Cardio Drugs & Pathophysiology

Front 1

Causes of Systolic HF

Back 1

Reduction in muscle mass (MI)
dilated caridomyopathy (infection/etoh/cardiotoxins)
ventricular hypertrophy (pressure overload due to HT/aortic stenosis)
Volume overload (valvular regurgitation)

Front 2

Causes of Diastolic HF

Back 2

increased ventricular stiffness (ventricular hypertrophy/infiltrative myocardial diseases/MI)
Valvular stenosis
Pericardial disease

Front 3

HF signs & symptoms

Back 3

jugular venous distension
orthopnea
edema
pulmonary congestion
dysnea on exertion
pexroismal nocturnal dysnea

Front 4

Dyspena

Back 4

breathness on exertion

Front 5

orthopnea

Back 5

dyspnea in the supine position

Front 6

parxoysmal nocturnal dyspena

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attacks of severe SOB and coughing that occur at night

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NYHA Class I

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No limitation of physical activity

Front 8

NYHA Class II

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slight limitation of activity. Dyspnea and fatigue with moderate activity like walking up the stairs too quickly

Front 9

NYHA Class III

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Marked limitation of activity. Dyspnea with minimal acitivy such as walking slowly up statirs

Front 10

NYHA Class IV

Back 10

severe limitation of activity. have symptoms at rest

Front 11

Physical Signs of left-sided HF

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pulmonary rales, pleural effusions, loud P2 component of second heart sound, S3, S4, or Signs of poor CO
-cyanosis
-diaphoresis
-cool extremities
-tachypnea
-cheyne-stoke breathing pattern
-tachycardia
-pulsus alternans

Front 12

cyanosis

Back 12

(a bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished (as in carbon monoxide poisoning)

Front 13

Pulsus alternans

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physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.

Front 14

Cheyne-stokes breathing pattern

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An abnormal type of breathing seen especially in comatose patients, characterized by alternating periods of shallow and deep breathing

Front 15

Physical findings of right-sided of HF

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Signs of volume excess:
-jugular venous distention
-heptomegaly (enlarged liver)
-hepato-jugular reflex
-perpheral edema

Front 16

cardiomegaly

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cardio-thoracic ration of greater than 0.5 on xray film
can be present in HF

Front 17

Echocradiogrpahy Dx of Systolic dysfunction

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dilated LV from prior MI with depressed LV function

Front 18

Stage A HF

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at high risk for HF but no structural heart disease of symptoms of HF. These include patients with HT/CAD/DM/using cardiotoxins/FH. Treat HT, lipid disorders, and ACEi in appropiated patients

Front 19

Stage B HF

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Structural heart disease without HF symptoms. Include patients with prior MI, LV systolic dysfunction, or asymptomatic valvular disease. Tx: ACEi & BB in appropriate patients

Front 20

Stage C HF

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Structural heart disease w/prior/current HF symptoms. Include patients w?known structural heart disease, SOB, fatigue, reduced exercise tolerance. Tx: diuretics/ACEi/BB/Digoxin/Na+ restriction

Front 21

Stage D HF

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end stage HF/refractory HF requiring interventions. Include patients with HF symptoms @ rest and are repeatably hospitalized. TX: all measure under stage a/b/c, mechanical assist devices, continuous not intermittent IV inotopic infusions for palliation & hospice care

Front 22

see ventricular hypertrophy

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on chest x-ray or ECG

Front 23

Chest x-ray

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see ventricular hypertrophy
plueral effusions
pulmonary edema

Front 24

ECO

Back 24

single most useful evaluation procedure. It can identify abnormalities of the pericardium, myocardium or heart values and quantify the LVEF

Front 25

NYHA

Back 25

classifies symptoms

Front 26

ACC/AHA

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stages HF for evaluating, preventing and treating

Front 27

Nonpharmacologic interventions for treatment of HF

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cardiac rehabilitation
restrict fluid intake to 2L/day
restrict Na+ to 2-3g/day

Front 28

Stage A tx

Back 28

treat underlying disorders
ACEi should be strongly considered for HT in patients with multiple vascular risk factors

Front 29

Stage B tx

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previous MI and/LVEF < 40% take ACEi and BB

Front 30

Stage C tx

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all patients on ACEi and BB
diuretic if clinical evidence of fluid retention
if symptoms do not improve an aldosterone antagonist, digoxin and/hydralazine/isosorbide dinitrate

Front 31

Stage D tx

Back 31

symptoms @ rest despite maximal medical therapy
mechanical circulatory support, continuous IV positive inotropic therapy, cardiac transplantation, hospice care

Front 32

Diuretics in HF

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thiazide (HCT) & thiazide-like (metolazone) are rarely used alone/usually w/a loop
do not maintain effectiveness in impaired renal function

Front 33

Loops in HF

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restore & maintain euovlemia
increase dose w/decreased CrCl
furosemide/bumetanide/tosemide
doses above ceiling dose are not more effective(increase doses/day)

Front 34

Furosemide

Back 34

usual dose: 20-160 mg/day PO
CrCl= 20-50 mL 160 mg
CrCl < 20 mL 400 mg

Front 35

ACEi in HF

Back 35

reduce ventricular remodeling, myocardial fibrosis, myocyte apoptosis, cardiac hypertrophy, NE release, vasoconstriction, and na and h20 retention. improve symptoms, slow disease progression and decrease mortality

Front 36

BB benefits in HF

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slow down disease progression, decrease hospitalization, reduce mortality, antiarrhythmic effects, slow/reverse ventricular remodeling, decrease catecholamine induce myocyte death due to necrosis or apoptosis, prevent fetal gene expression, improve LV function, decrease HR which decreases O2 demand and inhibit plasma renin release

Front 37

BB in HF

Back 37

only metoprolol CR/XL, carvedilol, and bisoprolol have been shown to decreases mortality
doses should be doubled Q2weeks due to negative inotropic effects to avoid symptomatic worsening/acute decompnstation

Front 38

Carvedilol in HF

Back 38

initial dose: 3.125 mg BID
target dose: 25 mg BID (50 mg >85 kg)
Also correg CR

Front 39

Metoprolol CR/XL in HF

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initial dose: 12.5-25 mg QD
target dose: 200 mg QD

Front 40

Bisoprolol

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1.25 mg starting does-not available dosage form therefore not used!
target: 10 mg QD

Front 41

FDA approved ARBs for HF

Back 41

Candesartan & Valsartan

only used when can't take ACEi

Front 42

Candesartan

Back 42

initial dose: 4-8mg QD
target dose: 32 mg QD

Front 43

Valsartan

Back 43

initial dose: 20-40 mg BID
target dose: 160 mg BID

Front 44

When do you use aldosterone antagonists in HF:

Back 44

patients w/moderate-severe HF on in addition to standard therapy & those w/ LV dysfunction early after MI

Front 45

When NOT to used aldosterone antagonists:

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renal impairment, recent worsening of renal function, high K+ levels, history of severe hyperkalemia

Front 46

Spironolactone

Back 46

intial does: 12.5 mg QD
target dose: 25 mg QD

Front 47

eplereonone

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initial does: 25 mg QD
target dose: 50 mg QD (titrated in 4 weeks)

Front 48

monitoring w/ aldosterone antagonists

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renal function and potassium concentrations

Front 49

Digoxin

Back 49

in HF & suprventricular arrhythmias like Afib it should be used in early in therapy for rate control. In NSR be used in addition to standard therapies in symptomatic HF to reduce hospitalizations

Front 50

Digoxin dosing

Back 50

achieve [plasma] = 0.5-1 ng/mL ~ 0.125 mg QD
in renally impaired, elderly, and DI (amiodarone) take 0.125 mg QOD

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hydralazine & ISDN dosing

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ISDN 20 mg and hydralazine 37.5 mg TID

Front 52

When to use hydralazine & ISDN in HF

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for African americans, can't tolerate ACEi/ARB (angioedema), or in addition to standard therapy for persistent therapy

Front 53

Prove ACEi in HF

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captopril, lisinopril, ramipril, trandolapril, and enalapril

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DO NOT USE in Stage B HF

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Digoxin
nutritional supplements
non-dihydorpyridine CCB

Front 55

Digoxin in Stage B HF

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should not be used in patients w/low LVEF, in NSR, and have no history of HF symptoms
harm>benefit

Front 56

CCB in Stage B HF

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do not used non-dyhropyrides (verapamil/dilitiazem) have negative inotropic activity which is bad in patients with low LVEF & asymptomatic (use amolodipine)

Front 57

Stage C HF

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LVEF < 40%

Front 58

Stage C HF + HT

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ARB/hydralazine&ISDN/amlopidine/felodipine in addition to ACEi and BB

Front 59

Stage C HF + angina

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nitrates/amoldipine/felodipine

Front 60

Drugs that can exacerbate HF (don't take in Stage C HF

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NSAIDS, antiarrhythics (disopyramides, flecainide, ropafenone), verampil/ditiazem, rosiglitazone and pioglitazone, ethanol

Front 61

Furosemide

Back 61

20-160 mg/day
CrCl 20-50ml/min: 160mg/day
CrCl < 20ml/min: 400mg/day
ID: 20/40 QD/BID
TD: 600 mg

Front 62

NSAIDS

Back 62

can worsen HF
cause hyperkalemia w/aldosterone antagonists and have DI w/ACEi

Front 63

Digoxin DIs

Back 63

amiodarone/BAS/diuretics/
erythormcyin/clarithomycin
/tetracycline/ketoconazole/
itaconazole/quinidine/propafenone/
spironolactone/verapamil

Front 64

Digoxin toxicity

Back 64

AV block, ventricular and atrial arrhythmias, ventricular fibrillation, atrail and ventricular tachycardia, sinus bradycardia

Front 65

Bumetanide

Back 65

initial does: 0.5-1 mg QD/BID
target does: 10 mg QD

Front 66

Torsemdie

Back 66

initial does: 10-20 mg QD
target dose: 200 mg QD

Front 67

Using diuretics in HF

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monitor dehydration, K+, Mg2+, volume overlaod
Avoid NSAIDs & COX-2 inhibitors

Front 68

D/C diuretic

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BUN/CR =20/1
Sign of decreased kidney perfusion

Front 69

Enalapril Dose

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prodrug
initial dose: 2.5 mg BID
target dose: 10 mg BID
eliminated renally

Front 70

Captopril dose

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initial dose: 6.25 mg TID (short acting)
target dose: 50 mg TID
eliminated renally

Front 71

Ramipril

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initial dose: 1.25-2.5 mg QD
target dose: 10 mg QD
eliminated renally

Front 72

ATLAS trial

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lisinopril
NYHA II-IV
high dose better than no dose
low dose better than no dose

Front 73

ACEi AEs

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hyperkalemia, dry cough (inhibits brady
kinin), angioedema
*cough could be due to worsening HF
from pulmonary congestion

Front 74

ACEi contraindications

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bilateral renal artery stenosis
pregnancy
angioedma w/ACEi

Front 75

ELITE II

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ARB/ACEi
EF < 40%, >60 yrs
losartan & captopril
no difference is all coause mortality

Front 76

CHARM

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EF=30% age~66 yrs
candesartan vs. placebo
30% reduction in death/hospitalization
for CHF

Front 77

VAL-HeFT

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NYHA II-IV
valsartan vs. placebo
decreased hospitalization

Front 78

CHARM-Added Study

Back 78

ACEi + candesartan
combined endpoint of CV death and HF hospitalizations was reduced
higher D/C rate due to AEs

Front 79

ARBS proven for HF

Back 79

candesartan, valsartan, and losartan

Front 80

Candesartan dose

Back 80

initial dose: 4-8 mg QD
target dose: 32 mg QD

Front 81

valsartan dose

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initial dose: 20-40 mg BID
target dose: 160 mg BID

Front 82

losartan dose

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initial dose: 25-50 mg QD
target dose: 50-100 mg QD

Front 83

RALES

Back 83

Sprionolactone + ACEi
30% reduction in mortality
AEs: gynecomastia & hyperkalemia

Front 84

EPHESUS

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Eplereonon +ACEi/BB/diuretics
15% reduction in mortality
more severe hyperkalemia than rales

Front 85

Aldosterone Antagonist requirments

Back 85

Cr<2.5 mg/dL in men
Cr< 2.0 mg/dL in women
K+< 5 meg/dL