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830 > HF Pharmaco > Flashcards

HF Pharmaco Flashcards

1
Q

Guideline Classes + Recommendations

A
  • Class I: Benefit&raquo_space;> Risk, SHOULD use treatment/procedure
  • Class IIa: Benefit&raquo_space; Risk, REASONABLE to perform procedure/treatment
  • Class IIb: Benefit >= Risk, MAY CONSIDER treatment/procedure
  • Class III: not shown to have any proven benefit, may cause harm or have excessive cost with no worthwhile benefit, DON’T USE/PERFORM
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2
Q

Guideline Levels + Recommendations

A
  • Level A: multiple RCT or meta-analyses
  • Level B: data derived from single RCT or nonrandomized studies
  • Level C: consensus opinion of experts was primary source of recommendation or case studies
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3
Q

Conditions to Treat + HF

A
  • HTN and lipid disorders should be controlled according to contemporary guidelines to reduce HF risk too (1/A)
  • DM, obesity, tobacco use, and other cardiotoxic agents should also be controlled since they may contribute to HF (1/C)
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4
Q

Patient Assessment: EVERY Visit

A
  • NYHA Functional capacity/activity level
  • Changes in body weight
  • Volume status: edema, JVD, HJR, hepatomegaly, swelling, bloating, dyspnea, DOE, orthopnea, PND
  • Vital signs
  • History of substance/drug use
  • Diet/sodium intake
  • Review of medical history
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5
Q

Patient Assessment: Diagnostic Tests

A
  • Initial labs/tests: CBC, serum electrolytes, BUN, SCr, glucose, fasting lipis, liver fxn tests, and TSH, 12-lead ECG, Chest x-ray, ECHO
  • Serial monitoring: serum electrolytes and renal fxn when indicated, ECHO for those with change in status or to determine level or response/eligibility for therapy/transplant
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6
Q

Patient Assessment: BNP

A
  • Useful to rule out HF as a cause of dyspnea
  • BNP < 100 pg/mL
  • NT-proBNP < 300 pg/mL
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7
Q

Patient Education

A

Provide education on the following:

  • Activity level
  • Diet
  • Discharge medications
  • Follow-up appointments
  • Weight monitoring
  • What to do if symptoms worsen
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8
Q

Weight Monitoring

A
  • Make sure they all have a scale
  • Instruct patient to weigh in the morning after first void
  • Scale is on hard surface
  • Patient should call provider if weight increases by 2lbs/day or 5 lbs/week
  • Weight gain has been connected to hospital admission
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9
Q

Sodium Restriction

A
  • Necessary in those with current or prior HF symptoms
  • Stages A/B: <1500 mg/day
  • Stages C/D: No more than 3000 mg/day
  • *Caution with salt substitutes and potassium sparing medications**
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10
Q

Activity Level and Life Habits

A
  • Exercise training to help improve functional status
  • Encourage cardiac rehabilitiation: reduces mortality, improves NYHA-FC, QOL, and more
  • Encourage weight loss if overweight/obese
  • Tobacco cessation
  • Avoid alcohol
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11
Q

Worsening Symptoms

A
  • Contact provider if worsening/new symptoms of: dyspnea, orhtopnea, DOE, PND, chest pain/pressure, dizziness, syncope, swelling, or weight gain
  • Contact for the weight gain previously defined too
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12
Q

HF Treatment Goals

A
  • Improve signs/symptoms: decrease SOB, weight, BNP levels, edema and improve exercise tolerance/functional class
  • Decrease morbidity: prevent hospitalizations and ER visits
  • Decrease mortality
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13
Q

Diuretics

A

-Recommended in HFrEF patients with evidence of fluid retention

Examples

  • Loop: Bumetanide, Furosemide, Torsemide
  • Thiazide: Chlorothiazide, Chlorthalizonde, Hydrochlorothiazide, Indapamide, Metolazone
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14
Q

Diuretic Effects

A
  • Decrease preload
  • Thiazide: good for eGFR > 30, work on distal tubule
  • Loop diuretics: ascending loop of henle, QD or BID
  • Resistance: use sequential nephron blockade (Loop + Thiazide)
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15
Q

Diuretic Monitoring

A
  • Goal: euvolemia

- Monitor electrolytes, renal fxn, BP, weight, urinary response, and symptoms in first 1-2 weeks

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16
Q

Diuretic Adjustments/Limits

A
  • Titrate dose until urine output increases and weight decreases (0.5-1 kg/daily)
  • May need to up to BID for reboudn fluid retention
  • K+: 4-5 mEQ/L
  • Supplement Mg++ if it drops below 1.6
  • Back down dose if having symptomatic hypotension or azotemia (BUN/SCr > 20)
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17
Q

ACE Use

A

Beneficial for all patients with prior or current symptoms of chronic HFrEF to reduce morbidity/mortality

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18
Q

ACE Monitoring

A
  • BP, BUN/SCr, electrolytes
  • Follow-up in 1-2 weeks on same labs and HF symptoms
  • Half initial dose if SBP < 100, SCR > 2, or Na+ < 130
  • Try to achieve target dose but not at expense of BB therapy
  • Avoid NSAIDs and recommend low-dose ASA if necessary (<160 mg)
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19
Q

ACE-I AE

A
  • Cough
  • Angioedema
  • AKI
20
Q

ARB Recommendation

A

Reduce mortality/morbidity in patients with prior/current symptoms of HFrED who are intolerant to ACE-I due to cough/angioedema

21
Q

ARB Monitoring

A
  • Precautions: renal impairment, hyperkalemia, hypotension, angioedema
  • Monitoring is same as ACE-I
22
Q

ACE-I/ARBs used for HF

A

ACE-I

  • Captopril**
  • Enalapril**
  • Fosinopril
  • Lisinopril**
  • Perindopril
  • Quinapril
  • Ramipril**
  • Trandolapril**

ARBs

  • Candesartan
  • Losartan
  • Valsartan
23
Q

BB Recommendations

A

Shown to reduce mortality in all stable patients

Worsen EF first, then improvement

24
Q

BB for HF

A
  • Bisoprolol
  • Cardvedilol (CR or not)
  • Metoprolol Succinate ER
25
Q

BB CI

A
  • Allergies
  • Reactive airway disease (Asthma)
  • Symptomatic bradycardia or >1st degree heart block unless they have a pacemaker
  • Evidence of fluid overload or recent requirement for IV inotropic agents
26
Q

BB Monitoring

A
  • 2 week follow up to assess tolerability
  • Monitor HR, BP, weight, volume status, and HF symptoms
  • Hold titration if symptomatic hypotension or bradycardia or if experiencing worsening symptoms
27
Q

BB AE

A
  • Fluid retention/worsening HF (diuretic adjustments)
  • Fatigue
  • Bradycardia and heart block (decrease dose)
  • Hypotension (separate or decrease ACE)
28
Q

Aldosterone Angtagonist Recommendations

A
  • Recommended for NYHA II-IV with LVEF =< 35%
  • Recommended following an acute MI with LVEF =< 40% wtih symptoms of HF or DM
  • Examples: Spironolactone, Eplerenone
29
Q

ARA AE

A

-Hyperkalemia: avoid NSAIDs/COX-II Inhibitors, D/C reduce K+ supplements, closely monitor

30
Q

ARA Dosing

A

ONLY USE IF

  • SCr =< 2.5 mg/dL in men or 2.0 in women
  • K+ < 5
  • eGFR >= 30
31
Q

ARA Monitoring

A

-K+ and renal fxn at 3 days, 1 week, monthly for first three months, then every 3 months from then on

32
Q

ARNI

A
  • Neprilysin is an endopeptidase that breaks down vasoactive peptides like BNP, bradykinin, and adrenomedullin
  • Entresto: Sacrubitril (neprilysin inhibitor) + Valsartan
  • Recommended for NYHA II/III patients who tolerate an ACE-I or ARB
33
Q

ARNI AE

A
  • More symptomatic hypotension
  • Angioedema
  • Start on low dose and titrate as tolerable to avoid AE
  • Decrease dosage of loop diuretics
34
Q

ARNI Dosing

A

-D/C ACE at least 36 hours prior to starting ARNI

Dosing based on ACE/ARB

  • E/L > 10 or R > 5: start at 100 mg BID
  • E/L =< 10 or R =< 5: start at 50 mg BID
  • If no previous ACE/ARB or eGFR < 30, start at 50 mg BID
  • Titrate every 2-4 weeks up to 200 mg BID (target dose)
35
Q

Hydralazines/Nitrates

A
  • Recommended for black, NYHA III/IV patients

- Can combine the two if the paitent cannot be given an ACE-I/ARB

36
Q

Hydralazine/Nitrates AE/Monitoring

A

Monitoring

  • Recommend follow-up in 1-2 weeks and with each dose increase to check BP/HR
  • AE: HA, dizziness, hypotension
37
Q

Ivabradine Recommendation

A

-Recommended to reduce hospitalization in those with symptomatic, stable chronic HFrEF who have a stable rhythm and resting HR >= 70

38
Q

Ivabradine Dosing

A
  • 5 mg BID or 2.5 mg BID in those who are hemodynamically compromised due to bradycardia
  • After 2 weeks, adjust dose to achieve HR between 50-60
  • Max: 7.5 mg BID
39
Q

Ivabradine AE

A
  • Bradycardia
  • Luminous phenomena
  • Atrial fibrillation
40
Q

Ivabradine Monitoring

A
  • Follow up in 2 weeks to check resting HR

- Avoid with CYP3A4 inhibitors, grapefruit juice, avoid St. John’s Wort (inducer)

41
Q

Ivabradine Counseling

A
  • Avoid while pregnant
  • Counsel about luminous phenomena
  • Tell to contact provider for racing HR or palpitations
  • Take with food
42
Q

Digoxin Hemodynamic Effects

A
  • Increased CO
  • Decreased PCWP
  • Increased LVEF
43
Q

Digoxin Neurohormonal Effects

A
  • Vagomimetic action
  • Improved baroreceptor sensitivity
  • Decreased norepinephrine serum concentration
  • Decreased activation of renin-angiotensin system
  • Direct sympathoinhibitory effect
  • Increased sympathetic CNS outflow at high doses
  • Decreased cytokine concentrations
  • Increased release of ANP and BNP
44
Q

Digoxin Electrophysiological Effects

A
  • SA node slowing of sinus rate
  • Slowed conduction of AV node
  • Possible decreased refractory period in atrium
45
Q

Digoxin Monitoring

A
  • SDC levels at initiation and if suspecting digoxin toxicity, suspecting nonadherence, or conditions that would alter SDC and predispose to toxicity
  • Draw at trough (>6 hours for oral, >4 for IV)
  • Ideal SDC: 0.5-0.9
  • Interactions: Amiodarone/Quinidine, Dilt., Verapamil, antibiotics, azole antifungals, propafenone
46
Q

Omega-3 Recommendation

A

-Reasonable as an adjunctive therapy in patients with NYHA II-IV and HFrEF OR HFpEF unless otherwise CI

47
Q

HFrEF Summary

A
  • ACE in all patients unless intolerant, then ARB
  • BB for all patients
  • ADA for NYHA II-IV patients given they meet requirements
  • ARNIs with LVEF < 40%, NYHA II/III, and on ACE/ARB and a BB
  • ISDN/Hydralazine for those intolerant to ACEI/ARB or if black and NYHA III/IV
  • Omega-3 (1000 mg combined EPA/DHA/day)
  • Ivabradine if on all others mentioned above, NYHA II/III, LVEF =< 35%, normal sinus rhythm, and HR > 70
  • Digoxin for symptomatic patients on optimal therapy

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