Cardio Heart Failure Pharma

Front 1

What is Stage A (Risk for) HF?

Back 1

Stage A: High risk, but no sx or structural disease

e.g., HBP, Atherosclerosis, DM

Front 2

What is Stage B (Risk for) HF?

Back 2

Stage B: Structural heart disease, no HF sx
e.g., previous MI, LVH or low EF, valvular disease

Front 3

What is Stage C HF?

Back 3

Stage C: Structural heart disease and HF symptoms

e.g., shortness of breath, fatigue, exercise intolerance

Front 4

What is Stage D HF?

Back 4

Stage D: Refractory HF

e.g., symptoms at rest despite maximal therapy, cannot be safely discharged from the hospital without special intervention

Front 5

How do you approach Stage A HF?

Back 5

Treat known risk factors, avoid high risk behaviors, control ventricular rate or restore sinus rhythm in AFib

Front 6

What drugs can worsen HF?

Back 6

NSAIDs, antiarrhythmics, adriamycin (chemo)

Front 7

What treatments are used for Stage A HF?

Back 7

Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

Front 8

What are ACE Inh side effects?

Back 8

Dry cough in 15%
Angioedema
Hypotension (start low dose in volume depleted and diuretic pts)
ACE Inh excreted renally, so adjust in renal failure

Front 9

What is an advantage of ARBs over ACEIs?

Back 9

1) More selective and complete Angiotensin II blockade
2) Do not affect bradykinin (a vasodilating peptide increased with ACEI which can give decrease BP further, cause coughing)
3) Better tolerated than ACEIs, generally
4) Do not produce cough

Front 10

What is an advantage of ACEIs over ARBs?

Back 10

ACEIs are generally similar or more effective for HF. ARBs should be an alternative for people who don't tolerate ACEIs.

Front 11

What is the suffix for ACEI drugs?

Back 11

-pril

Front 12

What ACEIs reduce mortality in Stage A (High Risk for) HF?

Back 12

zofenopril, ramipril

Front 13

What is the suffix for ARBs?

Back 13

-sartan

Front 14

What ARBs have proven efficacy in heart failure?

Back 14

valsartan, candesartan

Front 15

What patients are contraindicated for ARBs and ACEIs?

Back 15

pregnant, bilat renal artery stenosis or renal failure, hyperkalemia

Front 16

What is the treatment approach for Stage B HF?

Back 16

As in Stage A, PLUS Revascularization or valve replacement in appropriate pts

RX: Stage A: ACEI/ARB
PLUS Beta-blockers

Front 17

What do beta-blockers effect?

Back 17

Lower BP
Anti-arrhythmic, antioxidant, antiproliferative

Proven improved symptoms and survival in HF

Improve ventricular remodeling in systolic dysx

Front 18

What are beta-blocker side effects?

Back 18

Hypotension
Fluid retention / worsen HF
Fatigue
Bradycardia / Heart block

Front 19

When should you discontinue beta-blockers

Back 19

Only in severe cases!!!

Consider lower dose, pacemaker

Front 20

Who is contraindicated for beta-blockers?

Back 20

-Bradycardia, low BP, elongated PR interval or 2+
-AV block
-COPD / asthma
-Severe peripheral vascular disease

Front 21

How should beta-blockers ideally be introduced?

Back 21

low dose, double dose every 2-3 weeks until at target (may worsen symptoms for 1-2.5 months)

Front 22

What beta-blockers have proven efficacy in heart failure?

Back 22

carvedilol, metoprolol XL, bisoprolol

Front 23

What should patients monitor daily with beta-blocker use?

Back 23

weight - fast weight gain should be tx with diuretics;
dose should be reduced or paused for severe decompensation

Front 24

What is the treatment approach to Stage C HF?

Back 24

Same as in A/B, but drugs for all patients (ACEI, BB plus Diuretics)

For some patients:
Aldosterone agonists
Digitalis
Hydralazine/nitrates
ARBs (plus ACEI)

Front 25

What symptoms of HF is hydralazine indicated for?

Back 25

Decreases afterload, improving CO: hypotension and fatigue

Same as ACEI and ARBs

Front 26

What symptoms of HF are nitrates prescribed for?

Back 26

Decreases preload, improving water retention and pulmonary congestion

(similar to diuretics, ACEI and ARBs)

Front 27

In what direction does the Frank-Starling Curve move in HF?

Back 27

Down - lower CO for increased LVEDP

Front 28

What are the classes of diuretics?

Back 28

Loop diuretics (-ide)
Thiazides (HCTZ)
Aldosterone antagonists (spironolactone, eplerenone)

Front 29

What type of HF are loop diuretics more potent for?

Back 29

Congestive HF

Front 30

What patients are contraindicated for most thiazides?

Back 30

Renal dysfunction

Front 31

How much volume reduction should you aim for in hypervolemic Stage B HF?

Back 31

.5 - 1kg / day - don't pull out too much too fast

Front 32

Apart from diuretics, what HF drugs produce diuresis?

Back 32

ACEIs and ARBs, through renin-angiotensin-aldosterone system

Front 33

What are the effects of aldosterone?

Back 33

Competitive antagonist for aldosterone receptor in myocardium, artery walls, and kidneys

Also weak diuretic effect.

Front 34

Which aldosterone antagonists have proven efficacy in Stage C/IV HF?

Back 34

(aldactone, eplerenone)aldosterone inhib=-ONE

Also know spironolactone

Front 35

What electrolyte should you monitor at frequent intervals when prescribing aldosterone inhibitors?

Back 35

K+, -ones may raise K+, causing arrhythmias

Front 36

What is Digoxin's mechanism of action?

Back 36

Inhibits NA/K ATPase, which:
increases Na/Ca exchange
increases CA uptake by SR
increases Ca release by SR during depolarization
increases Ca-troponin C reaction (actin-myosin interaction)

Front 37

What are Digoxin's effects

Back 37

Enhances vagal tone, slows AV node conduction

Results in fewer hospitalizations for EF <45%, but no reduction in mortality

Front 38

What are some serious risks of digoxin?

Back 38

(Narrow therapeutic range) Enhanced automaticity
Prone to arrhythmia propagation
Reentry

Front 39

What are the characteristics of EKGs for Digoxin patients

Back 39

"Scooped out" ST segment

Front 40

What are common digoxin side effects?

Back 40

Xanthopsia (yellow vision), halo effect around lights, dizziness, confusion, visual disturbances
N/V/D, anorexia
Gynecomastia

Front 41

In what patient group is hyrdralazine and nitrates proven to improve survival/symptoms?

Back 41

African Americans

Front 42

When would you prescribe Hydralazine and Nitrates?

Back 42

For African Americans, renal failure (intolerant of ACEIs / ARBs) or for refractory patients not responding to ACEI and beta blocker

Front 43

What drug should you prescribe for symptomatic Stage C HF patients with reduced LVEF?

Back 43

NOTHING! May be harmful, should use ICD in appropriate patients, and cardiac rehab

Front 44

What is the treatment approach for Stage D HF?

Back 44

Relieve symptoms, devices, discussion of end-of-life care

Front 45

What therapies are available for Stage D HF?

Back 45

Cardiac transplant, valve replacement/repair,

Drugs for other stages, plus palliative positive inotrope infusion

Front 46

What inotropes are used for Stage C HF?

Back 46

Digoxin
Amrinone, milrinone, dopamine, adrenergic

Front 47

What are the potential side effects of dopamine or dobutamine for HF?

Back 47

No survival benefit, tachycardia and may predispose to arrhythmias

Narrow, dose-dependent relationship between drug and effects