Pharm: HF Flashcards
Most effective medical therapy for patients in HF with renal insufficiency.
Loop Diuretics
Unique side effect of loop diuretics and which one is it the worst?
Ototoxicity
-ethacrynic acid is the worst (however only one to give in patients with sulfa allergy)
Most serious metabolic side effect of loop diuretics and how it is caused.
Hypokalemia: loop diuretics block the NKCC pump. So K and Na remain in the lumen in the thick ascending loop of henle. In the collecting duct, the sodium is reabsorbed in exchange for potassium secretion further leading to K loss.
Thiazide diuretic still effective in renal insufficiency.
metolazone - good to use with loop diuretics but monitor the potassium levels
Most notable metabolic side effect of thiazide diuretics.
Hyperlipidemia
What effects do the 3 types of vessel dilators have on heart performance and which drugs are included in each type?
- Venodilators: nitrates
- Vasodilators: hydralazine
- Balanced: ACE-Is, ARBs, Na Nitroprusside, Nesiritide, isosorbide dinitrate & hydralazine combo
Other than hypotension, headache, and flushing; what are two problems when using IV nitro or other nitrates?
- Methemoglobinemia: similar to CO poisoning
2. Tolerance
Why are ARBs and ACE-Is good to use in diabetics?
Slows progression of kidney disease
How do ARBs and ACE-Is lead to hyperkalemia?
Inhibition of aldosterone production
-no sodium reabsorption or potassium secretion in the collecting duct
In what two situations can ACE-Is and ARBs increase progression of renal failure?
- Hypovolemia
2. Bilateral renal artery stenosis
Major side effect of ACE-Is.
Dry cough
-due to increase bradykinin levels
First line treatment in patients with systolic HF.
ACE-Is
Type of HF that direct vasodilators are most effective.
Systolic
-the weaker contracting heart will be able to pump more blood against a lower afterload when the arteries are dilated.
Best drug therapy for treating systolic HF in African American patients.
Hydralazine + Isosorbide dinitrate
ACE-Is
Major side effect of Hydralazine (arteriolar dilator)
Lupus-Like symptoms
fever, arthritis, rash
Main complication of sodium nitroprusside (balanced vaso and venodilator).
Cyanide toxicity
Only indication for nesiritide (balanced vaso and venodilator).
Acute decompensated HF
MOA of (+) inotropic agents and describe the 3 mechanisms.
All increase intracellular calcium of cardiac myocytes
- Digoxin: inhibits Na/K pump leading to activation of a sodium calcium antiport
- Sympathomimetic amines: encourage cAMP formation, activating PKA which activates (opens) calcium channels
- Phosphodiesterase Inhibitors: prevent cAMP breakdown
Effects of dopamine based on dose.
less than 2ug/kg/min: renal artery dilation
2-10ug/kg/min: (+) inotropic effects on heart
greater than 10: peripheral vasoconstriction
Indication for all the sympathomimetics.
Acute decompensated HF
Name the two PDE inhibitors.
Amrinone
Milrinone
What are the 3 cardiac toxic effects of digoxin.
- Exaggerated vagal tone (AV block, bradyarrhythima)
- Enhanced automaticity (tachyarrhythmia)
- Enhanced Re-entry including most commonly DADs and seldom EADs
Earliest side effect of Digoxin toxicity.
Anorexia
Unique neuro characteristic of digoxin.
Yellow Vision
What is an important test to run before prescribing digoxin?
Serum Electrolytes
-any imbalance increases risk of dig toxicity
Which beta blockers have lowest chance of CNS side effects?
Carteolol Atenolol Nadolol Sotalol (least lipophilic)
Which beta blockers should be avoided in patients with renal insufficiency?
Carteolol Atenolol Nadolol Sotalol (renal excretion)
When in HF are BB used?
Chronic Systolic compensated HF
-depresses SANS
Which 4 BB have intrinsic sympathomimetic activity?
Carteolol
Acebutolol
Penbutolol
Pindolol
How do the aldosterone antagonists treat HF?
Spironolactone and Eplerenone both block aldosterone. It is thought that aldosterone enhances the progression of fibrosis and ventricular remodeling that occurs in HF.
Major contraindications for BB use in HF.
- decompensated HF
- brittle diabetes w/ HF
- bronchospasm
- prinzmetal angina
What is compensated vs. decompensated HF?
Compensated HF can be though of as regular HF with normal HF symptoms.
Decompensated occurs when the normal HF symptoms are exacerbated by another condition that adds stress to the heart such as infection, hyperthyroidism, pregnancy, exertion. The exacerbated symptoms must be immediately corrected or the patient dies.
