Module 4 Unit D&E HF and Antiarrhythmic & Angina Flashcards
Which antihypertensives can be used to used for heart failure?
Loop Diuretics (lasix), ACEIs (-prils), ARBs (-sartan), Aldosterone Antagonists (Aldactone or Inspra), Beta-Blockers (-lol)
What BBW is associated with ACEIs and ARBs?
Fetal injury: discontinue in pregnancy: ↑ 2nd and 3rd-trimester fetal harm
Which ARBs can be used for HF?
valsartan, candesartan
What is an example of a Angiotensin receptor- neprilysin inhibitors and its MOA?
sacubitril/valsartan (Entresto)
sacubitril MOA: ↑ natriuretic peptides while ↓ negative effects of RAAS
valsartan MOA: Block angiotensin receptor sites in blood vessels (vasodilation), heart (prevent/reverse cardiac remodeling), adrenals (↓ aldosterone)
What is an indication for Angiotensin receptor- neprilysin inhibitors [sacubitril / valsartan (Entresto)]?
HF
What side effects may be see with Angiotensin receptor- neprilysin inhibitors [sacubitril / valsartan (Entresto)]?
hypotension, hypersensitivity, angioedema, hyperkalemia
What adverse effects may be see with Angiotensin receptor- neprilysin inhibitors [sacubitril / valsartan (Entresto)]? What patients may we need to avoid use in?
↓ renal function, especially in the presence of renal artery stenosis
What BBW is associated with Angiotensin receptor- neprilysin inhibitors [sacubitril / valsartan (Entresto)]?
Fetal toxicity
Why would we use Aldosterone Antagonists like aldactone or inspra for HF?
In HF can ↓ symptoms and hospitalizations. Can prolong life in HF pts.
What is an example of Cardiac glycosides and their MOA?
digoxin (Lanoxin)
MOA: ↑ myocardial contractility by inhibiting NaK-ATPase, leading to ↑ Ca in myocytes which ↑ contractility by optimizing the action of actin and myosin in the myocardium.
↑CO causes ↓ sympathetic tone and renin release while ↑ urine output.
What risks are associated with Cardiac glycosides (digoxin)?
↑ Risk of dysrhythmias with hypokalemia and digoxin toxicity.
Digitalis toxicity: confusion, irregular pulse, new palpitations, loss of appetite, nausea, vomiting, diarrhea, tachycardia, vision changes (unusual), including halo, blind spots, blurred vision, color changes, spots in the field of vision.
What medications should we not use Cardiac glycosides (digoxin) with?
diuretics, ACEIs, ARBs, sympathomimetics, quinidine, amiodarone, verapamil, and more
What condition should we use Cardiac glycosides (digoxin) cautiously with?
renal insufficiency
What monitoring should be done for someone on Cardiac glycosides (digoxin)?
Baseline and monitor ECG, electrolytes, and renal function
When should Cardiac glycosides (digoxin) be held?
HOLD medication if HR < 50
How do we treat digoxin toxicity? How else can we use it?
Digoxin immune fab (DigiFab)
Also used to treat OD
What is the MOA of ivabradine (Corlanor)?
Inhibits f-channels in SA, which ↑ depolarization and ↓ HR.
Slows HR without ↑QTc or ↓ contractility
WHen would we use ivabradine (Corlanor)?
Stable HF with EF <35%, in sinus rhythm, and HR > 70.
When is ivabradine (Corlanor) contraindicated?
Contraindicated with acute decompensated HF, significant hypotension and/or bradycardia, sick sinus syndrome, sinoatrial block, or third-degree AV block (unless a functioning demand pacemaker is present); clinically significant bradycardia; severe hepatic impairment; pacemaker, potent CYP3A4 inhibitors.
Which HF medication will we typically not use in primary care?
ivabradine (Corlanor)
When we use Beta-blockers (-lol) for HF?
In addition to conventional HF therapy
What BBW is associated with beta-blockers (-lol)?
Abrupt discontinuation can cause exacerbation of angina and increased risk of MI
What are some examples of antiarrhythmic meds and their MOA?
-RONE
Cordarone
Nexterone
Pacerone (amioderone)
It is a potassium channel blocker that delays repolarization
What are the indications for Antiarrhythmics (-rone)?
Ventricular arrhythmias, atrial fibrillation
When are antiarrhythmic drugs contraindicated?
AV block, 2nd-3rd degree, long QT syndrome, electrolyte abnormalities.
When should we be cautious in prescribing antiarrythmics?
elderly patients, QT prolongation, hepatic impairment, recent MI, CHF, pulmonary disease, thyroid disease, surgery.
What is the BBW associated with antiarrhythmics?
Thyroid disorders, pulmonary toxicity, hepatotoxicity, and life-threatening arrhythmias
What monitoring should be done when starting and while on antiarrhythmic (-rone) drugs?
Obtain baseline chest x-ray, pulmonary function test, and liver function tests (LFTs). Monitor periodically LFTs.
What is an example of a short-acting nitrate?
nitroglycerin (Nitrostat)
What are the indications for Short-acting nitrates (nitroglycerin)?
stable and variant angina
When should we not use nitrates?
Do not use with PDE5 inhibitors (sildenafil, tadalafil, etc.) - profound hypotension.
Do not use with ergotamine or DHE.
What adverse effects are associated with nitrates?
Hypotension, HA, reflex tachycardia, orthostatic hypotension, hypersensitivity
When should we use nitrates cautiously?
Potentiates antihypertensives=hypotension
What should we consider when prescribing nitrates?
Sublingual tablets deteriorate within 3-6 months after opening. Be sure to write RX with many refills!
Why can short-acting nitrates become less effective, and how quickly?
Tachyphylaxis/tolerance can develop within 24 hours.
What are examples of long-acting nitrates?
isosorbide mononitrate
isosorbide dinitrate
NTG ointment
NTG patches
What is the MOA of nitrates?
↓ cardiac O2 demand via vasodilation (veins>arteriole), nitrate converted to active form nitric oxide (↓ preload)
↑ O2 supply by relaxing coronary vasospasm
How should long-acting nitrates be discontinued?
Discontinue slowly after long-term use
How should long-acting nitrates be given to prevent tolerance?
Schedule “breaks” between doses to ↓ tolerance (8 “drug-free: hours/day)
What medication can be given with long-acting nitrates to counter reflex tachycardia?
CCB
What medication should we immediately think of for HF?
ACEs (-PRILs)
What medication should we think of for MI?
Beta-Blocker (-lol)
What BBW is associated with amiodarone (Pacerone)?
Risk of thyroid disorders, pulmonary toxicity, hepatotoxicity, and life-threatening arrhythmias. It is intended for use only in patients with life-threatening arrhythmias because its use is accompanied by substantial toxicity.
The most lethal effect that can occur is pulmonary toxicity.
What monitoring is required when using amiodarone (pacerone)?
baseline chest X-ray
pulmonary function test.
Obtain baseline and periodic liver transaminase.
Discontinue if the level increase exceeds three times normal or doubles in a patient with an elevated baseline.
What drugs are first line treatment for angina?
Beta-blockers (-lol) and Calcium channel blockers (-pine, -mil, -zem)
What patients should be prescribed ASA?
Aspirin should be reserved for people with the highest cardiovascular risk and the lowest risk for bleeding
Abrupt d/c of long acting nitrates can cause what?
Vasospasm
S/S of nitrate overdose
bluish-colored lips, fingernails, or palms of hands; dizziness or fainting; feeling of extreme pressure in the head; shortness of breath; unusual tiredness or weakness; weak and fast heartbeat; fever; and convulsions. This is a medical emergency.
