HF pt 4 Flashcards
sowinski pg 106-145 (BB, MRA, SGLT2i)
what is the rationale behind BB usage in HF?
decreases ventricular arrythmias
cardiac hypertrophy and cardiac cell death
VC and HR
cardiac remodeling
what pts should receive BB but cautiously?
in pts with bronchospastic disease and asymptomatic bradycardia
while initiating BB in hospitalized pts
what is the dosing of bisoprolol?
initial: 1.25 mg daily
targeT: 10 mg daily
what is the dosing of carvedilol?
initial: 3.125 mg BID
target: 25-50mg BID
when should 25 or 50 mg BID be targeted in carvedilol?
if pt under 85 kg, 25 mg
if pt over 85 kg, 50 mg
what is the dosing of carvedilol CR?
initial: 10 mg daily
target: 80 mg daily
what is the dosing of metoprolol succinate?
initial: 12.5-25 mg daily
target: 200 mg daily
how should BB be titrated?
double the dose every 2 weeks
monitor closely vital signs and symptoms (if get worse, then maybe change diuretic dose instead of BB)
how long after initiation should the target dose be achieved?
aim for in 8-12 weeks or highest dose
what is the conversion between carvedilol and carvedilol CR?
3.125 mg BID = 10 mg QD
6.25 mg BID = 20 mg QD
12.5 mg BID = 40 mg QD
25 mg BID = 80 mg QD
what are the core monitoring parameters of BB?
BP (and symptomatic hypotension)
HR (no goal)
when should a reduction of BB dose be considered?
if pt is on a slow titrate and is experiencing symptomatic hypotension, bradycardia, and dizziness –> reduce dose by 50%
if hypotension only, reduce other drugs like diuretics first
what are other monitoring parameters of BB?
edema and fluid retention
weight
fatigue or weakness
in what stage should BB be recommended?
stage B and stage C unless CI
what is angioedema?
notable swelling of the face, lips, and tongue
when aldosterone is elevated in HF, what does it lead to?
continued sympathetic activation
parasympathetic inhibition
cardiac and vascular remodeling
BAD THINGS
how does selectivity vary in MRAs?
spironolactone is non-selective
eplerenone is selective
what are the main effects of MRAs?
decrease K and Mg losses
decrease sodium retention
decrease sympathetic simulation
block direct fibrotic action on myocardium
why is it important that MRAs decrease K/Mg losses?
may protect against arrhythmias
why is it important MRAs decrease Na retention?
decrease fluid retention
what are the AE unique to spironolactone?
gynecomastia
impotence
menstrual irregularities
why is eplerenone not preferred over spironolactone?
usually comes down to $$
also a substrate of CYP3A4 so need to avoid interactions with KTZ
what is the dosing of eplerenone if eCrCl is over 50?
initial: 25 mg QD
maintenance: 50 mg QD
what is the dosing of eplerenone if eCrCL is between 30-49?
initial: 25 mg QOD
maintenance: 25mg QD
what is the dosing of spironolactone if eCrCl over 50?
initial: 12.5-25mg QD
maintenance: 25 mg QD
what is the dosing of spironolactone if eCrCl is between 30-49?
initial: 12.5 mg QD or QOD
maintenance: 12.5-25mg QD
when should MRAs be avoided?
if SeCr is over 2.5 in males or 2.0 in females
if SeK is over 5
if CrCl is under 30
hx of severe hyperkalemia or recent worsening kidney function
what concomitant usage should be avoided with MRAs?
K sparing diuretics or supplements (unless hypokalemia of under 4)
NSAIDs
triple therapy of ACEi/ARB/MRA
caution with high dose of ACEi/ARB
what should be monitored with MRAs?
renal function and K
within 3 days-1 week after any change or addition, disease, or acute illnesses that may influence K concentrations, then every 3 months, then every 3-4 months and with increase ACEi or ARB restart
what is important counseling of MRAs?
avoidance of salt substitutes (due to K being in most of them – use Mrs. Dash instead)
close questioning for all other sources of K
what stage is MRA recommended?
Stage C only if eGFR over 30 and K under 5
when should MRAs be d/c?
if K cannot be maintained to under 5.5 then needs to avoid life threatening hyperkalemia
what are the benefits of SGLT2i?
osmotic diuresis and natriuresis
decreased arterial pressure and stiffness
preload/afterload reduction and associated reduction in hypertrophy and fibrosis (reduced myocardial remodeling)
what is the dosing of SGLT2i?
10mg QD
under what eGFR should SGLT2 be not used?
under 30 for dapagliflozin
under 20 for empagliflozin
what are the AE of SGLT2i?
volume depletion
KTA in DM, hypoglycemia, infection risk (UTI/PN, NFP, mycotic)
when are SGLT2i recommended?
in pts with symptomatic chronic HFEF w/wo DM to reduce hospitalization and CV mortality
stage C
