Chapter 31 - Chronic Heart Failure (Chf)

Front 1

What is the target dose of Metoprolol Succinate ER?

Back 1

Back (Definition)

Front 2

Most cases in US are due to __?

Back 2

Damage from an MI or from long-standing hypertension.

Front 3

A problem the systolic function of the heart refers to __?

Back 3

Contraction

Front 4

A problem the diastolic function of the heart refers to __?

Back 4

Relaxation

Front 5

What test is done when heart failure is suspected?

Back 5

Echocardiograph (ECHO)

Front 6

An EF < 40% indicates what?

Back 6

Systolic dysfunction or heart failure with reduced ejection fraction (HFrEF)

*most common type

Front 7

1. EF of 55-70% means __?

2. EF of >/= 50% means__?

3. EF of 40-49% means__?

4. EF of <40% means__?

Back 7

1. EF of 55-70% means normal

2. EF of >/= 50% means HFpEF (diastolic)

3. EF of 40-49% means HFmrEF

4. EF of <40% means HFrEF (systolic)

Front 8

What are the 2 classification systems currently recommended for HFrEF?

Back 8

1. The American College of cardiology and the American heart Association (ACC/AHA)

—> recommended categorizing patients by the heart failure stage. The staging system is used to guide treatment in order to slow progression in asymptomatic patients (A&B) or in symptomatic patients (C&D).

2. New York heart Association (NYHA)

—> classified by the level of limitation in physical function.

Front 9

Explain and describe each stage in the ACC/AHA and the NYHA staging system

Back 9

Refer to pic

Front 10

What are some signs and symptoms of systolic heart failure seen in labs?

Back 10

Refer to pic

Front 11

What are some left sided signs and symptoms of systolic heart failure?

Back 11

Refer to pic

Front 12

What are some right sided signs and symptoms of systolic heart failure?

Back 12

Refer to pic

Front 13

What are some general signs and symptoms of systolic heart failure?

Back 13

Refer to pic

Front 14

How do you calculate cardiac output (CO)?

Back 14

CO = Heart Rate * Stroke Volume

Front 15

1. How do you calculate cardiac output (CO)?

2. How do you calculate cardiac index (CI)?

Back 15

CO = Heart Rate * Stroke Volume

CI = Cardiac Output / Body Surface Area

Front 16

During low cardiac output states neurohormones are released that do you what?

Back 16

They increase the blood volume or increase the force or speed of contractions which can lead to cardiac remodeling.

Front 17

During low cardiac output states neurohormones are released that do what?

Back 17

They increase the blood volume or increase the force or speed of contractions which can lead to cardiac remodeling.

Front 18

What are the three main pathways activated in heart failure?

Back 18

RAAS, SNS, Vasopressin

Front 19

What effect does angiotensin II have?

Back 19

Vasoconstriction

Front 20

What does aldosterone do?

Back 20

Causes sodium and water retention (and inc. potassium excretion)

Front 21

What does vasopressin do?

Back 21

Causes vasoconstriction and water retention

Front 22

When the central nervous system is activated what happens?

Back 22

Norepinephrine and epinephrine are released, which increases heart rate, contractility (positive inotropy), and vasoconstriction

Front 23

What are some lifestyle management options for patients with heart failure?

Back 23

My other document body weight daily, notify the provider when weight increases by 2-4 lbs, maintain sodium restriction of <1500 mg/day in stage B heart failure, maintain fluid restriction in stage D, stop smoking, limit EtOH, avoid illicit drugs, get vaccines, exercise

Front 24

What are OTC and alternative medication options for patients with heart failure?

Back 24

Omega-3 fatty acid supplements, Hawthorn and coenzyme Q10, avoid stimulants

Front 25

What are OTC and alternative medication options for patients with heart failure?

Back 25

Omega-3 fatty acid supplements, Hawthorn and coenzyme Q10, avoid stimulants

Front 26

What drugs cause or worsen heart failure?

Back 26

DI NATION

Front 27

Drugs that cause or worsen heart failure to do so by what mechanism?

Back 27

Fluid retention/edema, by increasing blood pressure or via negative inotropic effect

Front 28

1. What medications decrease mortality and are recommended for all patients without CI?

2. What medications decrease mortality for select patients?

3. What medications improve other aspects of HF (not proven to dec mortality)?

Back 28

Back (Definition)

Front 29

Loop diuretics block what ions and where?

Back 29

Block Na and Cl reabsorption in the thick ascending limb of the loop of Henle. They increase excretion of Na, K, Cl, Mg, Ca and water.

Front 30

T/F: Loop diuretics have not been shown to alter the survival of heart failure patients.

Back 30

True

Front 31

What are the equivalent doses for the loop diuretics?

Back 31

Furosemide 40 mg = Bumetanide 1 mg = Torsemide 20 mg = Ethacrynic acid 50 mg

Furosemide IV:PO ratio 1:2

Front 32

What is the warning associated with loop diuretics? What loop diuretic does not have this warning?

Back 32

Sulfa allergy

Ethacrynic acid

Front 33

How do you properly store furosemide injections?

Back 33

At room temperature

Front 34

What are the side effects and monitoring parameters for loop diuretics?

Back 34

Back (Definition)

Front 35

Avoid NSAIDs (including COX-2 inhibitors)

Back 35

Back (Definition)

Front 36

ACEi blocks the conversion of angiotensin I to angiotensin II resulting in what?

Back 36

Decreased vasoconstriction and decreased aldosterone secretion

Front 37

What is the mechanism of action of angiotensin receptor blocker‘s?

Back 37

Blocks angiotensin II from binding

Front 38

T/F: ACEi and ARBs decrease morbidity and mortality.

Back 38

True

Front 39

T/F: An ACEi (or ARB if intolerant to ACEi) is recommended for select heart failure patients regardless of symptoms.

Back 39

False!

An ACEi (or ARB if intolerant to ACEi) is recommended for all heart failure patients (NYHA Class I-IV) regardless of symptoms.

Front 40

T/F: You do not have to titrate the dose for an ACEi or ARB.

Back 40

False!

Titrate the drug to the target those if possible

Front 41

T/F: Combining an ACEi and an aldosterone receptor antagonist (ARA) is not as common as combining an ACEi and an ARB.

Back 41

The combination of an ACE inhibitor and an ARB has been shown to decrease hospitalizations for heart failure, but it is more common to combine either one with an aldosterone receptor antagonist. Triple combination therapy of ACEi + ARB+ ARA is NOT recommended due to higher risk of hyperkalemia and renal insufficiency.

Front 42

T/F: Combining an ACEi and an aldosterone receptor antagonist (ARA) is not as common as combining an ACEi and an ARB.

Back 42

The combination of an ACE inhibitor and an ARB has been shown to decrease hospitalizations for heart failure, but it is more common to combine either one with an aldosterone receptor antagonist. Triple combination therapy of ACEi + ARB+ ARA is NOT recommended due to higher risk of hyperkalemia and renal insufficiency.

Front 43

With what class of medications and what ethnicity is Angioedema most common? What should you do if a pt has experienced this?

Back 43

Occurs more frequently with ACEi (than with ARBs or Aliskiren) and in black patients. If a patient develops angioedema with any of these medications the others should be avoided.

Front 44

What is the target dose for Vasotec, Zestril, Accupril, and Alsace?

Back 44

Back (Definition)

Front 45

What is the black box warning associated with ACEi?

Back 45

Injury and death to the developing fetus (in 2nd and 3rd trimester) discontinue as soon as pregnancy is detected.

Front 46

What are the contraindications for ACEi?

Back 46

History of angioedema, use within 36 hours of neprilysin inhibitor (Entresto (sacubitril/valsartan))

Front 47

What are the warnings for ACEi?

Back 47

Angioedema, hyperkalemia, hypotension, renal impairment

Front 48

What are the SE and CI for ACEi?

Back 48

SE: cough

CI: BP, renal function, s/sx of HF

Front 49

What is the difference between using an ACEi and ARB?

Back 49

Less cough and angioedema, no washout period required with neprilysin inhibitor

Front 50

An ACEi should not be used within __ hrs of a neprilysin inhibitor? What is an example of an neprilysin inhibitor?

Back 50

36 hrs

Entresto (Valsartan(ARB) + Sacubitril(neprilysin inhibitor))

Front 51

What is the target dose for losartan and valsartan?

Back 51

Losartan: 50-150 mg/day

Valsartan: 160 mg BID

Front 52

Neprilysin is the enzyme responsible for degrading what?

Back 52

Degration of several beneficial vasodilatory peptides

Front 53

What is Entresto a combination of and what MOA does each part have?

Back 53

Sacubitril: neprilysin inhibitor

Valsartan: ARB

Front 54

ARNI is indicated in NYHA class 2-4 pts to do what?

Back 54

Reduce heart failure hospitalizations and cardiovascular death.

It’s recommended as a potential first line option in place of an ACEi or ARB as monotherapy

Front 55

What is the black box warning associated with Entresto?

Back 55

Injury and death to the developing fetus, discontinue as soon as pregnancy is detected

Front 56

What are the CI’s associated with Entresto?

Back 56

Use with ACEi or ARB

Front 57

What are the warnings associated with Entresto?

Back 57

Angioedema, renal impairment, hyperkalemia, hypotension

Front 58

What are the SEs and monitoring parameters associated with Entresto?

Back 58

SE: cough

Monitoring: BP, K, renal function, s/sx of HF

Front 59

If the pt is taking Entresto and they come in with a Rx for an ACEi what should you do?

Back 59

Do not use with an ACE inhibitor or another ARB. Must have 36 hour a washout period between stopping an ACEi and starting Entresto.

Front 60

T/F: ACE inhibitors and ARBs can decrease lithium renal clearance and increase risk of lithium toxicity.

Back 60

True

Front 61

T/F: Avoid using ACEi +/- ARB +/- Aliskiren and the triple combination with an ACEi, ARB, and ARA.

Back 61

True

Front 62

Combining an ACEi and ARB with an ARA is very common in HF.

Back 62

Combining an ACEi or ARB (not both) with an ARA is very common in HF.

Front 63

What is the MOA of beta blockers?

Back 63

They antagonize the effects of catecholamines (especially NE)

They decrease morbidity and mortality, they are recommended for all heart failure patients.

Front 64

What beta blockers are recommended in the guideline to treat heart failure?

Back 64

Bisoprolol, Carvedilol (IR & ER), and Metoprolol Succinate ER

Front 65

When should beta blockers be avoided and when should they be stopped?

Back 65

Beta blockers with intrinsic sympathomimetic activity should be avoided. Beta blockers should only be stopped in ADHF if hypotension or hypoperfusion is present.

Front 66

What is the black box warning associated with beta blockers?

Back 66

Do not discontinue abruptly

Front 67

What are the warnings to watch out for when using beta blockers?

Back 67

Caution in patients with diabetes can worsen hyperglycemia and hypoglycemia and mask hypoglycemic symptoms, use caution with bronchospasmic diseases like asthma or COPD

Front 68

What are the side effects and monitoring parameters associated with beta blockers?

Back 68

Side effects : Decreased heart rate, hypertension, fatigue, dizziness, depression, increased triglycerides

Monitoring: HR, BP, s/sx of HF

Front 69

What form of metoprolol is used in the heart failure patients?

Back 69

Metoprolol succinate XL (Toprol XL)

Front 70

What form of metoprolol is used in the heart failure patients?

Back 70

Metoprolol succinate XL (Toprol XL)

Use succinate for success in HF

Front 71

What is the metropolis IV to PO conversion ratio?

Back 71

IV:PO

1:2.5

**important cuz med error possible

Front 72

T/F: Toprol XL can be cut at the score line.

Back 72

True

Front 73

What nonselective beta blocker and alpha-1 blocker is used in heart failure patients?

Back 73

Carvedilol (Coreg)

Front 74

How should you counsel your patient to take Coreg?

Back 74

Take with food!

Front 75

What is important to know about dosing conversions for carvedilol? What is the target dose for the immediate release form and the controlled release form?

Back 75

Back (Definition)

Front 76

What is important to know about dosing conversions for carvedilol? What is the target dose for the immediate release form and the controlled release form?

Back 76

Front 77

Where do aldosterone receptor antagonists act?

Back 77

In the distal convoluted tubule and collecting ducts

Front 78

What is the difference in mechanism between spironolactone and eplerenone?

Back 78

Spironolactone is a nonselective ARA (also blocks androgen) and Eplerenone is a selective ARA that does not exhibit endocrine side effects

Front 79

T/F: ARAs reduce morbidity and mortality and should not be added to standard treatment in patients with NYHA class II-IV.

Back 79

False! They should be added to standard treatment for patients with NYHA class II-IV.

Front 80

What is the brand name of spironolactone and what is its target dose?

Back 80

Aldactone

Target: 25 mg daily or BID

Front 81

What are the contraindications associated with spironolactone?

Back 81

Hyperkalemia, anuria, significant real impairment (CrCl = 30), Addison’s disease or other conditions that increase potassium

Front 82

What are the warnings, side effects, and monitoring parameters associated with aldosterone receptor antagonist?

Back 82

Back (Definition)

Front 83

T/F: triple combination of ace inhibitor ARA and ARB is recommended.

Back 83

False! It is not recommended

Front 84

T/F: The triple combination of ace inhibitor ARA and ARB is recommended.

Back 84

False! It is not recommended

Front 85

T/F: The triple combination of ACE inhibitor ARA and ARB is recommended.

Back 85

False! It is not recommended

Front 86

What is the mechanism of action of hydralazine and nitrates?

Back 86

Hydralazine is a direct arterial vasodilator which decreases afterload. Nitrates increase the availability of nitric oxide which causes venous vasodilation and decreases preload.

The combination of these products improves the survival of patients with heart failure.

Front 87

What is the brand name of The medication containing hydralazine and isosorbide dinitrate?

Back 87

BiDil

Front 88

T/F: BiDil is indicated in self identified black patients with NYHA class III-IV who are symptomatic despite optimal treatment with ACE inhibitors and beta blockers.

Back 88

True

Front 89

What is contraindicated with the use of BiDil?

Back 89

Use of PDE-5 inhibitor and riociguat. The combination can cause severe hypotension.

Front 90

What are the side effects and warnings associated with hydralazine?

Back 90

Warnings: Drug induced lupus erythematosus

SE: headache, hypertension, reflex tachycardia, palpitations

Front 91

What are the side effects and contraindications associated with BiDil?

Back 91

SE: Hypertension, headache, dizziness, lightheadedness, flushing, tachyphylaxis, syncope

CI: Use with PDE-5i or Riociguat

Front 92

What is the typical dose and therapeutic range of Digoxin?

Back 92

Typical dose: 0.125-0.25 mg daily

Therapeutic Range: HF=0.5-0.9 ng/mL (keep serum concentrations <1 ng/mL) and AFib=higher

Front 93

What are the brand names for Digoxin?

Back 93

Digitek, Digox, Lanoxin

Front 94

What is the antidote for Digoxin?

Back 94

DigiFab!! 💁🏻‍♀️

Front 95

What increases the risk of digoxin toxicity? And what should you monitor?

Back 95

Hypokalemia, hypomagnesemia, and hypercalcemia

Monitor: electrolytes, renal function

Front 96

What are the signs and symptoms of digoxin toxicity?

Back 96

Nausea/vomiting, loss of appetite, bradycardia (in severe cases you can see yellow/green vision, halos, and blurriness)

Front 97

What is the mechanism of action of digoxin?

Back 97

Digoxin inhibits the Na/K ATPase pump which results in a positive inotropic affect (increase in CO) and it exerts a parasympathetic affect which provides a negative chronotropic affect (decrease heart rate)

Front 98

When is digoxin used? What benefits does it provide?

Back 98

Digoxin improves symptoms exercise tolerance and quality-of-life it does NOT improve survival. Digoxin DOES reduces hospitalizations for heart failure.

Front 99

When should you consider lowering the dose of Digoxin?

Back 99

Lower doses for renal insufficiency, smaller, older, female

Front 100

What does Ivabradine inhibit?

Back 100

It inhibits the “funny” current in the sinus node

Front 101

When funny current is inhibited what happens?

Back 101

Inhibition of the funny current results in the reduction of sinus rate and hence heart rate.

Front 102

T/F: Ivabradine reduces the risk of hospitalization for worsening heart failure but does not affect mortality.

Back 102

True

Front 103

T/F: Ivabradine is recommended as adjunct therapy in symptomatic stable chronic heart failure patients with EF = 35% who are treated with all appropriate first line medications, are in sinus rhythm and have resting heart rate >/= 70 BPM.

Back 103

True!

Front 104

What is the target resting heart rate when using Ivabradine?

Back 104

50-60 BPM

Front 105

What are the warnings associated with Ivabradine?

Back 105

Bradycardia, increase risk of QT prolongation and ventricle arrhythmias

Front 106

What are some side effects of Ivabradine?

Back 106

Bradycardia, hypertension, atrial fibrillation, luminous phenomena

Front 107

What form of potassium supplementation is most commonly used? And when should you check potassium levels?

Back 107

Potassium chloride is used most commonly.

Check potassium levels if the renal function changes and after any change in diuretic, ACE inhibitor, ARB, or ARA dose

Front 108

T/F: Magnesium level should be checked and correct as needed after correcting the potassium level.

Back 108

False!! Check and correct magnesium level prior to correcting the potassium level

Front 109

What are the brand names of potassium chloride available?

Back 109

Klor-Con, Klor-Con 10, Klor-Con M20, Micro-K

Front 110

What is the treatment dose and what is the prevention dose of hypokalemia with potassium chloride?

Back 110

Prevent: 20-40 mEq/ day in 1-2 divided doses

Treatment: 40-100 mEq/day in 2-5 divided doses

Front 111

KCl 10% = __mEq/__mL

Back 111

KCl 10% = 20mEq/15mL

Front 112

What are the ways that each of the various brand names of potassium chloride can be taken?

Back 112

Back (Definition)

Hint 112

Micro-K:

K-Tab, Kylie-Con:

Kylie-Con M:

Front 113

HF exacerbations and quality improvement notes:

Many HF hospitalizations are you due to non-adherence with medications. Medicare now penalizes hospitals for excessive readmissions due to HF exacerbations. Lifestyle adherence is essential.

Back 113

Back (Definition)

Front 114

In the back of this chapter you see an action plan. The yellow means caution possibly indicating a change in medication needed. In the section you will see:

Back 114

Back (Definition)

Front 115

What is the listed medication summary for the treatment of chronic HFrEF?

Back 115

Back (Definition)