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PHRM 845: Therapeutics III > Sowinski Heart Failure > Flashcards

Sowinski Heart Failure Flashcards

1
Q

What is the definition of Heart Failure?

A
  • Classified as an abnormality of myocardial function that is responsible for the failure if the heart to pump blood at a rate commensurate with requirements of the metabolizing tissues
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2
Q

What are the types of Heart Failure?

A
  • HFrEF and HFpEF
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3
Q

What is HFrEF?

A

Heart Failure with Reduced Ejection Fraction
-Heart Failure symptoms with Ejection Fraction of <40%
-Systolic Dysfunction: DECREASED contractility
-Caused by Dilated Ventricles

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4
Q

What is HFpEF?

A

Herat Failure with Preserved Ejection Fraction
-Heart Failure symptoms with Ejection Fraction of >50%
-HTN is the most common cause

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5
Q

What are the other type of HFpEF?

A

-HFpEF, Boarderline: EF of 41-49 [Similar to HFrEF]
-HFpEF, Improved: EF > 40 [Had HFrEF before]

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6
Q

What is the way that we calculate Ejection Fraction?

A

-EF = [(EDV-ESV)/EDV] x 100%

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7
Q

Come back to slide 9

A
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8
Q

What is the most common precipitating or worsening factor for Heart Failure?

A
  • LACK OF COMPLIANCE [most common], HTN, Arrhythmias,…
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9
Q

What are some of the drugs that can induced Heart Faliure?

A

-Antiarrhythmias, Beta-Blockers, CCBs, Cancer Medications, NSAIDS,…

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10
Q

What is the way that Antiarrhythmics, Beta-Blockers, and CCBs may cause Drug Induced Heart Failure?

A
  • They cause a reduction in the HEART RATE [Negative Inotrope]
  • Are reversible
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11
Q

What are the ways that some Cancer Drugs and Monoclonal antibodies may cause Drug Induced Heart Failure?

A
  • They cause a build up of Ca2+ resulting in a weaken heart muscle.
  • Irreversible
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12
Q

What is the way that the drugs that increase Na+ and Retain Water may cause Heart Failure?

A
  • With drugs that increase the Na+ and Fluid retention, its going to cause possible EDEMA
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13
Q

What medication class could exacerbate HFrEF?

A
  • Any CCB [DHP: “-pines”? or NONDHP: Verapamil/Diltiazem
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14
Q

What are some of the clinical presentations associated with Heart Failure?

A
  • Shortness of Breath, Swelling of the Feet and Legs, Fatigue, Hard to sleep at night, Cough [Frothy Sputum], Increased Urination, Confusion…
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15
Q

What is the difference between RIGHT ventricular failure and LEFT ventricular failure?

A

RIGHT
- Venous Congestion
- Symptoms: Nausea, Vomiting, Constipation
- Signs: Edema, JVD, HJR

LEFT
- Pulmonary Congestion
- Symptoms: Othropnea, PND, Cough
- Signs: Rales, PULMONARY EDEMA,…

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16
Q

What are the major signs of Systemic Venous Congestion?

A
  • PERIPHERAL EDEMA [1+, 2+, 3+, 4+]
  • Jugular Venous Distentsion [JVD]: lying on their back can see their jugular vein
  • Hepatojugular Reflex [HJR]: push on patients liver the fluid will go up their jugular vein
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17
Q

What are the major signs of pulmonary congestion?

A
  • PULMONARY EDEMA
  • Exertional Dyspnea [DOE]
  • Paroxysmal Nocturnal Dyspnea [PND]: Need pillows at night to help breathe
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18
Q

What is the NYHA FC?

A

-It is the way that we classify a patients Heart Failure and determine what therapy is needed to treat them

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19
Q

What is the NYHA Class I?

A

-Patients with cardiac disease but WITHOUT RESULTING LIMITATION OF PHYSICAL ACTIVITY
-Asymptomatic

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20
Q

What is the NYHA Class II?

A

-Patients with cardiac disease resulting in SLIGHT LIMITATION OF PHYSICAL ACTIVITY
-Symptomatic

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20
Q

What is the NYHA Class III?

A
  • Patients with cardiac disease resulting LIMITATION OF PHYSICAL ACTIVITY
  • Symptomatic
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21
Q

What is the NYHA Class IV?

A
  • Patients with cardiac disease resulting in INABILITY TO CARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT
  • Symptomatic
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22
Q

What are the stages that we classify patients with CHF?

A
  • Stage A, B, C, D
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23
Q

How do we classify a patient with Stage A CHF?

A
  • These patients are at HIGH RISK of developing HF; There is no structural or functional abnomalitles of cardiac muscle
  • EX: HTN, CAD, DM,…
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24
Q

How Do we classify a patient with Stage B CHF?

A

-There is STRUCTURAL HEART DISEASE that is associated with HF but NO signs and symptoms of HF
-Fibrosis, LV dilatation, previous MI,…

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25
Q

How do we classify a patient with Stage C CHF?

A
  • They have CURRENT sign and symptoms of HF with underlying structural heart disease
  • Fatigue due to HFrEF, Receiving treatment for prior HF symptoms
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26
Q

How do we classify a patient with Stage D CHF?

A
  • ADVANCED heart disease and HAVE marked symptoms of HF; even at rest
  • A lot of hospitalizations and CANNOT be discharged, need heart transplant,…
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27
Q

What is the therapy based on stage for HF?

A
  • HIGH RISK: Stage A
  • Asymptomatic rEF: Stage B; NYHA FCI
  • HFrEF: Stage C & D; NYHA FC II-IV
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28
Q

What are some of the Non-pharmacological things patients can do for HF? [Think lab]

A

-Reduce Sodium [2-3g/day], Alcohol [2 drinks in men and 1 drink in women/day], Fluid [<2L/day], Increased exercise

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29
Q

What are some of the potential pharmacologic strategies used?

A

-Reduce intravascular volume [Diuretics]
-Increase myocardial contractility [+ Inotrope]
-Decrease ventricular afterload [ACEi, Vasodilator]
-Neurohormonal Blockade [ARNi, BB, ACEi, MRA,…]

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30
Q

What is the way that we treat a patient that falls in STAGE A CHF?

A
  • ACEi [or ARBs]: if atherosclerotic disease
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31
Q

What is the way that we treat a patient that falls in STAGE B CHF?

A
  • ACEi [or ARBs] & Beta-Blockers (class I indication): used if previous MI or asymptomatic rEF
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32
Q

What is the summary of treatment used for STAGE C CHF [symptomatic]?

A
  • Diuretics, ARNi/ACEi/ARBs, Beta-Blockers, MRA, SGLT-2i
  • OTHERS: ISDN/Hydralazine, Digoxin, Ivabradine, Amlodipine/felodipine
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33
Q

What medication class would be considered FIRST LINE in HF patients?

A
  • Diuretics
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34
Q

Who should get a diuretic within HF?

A
  • ANY and ALL patients with signs/symptoms of FLUID RETENTION [symptomatic] = NO SYMPTOMS, NO DIURETICS
  • They dont improve mortality
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35
Q

What is the Mechanism of Action for Diuretics?

A
  • Increase sodium and water excretion by reducing sodium reabsorption at a variety of sites in the nephron [NEED to get into the nephron to work]
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36
Q

What are the classes of Diuretics that we use for HF?

A
  • Loop Diuretics and Thiazide Diuretics
37
Q

What are the Loop Diuretics?

A
  • POTENT diuretics that block the Na and Cl reabsorption in the ascending limb of the Loop of Henle.
38
Q

What are the Loop Diuretics that are possibly used in HF?

A
  • Furosemide, Torsemide, Bumetanide, Ethacrynic Acid
39
Q

What is some of the dosing for Loop Diuretucs?

A
  • F: Initial: 20-40mg qd or bid. Max: 20-160mg qd or BID
  • T: Initial: 10-20 mg qd. Max: 10-80mg qd
  • B: Initial 0.5-1mg qd or bid. Max: 1-2mg qd or bid
  • EA: Initial 25-50mg qd or bid
40
Q

What is the approximate equivalent dose foe the Loop diuretics?

A

F 40mg = B 1mg = T 20mg = EA 50mg

41
Q

What are the Thiazide Diuretics?

A

-Relatively weak agents that block Na and Cl reabsorption in the DCT [used with Loops if need]

42
Q

What are the Thiazide diuretics that we might used in HF?

A
  • HCTZ: 25mg/day to 100mg/day
  • Metolazone: 2.5mg/day to 10mg/day
  • Chlorthalidone: 12.5-25mg/day to 50mg/day
43
Q

What are some of the side effects for the Diuretics in HF?

A
  • Increase Uric Acid, Increase Ca2+, Decrease K+, Decrease Mg2+
44
Q

What should the patient monitor while using Diuretics?

A
  • Fluid intake, Urine output, Electrolytes [K >4 and Mg >2], Renal Function
45
Q

What is the mechanism of action for the ACEi?

A

-They inhibit the conversion of Angiotensin I to Angiotensin II [Inhibiting Vasoconstriction]
-Stop the break down of Bradykinin [Promoting Vasodilation]

46
Q

Why is it important to use ACEi during HF?

A
  • They reduce any symptoms, improve the NYHA score, and most important improve mortality.
47
Q

What are the ACEi’s mostly used in HF?

A
  • Lisinopril: 2.5-5mg qd to 20-40mg qd
  • Enalapril: 2.5mg bid to 10mg bid
  • Capropril: 6.25-12.5mg tid to 50mg tid
48
Q

Why are the ACEi underdosed and underused?

A
  • CKD needs a lower dose & trying to avoid Hypotension
49
Q

When shouldn’t a patient use ACEi for HF?

A

-Volume depleted, SBP<80, K>5, SeCr>3 [may increase by 30%]
-Cough [switch to ARB]
-PREGNANT
-ANGIOEDEMA [switch to ARB]

50
Q

What is the difference between ACEi and ARBs?

A
  • No real difference; ARBs inhibit some of the Angiotension II activity on the AT1 receptor [decreasing BP and damage to the heart]
  • NO COUGH & LESS ANGIOEDEMA
51
Q

What are the ARBs that we may used in HF?

A
  • Losartan: 25-50mg qd to 150mg qd
  • Valsartan: 20-40mg bid to 160 bid
  • Candesartan: 4mg qd to 32mg qd
52
Q

What is the ARNi?

A

[Entresto]
- Sacubitril: Neprilysin Inhibitor
- Valsartan: ARBs

53
Q

What is the mechanism of action ARNi?

A

The MOA is two things: [Decrease blood pressure]
- Sacubitril is the Neprilysin Inhibitor, which stops the break down of the natriuetic peptide, increasing the excretion of Na and Water
- Valsartan is the ARB, stoping the binding of Angiotension II to the AT1 receptor

54
Q

What are some of the side effect of ARNi?

A

-Very similar to ACEi and ARBs; Hypotension, Increased SeCr, Increased K, Angioedema, Pregnancy
-VERY EXPENSIVE

55
Q

What clinical trail showed the efficacy of ARNi vs ACEi/ARBs?

A
  • PARADIGM-HF: Showed that ARNi was better than ACEi for preventing death from CV or reducing HF hospitlizations
56
Q

What is the dosing for ARNi?

A
  • Low: 24/27mg bid
  • High: 49/51mg bid
  • Max: 97/103mg bid
57
Q

What is the best way to convert between ACEi/ARBs and ARNi?

A
  • Stop ACEi/ARBs 36hours before starting ARNi
  • Low ACEi/ARBs to Low ARNi

*Enalapril 20mg = Captopril 150mg = Lisinopril 20-40mg

58
Q

What is the recommendation per STAGE for ARNi/ACEi/ARB?

A
  • Stage B: ACEi [ARB if intolerant to ACEi]
  • Stage C: ARNi [1st line]; ACEi [when ARNi cant work]; ARB [when ACEi and ARNi do not work]
59
Q

What is one medication class that shouldn’t be used in patients that have Heart Failure

A
  • CCBs
60
Q

What is the mechanism of action of the Beta-Blockers?

A

-They block the beta receptor from Norepi/Epi/Dopa, which will wont activate AC, decreasing cAMP levels and cause relaxation

61
Q

What is the proposed benefit of Beta-Blockers?

A
  • Help reverse remodeling; the problems have resulted in the remodeling
62
Q

What are the ONLY 3 beta-blockers used in heart failure?

A
  • Metoprolol: 12.5-25mg qd to 200mg qd
  • Carvedilol: 3.125mg bid to 25-50 mg bid
  • Bisoprolol: 1.25-2.5mg qd to10mg qd
63
Q

What patient population should receive a Beta-Blocker for heart failure?

A
  • Those that are STABLE and EUVOLEMIC [the patient shouldn’t have any fluid retention]: give diuretic
  • Considered with bronchospastic disease and asymptomatic bradycardia
64
Q

What is the monitoring parameters for Beta-blockers for heart failure?

A

-Blood Pressure & Heart Rate [Dairy]
-Edema [Increase diuretic if need be]
-Fatigue

65
Q

What is the recommendation per STAGE for Beta-Blockers in Heart Failure?

A

-Stage B: ALL patient should get one [reduce mortality]
-Stage C: ALL patient should get one [reduce mortality]

66
Q

Why is it important to inhibit ALDOSTERONE in heart failure?

A

Elevated aldosterone in HF may cause:
-Sympathetic Activation [increase HR]
-Parasympathetic inhibition [Increase HR]
-Remodeling

67
Q

What are the two Aldosterone Receptor Antagonists [MRA] that are used in Heart Failure?

A
  • Spironolactone: 12.5-25mg qd to 25mg qd
  • Eplerenone: 25mg qd to 50mg qd
68
Q

What do the MRAs help against?

A
  • Decrease K and Mg losses
  • Decrease Na Retention [move fluids out]
  • Decrease sympathetic simulation [Low HR]
69
Q

Explain Spironolactone?

A
  • Non Selective Agent
  • AE: gynecomastia, importance, menstrual irregularities, antiandrogenic effects
70
Q

Explain Eplerenone?

A

-Selective Agent with greater affinity
- AE: NO antiandrogenic effects

71
Q

When should MRAs be used in therapy for HF?

A

-Should be added to ACEi/ARB/ARNi and Beta-Blocker
-AVOID: NSAIDS and High dosed ACEi/ARB
-AVOID: SeCR > 2.5 [CrCl < 30] and K > 5

72
Q

What is the recommendation per STAGE for MRAs for HF?

A

-Stage B: No use
-Stage C: Patients with HFrEF and NYHA II-IV & GFR>30 and K<5 [K<5.5 discontinue]

73
Q

What is the indication for the SGLT-2 Inhibitors for HF?

A
  • Reduce the risk of CV death or hospitalization for HFrEF patients with NYHA Class II-IV [HFpEF]
74
Q

What are the SGLT-2 inhibitors for HF?

A
  • Dapagliflozin 10mg once daily
  • Empagliflozin 10mg once daily
75
Q

what is the recommendation per STAGE for SGLT-2 Inhibitors for HF?

A
  • Recommended for patients that have chronic HFrEF to reduce hospitalization and mortality
76
Q

What does ISDN/Hydralazine do within HF?

A
  • It is a combination product that tries to balance the VD[?] effects, causing a decrease in preload [ISDN] and afterload [Hydralazine]
77
Q

What are some of the adverse effects for ISDN/Hydralazine in HF?

A

-Headache, Nausea, Flushing, Dizziness, Tachycardia, Lupus-like syndrome, Hypotension,…

78
Q

Should we worry about nitrate tolerance dosing for ISDN/Hydralazine for HF?

A
  • NO, do not need to worry about that
79
Q

What is the dosing for ISDN/Hydralazine for HF?

A
  • Initial: 20/37.5mg tid
  • Max: 40/75mg tid
80
Q

What is important to know about ISDN/Hydralazine for HF?

A
  • It works better in African American populations? [no one is sure why, maybe something to do with the nitric oxide?]
81
Q

What is the recommendations per STAGE for ISDN/Hydralazine for HF?

A

-Stage B: no
-Stage C: Black patients with NYHA III-IV getting optimal therapy to improve symptoms and reduce mortality

82
Q

What is the indication for Ivabradine for HF?

A
  • Reduce the risk of hospitalization for symptomatic HF, EF<35% in NSR with rHF>70 in MAX tolerated beta-blocker
83
Q

What is the Dosing for Ivabradine in HF?

A

-Initial: 2.5-5mg bid
-Max: 7.5mg bid

Adjustments:
-HR >60: increase by 2.5mg to 7.5mg
-HR 50-60: no change
-HR <50: deacrease by 2.5mg or discontinue

84
Q

What are some of the side effects with Ivabradine for HF?

A

-Fetal toxicity, Afib, Bradycardia

85
Q

What is the mechanism of action for Digoxin in HF?

A

-Inhibit the Na+/K+ ATPase, causing a decrease in Na+ coming in and Ca2+ leaving, increasing the intracellular Ca2+, resulting in greater contraction [Positive Inotrope]

86
Q

What is Digoxin’s place in therapy for HF?

A
  • its good a decreasing hospitalization but NOT good at reducing mortality
  • When their optimized on max GDMT; add digoxin
87
Q

What is the dosing for Digoxin in HF?

A

-0.125mg [need 0.5-0.9 digoxin conc to use]

88
Q

What are the adverse effects of digoxin in HF?

A
  • Noncardiac: Anorexia, nuasea, vomiting, visual problems, fatigue, dizziness,…
  • Cardiac: PVCs, Av Block
89
Q

What is the mechanism of action of Vericiguat in HF?

A

-Guanylate cyclase inhibitor [Symptomatic HFrEF]

90
Q

What is the dosing for Vericiguat in HF?

A
  • Initial:2.5mg qd to 10mg qd

PHRM 845: Therapeutics III (25 decks)

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