HF pt 3 Flashcards
sowinski pg 67 - 105 (ACEi,ARBs, ARNIs)
what drugs are approved to reduce mortality or mortality/hospitalization in chronic HFrEF?
metoprolol succinate, carvedilol, captopril, enalapril, rampiril, trandolapril, quinapril, fosinopril, lisinopril, candesartan, valsartan, entresto, spironolactone, eplerenone, isosorbide/hydralazine, bisoprolol (not US), farxiga, jardiance
what drugs are approved to reduce hospitalization only in chronic HFrEF?
digoxin
ivabradine
what drugs are approved to improve hemodynamic or physical function in chronic HFrEF?
digoxin
isosorbide/hydralazine
what drugs are used to improve hemodynamic or physical function in AHF?
inotropes
milrinone
sodium nitroprusside
nesiritide
what drugs are approved to improve QOL or symptoms in chronic HFrEF?
digoxin
diuretics
what drugs are approved to improve QOL or symptoms in AHF?
nesiritide
diuretics
what pt population would benefit from ACEi therapy?
benefit in all pts regardless of etiology or severity of disease, must be used in all without CI
additional benefits in IHD, CKD, post-MI, or DM
when bradykinin is prevented from degraded by the use of ACEi, what happens?
increased NE, vasodilation, vessel permeability, and tPA/prostaglandin release
how does a cough develop with ACEi?
ACEi block the degradation of bradykinin which leads to the increase production of tPA/prostaglandin release which is what makes a cough occur
what is the moa of ACEi?
inhibition of angiotensin I converting into angiotensin II
what are the good effects of ACEi?
improved cardiac hemodynamics
reduced aldosterone
decreased endothelin-1
decreased arginine vasopressin
reduced vasoconstriction
reduce Na and water retention
what is the dosing of enalapril (vasotec)?
initial: 2.5-5 mg BID
target: 10 mg BID
what is the dosing of captopril?
initial: 6.25-12.5mg TID
target: 50mg TID
what is the dosing of lisinopril (prinivil, zestril)?
initial: 2.5-5mg QD
target: 20mg QD
what is the dosing of quinapril (accupril)?
initial: 5-10mg BID
target: 20-40mg BID
what is the dosing of ramipril (altace)?
initial: 1.25-2.5mg QD
target: 5mg BID or 10 mg QD
what is the dosing of fosinopril (monopril)?
initial: 5-10 mgQD
target: 40 mg QD
how should ACEi be dosed?
should be titrated to dose that shows reduction in mortality, not by symptoms or BP goal
start low and double dose every 1-4 weeks
how should ACEi be dosed in CKD?
lower doses if CrCl is under 30 mL/min
1/2 of initial and 1/2 target mortality dose
when should titrate of ACEi be cautioned?
if volume depleted and SBP under 80
if K over 5 and SeCr over 3
what are absolute CI of ACEi?
pregnancy or intending to become pregnant
history of angioedema or hypersensitivity
bilateral renal artery stenosis
history of well-documented intolerance due to symptomatic hypotension, decline in renal function, hyperkalemia, or cough
what should be monitored with ACEi/ARBs?
volume status (prior to initiation)
renal function and K
BP
other adverse effects
when should renal function and K be monitored in ACEi/ARBs?
prior to therapy
1-2 weeks after each increase in dose
at 3-6 months intervals
when other treatments are added that may decrease renal function
in pts with hx of renal dysfunction
what is an unacceptable increase in SeCr?
over 30%
what are AE of ACEi/ARBs?
hypotension
functional renal insufficiency
hyperkalemia
skin rash and dysgeusia
cough (ACEi only)
angioedema
how do ARBs differ from ACEi?
no cough because it doesn’t block bradykinin degradation
blocks nonspecific chymas
what is the dosing of losartan (cozaar)?
initial: 25-50mg daily
target: 150 mg daily
what is the dosing valsartan (diovan)?
initial: 20-40 mg BID
target: 160 mg BID
what is the dosing of candesartan (Atacand)?
initial: 4 mg daily
target: 32 mg daily
when should an ARB be used?
unable to take ACEi due to cough
ACEi-induced angioedema
if a pt has persistent Scr or K, does it make sense to switch from an ACEi to an ARB?
no
probably will see same effect
what is moa of an ARNI?
part ARB so blocks the Angiotensin II from activating the AT1-receptor and inducing vasoconstriction
part Neprilysin inhibitor so stops Neprilysin from binding to BNP and blocking vasodilation
what is the AE of ARNIs?
hypotension (more so than enalapril)
elevations in SeCr, SeK (less than enalapril)
angioedema rare
pregnancy
how should entresto be dosed?
based on previous use of ACEi/ARB or other factors
when should the initial dose of 49/51mg BID be used?
pt alr on high dose ACEi or high dose ARB
when should initial dose of 24/26mg BID be used?
pt alr on medium to low dose ACEi/ARB
ACEi/ARB naive
eGFR under 30
moderate hepatic impairment
age over 75 years
what is the equivalence of ACEi?
enalapril 20 = captopril 150 = lisinopril 20
what are the CI of ARNI?
within 36 hours of ACEi use
angioedema with an ACEi or ARB previously
pregnancy
lactation
severe hepatic impairment
concomitant aliskiren use in pt with DM
known hypersensitivity
what are the cautions of ARNI?
renal impairment
hepatic impairment
renal artery stenosis
hypotension
volume depletion
hyponatremia
post MI
in what class is ACEi recommended?
Stage B
Stage C if ARNI use not feasible
in what class is ARB use recommendeD?
Stage B if intolerant to ACEi
Stage C if intolerant to ACEi and ARNI not feasible
reasonable alternative in Stage C if taking an ARB for another indication
in what stage is an ARNI recommended?
Stage C in all pts
what is the monitoring of ARNIs?
BP
electrolytes
renal function
after initiation and during titration
how should ARNIs be titrated?
after 2 weeks of usage, assess tolerability and titrate if possible dose stepwise to target dose of 97/103 mg BID
