Therapeutics - Cassagnol Heart Failure Part 1 Flashcards by amanda kastel

what are the 2 drugs in entresto

sacubitril (neprilysin inhibitor) + valsartan (ARB)

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explain how sacubitril works in heart failure patients

inhibits neprilysin

normally, neprilysin is a peptide responsible for breaking down NATRIURETIC PEPTIDE

this isnt good because in cases of hypervolemia (heart failure) natriuretic peptide is released by the stretching heart, which travels to the kidneys, to cause the excretion of sodium and water

so we inhibit neprilysin with sacubitril – in hopes to INCREASE THE HALF LIFE of natriuretic peptide and help with volume control

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why is sacubitril given with an ARB??

why not with an ACE inhibitor?

increased renin levels cause natriuretic peptide not to work as well – so we give an ARB which antagonizes renin, + sacubitril which inhibits neprilysin – all of this helps to increase the effect of natriuretic peptide

sacubitril cant be given with an ACE inhibitor due to the risk of angioedema. both neprilysin and ACE breakdown bradykinin – so giving an inhibitor of both can cause a accumulation of bradykinin which significantly increases the risk of angioedema

NEED WASHOUT PERIOD BETWEEN ACE INHIBITOR AND ARNI!!!

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what is considered first line therapy for ALL heart failure in stage C

ARNI (entresto) is preferred, but ACE inhibitors and ARBS are also 1st line

also mineralocorticoid antagonists, SGL-2i

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what is considered a first line therapy for HFrEF ONLY in stage C

beta blockers – specifically carvedilol, metoprolol SUCCINATE, and bisoprolol

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explain the regimen for entresto (stage c) if the patient has previously been on over 10mg enalapril/ over 10 of lisinopril/ over 5 of ramipril

give an initial dose of 49/51mg BID

double the dose after 2-4 weeks – -target dose of 97mg/103mg – shown to have max benefit

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explain the regimen for entresto (stage C) if the patient HAS NOT previously been on an ACE inhibitor, or has been on one but at a low dose (less than 10mg enalapril, less than 10mL lisinopril, less than 5mL ramipril)

initial dose of 24mg/26mg BID

double dose after 2-4 weeks to 49/51mg BID

2-4 more weeks – try to get to goal of 97mg/103mg BID

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TRUE OR FALSE

ARNI + ACE inhibitor is a contraindication

TRUE - risk of angioedema

NEEDS A WASHOUT PERIOD OF 36 HOURS!!!!!!!

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ARNI should NOT be administered to patients with a history of….

angioedema

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monitoring parameters for ARNI

blood pressure
efficacy, hospital visits, etc
angioedema
dehydration

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4 scenarios in which ACE inhibitors/ARBS should be used with caution in heart failure patients

-hypotensive (BP under 80)
-SCr over 3
-bilateral renal artery stenosis (poor perfusion, risk of AKI)

-serum POTASSIUM over 5

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general ACE/ARB dosing strategy for stage C heart failure

initiate low doses and titrate SLOWLY

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explain the monitoring parameters for ace inhibitors and arbs

renal fxn and potassium should be monitored within 2 weeks of initiation in patients at risk for more toxicities

also – check BMP after 2-4 weeks and if everything normal – titrate dose up – and repeat until target dose is reached

monitor potassium, creatinine, BP, cough and angioedema (ACE inhibitor)
only rly check Mg if K abnormal

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counseling point for ACE/ARB patients

watch how much potassium you take in diet

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**patient presents to ER in acute heart failure exacerbation and is hypervolemic.
they have never been on a beta blocker. should you initiate one?

NOOOOOOOOOOOOO

this can cause cardiac suppression and make their heart failure WORSE

HAVE TO WAIT until the patient becomes euvolemic and is under volume control

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**patient presents to ER with a heart failure exacerbation and they are currently on a beta blocker.
should you keep them on ?

YES — NEVER ABRUPTLY STOP BETA BLOCKERS
will cause reflex tachycardia which is very bad for a failing heart

DO NOT TOUCH THE BETA BLOCKER IS THEY ARE TAKING

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monitoring parameters for beta blockers

heart rate
blood pressure (mostly carvedilol bc alpha blocker)
fluid retention (worsening HF)
fatigue (mainly metoprolol succinate)
heart block
bradycardia

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as mentioned, it’s possible that patients on beta blockers can experience fluid retention and worsening heart failure

what is done in this case?

we may need to decrease the dose to make the patient more tolerant

if this doesnt work, may need to permanently add a diuretic

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2 mineralocorticoid antagonists that are considered 1st line for all heart failure

how do they work to treat heart failure?

spironolactone
eplerenone

used for their aldosterone antagonism

in heart failure, aldosterone levels are high. these will bind to receptors on the heart, causing fibrotic growth on the heart and permanent morphological changes – want to prevent this

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3 specific lab values to monitor for mineralocorticoid antagonists

BUN, SCr, K

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explain the monitoring schedule for mineralocorticoid antagonists

3 days after initiating
1 week later
2 weeks later – continue every 2 weeks until STABLE and keep that dose

then, every 2-6 months

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mineralocorticoid antagonists are CONTRAINDICATED in creatinine clearance of….

less than 30mL/min

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mineralocorticoid antagonists are contraindicated in potassium levels over….

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creatinine levels over ___ in men and ___ in women means a contraindication for mineralocorticoid antagonists

over 2.5 in men and over 2 in women

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counseling point for patients on mineralocorticoid antagonists

watch potassium intake!!!!

true or false mineralocorticoid antagonists do not affect renal function

false -they do contraindicated in eGFR less than 30

name 2 SGLT2 inhibitors are they first line? what is starting dose?

dapagliflozin and empagliflozin first line for all heart failure - diabetic or not (stage c) and a and b for diabetics starting dose and target dose for both is 10mg daily

side effects and clinical considerations of SGLT2 inhibitors

increased urination (not a diuretic, but diuretic effect) increased risk UTI bc glucose in urine dizziness, dehydration DIABETIC KETOACIDOSIS also, hold the med for 3 days prior to a major surgery or prolonged fasting period - risk of euglycemic ketoacidosis

special consideration for dapagliflozin

if eGFR less than 30 --- do NOT give this drug if they've already been taking tho - can continue if tolerated

monitoring parameters for SGLT2 inhibitors

blood pressure kidney fxn volume and fasting status

in heart failure, when are diuretics given?

can be as needed for fluid overload, or chronically (ie - with a beta blocker to increase pt's tolerance)

which diuretics are first line

loop

***role of thiazides in heart failure

as an ADJUVANT -- only given to patients who show resistance to loops (ie - you keep upping the loop dose, but still no urine outpu)

pt counseling point when on thiazide + loop (when to take)

give thiazide 30 min before loop

name 4 loop diuretics

bumetanide furosemide torsemide ethacrynic acid

true or false diuretics in heart failure do NOT increase mortality

true -- they really just help with the pt's symptoms

when to use HCTZ vs metolazone

HCTZ cannot be used in CrCl less than 30 --- can use metolazone at crcl up to 5

advantage of ethacrynic acid over the other loops

has activity at PCT and DCT AND can be used in patients with sulfonamide allergy

goal diuresis when giving diuretics per day

0.5-2lITERS -- but this changes with age target would be on the lower end for older patients

3 AE of diuretics

azotemia (elevated BUN) hypokalemia metabolic alkalosis (bc ascending loop involved with acid-base control)

specific monitoring parameters for thiazides

WEIGHT potassium creatinine magnesium ~1-2 weeks after initiating

BUN: creatinine ratio should be....

20 or less greater than 20 = azotemia -- excess wastes in the blood

name 2 vasodilators that can be used in heart failure

hydralazine isosorbide dinitrate

can hydralazine and isosorbide dinitrate be used together?

YES

hydralazine/dinitrate should ALWAYS be combined with.....

mild diuretic and beta blocker usually used in combo with ACE/ARNI/ARB --- but can also be used if the pt has some contraindication to these

side effects of hydralazine/isosorbide dinitrate

headache, dizziness GI complaints

2 monitoring parameters for hydralazine/isosorbide dinitrate

blood pressure rash (hydralazine)

true or false ACE/ARB/ARNI should be tried before hydralazine/dinitrate

true

3 parameters that MUST BE MET in order to initiate ivabradine is this the same for digoxin

-normal sinus rhythm -heart rate over 70 bpm -on a beta blocker for digoxin -- -can be with OR without beta blocker -dont need normal sinus rhythm (i think heart rate still has to be over 70 bpm tho?)

true or false ivabradine does NOT reduce mortality

true only morbidity (hospitalizations)

target heart rate when giving ivabradine what is max dose?

50-60bpm max dose is 7.5mg BID

monitoring for ivabradine

HEART RATE

ivabradine is mostly used for which type of heart failure

HFrEF

target serum digoxin levels

0.5- less than 9mg/dL if goes over 1.2, mortality increases significantly

true or false a loading dose is necessary for digoxin when giving in heart failure

FALSE - not necessary

monitoring for digoxin

digoxin toxicity - GI and CNS effects renal function LOT of drug and food interactions heart rate!

when should the digoxin levels be measured

at steady state (3 or more doses) at least 6 hours after the dose was given

does digoxin reduce mortality

NO - like ivadbradine - reduce hospitalizations AND also used for HFrEF

furosemide IV:PO bumetanide IV:PO

furosemide: 2:1 (40MG po -> 40MG IV = double the dose) bumetanide: 1:1

explain the type of patient that is given digoxin

patients with persistent SYMPTOMS (late stage C) in AV block NOT considered 1st line