na to 1.5-2g/day
  3. Restrict fluid intake (daily weight monitoring, contact provider if experiencing 2-3lbs weight gain within 24 hours or 5lbs in 1 week)
36
Q

What are the pharmacotherapy options for acute decompensated HF?

A

Loop diuretics, vasodilators, inotropes

Loop diuretics are first line and given IV, if you’re still congested increase dose, add second diuretic or add metolazone 2.5-5mg PO daily (preferred in compromised renal function)

37
Q

What is the first line of tx for acute decompensated HF? What do you do when they don’t work?

A

Loop diuretics are first line and given IV, if you’re still congested,

  1. Na+ and fluid restriction
  2. Increase dose (2x) vs frequency
  3. Add second diuretic (thiazide) HCTZ 12.5-25mg po QD NOT IF CRCL IS <30mL/min
  4. metolazone 2.5-5mg PO daily (preferred in compromised renal function)
  5. Continuous infusion of loop diuretic
38
Q

When do you use vasodilators in acute decompensated HF? Benefits?

A
  • in absence of hypotension, addo-on tx, good for HTN or pulmonary edema

Benefits: no effect on hospitalization or mortality

Caution: increased monitoring due to HFpEF being more volume sensitive

39
Q

What are the vasodilators used for acute decompensated HF?

MOA, effects, indications, dosing, elimination, AE

A

IV nitroglycerin:
MOA: mimics nitric oxide stimulation of GC and production of cGMP

Effects: venous > arterial vasodilator
Indication: tolerance issue
Dosing: 5 mcg/min, up by 5 every 5 min to 200mcg/min
Elimination: inactive excreted in urine
AE: hypotension, reflex tachycardia, HA, tachyphylaxis within 24 hours

Na+ Nitroprusside:
MOA: nitric oxide mediated conversion of GTP to cGMP
Effects: balanced arterial and venous vasodilation
Indication: warm and wet
Dosing: 0.3-0.5 mcg/kg/min IV up 0.5 to 3 mcg/kg
Elimination: cyanide: hepatic, thiocyanate: renal
AE: hypotension, cyanide or thiocyanate toxicity

40
Q

What is the classification algorithm for acute decompensated HF?

A

Cl: 2.2

  • if above: warm
  • if below: cold

PCWP: 18

  • if above: wet
  • if below: dry
41
Q 
Inotropes 
MOA
When to use: cold and wet or cold and dry (only if PCWP > 15mm Hg)
Effects
Indications
Dosing 
Elimination
AE
Comments
A

Dobutamine
MOA: b1-agonist, converts ATP to cAMP to increase CO
Effects: inotropic and chronotropic
Dosing: 2-40 mcg/kg/min IV, may titrate to max 40 mcg/kg/min
Elimination: hepatic and renal
AE: proarrhythmic, tachycardia, ischemia, mortality with long term use
Comments: use if hypotensive

Milrinone
MOA: PDE-I, inhibits cAMP breakdown to increase CO in vascular smooth muscle to decrease SVR
Effects: inotropic and lusitropic, NO chronotropic
Dosing: 50 mcg/kg IV, then 0.375 mcg/kg/min IV, may titrate to max 0.75 mcg/kg/min
Elimination: 90% renal
AE: “ “
Comments: suggested if receiving beta blocker

42
Q

Treatment algorithm for dry and warm subset 1?

A

Maximize oral therapy by increasing dosing

43
Q

Treatment algorithm for wet and warm subset 2?

A

Primarily, no inotropes

  1. loops first line, if c/i: add thiazides
  2. add vasodilator or loop for rapid improvement if HTN
  3. may consider inotropes

Do not enhance diuresis too much

44
Q

Treatment algorithm for dry and cold subset 3?

A

Primary goal
Let PCWP and systolic blood pressure help guide decision
1) If PCWP is < 15 mm Hg, must give IV fluids to initially optimize CO
by assuring adequate filling pressures
2) If PCWP is > 15, assess systolic blood pressure
• If SBP < 90 mm Hg, consider IV inotropes
• If SBP > 90 mm Hg, consider IV vasodilator

45
Q

Treatment algorithm for wet and cold?

A

Primary goals

1) Therapy typically involves combination therapy
2) IV diuretics + vasodilator + inotrope
3) Requires careful monitoring

46
Q

What monitoring criteria do you follow with HF?

A

Weight, fluid intake/output, vital signs, edema, JVD, cough, electrolytes (Na, K, Mg), renal function (BUN, SCr)

47
Q

What are the discharge criteria for all HF patients?

A

To be addressed with all HF patients

  • Address exacerbating factors
  • Achieve near-optimal volume status
  • Transition from IV to PO diuretics
  • Provide patient and family education
  • Near-optimal pharmacologic therapy achieved
  • Follow-up clinic visit scheduled in 7 – 10 days
For recurrent administrations
- Oral medication regimen stable for 24
hours
- No IV vasodilator or inotropic agent for
24 hours
- Ambulation before discharge to assess
functional capacity
- Plans for post-discharge management

Cardiopulm II E1 (3 decks)

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