PHRM 845 > Heart Failure > Flashcards

Heart Failure Flashcards

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1
Q

What is the left ventricular ejection fraction (LVEF) for HF with reduced EF (HFrEF)?

A

Less than or equal to 40%

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2
Q

What is the LVEF for HFmrEF?

HF with mildly reduced EF

A

41 to 49%

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3
Q

What is the LVEF for HFpEF?

HF with preserved EF

A

Greater than or equal to 50%

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4
Q

What is the LVEF for HFimpEF?

HF with improved EF

A

Baseline of less than or eqaul to 40%, a minimum 10 point increase from baseline, and a second measurement of greater than 40%

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5
Q

What are the common causes of HFrEF?

A
  • coronary artery disease (MI or ischemia)
  • dilated cardiomyopathies (drug-induced, viral infections, postpartum)
  • pressure overload (HTN, pulmonic valve stenosis)
  • volume overload
  • ischemic dilated cardiomyopathies is 70% of cases
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6
Q

What are the common causes of HFpEF?

A
  • HTN is most common cause
  • increased ventricular stiffness
  • mitral or tricuspid valve stenosis
  • pericardial disease
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7
Q

What is the predominant abnormality in patients with HFrEF?

A

Abnormality in the systolic function of the LV (decreased contractility)

HFpEF have an abnormality in diastolic function

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8
Q

What are the compensatory mechanisms that activate upon a decrease in cardiac output (CO)?

A
  • tachycardia and increased contractility through SNS activation
  • Frank-starling – an increase in preload results in an increase in stroke volume (SV)
  • vasoconstriction
  • ventricular hypertrophy and remodeling
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9
Q

What are the 3 categories of drugs that induce heart failure?

A
  • Reduce contractility (negative inotropes)
  • Direct cardio toxins
  • Increase sodium and water retention
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9
Q

What are the signs and symptoms of right ventricular failure?

primarily systemic venous congestion

A
  • abd pain, nausea, bloating
  • peripheral edema, hepatomegaly, ascites
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10
Q

What are the signs and symptoms of left ventricular failure?

primarily pulmonary congestion

A
  • dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea
  • rales, S3 gallop, pulmonary edema
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11
Q

What are the major signs and symptoms of pulmonary congestion?

left ventricular failure

A
  • dyspnea on exertion (DOE)
  • orthopnea
  • paroxysmal nocturnal dyspnea (PND)
  • bendopnea
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12
Q

What is the major sign/symptom of systemic venous congestion?

right ventricular failure

A
  • peripheral edema
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13
Q

What BNP values may indicate HF?

A

BNP > 35 pg/mL

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14
Q

What NT-proBNP value may indicate HF?

A

NT-proBNP > 125 pg/mL

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15
Q

Describe NYHA functional class I:

A

Patients with cardiac disease but without limitation of physical activity

asymptomatic

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16
Q

Describe NYHA FC II:

A

Patients with cardiac disease resulting in slight limitation of physical activity

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17
Q

Describe NYHA FC III:

A

Patients with cardiac disease resulting in marked limitations of physical activity

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18
Q

Describe NYHA FC IV:

A

Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort

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19
Q

Describe stage A HF:

A
  • high risk for developing HF, but no identified structural or functional abnormalities
  • have never shown signs or symptoms of HF
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20
Q

Describe stage B HF:

A
  • structural heart disease that is strongly associated with HF, but NO s/s of HF
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21
Q

Describe stage C HF:

A

Current or prior symptoms of HF associated with underlying structural heart disease

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22
Q

Describe stage D HF:

A
  • Advanced structural heart disease and marked symptoms of HF at rest
  • multiple hospitalizations
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23
Q

List negative inotropes that can induce/worsen heart failure:

A
  • flecainide
  • beta-blockers
  • diltiazem
  • itraconazole

antirrhthmics, b-blockers, CCBs

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24
List direct cardio toxins that can worsen/induce heart failure:
- Blue cohosh - Ethanol - Amphetamines - Doxorubicin
25
List sodium and water retaining drugs that can induce/worsen heart failure:
- glucocorticoids - NSAIDs - pioglitazone - Androgens & estrogens
26
What is the beneficial effect of increased preload (due to sodium and water retention)?
Increased preload optimizes stroke volume via Frank-Starling mechanism.
27
What is the detrimental effect of increased preload (due to sodium and water retention)?
- pulmonary and systemic edema - increased MVO2 (myocardial oxygen demand)
28
What are the beneficial effects of vasoconstriction? | compensatory response
- maintains BP despite reduced CO - shunts blood from nonessential organs to brain and heart
29
What are the detrimental effects of vasoconstriction? | compensatory response
- increase MVO2 - increased afterload decreases stroke volume and further activates the compensatory responses
30
What is the beneficial effect of tachycardia and increased contractility (due to SNS activation)?
- helps maintain CO
31
What are the detrimental effects of tachycardia and increased contractility (due to SNS activation)?
- Increased MVO2 - shortened diastolic filling time - B1-receptor downregulation --> decreased receptor sensitivity - precipitation of ventricular arrhythmias - increased risk of myocardial cell death
32
What are the beneficial effects of ventricular hypertrophy and remodeling?
- helps maintain CO - reduces myocardial wall stress - decreases MVO2
33
What are the detrimental effects of ventricular hypertrophy and remodeling?
- Diastolic dysfunction - systolic dysfunction - increased risk of myocardial cell death - increased risk of myocardial ischemia - increased risk of fibrosis
34
What drug therapies are recommended for patients in stage A HF?
ACE inhibitor or ARB
35
What drug therapies are recommended for patients in stage B HF? | previous MI or asymptomatic rEF
- ACEI/ARB - Beta-blocker
36
What drug therapies are recommended for patients in stage C HF?
- ACEI/ARB (ARNI preferred) - Beta-blocker - Aldosterone antagonist - SGLT2 inhibitor - Loop diuretic (IF they're fluid overloaded!)
37
What impacts do diuretics have on HF treatment?
- they reduce hospitalizations but they DO NOT reduce mortality nor impact progression of HF - only given to patients with fluid overloaded symptoms
38
What is the mechanism of action of diuretics?
- increase sodium and water excretion by reducing sodium reabsorption at a variety of sites in the nephron
39
Which diuretics are used in HF?
- furosemide (Lasix) - bumetanide (Bumex) - torsemide (Demadex)
40
What are the dosages for furosemide (Lasix)?
- Initial: 20-40 mg QD or BID - Usual: 20-160 mg QD or BID - CrCl 20-50: 20-160 mg QD or BID - CrCl <20: 400 mg daily
41
What are the dosages for bumetanide (Bumex)?
- Initial: 0.5-1.0 mg QD or BID - Usual: 1-2 mg QD or BID - CrCl 20-50: 2 mg QD or BID - CrCl <20: 8-10 mg QD
42
What are the dosages for torsemide (Demadex)?
- Initial: 10-20 mg QD - Usual: 10-80 mg QD - CrCl 20-50: 40 mg QD - CrCl <20: 200 mg QD
43
What is the initial dose of ethacrynic acid (Edecrin)?
25-50 mg QD or BID
44
What are the IV equivalent doses for loop diuretics?
BTFE B 1 = T 20 = F 40 = E 50
45
When might thiazide diuretics be used in treatment?
- may be used in patients with mild HF and small amounts of fluid HF - can be used in combo with loops if the loops is losing efficacy
46
What are the dosages for hctz (hydrodiuril, microzide)?
- initial: 25 mg QD - max: 100 mg QD
47
What impact do loop diuretics have on Mg and K?
Decrease them
48
What BUN/Scr indicates volume depletion?
Anything greater than 20/1
49
What are indicators of volume depletion?
- hypotension - increased BUN/Scr ratio
50
When should K and Mg replacement be initiated?
- K < 4.0 - Mg < 2.0
51
When should switching loops or adding a thiazide be considered?
- If reaching a high dose of loop equivalent to 120 mg of furosemide twice daily | 3 mg B BID, 60 mg T BID
52
What are the benefits of using ACE inhibitors in HF?
- decreased aldosterone - decreased Na and water retention - decreased vasoconstriction - decreased norepinephrine - improved cardiac hemodynamics
53
List the ACE inhibitors used:
- benazepril (Lotensin) - ramipril (Altace) - quinapril (Accupril) - captopril (Capoten) - lisinopril (Zestril, Privinil) - enalapril (Vasotec) - fosinopril (Monopril)
54
How do you convert the dose between enalapril, captopril, lisinopril?
enalapril 20 = captopril 150 = lisinopril 20
55
What is the dosing for enalapril (Vasotec)?
- initial: 2.5-5 mg QD - target: 10 mg BID
56
What is the dosing for captopril (Capoten)?
- initial: 6.25-12.5 mg TID - target: 50 mg TID
57
What is the dosing for lisinopril (Zestril, Privinil)?
- initial: 2.5-5 mg QD - target: 20-40 mg QD
58
How should an ACE inhibitor dose be adjusted if the patient has an Scr > 3 and/or a CrCl < 30 mL/min?
Half the dose
59
What are the absolute contraindications for ACE inhibitors?
- pregnancy - history of angioedema or hypersensitivity - bilateral renal artery stenosis - well-documented intolerance | intolerance due to symptomatic hypotension, decline in renal, hyper K or cough
60
What adverse effects are unique to captopril (Capoten)?
- skin rash - altered taste
61
What ARBs are used in HF?
- candesartan (Atacand) - losartan (Cozaar) - valsartan (Diovan)
62
What is the dosing for losartan (Cozaar)?
- initial: 25-50 mg QD - target: 150 mg QD
63
What is the dosing for valsartan (Diovan)?
- initial: 20-40 mg BID - target: 160 mg BID
64
What is the dosing for candesartan (Atacand)?
- initial: 4 mg QD - target: 32 mg QD
65
What is the mechanism of action of sacubitril/valsartan (Entresto)?
- sacubitril: inhibits neprilysin which leads to increased levels of peptides and induces vasodilation and sodium excretion - valsartan: directly antagonizes the angiotensin II receptors. Reduces vasoconstriction, aldosterone release, arginine vasopressin release
66
What are the dosing options for sacubitril/valsartan (Entresto)?
- 24/26 mg BID - 49/51 mg BID - 97/103 mg BID
67
When would 24/26 mg Entresto be used?
- If the pt is ACE/ARB naive - if the pt was previously on a low/medium dose of ACE/ARB - moderate hepatic impairment - Age > 75
68
What is the initial dose of sacubitril/valsartan (Entresto) for patients taking high dose ACE/ARB? - High ACE: > 10 mg enalapril, 75 mg captopril, 10 mg lisinopril - High ARB: > 160 mg total daily valsartan
49/51 mg BID | Max dose: 97/103 mg BID
69
How much time must pass before a patient can start the ARNI after haven taken an ACEi?
36 hours
70
Which beta blockers are used in HF?
- carvedilol (Coreg) - metoprolol XL (Toprol XL) - bisoprolol (Zebeta)
71
What impact do beta blockers have on mortality and disease progression?
- decrease mortality - slow progression
72
What is the rationale for the use of beta blockers in HF?
- decrease ventricular arrhythmias - **reversal of cardiac remodeling** - reduction in myocardial cell death
72
Which patients are candidates for the initiation of beta blockers?
- stable - euvolemic
73
What is the dosing for bisoprolol (Zebeta)?
- initial: 1.25 mg QD - target: 10 mg QD
74
What is the dosing for carvedilol (Coreg)?
- initial: 3.125 mg BID - target: 25-50 mg BID
75
What is the dosing for metoprolol XL (Toprol XL)?
- initial: 12.5-25 mg QD - target: 200 mg QD
76
What are the weight dosing considerations for carvedilol (Coreg)?
- less than 85 kg --> 25 mg BID - 85 kg+ --> 50 mg BID
77
What are the monitoring parameters for beta blockers?
- BP, HR - fluid retention - fatigue or weakness
78
What are the benefits of aldosterone receptor antagonists? | spironolactone, eplerenone
- decreases K and Mg losses --> arrhythmia protection - decreases Na retention --> decreases fluid retention - decreases sympathetic stimulation - blocks direct fibrotic action on myocardium
79
Which aldosterone antagonist is non-selective?
spironolactone | This is why it has hormonal related adverse effects
80
What is the dosing for eplerenone (Inspra) for patients with CrCl > 50?
- initial: 25 mg QD - maintenance: 50 mg QD
81
What is the dosing for eplerenone (Inspra) for patients with CrCl 30-49?
- initial: 25 mg QOD - maintenance: 25 mg QD
82
What is the dosing for spironolactone (Aldactone) for patients with CrCl > 50?
- initial: 12.5 - 25 mg QD - maintenance: 25 mg QD
83
What is the dosing for spironolactone (Aldactone) for patients with CrCl 30-49?
- initial: 12.5 mg QD or QOD - maintenance: 12.5 - 25 mg QD
84
What are the contraindications for starting aldosterone antagonists?
- CrCl < 30 mL/min - K > 5 mEq/L
85
What are the monitoring parameters for aldosterone antagonists?
- check renal fx and K within 3 days to 1 week after any change or addition that may impact K concentrations - then once a month for 3 months - then every 3-4 months and with increases in ACEi/ARBs
86
What is the indication for SGLT2 inhibitors in HF?
- reduce mortality and hospitalization
87
Which SGLT2 inhibitors are used in HF?
- dapagliflozin (Farxiga) - empagliflozin (Jardiance) - 10 mg QD
88
What are the renal function requirements for the SGLT2 inhibitors?
- dapa CrCl > 30 - empa CrCl > 20
89
What is the brand name of hydralazine?
Apresoline | arterial vasodilator
90
What is the brand name for isosorbide dinitrate?
Isordil | venous vasodilator
91
What is the brand name of isosorbide dinitrate and hydralazine?
BiDil
92
What are the benefits to ISDN/hydralazine in HF?
- causes reductions in both preload and afterload - reduces mortality
93
What are the adverse effects to ISDN/hydralazine? | The adverse effects are a major limiting factor for these drugs
- headache - nausea - flushing - tachycardia - lupus-like syndrome - hypotension - myocardial ischemia - fluid retention
94
What is the dosing for hydralazine (Apresoline)? | used in combo with ISDN
- initial: 25 mg TID/QD - target: 75 mg TID - max: 100 mg TID
95
What is the dosing for ISDN (Isordil)? | used in combo with hydralazine
- initial: 20 mg TID/QD - target: 40 mg TID - max: 80 mg TID
96
What is the dosing for ISDN/hydralazine (BiDil)?
- initial: 20/37.5 mg TID - max: 40/75 mg TID
97
What are the indications for ISDN/hydralazine therapy?
- stage C, black patients in adjunct to their **optimized** medical therapy to improve symptoms and reduce mortality - stage C, patients with sxs who can't receive ARNI/ACEi/ARB due to intolerance or **renal insufficiency**
98
What is the indication for ivabradine? | Dose: 2.5-5 mg BID; max 7.5 mg BID
- reduce the risk of hospitalization for symptomatic HFrEF patients with NSR that are already being treated with a maxed out beta blocker and HR > 70 BPM at rest - NO MORTALITY REDUCTION
99
What are the benefits to digoxin (Lanoxin) in HF?
- increases parasympathetic activity - reduces HR at rest and slows AVN conduction - re-sensitization of baroreceptors
100
What is the indication for digoxin (Lanoxin) in HF?
- pts with HF and Afib - consider in patients with symptomatic HFrEF despite optimized GDMT, or who can't tolerate GDMT - DECREASES HOSPITALIZATION, not mortality
101
What is the dosing and serum concentration goal for digoxin (Lanoxin)?
- **0.125** - 0.25 mg daily - 0.5 - 0.9 ng/mL - lower doses in > 70 years, impaired renal fx, low weight
102
What drugs interact with digoxin (Lanoxin)?
- amiodarone (200% increase) - quinidine (80% increase) - verapamil (50% increase) - Itra/KTZ (50% increase) | increases dig concentration
103
What are the adverse effects of digoxin (Lanoxin)?
- nausea, vomiting, abd pain - visual disturbances - weakness, confusion, delirium - sinus bradycardia
104
When could vericiguat (Verquvo) be used in HF? | just know it exists
- consider in select high-risk pts with worsening symptoms despite optimized GDMT to decrease mortality and hospitalizations
105
How can omega-3 PUFAs be used in HF?
Reasonable as adjunct therapy
106
How can antiplatelets be used in HF?
- use aspirin for HF pts with IHD/CAD/ASCVD - otherwise, not recommended for routine use
107
How can anticoagulants be used in HF?
- Recommended in HF in patients with Afib - **Routine anticoagulation is not recommended**
108
How can calcium channel blockers be used in HF?
- **felodipine and amlodipine** may be useful in managing angina/HTN if not effectively managed with HF therapies | diltiazem, verapamil, and nifedipine should not be used
109
When might an ICD be considered in HF?
- LVEF <35%, NYHA II-III - LVEF <30%, NYHA I - both at lease 40 days post-MI
110
Is digoxin (Lanoxin) used in HFpEF?
No
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