HF & PAD/DVT Flashcards
Population among which a diagnosis of diastolic HF is now fairly common
older women
Furosemide & Hydrochlorothiazide cause this type of HSN rxn
sulfa HSN rxn
This type of discontinuation of carvedilol can trigger rebound angina or MI
abrupt
Loop diuretic w/ longer 1/2 life & better oral absorption than furosemide
Torsemide
Type of deadly pulmonary edema w/ sudden increase in LA pressure caused by ischemia in pt w/ HFpEF
flash pulmonary edema
Major concern w/ use of digoxin w/ K+ losing diuretics
digoxin toxicity
Tx for digoxin toxicity
lidocaine & anti-digitalis ABs
Type of overload due to aortic stenosis or chronic HTN
pressure overload
changes in heart due to pressure overload
concentric hypertrophy (parallel addition of new myofibrils)
Antidote for too much heparin
protamine
challenge w/ heparin & warfarin that requires frequent monitoring thru coagulation tests
highly variable plasma levels
What is milrinone?
PDE3 inhibitor that increases cAMP in heart & BVs to increase contractility & vasodilation (may decrease survival if used w/ sympathomimetic drugs)
What are contraindicated in HF b/c impair of salt & H2O excretion?
NSAIDs (worsen HF sxs)
What dz is contraindication for use of carvedilol in HF pts?
bronchospastic dz
Type of overload due to valvular regurgitation
volume overload
changes seen in heart in volume overload
eccentric hypertrophy due to addition of sarcomeres in series
What is dabigatran?
orally active & reversible direct inhibitor of thrombin
Dietary rec for HF pts
<3g of salt per day
Digoxin decreases what tone due to decrease in CO?
decreases sympathetic tone (lowers HR, inootropy & peripheral vascular resistance)
What is HFpERF?
diastolic HF where EF is preserved
due to smaller ventricular vol & poor filling
What is bivalirudin?
synthetic peptide similar to hirudin
direct inhibitor of thrombin but limited use b/c only used IV & v expensive
What should be greater than 60 before digoxin is administered?
Heart Rate
What is enoxaparin?
low molec weight heparin
binds to anti thrombin to inhibit factor Xa but unable to form ternary complex to inhibit thrombin
What is the antidote for dabigatran?
Idarucizumab
What are cardiac glycosides that were previously used for HF & now only used in systolic HF w/ low EF?
digitalis (aka digoxin)
What is vitamin K needed for?
synthesis of biologically active clotting factors II, VII, IX, X & protein C & S
What is an antidote for warfarin?
vitamin K
What is the MOA of aspirin?
irreversibly blocks synthesis of thromboxane A2 by platelets (which promotes activation & aggregation of platelets if pts w/ PAD)
What are added to loop diuretics if they alone are insufficient to eliminate edema of HF?
thiazides
What is a well known toxicity of loop diuretics?
ototoxicity
What is the primary reason pts stop taking ACEi to control BP?
COUGH
sign of CHF
What is alteplase?
glycoprotein that is identical to aa sequence to human tPA
can be injected directly into large peripheral blood clots that are obstructing flow
What is the advantage of dabigatran & rivaroxaban in comparison to warfarin?
rapid onset
What is a contraindication for aliskiren, ACEi & ARB?
pregnancy
What is digoxin used for in pregnancy?
safe tx of supraventricular arrythmias
Which CCBs cause arterial vasodilation and used in HF?
amlodipine
felodipine
Which CCBs are contraindicated in HF?
verapamil
dilitazem
What is a critical component of HF therapy?
DIURETICS to eliminate fluid causing congestion in acute decompensated HF
prevent accumulation of fluid in stable HF
decrease blood vol to keep blood from overfilling
What drug suppresses platelet aggregation by irreversible blocking P2Y12 receptors?
clopidogrel
What increases the incidence & prevalence of HF?
age
What is the main focus of heart failure therapy?
blocking vicious cycle of remodeling
What is an antidote for factor Xa inhibitors like rivaroxaban & apixaban?
andexanet alfa
What is sacubitril?
neutral endopeptidase inhibitor that prolongs 1/2 life of BNP
marketed in combo w/ valsartan to tx HF
What is a class III anti-arrythmic drug used to tx arrhythmias in HF pts?
amiodarone
What metabolizes the more potent S warfarin to more potent form?
CYP2C9
What must a pt be to administer carvedilol w/ symptomatic CHF & EF<40?
clinically stable (to prolong survival)
What is systolic HF?
HF w/ reduced EF that manifests as progressive chamber dilation w/ eccentric remodeling
What is used as a diagnostic marker for HF in pts taking sacubitril?
BNP
What is seen in dixogin toxicity on ECG?
bigeminy (ectopic beat alternating w/ normal beat)
What is used to assess anticoagulation caused by dabigatran?
diluted thrombin time
What is a potential adverse effect of spironolactone use in females?
hirsutism
What is always a concern when anti platelet or anti coagulant drugs are administered?
bleeding
Why are Blacks more resistant to warfarin & Asians more sensitive to it?
genetic availability of VKORC1
What is used to monitor anticoagulant activity of heparin?
aPPT
What is an indication for rivaroxaban or dabigatran?
non-valvular atrial fibrillation
Why can fondaparinux & low molec heparins be self administered at home?
b/c have predictable pharmacokinetics
What are signs of digoxin toxicity?
yellowish green halos in eyes
also anorexia, N/V, salivation
Which drugs to tx HF did not show prolongation of life?
cardiac glycosides (digitalis)
What is a prototype of ARBs that is now available as a generic drug?
losartan
What is dobutamine?
synthetic catecholamine that selectively activates B1 receptors
preferred for symptomatic hypoTN or hypoperfusion even if have optimal cardiac filling pressure w/ low CO
What type of heart valve does dabigatran NOT decrease risk of thromboembolism for?
mechanical heart valve
Which receptor does digoxin compete w/ K+ for binding?
Na/K ATPase
why must keep K+ levels in normal range
What is the MOA of warfarin?
slow onset anticoagulation effects by blocking conversion of vit K epoxide to active reduced form
depletes active vit K results in inability to produce clotting factors
What is the route of administration for warfarin, dabigatran & rivaroxaban?
ORAL
What is the route of administration for heparin & argatroban?
IV
What is seen in lead II of ECG by therapeutic levels of digoxin?
ST depression
How do deficiencies in clotting factors present?
deep tissue bleeding that forms large subcutaneous & soft tissue hematomas, hemarthroses
may be delayed & oozing after procedures
What is a potentially deadly adverse effect assoc w/ use of ACEi?
angioedema
What is ivabradine?
“funny” current blocker used in HF if sinus rhythm but EF<35% & HR <75 when B blockers are contraindicated or @ max dose of Bblocker
What is a contraindication of carvedilol in HF & digoxin & class II/IV antiarrythmic drugs?
heart block
What is Stage C in HF?
HF & structural dz w/ prior or current sxs
How do you tx Stage C of HF?
w/ ACEi or ARB B blocker Diuretics Aldosterone Antagonist Ivabradine
as necessary to control sxs
What is Stage A of HF?
@ risk for HF but neither structural dz nor sxs
should promote healthy lifestyle, prescribe ACEi or ARB +/- statins to reduce risk
What is HFrEF?
systolic HF when EF is reduced
What is a loop diuretic w/ longer 1/2 and better oral absorption than furosemide?
torsemide
What can cause fall in CO, hypoTN & death in pts on loop diuretics?
super decreased preload
What is the transporter in TAL that is target of loop diuretics?
Na K 2CL
What is argatroban?
IV thrombin inhibitor for prophylaxis & tx of thrombosis in pts w/ or @ great risk for developing HIT
What is commonly seen in platelet defects but uncommon with clotting factor defects?
petechiae
Which alpha/beta blocker initially appeared to work best in HF & L systolic dysfunction post MI?
carvedilol
What is major benefit of carvedilol use?
reduces mortality in HF pts
What is rivaroxaban?
direct inhibitor of activated factor X
rapidly inhibits generation of thrombin from prothrombin
Which drugs require a loading dose due to long 1/2 life?
digoxin & amiodarone
What is angiotensin II and what is its role?
potent vasoconstrictor that causes renal retention of salt & H2O by promoting aldosterone secretion
mitogen for CV remodeling that causes progressive deterioration of CV fxn in HF pts
What is furosemide?
loop diuretic that works when GFR is LOW
important for mobilizing LARGE volumes of fluid that accumulate in HF pts that causes congestion
In what type of bottle must dabigatran be stored?
dessicator (b/c is an unstable drug)
What are ACE inhibitors?
class of drugs that partially correct adverse consequence of chronic HTN on blood vessels & preserve failing HF fxn & prolong life
What is cilostazol & what is it used for?
PDE3 inhibitor used to suppress platelet aggregation & cause peripheral vasodilation
indicated for intermittent claudication
What is heparin & its MOA?
mix of highly negative polysaccharide chains
binds to antithrombin to facilitate its inhibition of factor Xa & INACTIVATES THROMBIN
What is bidil?
a vasodilator combo containing isosorbide dinitrate to dilate veins & hydralazine to dilate arteries in chronic HF
more useful in Black pts who cannot use ACEi or ARB
Does dopamine spare renal function?
no
What is the mechanism of HIT?
platelet Fc receptors bind an IgG bound to heparin & PF4
leads to platelet activation/thrombosis & platelet removal by splenic macrophages
What is the result of increased CO w/ digoxin?
increased urine production
What is a potential adverse effect of spironolactone use by males?
gynecomastia
What is the major pathway for Mg2+ reabsorption in TAL?
paracellular
What is a relative contraindication for alteplase when severe and uncontrolled?
hypertension
What is nitroglycerin and what are its uses?
venous vasodilator used to tx angina
can administer w/ loop diuretic in normotensive to tx acute decompensated HF if heart overfilled & venous pooling of blood until diuretics get kidneys to excrete excess volume
What is Stage D in HF?
@ risk for HF w/ advanced structural dz & sxs @ rest despite max therapy including digoxin
discuss end of life goals & advanced care measures
What is the ending for ACE inhibitors?
“pril”
What was the 1st prototypical ACEi?
captopril
What is metoprolol & its use?
B1 selective blocker w/ ability to prolong life in HF when other txs are ineffective
What can occur with abrupt discontinue of carvedilol?
trigger rebound angina & MI
What is fondaparinux & its MOA?
synthetic pentasaccharide
binds to anti-thrombin & inhibits factor Xa, no effect on thrombin
What color are arterial clots?
WHITE
due to abundance of platelets
What type of drugs are used for white clots?
platelet targeting drugs
Ending for drug names that tells you it is a AT1 blocker
“sartan”
ARBs
What color are venous clots?
RED
due to large fibrin mesh that forms
What is the more selective aldosterone antagonist?
eplerenone
What is significant about overdosage of carvedilol?
prevents sympathetic agents from exerting positive inotropic effects
where milrinone might be of benefit
What mineralocorticoid is secreted by blood vessels adj to MIs that promotes myocardial fibrosis?
aldosterone
What is the alternative drug of first choice for pts @ risk for developing HF?
ARB
What is activated by heparin, LMW hepain & fondaparinux?
anti-thrombin (plasma protein)
Which drugs do NOT require INR monitoring?
dabigatran & rivaroxaban
What is diastolic HF?
EF is preserved but problem is that heart doesn’t fill enough
concentric remodeling w/ sitffness
What is prolonged on ECG by therapeutic levels of digoxin?
PR interval
may result in heart block w/ toxic levels
What serum level of K+ is safe to administer ACEi or ARB to pt w/ HF?
K+ <5.5 mEq/L
What occurs in skin w/ warfarin? Why?
skin necrosis
when rapid fall in protein C leads to hypercoaguable state
What is stage B of HF?
@ risk for HF & structural dz but no sxs
use ACEi or ARB +/- B blocker, defib or revasc to prevent further cardiac remodeling
Why are loop diuretics used in HF?
to reduce edema in lungs in L sided HF & edema in legs & ankles in R sided HF
What do you do when a person w/ chronic HF is already on furosemide & now presents w/ volume expansion edema due to acute decompensation?
GIVE MORE FUROSEMIDE
What is the first choice drug for tx & prevention of DVT?
LMW heparin
What is bivalirudin & its MOA?
synthetic peptide similar to hirudin
direct inhibitor of thrombin
How does metabolic alkalosis occur?
when K+ & Cl- are lost in urine due to diuretics or hyperaldosteronism
cells donate K+ while taking up H+ & leave HCO= in effort to maintain hypokalemic plasma K+ levels closer to normal
What drug class is the 1st line therapy for decreasing risk for PAD?
Statins
What is INR?
normalized prothrombin time
How is INR used?
if <2, increased risk for thromboembolism in pts on warfarin
if >3, higher risk of intracranial hemorrhage in pts on warfarin
What do both heparin & warfarin drugs increase risk for?
hematomas forming in brain, eye or spinal cord
What influences activity of warfarin & mandates regular testing whenever changes made to daily tx regimen?
many drug interactions
What loop diuretic can be used in pts w/ sulfa allergy?
ethacrynic acid
How does the LV change in cardiac remodeling in systolic HF?
changes from V to U shape
increased ventricular capacitance but also has requires increased wall tension to eject blood
