Treatment of HF

Question 1

ACE inhibitors

Answer 1

“pril”
natriuresis, decrease TPR and aldosterone (can have aldosterone escape)
advantages: decrease mortality post MI, preserve renal function in diabetics, little lipid/sexual effects, bradykinin (vasodilator)
decrease preload/afterload
AE: hypotension, Na depletion, dry cough (bradykinin), hyperkalemia, angiodema, renal insufficiency, hepatotoxicity, pancreatitis, increase PGs, FETOTOXICITY
AA/low renin hypertensives respond poorly: add diuretic
many are prodrugs (not captopril and lisinopril)
preferred over ARB (although the two are comparable)

Question 2

ARB

Answer 2

“sartan”
block AT1 receptor: vasodilation and Na/water excretion
reduce preload/afterload
SE: hypotension, hyperkalemia, hepatic, FETOTOXICITY
olmesartan AE: spruelike enteropathy

Question 3

aliskiren

Answer 3

renin inhibitor: inhibits protease activity
vasodilation and natriuresis
ZE: hypotension, hyperkalemia, angiodema, FETOXICITY
DI: inhibit p-gp

Question 4

Tx for class I HF

Answer 4

no symptoms, EF

Question 5

Tx for class II HF

Answer 5

dyspnea on exertion, edema

add diuretic

Question 6

Tx for class III HF

Answer 6

dyspnea, orthopnea, PND, edema

add digoxin and spironolactone

Question 7

Tx for class IV HF

Answer 7

refractory edema

add combination diuretics, IV vasodilators, transplant/assist devices

Question 8

digitalis

Answer 8

also digoxin, digitoxin, ouabain
MOA: increase intercellular availability of Ca via inhibition of Na/K ATPase
toxicity: atrial, ventricular arrhythmias, yellow-green halo, headache, fatigue, drowsy, confusion, seizures
CI (digoxin toxicity): quinidine and amiodarone (decrease elimination), verapamil (slow HR), diuretics (hypokalemia)
does NOT effect mortality

Question 9

digibind

Answer 9

Ab to digoxin

Question 10

B-blockers

Answer 10

attenuate NE/Epi effects
short term: reduce CO, BP (get worsening of symptoms before improvement)
long term: increase CO, decrease LVEDP
improved mortality
CI: heart block, bradycardia, decompensated CHF/need for IV inotropes (dobutamine), volume overload

Question 11

NE/Epi effects on CHF

Answer 11

B-AR down regulation, arrhythmias, increased myocardial consumption/ischemia, mycyte apoptosis followed by cardiac fibrosis

Question 12

B blockers approved for CHF

Answer 12

metoprolol
carvedilol
bisprolol
nebivolol (Europe ONLY)

Question 13

Tx Stage A CHF

Answer 13

at risk
preventative measures (HTN, lipids, smoking, diabetes, EtOH)

Question 14

Tx Stage B CHF

Answer 14

class I CHF
add ACE I/ARB: prevent metabolic stress, apoptosis, remodeling stimulated by angiotensin, aldosterone and NE (prevent decline in cardiac function)

Question 15

Tx Stage C CHF

Answer 15

class II and III CHF
add B blocker, diuretic, digoxin, spironolactone

Question 16

Tx Stage D CHF

Answer 16

class IV CHF
add IV inotrope, transplant
STOP B-blockers

Question 17

diuretics

Answer 17

reduce preload, CO NOT increased
no improved survival
AE: electrolyte disturbance, hypokalemia, hyponatremia, hypochloremic metabolic alkalosis, azotemia (high NO in blood), dehydration, hypotension
DI: NSAIDs reduce efficacy (promote fluid retention)
reduce dose with ACE I/ ARB (both have mild diuretic effects)

Question 18

spironolactone/eplerenone

Answer 18

ONLY diuretics that improve prognosis of CHF
K sparing
block aldosterone effects
use in combo with loop diuretics

Question 19

furosemide/ bumetanide

Answer 19

high ceiling (loop) diuretic
AE: ototoxicity

Question 20

triamterene, amioloride

Answer 20

K sparing diuretics
amioloride NOT used in CHF
used in combo with loop diuretics

Question 21

nitrate

Answer 21

venodilator: reduce preload/afterload

reduce pulmonary congestion and LV filling pressure/wall stress

Question 22

hydralazine

Answer 22

arterial vasodilator: increase CO
reduce preload
effective in CHF but: stimulates RAS, variability in dose
AE: nausea, anorexia, +FANA, drug induced lupus, exacerbate angina (coronary steal)
use: limited to patients than are unable to tolerate ACE I
other vasodilators not effective in CHF (ex: parson, minoxidil, dihydropyrindine)

Question 23

nitroprusside

Answer 23

veno and vasodilator: reduce preload and afterload

Question 24

dobutamine

Answer 24

IV
B agonist (B1>B2), alpha 1 agonist, postive inotrope, vasodilator
limited by B-AR desensitization, arrhythmias
CI: B blocker prevents vasodilator effect of dobutamine and can cause vasoconstriction

Question 25

milirinone

Answer 25

IV
PDE inhibitor: cAMP is not degraded: inotropic
decrease after load
long term use: increases mortality in CHF

Question 26

nesiritide

Answer 26

recombinant B-type natriuretic peptide
reduce preload and after load
use: limited to those that do not respond to nitroglycerin
AE: hyoptension

Question 27

B-type natriuretic peptide and Atrial natriuretic peptide

Answer 27

released from atria in response to volume/pressure increase
elevated in CHF
promotes vasodilation, venodilation, natriuresis
reduce preload, inhibit renin and aldosterone, afferent arteriolar vasodilation, inhibits Na reabsorption