Inotropic Agents in CHF Flashcards

1
Q

What does digoxin do?

A

blocks Na/K+ ATPase

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2
Q

How does digoxin affect inotropy

A

1) block Na/K+ ATPase
2) accumulate Na+ inside cell
3) Na+ exchanged for Ca2+ entry
4) Ca2+ stored in SR
5) incr # of crossbridge btwn actin/myosin
6) incr force of contraction –> inotropy

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3
Q

how does digoxin affect sympathetic NS?

A

baroreceptors lose sensitivity with digoxin

digoxin incr parasympathetic NS, incr SA and AV node

decr HR

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4
Q

Hemodynamic effects of Digoxin

A

incr CO
Decr WEdge pressure (from lungs to LA)
incr LV ejection fraction

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5
Q

Neurohormonal effects of Digoxin

A

1) parasympathetic incr
2) incr baroreceptor sensitivity –> parasymp
3) decr NE
4) decr RAAS

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6
Q

Electro effects of Digoxin

A

1) slow SA and AV node

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7
Q

How is Digoxin excreted

A

renally = 70%

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8
Q

Bioavailability of Digoxin at various forms

a) oral
b) IV

A

a) oral = 75%

b) IV = 100%

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9
Q

metabolism of Digoxin

A

blocks P-glycoprotein (normally pumps drug out)

accumulate digoxin

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10
Q

Time to peak steady state of digoxin

A

7-10 days

(half-life = 38 hrs) * 4-5

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11
Q

what is therapeutic serum concentration of digoxin

A

between 0.5 -1 ng/mL

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12
Q

which drugs have DDI with digoxin due to inhib P-glycoprotein

A
Quinidine
Verapamil
Amodarone
Dronedarone
Propafenone
Itraconazole
Erythromycin
Clarithromycin
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13
Q

What three electrolyte abnormalities cause digoxin toxicity?

A

1) hypokalemia - incr dig binding
2) hypercalcemia - incr Ca2+ abs into myocytes, incr inotropy
3) hypomagnesemia - cause arrhythmias

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14
Q

Symptoms of Digoxin TOXICITY

A

1) N/V/ABD PAIN
2) CONFUSION
3) HYPERKALEMIA
4) BRADYKARDIA/ARRHYTHMIA
5) visual effect

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15
Q

Digoxin immune fab mechanism

A

binds Digoxin and doesn’t allow Digoxin to bind receptor

–> toxicity (arrhythmia, bradycardia, heart block)

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16
Q

Effects of digoxin

A

reduce # of HOSPITALIZATIONS for worsening heart failure but DOES NOT decrease mortality

17
Q

WHICH patients benefit from digoxin?

A

NYHA Class 3 and 4 and those with low ejection fraction

18
Q

Does digoxin help HFpEF patients?

A

NO EFFECT

19
Q

GENERAL approach to treat Heart failure

A

1) reduce congestion and volume overload with sodium and fluid restriction + diuretics
2) may add IV vasodilators
3) rarely use inotropes

20
Q

Mechanism of action of dobutamine

A

β-1 agonist to increase contractility,

slight peripheral vasodilation

21
Q

when to use dobutamine

A

ADHF short-term management - “Cold & wet”

recommend if hypotensive

22
Q

Half life of dobutamine

A

2 minutes

23
Q

side effects dobutamine

A

tachyarrhtyhmia

24
Q

mechanism of action of milrinone

A

PDE inhibitor

moderate peripheral vasodilation

25
Q

when to use milrinone

A

ADHF short term management- cold and wet

recommend if receiving a beta blocker

26
Q

side effects milrinone

A

POTENT VASODILATOR

hypotension
thrombocytopenia
increased LFTs

27
Q

general rule with inotropes

A

DO NOT USE IF YOU CAN AVOID

28
Q

Dopamine mechanims

A

precursor of norepinephrine

stim adrenergic receptors + release norepi from nerve terminals

29
Q

Benefits of dopamine at different doses

A

R I P

renal (dopaminergic) at low dose
inotrope (beta receptor effect) at med dose
Pressor (alpha receptor effect) at high dose

30
Q

side effects of dopamine

A

arrhythmias
angina
incr HR
incr vascular resistance