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CPR 2 Exam 1 > Wolff Heart Failure Drugs > Flashcards

Wolff Heart Failure Drugs Flashcards

1
Q

What class does Captopril fall under, what does it do, and what are its clinical applications?

A
  • ACEI (“pril”)
  • prevents angiotensin I converting to angiotensin II therefore:
    • lowers AT II levels
    • increases renin plasma levels
    • Decreases aldosterone secretion
    • Lowers BP overall
  • Used for Htn, HFrEF, and diabetic neuropathy
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2
Q

What are the toxicities of Captopril?

A
  • Cough is #1 reason people stop taking ACEI’s
  • Angioedema (fatal stop immediately)
  • Fetal toxicity (black box warning)
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3
Q

What class does Losartan fall under, what does it do, and what are it’s applications?

A
  • ARB (“sartan”)
    • its a non peptide angiotensin II receptor antagonist
  • Leads to more complete inhibition of the RAS than ACEI’s
    • doesn’t potentiate bradykinin
  • Used in:
    • Diabetic nephropathy
    • Htn
    • HF
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4
Q

Losartan has a higher selectivity for ___ than ___ receptor.

A

Losartan has a higher selectivity for AT1** than **AT2 receptor.

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5
Q

Toxicities of Losartan?

A
  • Fetal toxicity
  • Angioedema (?)
  • AE’s are more common in those with diabetic nephropathy
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6
Q

What is “noteworthy” about Valsartan?

A

It is not a prodrug meaning that it doesn’t required activation by the liver and it is excreted in feces relatively un changed

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7
Q

ACEI and ARB should be administered to who? (ACEI are slightly preferred to ARB’s)

A
  • all patients with LV systolic failure o LV dysfunction without HF unless:
    • not tolerated (try ARB)
    • Pregnant
    • Hypotensive
    • Serum creatinine >3
    • Hyperkalemia
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8
Q

What are the renal/adrenal effects of ANP?

A
  • Increased GFR
  • Decreased renin and aldosterone secretion
    • decrease Na and water reabsorption in collecting duct
  • Decrease ADH secretion and it’s effects in collecting duct
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9
Q

What is the MOA of Valsartan/Sacubitril?

A
  • Sacubitril is prodrug that inhibits Neprilysin
  • Valsartan is ARB that is not a prodrug
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10
Q

What are the effects and indications for Valsartan/Sacubitril?

A
  • Neutral endopeptidase blockage leads to increasesd levels of ANP & BNP
  • Valsartan antagonizes AT1 receptors
  • Used for Heart failure
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11
Q

Common AE’s of Valsartan/Sacubitril?

A
  • Hypotension
  • Hyperkalemia
  • Increased serum creatine

Angioedema is not common, but is serious

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12
Q

What classes of drugs/drugs are used to prevent deterioration of cardiac function?

A
  • ACEI/ARB
  • Beta adrenergic blockers
  • Spironolactone/Eplenerone
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13
Q

Heart failure ___ sympathetic activity which will result in, ____ HR, ____ contractility, and__vascular resistance.

A

Heart failure increases** sympathetic activity which will result in, **increased HR, increased** contractility, and_increased_** vascular resistance.

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14
Q

What are the three Beta Blockers that are used for heart failure?

A
  • Metoprolol
  • Bisoprolol
  • Carvedilol
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15
Q

How is Carvedilol different than Metoprolol and bisoprolol for patients with HF?

A
  • Inverse agonist at B2 receptors which are present in the heart
  • “biased” ligand that causes phosphorylation of cytoplasmic tail of receptor or interaction with B-arrestin and downstream signaling occurs
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16
Q

What is Carvedilol’s MOA?

A
  • nonselective beta and alpha adrenergic blocker
    • blocks Beta more than alpha
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17
Q

Carvedilol clinical uses?

A
  • Given if stable to prevent symptomatic HF
  • Given if there is a recent or remote hx of MI or ACS and reduced ejection fraction
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18
Q

What is Labetalol used for?

A

Severe htn or treatment of hypertensive emergencies

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19
Q

What two types of drugs should be given to all patients (unless contraindicated) with left ventricular systolic dysfunction caused by MI to reduce their mortality?

A
  • Carvedilol/Metoprolol/Bisoprolol (1 of these beta blockers)
  • ACEI
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20
Q

Beta blockers should be given to all patients with symptomatic CHRF and LVEF <40% except in the case of…?

A
  • Bronchospastic disease
  • Symptomatic bradycardia or heart block
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21
Q

What are the contraindications to Beta blockers?

A
  • Hypersensitivity to Carvedilol
  • decompensated cardiac failure
  • Bronchospastic disorders/asthma
  • Cardiogenic shock
  • Hepatic impairment
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22
Q

What are patients cautioned against abrupt withdrawal of Beta blockers?

A
  • If the drug is abruptly stopped rather than gradually, patients with CAD run the risk of acute tachycardia, htn, or ischemia
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23
Q

What other diseases are exacerbated by Beta blockers?

A
  • Vasospastic angina
  • Bronchospastic disease
  • DM
  • HF
  • Hepatic impairment
  • Myasthenia gravis
  • PAD
  • Pheochromocytoma
  • Psoriasis
  • Thyorid disease
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24
Q

What is the MOA and effects of Ivabradine?

A
  • Specific inhibition of hyperpolarization activated cyclic nucleotide gated channels within SA node
  • Its effects are disrupting the funny Na current to prolong diastole and slow HR down
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25
Q

What is Ivabradine used for?

A
  • Treatment of resting HR over 70 bpm in patients who are stable but have symptomatic LVHF <35% and cannot tolerate more beta blockers
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26
Q

What are the Contraindications of Ivabradine?

A
  • Acute decompensated HF
  • Hypotension
  • Sick sinus syndrome/AV block
  • Pacemaker
  • Severe hepatic issues
  • Strong CYP3A4 inhibitor use
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27
Q

what is the MOA of Spironolactone?

A
  • Competitive antagonist of aldosterone receptors
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28
Q

Effects and uses of Spironolactone?

A
  • K sparing diuretic
  • Antagonizes profibrotic effect of aldosterone
  • Used to:
    • Counteract K loss induced by other Diuretics
    • Reduce fibrosis in HFrEF and post MI heart failure
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29
Q

Toxicities of Spironolactone?

A
  • Hyperkalemia
  • amenorrhea, hirsutism, gynecomastia, impotence
  • Tumorigen in chronic animal toxicity studies so avoid unnecessary use
30
Q

What are common reasons to give diuretics?

A
  • Essential Htn
  • Edema associated with CHF, Liver failure, and Kidney failure
31
Q

If a diuretic works upstream from the collecting duct what is it’s effect on K?

A

K losing

  • Thiazides and loop diuretics
32
Q

If a diuretic exerts effects in the collecting duct what happens with K?

A
  • They are K sparing
  • Spironolactone (aldosterone blocker)
  • Triamterene and amiloride (Na channel blocker)
33
Q

What is the effect of extracellular K on excitable tissues?

A
  • If we are hyperpolarized (hypokalemic) we are too far from threshold to fire an AP
  • If we are hyperkalemic we are more depolarized than normal and can be fired by “noise”
  • Increase RMP to above threshold to where the cell can’t repolarize to fire a second time properly
34
Q

H___kalemia increases the toxicity of digitalis in patients with CHF?

A

Hypokalemia

35
Q

What are the effects of hyperkalemia on the heart?

A
  • Tall T waves
  • Prolonged PR
  • Widened QRS
  • Flattened P
  • Bradycardia, ventricular tachy, or fibrillation
  • Sinus arrest or nodal rhythm with asystole
36
Q

Hypokalemia effect’s on heart?

A
  • Flattened T waves
  • ST segment depression
  • Prolonged QT
  • Tall U waves
  • Atrial arrhythmia
  • Vent tachy or V.fib
37
Q

What do loop diuretics block?

A
  • Na K and 2CL cotransporter blockers
  • they are K losing
38
Q

MOA of Furosemide and class?

A
  • inhibits reabsorption of Na and Cl in thick ascending loop of henle blocking the NaK2Cl transporter
  • Loop diuretic
39
Q

Furosemide clinical uses?

A
  • management of edema assoc. with
    • HF
    • Liver failure
    • Renal failure
  • Decreases preload and decreases ECV
  • rapid dyspnea relief
  • treats htn
  • works in patients with low GFR unlike thiazides
40
Q

Toxicities of furosemide?

A
  • Hypokalemia
  • Hyponatremia
  • Hypocalcemia (Increased risk kidney stones)
  • Hypomagnesemia
  • Hypochloremic metabolic alkalosis
  • Hyperglycemia
  • Hyperuricemia
  • Ototoxicity
  • Sulfa drug so hypersensitivity risk
41
Q

If you have a patient with a sulfa allergy, what loop diuretic can you give them?

A

Ethacrynic acid

42
Q

What drugs do loop diuretics interact with?

A
  • Digoxin
  • Ototoxic drugs
  • Potassium sparing diuretics
43
Q

MOA for HCTZ?

A
  • Inhibits sodiuim reabsorption in distal tubules by blocking NaCl transporter
  • K losing
44
Q

What is HCTZ used for?

A
  • Hypertension
  • not effective with low GFR
  • treatment of edema
  • Calcium nephrolithiasis off label
45
Q

What vasodilators are used for Chronic HF?

A
  • Isosorbide dinitrate to dilate veins and decrease preload
  • Plus hydralazine to dilate arteries and decrease afterload
  • Packaged as BiDil
  • Useful for African Americans
46
Q

Nitroglycerin effects and clinical uses?

A
  • Vasodilator effect on veins and arteries
  • used for angina pectoris
  • acute decompensated HF especially when assoc with acute MI
47
Q

Effects of hydralazine? Clinical uses for it?

A
  • direct vasodilation of arterioles
  • Moderate to severe hypertension
  • off label for HFrEF and hypertensive emergency
48
Q

Hydralazine AE’s?

A
  • Angina pectoris
  • Flushing
  • Peripheral edema
  • tachycardia
  • Pruritis
  • Drug induced lupus like syndrome
49
Q

MOA of Digoxin? Effects?

A
  • Na K ATPase inhibition
  • Direct suppression of AV node conduction
  • Increased contractility
  • Positive inotropic effect, enhanced vagal tone and decreased ventricular rate to fast atrial arrhythmias
50
Q

Pharmacokinetics of digoxin?

A
  • crosses placenta but long hx of safe use in pregnant women with SVT
51
Q

Digoxin non cardiac adverse effects?

A
  • anorexia
  • N/V
  • salivation
  • halos, yellowish or greenish tinge to objects
52
Q

Digoxin drug interactions?

A
  • Diuretics- these cause hypokalemia and that leads to increased digoxin binding leading to increased toxicity
  • ACE inhibitors ARBS increase K levels decreasing digoxin effects
  • Sympathomimetics
  • Quinidine, spironolactone, varapamil,propafenone, and alprazolam
  • Cholesterol binding resins
53
Q

How does Digoxin impact the EKG?

A
  • depression of ST segment and longer PR interval at therapeutic levels
  • toxic levels you get AV dissociation (lacking QRS after every P)
  • toxic levels also result in ectopic ventricular beats
54
Q

In order to administer digoxin what must the heart rate be?

A
  • “normal” cant be less than 60 bpm or toxicity can occur causing an AV block
55
Q

How do you treat a digoxin OD?

A
  • KCl
  • Lidocaine (Na channel blocker)
  • Phenytoin (Na channel blocker)
  • Anti digitalis Ab’s (Digibind)
56
Q

For patients who are classified into Stage A (ACCF/AHA) what medications are going to be used?

A
  • ACEI or ARB in patients with vascular disease or DM
  • Possibly statins
57
Q

For patients who are classified into Stage B (ACCF/AHA) what medications are going to be used?

A
  • ACEI or ARB
  • Beta blockers if appropriate
  • Potentially defibrillator or revasculartaion
58
Q

For patients who are classified into Stage C (ACCF/AHA) what medications are going to be used?

A
  • ACEI or ARB’s or ARNI with a beta blocker and aldosterone antagonist
59
Q

Valsartan/Sacubitril should not be administered with what class?

A

ACEI as it increases bradykinin and increases risk of angioedema

60
Q

What medications are tolerated better when patients are “dry”? (stage C)

A

Beta blockers, but only carvedilol, metoprolol, or bisoprolol

61
Q

What medications are better tolerated when patients are “wet”? (stage C)

A
  • ACEI/ARB/Angiotensin receptor neprilysin inhibitor (ARNI)
  • ARNI are preferred
62
Q

Once you have a beta blocker and angiotensin antagonist and still aren’t seeing results (stage C), what should you add?

A

aldosterone antagonist or a SGLT2 inhibitor

63
Q

In an African American patient who is persistently symptomatic despite their therapies what should you consider?

A
  • consider hydralazine and isosorbide dinitrate
  • If resting HR is above 70 in sinus rhythm despite max beta blocker add ivabradine
64
Q

For patients with HFrEF in stage D, what are additional therapy options that need to be considered?

A
  • Palliative care
  • Transplant
  • LVAD
  • Investigational study
65
Q

In a patient with HFpEF, what drugs have NO evidence of improving the sx?

A
  • nitrates
  • PDE5 inhibitors
  • Digoxin
66
Q

For a patient with HFpEF what should the therapy be directed at?

A
  • symptoms and the associated symptoms
    • htn
    • lung dz
    • CAD
    • a. fib
    • obesity
    • anemia
    • DM
    • Kidney dz
    • sleep apnea
67
Q

What do you give to a patient in ADHF?

A

More Diuretics

68
Q

ADHF who is hypertensive, what do you give?

A

Loop diuretic + vasodilator

69
Q

Hypotensive ADHF patient, what do you give them?

A

Loop diuretic

70
Q

Drugs to avoid in patients with HF?

A
  • Class 1 antiarrhythmics
  • CCB
  • NSAIDs

CPR 2 Exam 1 (21 decks)

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