Nu 735 Medications HF

Question 1

**

Goal for Medical Tx

Answer 1

Goals
* Alleviate symptoms
* Prevent ventricular remodeling
* Extend survival

Question 2

**Drug therapy: combination **

Answer 2

• β-blocker
• ARB/ACEi
• ARNi / Angiotensin Receptor-Neprilysin Inhibitor : (Sacubitril/Valsartan (Entresto)
• SGLT2i
• Digoxin

*** Diuretics **
* Aldosterone antagonists
* Loop diuretic
*
* Vasodilator agents
* Hydralazine plus nitrate
* Alternative if ACEi/ARB/ARNi not tolerated

Question 3

Angiotensin Converting Enzyme Inhibitors (ACEi)
(PRIL )

Answer 3

Examples of ACEi **(PRIL) **
Captopril, Lisinopril, Enalapril, Ramipril, Quinapril

First line agent when EF <40% symptomatic or asymptomatic; with Diuretics
BBB can be used for Rate control

Pt have to be Euvolemic,
Can cause AKI, that can lead to
HyperKalemia,

**Function : **
* Improves mortality/morbidity & exercise tolerance
* Improves EF
* Reduces ventricular remodeling
* Reduction in arterial resistance (afterload)
* Reduction in venous tension (preload)
* Reduction in aldosterone secretion

Question 4

ACE S/F

Answer 4

• dry persistent cough, lead to noncompliant
  Angioedema
• Cannot take while pregnant lead to Fetotoxicity

Question 5

What medications is that :
Catapril, Lisinopril Enalapril, Ramipril. Quinapril ?

Answer 5

Angiotensin Converting Ensymes (ACE)

Question 6

Angiotensin Receptor Blockers (ARB) II
Example of medications

Answer 6

“TAN”
Losatan, Irbesartan, Carndersartan

Question 7

ARB function and indication

Answer 7

• ARB competitive antagonists of Angiotensin II
• Indication: Reflactory to treat with ACE/BB/Aldosterone inhibitor
• Expensive
• Caution with Vasodilators b/c casing Hypotension
• Blocks Vansodilators
• Caution with cKD

Question 8

Angotensin Receptor -Neprilysin (ARNi)
Example of medication

Answer 8

Entresto

Question 9

Angotensin Receptor -Neprilysin (ARNi)
Action

Answer 9

**1. Inhibition of Neprilysin: **

(By inhibiting neprilysin, ARNIs prevent the breakdown of beneficial peptides, such as natriuretic peptides. These peptides promote **
vasodilation** (widening of blood vessels), diuresis (increased urine output), and natriuresis (excretion of sodium), which reduces blood volume and pressure, helping to decrease the workload on the heart.* Inhibits Neprilysin (
* Selectively Blocks of Angiotensin II to AT1 receptor
* Expensive
* Monitor for Renal Failure

Question 10

SGLT2i example
Jardiance

Answer 10

Proposed Mechanism(s)

• Improvement in ventricular loading d/t reductions in preload & afterload
• Alternative cardiac energy supply in form of cardiac ketones
• Direct inhibition of sodium/hydrogen (Na+/H) exchanger in myocardium
• Reduction in LV mass & improvement in diastolic function
• Improvement in endothelial dysfunction
• Stimulation of increased glucagon secretion
• Recommended for HFrEF & HFpEF w/wo T2DM

Question 11

Diurtetics

Answer 11

**Reduce Symptoms of Volume Overload
**Decreasing the extra Cellular Volume
* Decrease the Venous Returne

****Chronic Management
**Symptomatic Control
No effect on mortality

Question 12

Loop Diurtetics

Answer 12

Bumetanide
Furosemide
Torsemide

Question 13

Thiazides Diuretics

Answer 13

HCTZ
Metolazone

Question 14

Potassium Sparing

Answer 14

Amiloride
Spironolactone
Triamterene

Question 15

Aldosterone Antagonists
Example

Answer 15

Sprirololactone
Epleroenone

Question 16

Aldosterone Antagonists

Answer 16

• Aldosterone inhibition minimizes potassium loos
• Prevent sodium and water retension
• Prevents endothelial dysfuntion and myocardial fibrosis
• Commontly used with NYNA HF classes II and IV with EF <35%

Question 17

BBB

Answer 17

Toprol
Carvedilol
Metoprolol

Question 18

BBB Function

Answer 18

• Inhibits sympathetic NS
• Increases beta receptor sensitivity
• Anti-Arrhythmic Properties
• Anti-oxiant properties
• Re-sentitization of the down regulated receptor(Imrpove myocardial contractility)
• Reduced remodeling

Question 19

Cardiac Glycoside
Example

Answer 19

Digoxin

Question 20

Cardiac Glycoside

Answer 20

**2nd Line Agent for CHF in A-fib
Positive - Inotrope
Negative - chronotrope
Abolish Sympathetic over activity
**

Question 21

Cardiac Glycoside
Side Effect

Answer 21

*Digoxin Toxicity
** N/V, visual disturbances, and Psychosis
Ventricular bigeminy, AV block and bradycardia

Digitalis Antidote: DigiFab
Hemodialysis not effective in removal

Question 22

Vasodilators

Answer 22

**Nitroglycerin **
* Lowers preload
* Reduces pulmonary congestion
*
**Nitroprusside **
* Reduces preload & afterload
* Dilates pulmonary vasculature
*
Adverse reactions
Marked hypotension
Thiocyanate toxicity

Question 23

Inotropes

Answer 23

**Milrinone (Primacore ) **
* Increase myocardial contractility
* Vasodilating effect
* Late stage HF
*
Dobutamine
Stimulates beta-adrenergic receptors
* Produces a positive inotropic response
* Produces a mild vasodilatation in smaller doses

Question 24

Treatment Plan

Answer 24

**CCC AVOID during CHF **

b/c this agent have potential to deteriate cardiac function b/c of they **negative Anatropic ACTION
The provided no benefit
Pt with DM and Reduce EF:

• should be taking Aldactone . Provide Renal and Cardiovascular Benefits .
• Hydralazine is an option African American

Question 25

Advanced Therapies

Answer 25

Continuous IV inotropes
< Milrinone
< Dobutamine
**Left Ventricular Assist Device (LVAD)
<Bridge to transplant or bridge to decision

** Tramsplant **
* Selection Process
* Apromimate 10 % mortaliy

Question 26

Defibrillators

Answer 26

• **AICD Indication **
• Primary Preventio EF < 35% or less
• After 3 month maximum medication therapy

Live Vest
Use while awaiting AICD
Wear up to 90 days to assess LV recoveru