HF pt 2 Flashcards
sowinski 38 - 66 (background of therapy + diuretics)
what are the goals of therapy for Asymptomatic rEF and HFrEF?
- slow disease progression
- reduce symptoms, improve QOL, and prevent/reduce hospitalization and need for emergency care
- reduce mortality
what are general measures HF pts can take?
treat underlying cause (HTN, CAD, DM)
remove precipitating causes (excessive fluid, inappropriate drug tx)
exercise
how can a HF pt exercise?
encouragement of regular exercising like walking and cycling in stable HF
dynamic exercise to increase HR to 60-80% of maximum for 20-60 minutes 3-5 times/week
how should sodium be limited in HF?
2-3g/day if possible
avoid salty food and salt at table
if severe, under 2g/day
how should alcohol be limited in HF?
pt with EtOh induced HF should abstain totally from it
2 drinks/day if male, 1 drink/day if female
how should fluid intake be limited in HF?
restrict to under 2L/day in pts with hyponatremia
tx with diuretics if difficult in maintaining fluid volume
what are some other general measures to take for HF?
weight monitoring
general education of pts and families
smoking cessation
immunization
monitor and replace electrolytes (esp. K/Mg)
appropriate thyroid dz management
what are the educational points for pts and families?
non-drug and drug therapies
symptoms of worsening HF like weight and changes
prognosis
what drugs therapies reduce intravascular volume/preload?
diuretics
SGLT2i
what drugs increase myocardial contractility?
positive inotropes
what drus decrease ventricular afterload?
ACEi
vasodilators
SGLT2i
what drugs make up a neurohormonal blockade?
ARNIs
BB
ACEi/ARBs
MRAs
SGLT2i
how should stage A be treated?
if atherosclerotic vascular disease is present, then ACEi/ARB
how should Stage B be treated?
if previous MI or asymptomatic rEF, then ACEi/ARB and BB
how should stage C be treated?
ARNI (ACEi/ARB if not tolerated)
BB
MRA
SGLT2i
Loop diuretics prn for excessive fluid
what pt population favors the usage of hydral-nitrates?
AA with NYHA III-IV, Stage C, and persistently symptomatic on GDMT
what pt population favors the usage of ivabradine?
stage C and NYHA class II-III if persistently symptomatic
needs to have normal sinus rhythm and HR over 70 bpm on maximally tolerated BB dose
what pts should be on diuretics?
all HF pts with s/sx of fluid retention
why should diuretics be used?
reduce hospitalization and symptoms associated with fluid overload
improve exercise tolerance and QOL
what are short-term benefits of diuretics?
reduce fluid retention via decreased edema, pulmonary congestion, and JVD by reducing preload and cardiac filling pressure
what are the long term benefits of diuretics?
reduce daily symptoms and improve ability to exercise
why are loop diuretics prefered in HF?
block Na and Cl reabsorption in the ascending limb of LOH
enhance renal release of prostaglandins
why is it good that loop diuretics enhance renal release?
increases renal blood flow which enhances venous capacitance (amount of blood in renal veins at a certain pressure)
what loop diuretic is first-line?
furosemide due to be cheap, having good dosgae forms, and doctors being comfortable with use
what is the main drawback of furosemide?
erratic bioavailability (10-90%) –> switching to torsemide may be an advantage
what is the dosing of furosemide?
initial: 20-40mg QD or BID
usual: 20-160 mg QD or BID
what is the dosing of bumetanide?
initial: 0.5-1mg QD/BID
usual: 1-2mg QD/BID
what is the dosing of torsemide?
initial: 10-20mg QD
usual: 10-90mg QD
what is the equivalence of oral furosemide to other diuretics?
40 mg = B 1 mg = T 20 mg = E 50 mg
what is the equivalence of IV furosemide to other diuretics?
20 mg = B 1mg = T X = E 1mg
why are thiazides diuretics not prefered?
relative weak at blocking Na/Cl reabsorption in the DCT
lose effectiveness as renal function decreases (higher doses needed if eGFR under 30)
what pt populations may benefit from thiazide diuretics?
mild HF and small amounts of fluid retention
anything else –> use loop
what is unique about matolazone (MTZ)?
erratically absorbed and has a longer half life
can be used in combination with a loop diuretic in pts who become resistant to single-drug (same thing with HCTZ)
what is the dosing of HCTZ (esidrix, hydrodiuril)?
initial: 25 mg/day
max: 100 mg/day
what is the dosing of MTZ (mykrox, zaroxolyn)?
initial: 2.5 mg/day
max: 10 mg/day
what is the dosing of chlorthalidone?
initial: 12.5-25 mg/day
max: 50 mg/day
what is the dosing of CTZ?
initial: 250-500 mg/day IV
max: 2000 mg/day IV
what is the dosing of indapamide?
initial: 2.5 mg/day
max: 5 mg/day
what are the major adverse effects of diuretics?
decreased Mg, K, Na
decrease renal function, volume depletion, pre-renal azotemia
increased uric acid
Ca increases with THZ and decreases with loops
how should loop diuretics be initiated?
initiate at low-doses then double and titrate
adjustments based on weights and symptoms
how should weight be monitored with diuretics?
report if there is weight gain of 3-5 pounds/week
pt should try and reduce weight by 1-2 lbs/day if fluid overload
what factors are indicative of volume depletion while on loop diuretics?
hypotension
increased Se Cr or BUN/Cr ratio
when is monitoring required in diuretics?
1-2 weeks after initiation and at every increase of dose
what should be monitored in diuretic therapy?
fluid intake and urinary output; body weight; signs of congestion/JVD
BP, serum electrolytes, and renal function
when should K and Mg be supplemented during diuretics?
if K is under 4 or Mg is under 2
what stages required a diuretic?
B - maybe thiazide for HTN
C - yes, at lowest possible dose to keep euvolemic
