Quiz 3 Flashcards

Question

Garlic

Answer 1

* antiplatlet * ASA, warfarin, ticlopidne, clopidogrel, dipyridamole

Answer 2

* potent thromboxane synthetase inh * warfarin

Answer 3

* MAOi * phenelzine - MAOi * pseudoephedrine/ephedra potentiated by MAOi * SSRI activity - seratonin overload * fluoxetine, paroxetine

Answer 4

* HR x SV * SV * preload (forced in) * afterload (resistance) * contractility (inotropes)

Answer 5

* inc preload stretches cardiac m, inc contractility * primary compensatory mec to inc CO * SV/preload (LVEDV/P) * normal fx in steep range where inc LVEDV/P has big inc in SV * LV dysfx curve is flatter, so LVEDV/P inc shows little inc in SV * eventually attempted preload inc backs up system to fluid volume overload = sx

Answer 6

* Most/classic assumption: sx imply HD changes, improved sx imply HD improvement * Some: inc EF, sx remain OR dec EF, no sx * Cannot assume like -\> 2 separate goals in tx * improve sx * improve HD

Answer 7

* dec perfusion of vital organs * arrhythmias

Answer 8

* cardiac remodeling = change in geometry of left ventricle * chamber dilation - more blood in, more CO, good thing * hypertrophy - more muscle inc strength, good thing * too much m dec compliance * spherical shape - inc contractile strength, good * over time inc mech strains, leaky valves

Answer 9

* Neurohormonal systems - these can be targeted with drugs * Ang II * NEPI * ALD * Natruiuretic peptides * Arginine Vasopressin * Endothelin

Answer 10

* short term sx benefit, no HD effects - in ICU, acutely ill * positive inotropes * dec impedence * relax peripheral vessels, vasodilators * slow remodeling process, dec risk of major cardiac event * ACEi, BB, experimental agents

Answer 11

* **functional** status at a point in time, sx control, not criteria for tx * sx = fatigue, dyspnea, palpatations, fluid overload/edema * Class I - no sx w/ normal activity * Class II - sx w/ normal activity * Class III - sx w/ less than normal activity, ok at rest * Class IV - sx at rest, inc discomfort w/ inc activity Can move up and down classes, class II with illness -\> class IV, back to class II when recover from illness

Answer 12

* functional status * fluid status * EF * other

Answer 13

* NYHA Classification * Exercise testing during graded exercise * QOL instruments * Peak O2 consumption during graded exercise

Answer 14

majority of sx associated with fluid overload * body wt * JVD * pulm/hep congestion/edema * peripheral edema (legs, abd, presacral)

Answer 15

* single most important measurement - gold standars w/o cath * distinguish systolic HF from other processes * Quantitative measurement * Left vent EF * LV dimensions, geometry, thickness, regional motion, spherical changes * repeat w/ important changes in clinical status

Answer 16

* invasive HD testing * R heart cath * electrophysiologic testing - EP testing - give drug to cause arrhythmia and see which agent will treat this pt arrhythmia * neurohormonal eval - BNP -\>fluid overload, preload * do not predict extent of damage

Answer 17

* Tx guidelines focus here, where NYHA is sx control * AHA and ACC (college of cardiologists) * Stages A-D

Answer 18

* at risk w/o structural changes or sx of HF * HTN #1 risk factor is long term HTN * Atherosclerosis * DM * Obesity * Met syndrome * Cardiotoxic drug use (adriomycin chemotherapy) * Family hx cardiomyopathy

Answer 19

* Structural heart dz w/o sx HF (compensatory mechanisms) * previous MI * LV remodeling/hypertrophy or dec EF * asymptomatic valvular dz (mitral regurg or aortic stenosis)

Answer 20

* struct dz w/ current or hx sx (SOB, edema, dyspnea, paroxysmal nocturnal dyspnea)

Answer 21

* refractory HF requiring specialized intervetions * marked sx at rest despite max medical therapy * recurrently hospitalized/cannot be safely d/c'd w/o spec interventions

Answer 22

* Prevent initial injury * treat hyperlip, sys/dia HTN, stop smoking * Prevent further injury * thrombolytic/angioplasty in AMI * ACEi or BB * ACEi and BB * Prevention of post-injury deterioration * ACEi

Answer 23

* remove underlying cause - repair congenital defects, valvular lesions, treat HTN and endocarditis * remove precipitating cause - infections arrhythmias, drugs * control of HF state - dec workload, inc pump performance, control excess salt/water * avoid CCB's (neg inotropes), NSAIDS, some antiarrhythmic agents

Answer 24

* coenzyme Q10 * carnitine * inosine * vitamins * growth hormone

Answer 25

* SV/preload curve is flat in range of sx * dec preload below sx range w/o sig dec in SV * similar preload dec in non-HF would drastically dec SV * MOA * block reabs Na from tubule system back into blood, therefore water * trap Na in tubule system and pee out with water

Answer 26

* max level of salt reduction that is tolerable to pt is goal * effects of diuretics can be overcome w/ high salt diet * no salt added in cooking or at table

Answer 27

* work at distal tubule * 5-8% of Na reabsorption here, so weak * not really used in HF * not effective w/ CrCl\<30, as in HF w/ renal insufficiency * don't work chronically as diuretics (2 wks), abs Na earlier than distal tubule * #1 antihypertensive, not by dec volume though, mech unk * 25-50mg q day, start w/ 10mg in elderly

Answer 28

* Block Na reabs in asc LOH * 20-25% dec reabs * work in mod-severe HF * work in RF (inc dose req) * high ceiling diuretics * HCTZ diminished returns * Loops diuresis inc w/ dose, up to causing renal failure * lasix 99% usage * 20-40 mg q 6-8h until diuresis ensues * give effective dose 1-2 qd to maintain edema control

Answer 29

* hypokalemia - more V loss, more K loss * HF prone to hypoK d/t hyperALD * dec renal perf P results in kidney RAAS activation * hyperALD=hypoK, now adding drug that dec K * arrhythmias - d/t hi or lo K, #1 cause of death in HF * monitor K all the time * ass w/ lo Mg also - Mg involved in reabs of K * dig - can cause arrhythmias w/ lo K, so caution * dz state (HF-\>ALD-\>hypoK-\>arrhythmias) * diuretic (dec K) * adding dig inc arrhythmias w/ lo K = perfect storm for Ventricular Arrhythmias

Answer 30

* ACEi/ARB dec ALD and its K wasting effects * Spironolactone = ALD ant * K supplements or K sparing diuretics * caution w/ACEi (hyper K) * caution w/impaired renal fx * K dose 40-100mEq/day tx, 20 prevent

Answer 31

* diuretic goal is to remove 1 kg/day * overaggressive diuresis depletes intravascular V, proximal tube reabs water and urea * prerenal azotemia is max goal for diuresis * BUN:Cr\>10-20:1 -\> dec dose * ARF is next step * normal mech is Alb to draw fluid from tiss d/t onc/osm P

Answer 32

* HF is most common setting for diuretic resistance 1. slow abs in gut = dec Cmax - IV or inc PO dose 2. inc tubular Na reabs - block reabs at 2 points, dramatic inc 1. thiazide + furosemide (HCTZ potent in this combo) 2. metolazone 5-10mg + furosemide 3. Avoid NSAIDs - afferent dilation d/t prostaglandins, effect of NSAID is to dec filtrate to glom/tubules * can cause ARF in HF

Answer 33

* inc urinary Na excretion, dec sx fluid retention * dec JVP, pulm congestion, ascites, peripheral edema, wt * improve cardiac fx by dec preload, which was too high for heart to handle effectively * inc exercise tolerance * effects not sustained in monotherapy, also need to treat remodeling aspect of dz * cannot sub ACEi for diuretic, will work initially because blocks ALD which is causing fluid retention * dose: too lo dim resp to ACEi, too hi hypotension and renal insufficiency w/ACEi

Answer 34

* pt w/ sx of volume overload

Answer 35

* don't do it. * even if sx improved/controlled * dec volume -\> neurohormonal/RAAS activation * drives remodeling and dz progression long term * inc electrolyte depletion ---\> malpractice * ACEi or BB w/ diuretic needed to offset remodeling changes

Answer 36

* low initial dose - 20-40mg qd furosemide * titrate to inc UO/dec wt 0.5-1 kg/day * loops preferred, esp in renal impairment and high fluid retention * goals of therapy: * reduce sx * eliminate physical signs of fluid retention * restore JVP toward normal * eliminate edema

Answer 37

1. Potent vasoconstrictor - inc afterload 2. Causes norepi release - causes arrhythmias 3. Causes ALD release - fluid retention

Answer 38

1. ang I -\> ang II 2. breaks down bradykinins * ACEi -\> build up of bradykinins -\> cough * use ARB to avoid cough

Answer 39

* -prils * effects * dec sx - dyspnea * prolong exercise tol * dec hospitalization, ER * work in mild, mod, severe HF - inc LV EF * can be used in combo w/ other drugs - +/- digoxin, w/ diuretic to dec dose, ok w/BB's * dec morb/mort - death, dz progression

Answer 40

* HF d/t LV systolic dysfx - unless unable to tolerate * any systolic dysfx * mild, mod, sev HF * LV EF \<35-40% * w/ diuretic in fluid retention * ok w/ dig or BB

Answer 41

* Use w/ caution * SBP\<80 * Cr\>3 * bil renal art stenosis * K\>5.5 * Not used * previous life-threatening rxn like angioedema * pregnancy = teratogen

Answer 42

* Assess fluid status, if depleted hold diuretic 24-48h * Dosing (start **safe**/low w/ captopril short acting, switch to = dose long acting once dosage established) * risk of hypotension 6.25mg captopril and monitor for 2h * (severe LV dysfx, SBP\<100, Na\<135) * \>75yo 12.5mg captopril qd and titrate as tol * hypertensive 25mg captopril TID * others 12.5mg TID * 48h phone call - dizzy/weak? * 1 wk f/u visit - modify if +Cr 0.5, K\>5.5, sx hypotension * 2-3wk titration to 150mg capt, 20mg enal/lisin qd =**effective tx dose**

Answer 43

* hypotension * most common ADR in HF, usually asymptomatic * concern w/dec renal fx, blurred vision, syncope - often w/init * more common w/ very active RAAS, hypoNa, recent rapid diuresis * w/ inc risk, hold diuretic 1-2 days * guideline states "all attempts should be made to continue ACEi" - Need RAAS blockade with ACEi or ARB

Answer 44

* in dec renal perfusion, GFR dep on ang-mediated efferent arteriole vasoconstriction * high risk in NYHA class IV, hypoNa, w/NSAIDs * mgt: * dec diuretic, try again * mild-mod azotemia may need to be accepted in order to continue ACEi in HF (not just HTN)

Answer 45

* may cause cardiac conduction disturbances * highest risk w/ * dec renal fx * K supplements * DM (dec renal fx)

Answer 46

* non-productive * disappears 1-2wks after d/c * recurs w/ rechallenge * switch to ARB

Answer 47

* -sartan * sfx, risks, hypotension, renal dysfx, hypoK... same as ACEi * no cough * possibly less risk of angioedema, but let someone else take that risk, may be malpractice

Answer 48

* used to be contraindicated in HF, now drug of choice * neg chronotropes, poss neg inotropes, but... * block sympathetic NS effects... * vasoconstriction * cardiac hypertrophy * provoke arrhythmias * promote hypoK * protective benefit greater than neg risk of BB * so come with restrictions * sx benefit and dec m/m

Answer 49

* _stable_ NYHA class II/III * class IV severly decomp, negs outweigh benefits * LV EF\<34-40% * added to ACEi and diuretic * DM particularitly experience dec m/m, despite poss masking of hypoglycemia

Answer 50

* bronchospastic dz - asthma, COPD w/bronchoconstrictive component * symptomatic brady * advanced HB - II/III * acutely decomp HF * req intense diuresis * req hospitalization

Answer 51

* 1st long PR * 2nd occasional dropped QRS * winkyback longer and longer PR interval til the drop * 3rd complete A/V separation

Answer 52

* not class effect, only use... * start low w/ * 3.125 carvedilol (also alpha1 ant) * 1.25 bisoprolol * 12.5 metoprolol **SR** * 2x dose q 2-4wks to highest tolerable dose * hypotension, brady, fluid retention, worsening HF * more improvement w/ higher doses * may need to back of ACEi to inc BB, then bring ACEi back * ACEi at tx dose, BB at highest tolerable * don't mess with diuretic - d/t poss fluid ret, worsening HF

Answer 53

* hypotension * carv d/t a1 block/vasodilation * more common w/ first or inc dose (react not overreact) * tolerance w/ continued use * dec ACEi temporarily * avoid fluid ret by maintaining diuretic dose * Fluid ret + worsening HF d/t neg effect on efficiency (neg chron/ino) * pulm/peripheral congestion * daily wt + adjust diuretic * optimize fluid status before starting BB * Brady/HB - usually asymptomatic, dose dependent, dec dose hr\<50, 2/3 deg HB

Answer 54

* lack of evidence supporting efficacy * safety concerns esp verapamil - avoid in HF * known neg inotropes * no substantial benefits in HF

Answer 55

* dec sx and improve clinical status * QOL * fx capacity, no effect on remodeling * exercise tolerance * no dec m/m, risk of death or hospitalization

Answer 56

* not replace other drugs, maximize then add to them for sx relief * early or late in therapy * preferred in Afib - dig dec ventricular response, Afib worsening HF, get rid of Afib, get rid of symptomatic HF * not in class I, ie not if no sx

Answer 57

* \>70y, impaired renal fx, or really small * 0.125mg * otherwise 0.25mg * no data on optimal dose or serum conc * don't get aggressive - may cause arrhythmias * serum level - only test if concerned about tox

Answer 58

* arrhythmias * GI sx * Neurologic complaints (halo?)

Answer 59

* hypoK * augmented cardiac effects * get arrhythmias in therapeutic range * intracellular K more important than serum K * hypoMg * met alk * hyperCa * underlying heart dz * hypoThy - altered dist, abs, renal excretion, R sensitivity

Answer 60

* option when ACEi intol * little evidence of either alone * many w/HF cannot tolerate sfx of doses used in clinical trials * hyd=art dil, nit=ven dil -\> dec pre and afterload * orthostasis major concern * particular benefit shown to African-American pts

Answer 61

* isosorbide dinitrate 20mg/hydralazine 37.5mg * $2 combo branded tab * $0.29 generic tabs * indication: tx HF as adjunct to std tx in self-identified black pts * improve survival * prolong time to hosp for HF * improve pt reported fx status

Answer 62

* African-American Heart Failure Trial (A-HeFT) * double blind, placebo controlled * 1,050 self-id black pts w/ NYHA class II-IV HF * all continued std tx * trial halted d/t sig higher mortality in placebo group (10.2% v 6.2%) * 21% of pts d/c Bidil d/t adverse effects (placebo = 12%) * Concerns * proved Bidil add-on therapy works in blacks, which was already known, not that it doesn't work in whites * "self-reported" blacks * AE's - HA/severe HA, orthostatic dizziness

Answer 63

* spironolactone - NOT "K sparing diuretic" (only Amiloride and Triamterene), dif MoA * only works w/ high ALD levels (HF and chronic liver dz) * In class IV HF - was avoided as just one more drug to effect K * low dose (\<25mg) * dec death/hosp * early term of study d/t unethical to withhold from control group * worse HF, higher ALD - the better it works * lactone ring - hormonal effects - gynecomastia, menstral irreg, ED, libido, hirsutism --- Eplerenone doen't have these sfx but cost more and only 10% see these sfx, would be overcharging 90%, sfx temporary

Answer 64

* combo ARB and Neprilysin Inh = ARNI * valsartan + sacubitril * HFrEF * dec CV deaths, hosp, all cause mortality compared to enalapril (ACEi only) * deg amyloid peptides in brain - dimentia concern but outweighed by severe HF

Answer 65

* Atrial and Brain = ANP and BNP * produced in response to inc LV filling in fluid overload * causes natriuresis + diuresis -\> dec art P -\> imp HD (wedge P) * not just a marker, works to alter overload state

Answer 66

* synth BNP * +inotrope, great in HF w/ severe HD changes * dec dyspnea and wedge P (good) * $$, IV only, hypotension (bad) * no dec in m/m in HF, chronically * approved and used in acute decomp HF

Answer 67

* neprilysin inh and ACEi * inc NP by inh degradation * dec BP and inc HD (good) * inc freq/sev angioedema (bad) * no sig ben over enalapril, d/c'd dev

Answer 68

* Stage A = risk... dec risk * control HTN, lipids, DM * stop smoking, EtOH, illicit drug use * echo w/fam hx cardiomyopathy or using cardiotoxic meds * use ACEi if you can find a good reason * atherosclerosis, DM, HTN

Answer 69

* stage B =struct dz w/o sx... stage A recs plus... * BB+ACEi/ARB/ARNI if hx MI, regardless of EF * ACEi if dec EF and no sx HF, even if no MI * ARB if hx MI, w/o HF, if ACEi intol and low EF * ARNI in class II or III HFrEF, even if tolerating ACEi/ARB * Dig not used w/ low EF, NSR and no sx HF * Diuretics not used w/o sx HF

Answer 70

* stage C=struct dz+hx/current sx... stage A+B plus... * diuretics+salt restriction if evidence of fluid ret * ACEi if sx HF and dec LVEF unless contraindicated, else ARB * BB's for stable pt w/ sx HF dec LVEF unless contraindicated * avoid NSAIDs, antiarrhythmics and CCB's * ALD ant reasonable in mod sev to sev sx HF if renal fx and K monitored - Cr\<2.5m/\<2f, K\<5 * hydralazine/nitrate reasonable if sx still w/ ACEi and BB, or if ACEi/ARB intol * ARB addition may be considered if sx w/ conventional tx * ACEi, ARB and ALD ant not recommended together (hyperK risk)

Answer 71

CrCl in ml/min... (140-age)IBW CrCl = ------------------- x (\*.85 for females) (Cr)(72) * IBW * male 50kg + (2.3 x inches over 5ft) * female 45kg + (2.3 x inches over 5ft)