HF questions Flashcards
Low cardiac output results in the activation of compensatory neurohormonal pathways. Activation of the SNS results in which one of the following effects?
Increased HR
Which of the following meds may exacerbate HFrEF?
A. Metformin B. Amlodipine C. Atorvastatin D. Ibuprofen
-ibuprofen
-Na retention bc block prostaglandins = no renal dilation = reduce flow
Physical exam findings consistent w symptomatic HF
-Dyspnea
-JVD
-peripheral edema
-rales
Which of the following are common causes of heart failure (Select all that apply)?
-MI
-HTN
Which of the following doses would be considered “equivalent” to 1 mg PO bumetanide?
-Furosemide 40mg PO
-Furosemide 20mg IV
TZDs
-relatively weak blockage of Na Cl absorption in DCT
-may use in mild HF w small amt of fluid retention
-lose effectiveness as renal fx dec = give higher dose when GFR < 30
-HCTS and MTZ used in combo w loops in resistant pt
TZD drugs for HF
-HCTZ (Esidrix, Hydrodiuril): 25-100mg/day
-Metolazone (Mykrox, Zaroxolyn): 2.5-10mg/day
-use in combo w loop in pt that are resistant
Diuretic adverse effects
-dec K, Mg, Na, Ca
-TZD inc Ca
-volume depletion
-dec renal fx
-pre-renal azotemia
-postural hypotension
-inc uric acid
Loop diuretic initiation
-low dose then double and titrate based on wt and sx
-if fluid overload, dec wt 1-2 lbs/day (500mL to 1L/day)
-hypotension and inc SeCr or BUN/Cr ratio may be indicitive of volume depletion
-might need to adj during ACE/ARB/ARNI or BB titration
indication of volume depletion
-hypotension
-inc SeCr and BUN/Cr ratio
Loop use and monitoring
-1-2 weeks
-fluid intake/output
-wt
-congestion
-JVD
-BP
-electolytes (replace K and Mg if needed)
-renal fx
Stage B recommendation for diuretic
-no need
-maybe TZD in HTN
drugs w highest reduction in mortality
-ISDN/Hyd
-BB
Neurohormonal blockers
-RAS inhibitors
-BBs
-SGLT2i
-MRAs
-hyd/ISDN
ACEi MOA
-blocks angiotensin I to II (arterial dilation, dec fibrosis, dec NE, dec constriction)
-blocks bradykinin breakdown (venous dilation, incNE, permeability, prostaglandin release, cough)
ACEi benefits
-inc endothelial fx
-dec NE
-inhibit hypertrophy
-improve hemodynamics
-dec aldosterone
-dec arginine vasopressin
-dec endothelin-1
-dec vasoconstriction
-dec Na and water retention
ACE drugs
-Enalapril (Vasotec): 2.5-5 up to 10mg BID
-Captopril (Capoten): 6.25-12.5 upto 50mg TID
-Lisinopril (Prinivil, Zestril): 2.5-5 upto 20-40mg QD
-Quinapril (Accupril): 5-10 upto 20-40mg QD
-Ramipril (Altace): 1.25-2.5 upto 5mg BID-10mg QD
-Fosinopril (Monopril): 5-10mg up to 40mg QD
Dosing of ACEi considerations
-IF CrCL< 30, START W HALF DOSE AND GET TO HALF TARGET DOSE
-push for target dose in hypotension unless sx
-start low and double q1-4 weeks
-CAUTION if: volume depleted, SBP<80, K>5, SeCR >3
-lower doses and more monitoring required in SCr >3 and CrCl <30
Absolute contraindications to ACEis
-pregnancy
-angioedema
-bilateral artery stenosis (BP will drop)
-hx of intolerance due to sx hypotension, decline in renal fx, hyperkalemia, cough
ACEi monitoring
-volume status
-renal fx
-K
-BP
-prior to tx, 1-2 weeks after inc, then 3-6 month intervals
-when other tx that might dec renal function
-SeCR may rise after initiation (30% acceptable)
Acceptable rise ini SeCr after ACE initiation?
up to 30%
ACE adverse effe
-fx renal insufficiency
-hyperkalemia
-skin rash/dysgeusia
-cough
-angioedema
How does ARB mech differ from ACE
-blocks angiotensin II to AT1 receptor
-no cough and less venodilation (bradykinin breakdown)
-might block some receptors that ACEs miss
ARB drugs
-Losartan (Cozaar): 25-50mg up to 150mg QD
-Valsartan (Diovan): 20-40mg up to 160mg BID
-Candesartan (Atacand): 4mg upto 32mg QD
Angiotensin Receptor Neprilysin Inhibitors
-blocks NEP and AT1 receptors
-valsartan (ARB) blocks AT1
-sacubitril metabolite blocks NEP and inhibits degradation of BNP
-dec Na retention
-dilate
-dec SNS hypertrophy, fibrosis, permeability
Sacubitril/Valsartan
-ARNI
-use in stage C pt
-Entresto
-valsartan equivalents?
-EXPENSIVE!
Sacubitril/Valsartan AEs
-hypotension (more than ACE)
-inc SeCr and K (less than ACE)
-angioedema rare
-DO NOT USE in pregnancy
S/V dosing
-if high dose ACE/ARB:
-49/51mg BID initial
-97/103mg BID max
-if none/low/medium dose ACE/ARB, eGFR <30, mod hepatic impairment (inc LFTs), or over age of 75:
-24/26mg BID
-high dose ACE: enalapril 10 = captopril 75 = lisinopril 10-20mg qd
-high dose ARB: >160mg valsartan qd
Entresto (S/V) contraindications
-same as ACE/ARB
-do NOT take within 36 hours of ACEi
Entresto (S/V) side effects
-renal/hepatic impairment
-renal artery stenosis
-HYPOtension
-volume depletion
-HYPOnatremia
-post MI
Sacubitril/valsartan is contraindicated in patients with HFrEF and with which one of the following?
angioedema with ramipril
Beta blockers benefit for HF
-dec ventricular arrhythmias
-dec hypertrophy and cell death
-dec VC and HR
-dec remodeling
-by blocking NE and EPI
Beta blocker patient selection
-EUVOLEMIC!!!!
-sx pt should receive diuretics
-caution in bronchospastic disease and asx bradycardia
-initiation in hospital
-do NOT abruptly dc
-may take months to see effects (reverse remodeling)
Beta blocker drugs for HF
-bisoprolol () 1.25-10mg qd
-carvedilol 3.125-25(if less than 85kg)-50mg BID
-carvedilol CR: 10-80mg
-metoprolol succinate XL (Toprol XL): 12.5-25-200mg qd
-
Beta blocker dose titration
-double every 2 weeks
-monitor vitals and sx
-aim for target dose or highest tolerated dose in 8-12 weeks
Dose conversion between agents
-carvedilol to Coreg CR
-3.125/10
-6.25/20
-12.5/40
-25/80
-BID to qd
BB monitoring
-BP
-sx hypotension (if only hypotension, change other drugs first
-HR (no defined goal)
-less common if slow titration
-edema/fluid retention
-fatigue
Use of BB
-Stage B and C
Aldosterone
-elevated in HF
=SNS activation
=PSNS inhibition
=remodeling
-use MRAs
MRAs (aldosterone antagonists)
-blocks aldosterone effects independent of effects of ACE/ARBs
-dec K and Mg loss (might protect against arrhythmias)
-dec Na retention
-dec SNS
-block fibrotic action on heart
Spirinolactone
-MRA
-cheap
-NON-selective
-similar to progesterone
-inhibits testosterone and inc conversion of testosterone into estrogen
-gynecomastia, impotence, menstrual probs
-12.5-25mg
Eplerenone
-SELECTIVE
-less affinity for receptors than spirinolactone
-no antiandrogenic effects
-CYP3A4 substrate
-25-50mg
Spirinolactone dosing
-initial: 12.5-25mg qd, if CrCl <50, 12.5mg qd or qotherd
-maintenance: 25mg or 12.5-25mg if CrCl <50
Eplerenone dosing
-initial: 25mg qd, if CrCl <50 25mg every other day
-maintenance: 50mg qd, if CrCl < 50 25mg qd
When to avoid MRAs
-SeCR > 2.5 or 2
-CrCl <30
-SeK>5
-history of hyperkalemia or worsening kidney fx
What to avoid w MRAs
-K-sparing diuretics unless hypokalemia
-NSAIDs, and caution in high dose ACE/ARB
MRA monitoring
-renal fx and K within 1 week after any change
-then q3 months and with inc ACE or ARB restart
-pt should avoid salt substititues bc high potassium
MRA guidelines
-not in stage B
-Stage C pt w GFR > 30 and K<5
-careful mx of K, renalfx, and diuretic dose
-dc if K wont stay <5.5
SGLT2 inhibitor mech
-unclear mech
-diuresis and natriuresis
-dec arterial pressure/stiffness
-preload and afterload reduction and associated reduction in hypertrophy and fibrosis
-reduced remodeling
SGLT2 drugs
-dapagliflozin (Farxiga) 10mg
-Empagliflozin (Jardiance) 10mg
-starts to work right away
-inititiate at 10mg dose
SGLT2 side effects
-volume depletion
-KTA in DM
-hypoglycemia
-infection risk
-empagliflozin might be good for eGFR
Titration of therapy after 42 days (6 weeks)
-maintenance or additional titration
-consider EP device or transcatheter valve repair
-consider add-ons
-manage comorbidities
Blood pressure monitoring on 4 main therapies
-SBP>100
-all have side effect of hypotension
RASi and MRA labs
-K <5.5
-eGFR > 30
-SeCr inc < 30% in 4 weeks
BB labs
-SBP > 100
-HR >60
SGLT2 labs
-eGFR > 20
-watch for genital infection
-SeCr inc >30% within 4 weeks
-ketones/lactones
ISDN/hydralazine (BiDil) mech
-reduce preload and after load
-ISDN venodilator
-hydralazine arterial dilator
-first drug combo w reduction in mortality!
-less effective than ACEs
ISDN/hydralazine (Bidil) indication
-black patients receiving optimal therapy to improve sx
-pt that can’t receive ACE/ARB/ARNi (preg, angiodema, renal insufficiency)
ISDN/Hydralazine (BiDil) side effects
-sig problem, limiting factor
-HA, N
-flushing, dizziness
-tachycardia!
-lupus-like syndrome
-hypotension
-inc HR
-myocardial ischemia
-fluid retention
ISDN/Hydralazine dosing
-initial 20/37.5mg TID
-target: 40/75mg TID
Ivabradine (Corlanor) indication
-reduce risks/death in stage C HFrEF (<35%) treated w max BB (or CI) who have HR > 70 bpm at rest
Ivabradine dosing
-2.5-5 mg BID initial, max 7.5mg BID
-adjust q2weeks based on HR
-if HR >60 inc dose by 2.5mg up to 7.5mg BID
-if HR 50-60: maintain
-if HR<50 or sx of bradycardia: dec dose 2.5mg BID or dc if 2.5mg
Ivabradine (Corlanor) side effects
-fetal toxicity
-AFib
-bradycardia
-conduction disturbances
-CYP3A4 substrate
=AVOID: KTZ, diltiazem, verapamil, GFJ
-expensive
Digoxin/Digitalis MOA
-blocks Na/K ATPase channel
-inc Ca = inc force (mild positive ionotrope)
-PSNS activation = dec conduction (AFIB tx) = low HR rate
-resensitization of baroreceptors
Digoxin indication
-HF w Afib
-does NOT reduce mortality (reduce hospitalization tho)
-consider in pt w sx despite optimized tx or in pt who cant tolerate GMDT to dec hospitalization
Digoxin dosing
-NTI!
-0.125-0.25mg qd
-0.125mg good for most pt w 0.5-0.9ng/mL goal serum digoxin concentration (SDC)
-lower dose in >70 yo, renanl probs, low wt, drug interactions
When to lower digoxin dosing
->70yo
-renal probs
-low wt
-drug interactions: amiodarone, quinidine, verapamil, Itra/KTZ
Digoxin drug interactions
-amiodarone
-quinidine
-verapamil
-Itra/KTZ
-all inc digoxin concentration
-half dose of digoxin
Digoxin side effects (CNS)
-Non-cardiac (CNS):
-ana, N/V, ab pain
-visual disturbances (halos, color perception) van gogh!
-fatigue, weakness, dizziness, HA
-neuralgias, confusion, delirium, psychosis
Digoxin cardiac toxicity
-ventricular: PVCs, bigeminy, trigeminy, VT, VF
-AV block: 1,2,3rd degree
-AV junctional escape rhythyms, junctional tachycardia
-atrial arrhythmias w slowed AV conduction or AV block
-sinus bradycardia
Vericiguat MOA
-soluble guanylate cyclase stimulator
-reduce death/hospitalization
Vericiguat indication
-stage C still sx on standard therapy
Vericiguat dosing
-2.5mg qd upto 10mg qd
Vericiguat side effects
-hypotension and anemia
-CI in pregnancy
misc topics
-Omega-3 has some evidence as adj tx
-long term 81mg ASA in pt w IHD/CAD/ASCVD, otherwise dont use routinely
-anticoagulants rec in HF w Afib or hx of PE, otherwise NO
-CCBs: only felodipine and amlodipine MAY be used for angina/HTN if still not managed
Non-pharma HFrEF options
-implant ICD (cardio defibrilator)
-cardiac resynchronization therapy
