Naplex 2023 > Chronic Heart Failure > Flashcards

Chronic Heart Failure Flashcards

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1
Q

heart “failure”

A

heart not able to supply enough oxygen-rich blood
from impaired ventricle ability to fill or eject blood

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2
Q

causes of HF

A

MI
long-standing hypertension

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3
Q

general symptoms of HF

A

SOB/Dypsnea
cough
fatigue/weakness
reduced exercise capacity

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4
Q

lab/biomarkers of HF

A

inc BNP (norm is <100)
inc NT-proBNP (normal is <300)
shows cardiac vs non-cardiac causes of dyspnea

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5
Q

left-sided signs and symptoms

A

orthopnea: SOB lying flat
paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
bibasilar rales: crackling lung sounds heart on lung exam
S3 gallop: abnormal heart sound
hypoperfusion (renal impairment, cool extremities)

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6
Q

right-sided signs and symptoms

A

peripheral edema
ascites: abdominal fluid
jugular venous distention
hepatojugular reflux
hepatomegaly: enlarged liver from fluid congestion

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7
Q

CO

A

blood pumped by heart in 1 min
HR x SV = CO

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8
Q

stroke volume

A

volume of blood ejected from left ventricle in 1 heartbeat

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9
Q

compensatory mechanisms

A

neurohormonal pathways to inc blood volume or force/speed of contractions
leads to cardiac remodeling
RAAS
SNS
vasopressin
natriuretic peptides that balance become deficient

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10
Q

Angiotensin II

A

vasoconstrictor

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11
Q

aldosterone

A

sodium and water retention

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12
Q

vasopressin

A

vasoconstriction and water retention

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13
Q

SNS activation = NE

A

inc HR
inc contractility (positive inotrope)
vasoconstriction

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14
Q

lifestyle

A

monitor/document body weight daily
notify provider if weight inc 2-4 pounds in 1 day or 3-5 pounds in 1 week or if symptoms worsen
restrict sodium <1500 mg/day in stage A and B

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15
Q

ejection fraction

A

<=40%
HFrEF
systolic dysfunction
impaired ability to eject blood during systole

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16
Q

ACC/AHA

A

american college of cardiology and american heart association

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17
Q

NYHA

A

new york heart association

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18
Q

ACC/AHA Stage B

A

pre-HF
no signs/symptoms of HF but with structural heart disease, abnorm cardiac function, inc biomarkers

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19
Q

ACC/AHA Stage C

A

structural and/or function cardiac abnormality with prior/current symptoms

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20
Q

NYHA Class II

A

in ACC/AHA Stage C
ordinary physical activity results in HF symptoms

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21
Q

NYHA Class IV

A

in ACC/AHA Stage C or D
symptoms of HF with all physical activity or symptoms of HF at rest

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22
Q

ACC/AHA Stage D

A

advanced with severe symptoms, symptoms at rest

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23
Q

natural products

A

omega-3 fatty acids/fish oils
hawthorn and coenzyme Q10

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24
Q

Beta blockers in drug treatment

A

dec SNS = dec HR, dec contractility, negative inotrope
dec mortality

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25
ACEI/ARBs/ARA in drug treatment
dec RAAS = dec vasoconstriction/afterload; dec fluid retnetion/preload dec mortality
26
loop diuretics in drug treatment
dec fluid retention/preload dec symptoms no decrease in mortality
27
digoxin in drug treatment
inc CO dec hospitalizations no decrease in mortality
28
sacubitril in drug treatment
inc natriuretic peptides = inc vasodilation/diuresis dec mortality
29
initial meds rec for all w/o CI
ARNI/ACEI/ARB: ARNI preferred bc more morbidity/mortality dec beta-blockers control HR/reduce arrhythmia risk loop diuretics: reduce blood volume = dec edema/congestion
30
secondary add-on medications
ARA: dec morbidity/mortality; more diueresis; dec symptoms; inc EF; meed eGFR, SCr, K criteria SGLT2i: dec morbidity/mortality; meet eGFR criteria hydralazine and nitrates (BiDil): dec morbidity/mortality in black patients/patients who cannot tolerate ACEi/ARB Ivabradine (Corlanor): dec hospitalization; normal sinus rhythm and HR >=70 on max BB
31
addition medications
digoxin: small inc CO; improve symptoms/dec hospitalization (not mortality) vericiguat, soluble guanylate cyclase stimulator: dec hospitalzation and CV death after hospitalization / need for IV diuretics; not in guidelines
32
Entresto MOA
neprilysin inhibitor (sacubitril) = stops degradation of vasodilatory peptides dec HF hospitalizations/cardiovascular death first line use in place of ACEI/ARB
33
Entresto BBW
injury and death to developing fetus d/c as soon as pregnancy found
34
Entresto CI
do not use w/i 36 hrs of ACEi do not use with angioedema history
35
Entresto warnings
angioedema hyperkalemia hypotension renal impairment bilateral renal artery stenosis (avoid)
36
Entresto side effects
cough hyerkalemia inc SCr hypotension
37
Entresto monitoring
BP K renal function s/sx of HF
38
Entresto notes
do not use with ACEi/ARB
39
ACEI MOA
block angiotensin I to II = dec vasoconstriction and aldosterone secretion
40
ARBs MOA
block Ang II binding to AT1 receptor
41
captopril dosing
TID
42
enalapril dosing
target dose: 10-20 mg PO BID
43
lisinopril dosing
target dose: 20-40 mg daily
44
quinapril dosing
target dose: 20 mg BID
45
ramipril dosing
target dose: 10 mg daily
46
losartan dosing
target dose: 50-150 mg daily
47
valsartan dosing
target dose: 160 mg BID
48
ACEis/ARBs BBW
injury/death to developing fetus; d/c as soon as pregnancy found
49
ACEis/ARBs CI
history of angioedema w/i 36 hrs of Entresto
50
ACEIs/ARBs warnings
angioedema hyperkalemia hypotension renal impairment bilateral renal artery stenosis (avoid)
51
ACEis/ARBs side effects
cough hyperkalemia inc SCr hypotension
52
ACEis/ARBs monitoring
BP K renal function s/sx of HF
53
differences between ARBs compared to ACEis
less cough less angioedema no washout period for Entresto
54
ACEi/ARB/ARNI DI
hyperkalemia: other drugs that inc potassium (K-sparing diuretics; salt substitutes w/ K) do not use more than 1 RAAs inhibitor together or triple combination bc renal impair, hypotension, hyperkalemia - ACEi +/- ARNI +/- aliskiren or ACEi + ARB/ARNI + ARA can dec lithium clearance = toxicity
55
beta blockers MOA
antagonize catecholamines (esp NE) effects dec morbidity and mortality all HF patients rec only bisoprolol, carvedilol and metoprolol succinate (ER) only d/c in acute decompensated HF if hypotension or hypoperfusion metoprolol/bisoprolol: B-1 selective carvedilol: non-selective beta blocker; A-1 blocker
56
metoprolol succinate ER dosing
target dose: 200 mg daily
57
carvedilol IR dosing
target dose: <=85 kg: 25 mg BID >85 kg: 50 mg BiD
58
carvedilol CR dosing
target dose: 80 mg daily
59
BB BBW
do not d/c abruptly; taper over 1-2 weeks to avoid tachycardia, HTN, ischemia
60
BB warnings
caution in diabetes - worsen hyperglycemia/hypoglycemia; mask hypoglycemia caution w/ bronchospastic disease (asthma/COPD) caution withRaynaud's
61
BB side effects
bradycardia fatigue hypotension dizziness depression impotence exacerbate Raynaud's
62
BB monitoring
HR BP s/sx of HF
63
BB notes
metoprolol IV to PO is 1:2.5 Toprol XL: can cut in half; take w/immediately after meals
64
carvedilol notes
take with food to dec rate of absorption/risk of orthostasis
65
beta-blocker DI
enhance hpyoglycemia effects of insulin and mask symptoms of hypoglycemia - insulin and SU caution w/ dec HR: digoxin, verapamil, diltiazem
66
loop diuretics MOA
block sodium and Cl reabsorption in ascending LOH inc excretion of Na, K, Cl, Mg, Ca, H2O dec fluid volume do not improve survival symptom control
67
loop diuretics warning
sulfa allergy does not apply to ethacrynic acid
68
loop diuretics side effects
dec electrolytes: K, Mg, Na, Cl, Ca inc HCO3 (metabolic alkalosis), UA, BG, TG, TC otoxicity (more with ethacrynic acid/rapid IV of any loop orthostatic hypotension photosensitivity
69
loop diuretics monitoring
renal function fluid status (in/out/weight) BP electrolytes audiology testing s/sx of HF
70
loop diuretics notes
furosemide injection: store at room temp oral equivalent dosing: furosemide 40 mg - torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 5- mg furosemid IV: PO ratio is 1:2
71
loop diuretics DI
avoid NsAIDs: inc sodium and water = counter loop diuretics dec lithium renal clearance = toxicity
72
ARAs MOAs
compete with aldosterone at DCT and CD spiro: non-selective; also blocks androgen and endocrine side effects eplerenone: selective; not endocrine side effects dec morbidity and mortality
73
spironolactone target dose
50 mg daily or BID
74
ARA CI
do not use if hyperkalemia, severe renal impairment, Addison's disease (spiro)
75
ARA warnings
do not initiate for HF if K >5
76
ARA side effects
hyperkalemia inc SCr dizziness spiro: gynecomastia, breast tenderness, impotence eplerenone: inc TGs
77
ARA monitoring
BP K renal function fluid status s/sx of HF
78
ARA DI
hyperkalemia: other drugs that inc K caution no triple combo with ACEi + ARB/ARNI = hyperkalemia, renal insufficiency inc lithium renal clearance = inc toxicity
79
dapagliflozin dozing
eGFR <25: initiation not recommended
80
empagliflozin
eGFR <30: insufficient data
81
hydralazine MOA
direct arterial vasodilator dec afterload
82
nitrate MOA
inc NO = vasodilation and dec preload
83
hydralazine + nitrate (BiDil) benefit
improve survival alternative to those who can't take ACEi/ARBs indicated in black patients who are symptomatic despite optimal treatment with ARNI, BB, ARA, SGLT2s
84
BiDil notes
no nitrate tolerance
85
hydralazine warning
drug-induced lupus erythematosus
86
hydralazine side effects
peripheral edema headache flushing palpitations reflex tachycardia
87
isosorbide CI
do not use with PDE-5i
88
isosorbide side effects
hypotension headache dizziness lightheadedness flushing tachyphylaxis (need 10-12 hr nitrate-free interval) syncope
89
BiDil DI
not use PDE-5 inhibitors = hypotension
90
ivabradine MOA
disrupts SA node = dec HR dec hospitalization not dec mortality use on those in sinus rhythm with HR >=70
91
Ivabradine dosing
target resting HR 50-60 BPM
92
Ivabradine warnings
bradycardia = inc QTc and ventricular arrythmias
93
Ivabradine side effects
bradycardia hypertension atrial fibrillation
94
Digoxin MOA
inhibit Na-K-ATPase pump = positive inotrope inc CO negative chronotropy (dec HR) does not improve survival; dec hospitalizations add to improve symptoms, exercise tolerance, QOL
95
digoxin dosing
lower dose if renal insufficiency, smaller, older, female typical: 0.125-0.25 mg daily CrCl <50: dec dose/frequency PO to IV: dec 20-25% therapeutic range: 0.5-0.9
96
Digoxin monitoring
electrolytes renal function HR
97
Digoxin toxicity
initial: n/v, loss of appetite, bradycardia severe: blurred/double vision, greenish-yellow halos
98
Digoxin notes
antidote: DigiFab
99
Digoxin DI
those that dec HR (BB, clonidine, non-DHP CCBs, amiodarone) hypokalemia, hpyomagnesemia, hypercalcium inc risk of digoxin toxicity substrate of P-gp; inhibitors will inc digoxin (dec dose 50% when starting amiodarone)
100
Vericugat MOA
soluble guanylate cyclase stimulator
101
vericugat CI
do not use with riociguat
102
Vericugat side effects
hypotension
103
potassium oral supplementation
KCl most common
104
KCl: hard to swallow
Micro-K, Klor-Con Sprinkle: sprinkle of small amt applesauce/pudding K-tab, Klor-Con: swallow whole Klor-Con M: can cut in half of dissolved in water (stir 2 min and drink immediately) oral packet: dissolve in water and drink immediately oral solution: KCl 10% = 20 mEq/15 mL; mix 15 mL with 6 oz water comes as injection
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