Chf Drugs

Front 1

T or F: CHF is the leading cause of hospitalization in the elderly

Back 1

True

Front 2

what are RF of CHF?

Back 2

anemia

diabetes

hyperlipidemia

obesity

valvular abnormalities (stenosis)

physical inactivity

smoking

family hx of HF

sleep d/o breathing

Front 3

define the new york heart association HF class system

Back 3

Class I- no limitation of physical activity

II- slight limitation of physical activity. comfortable at rest, but ordinary physical activity results in SOB, fatigue, palpitations

III- marked limitation of PA. less than ordinary activity causes SOB, fatigue, palpitations

IV- unable to carry out any PA w/o discomfort. sx of cardiac insufficency at rest.

pts can go from one class to another. they may enter the hospital at class IV but have to be discharged at II or I.

Front 4

what are limitations to this classification system?

Back 4

-subjective by the provider

-does not recognize preventative measures or progressive nature of HF

Front 5

what is the new HF classification? is this changeable?

Back 5

A- high risk for developing HF (HTN, CAD, DM)

B- asymptomatic HF- previous MI, LV systolic dysfxn, asymptomatic valvular dz

C- symptomatic HF- SOB, fatigue, ↓ exercise tolerance, known structural heart dz

D- refractory end-stage HF- marked sx despite max. medical therapy

not changeable.

Front 6

S/S of CHF

Back 6

may be asymptomatic

DOE

↓ exercise tolerance

orthopnea

PND

fatigue

edema

abd pain/distention → ascites

palpitations

syncope

Front 7

what are non-pharmacological therapy of HF?

Back 7

dietary restriction

sodium restriction (2-3 grams/daily)

fluid restriction to <2 L in severe hyponatremia

pneumocccal and annual influenza vaccine

Front 8

name the classes of drugs involved w/ treating HF

Back 8

ACEI/ARBs

BB

diuretics

DIrect vasodilators

inotropic agents

aldosterone antagnoists

Front 9

which drugs does not prolong life? does not improve symptoms?

Back 9

does not prolong life- diuretics and digitalis

does not improve symptoms- BB

Front 10

what is the hallmark of pain relief but does not have any effect on mortality?

Back 10

diuretic therapy

Front 11

how do you manage acute decompensation?

Back 11

diuresis- get the pt to euvolemia

ACEI

Nesiritide or NG if inadequate response to diuresis

Dopamine/Dobutamine- if going into shock

sit patient upright

O2

morphine to calm pt and vasodilate

Front 12

how do you manage chronic HF?

Back 12

ACEI and BB- used in EVERYONE W/ LOW HF unless CI

Spironolactone- used in post-MI and NYHA III-IV

Diuretics, Digoxin, ARBs- PRN for S/S

Front 13

what affects does angiotensin II have on the body?

Back 13

angiotensin II can vasconstricts, release aldosterone and vasopressin, and stim. SNS.

Front 14

what are indications for ACEI?

Back 14

all PTS W/ ↓ LV SYSTOLIC FUNCTION

REGARDLESS OF SYMPTOMS

-also use in in preventing HF in pts at high risk like CAD, PVD, or CVA

-use in asymptomatic pts w/ reduced (<40%)

-diabetics

-microalbuminuria

-↓ s/s and hospitalizations

-retards progress of HF

-↓ mortality regardless of NYHA class

Front 15

MOA of ACEI?

Back 15

competitively blocks converting enzyme to transform angiotensin I into angiotensin II.

1. ↓ preload, afterload, and wall stress w/o ↑ HR (vasodilator)

2. ↑ renal bld flow and ↓ prod. of aldosterone and ADH

3. prevent antihypertrophic effects

4. blunts progressive dilation

5. ↓ ischemic events

it can also increase Kinase II levels which can release vasodilators (E2 and F2), prostaglandins, and tPA (fibrinolytic)

Front 16

what do you have to monitor if using an ACEI?

Back 16

renal function- CrCl

hyperkalemia

hypotension

Front 17

CI of ACEIs?

Back 17

significant renal artery stenosis

PG in 2nd and 3rd trimester

Front 18

which ACEIs are preferred?

Back 18

Lisinopril

Enalapril

Front 19

SE of ACEIs?

Back 19

class effect:

Renal insufficiency

hyperkalemia

hypotension

cough (may be higher in Asians)

Angioedema (head and neck soft tissue swelling which can cause airway obstruction)

fetal anomalies

Dysgeusia (metallic taste)

Front 20

name some ACEI

Back 20

Captopril

Enalapril

Fosinopril

Lisinopril

Quinapril

Ramipril

Trandolapril

Perindopril

Front 21

here are some pearls for ACEIs

Back 21

kidney protection in DM

all PO except enalapril (IV)

cough

rash, fever

hyperkalemia

CI in PG

interacts w/ allopurinol, antacids, digoxin, indomethacin, lithium, bactrim

Front 22

what is the benefit of using hydralazine ISDN w/ the standard therapy?

Back 22

↓ mortality in AA w/ HF by 40%

Front 23

what are indications for hydralazine and isordil?

Back 23

when intolerant of ACEIs or w/ renal impairment

specific benefit to AA.

Front 24

these drugs are what type of class:

hydrazaline

ISDN

Isosorbide mononitrate

sodium nitroprusside (nitropress)

Nesiritide bolus/infusion

Back 24

direct vasodilators

Front 25

name some ARBS

Back 25

Candesartan

Losartan

Telmisartan

Valsartan

Olmesartan

Irbesartan

Front 26

what are indications to using ARBs?

Back 26

if pts are intolerant to ACEIs due to cough or angioedema

Front 27

what are the benefits to using an ARB over an ACEI?

Back 27

less renal insufficiency or hyperkalemia

less cough

Front 28

if pts can't tolerate ARB, ______ is considered for these pts

Back 28

combo of hydralazine and oral nitrate

Front 29

_____ and ARB are not recommended together

Back 29

ACEI

Front 30

pearls about ARBs

Back 30

end in -sartan

no cough

edema, fatigue, abd pain

Front 31

what drug can you not use in acute decompensated HF until stabilized?

Back 31

Beta blockers

Front 32

what are indications for Beta blockers?

Back 32

systolic dysfxn and mild to severe COMPENSATED HF w/ class II-III s/S

Front 33

how long should you prescribe BB for?

Back 33

indefinitely

Front 34

what are the best BB to use in HF?

Back 34

Carvedilol (Coreg)

Metoproplol succinate (Toprol XL)

Front 35

benefits of BB

Back 35

↓ contractility and HR

↓ mortality

↓ SNS

↓ arrhythmias

Front 36

SE of BB

Back 36

bradycardia

hypotension

fatigue

dizziness

Front 37

CI of BB

Back 37

BRONCHOSPASTIC DZ

2ND OR 3RD DEGREE HEART BLOCK

SICK SINUS SYNDROME

SEVERE BRADYCARDIA

Front 38

what are some BB

Back 38

atenolol (Tenormin)

Carvedilol (Coreg)

Metoprolol (Toprol-XL, Lopressor)

Bisoprolol

Front 39

pearls about BB

Back 39

end in -lol

less effective in AA and elderly

reduce mortality in HF

do not lower normotensive pt BP

coreg and labetolol- special

caution w/ DM and bradycardia (<60)

Front 40

when do you discontinue BB therapy?

Back 40

cardiogenic shock

refractory volume overload

symptomatic bradycardia

mask symptoms of hypoglycemia

abrupt withdrawal can lead to HTN

Front 41

what drugs do not use w/ BB? why?

Back 41

amiodarone and CCB

can increase risk of bradycardia

Front 42

what is the drug of choice for CHF?

Back 42

Coreg

Front 43

what's the MOA of Coreg?

Back 43

nonselective BB that also block alpha-receptors

Front 44

what are SE of Coreg?

Back 44

like labetolol- it's really fast onset

does not increase glucose

orthostatic hypotension

rebound effect if stopped abruptly

Front 45

what are indications for diuretics?

Back 45

PE or not symptoms not controlled w/ ACEI or BB

Front 46

what do you have to do to prevent activation of RAS when using a diuretic?

Back 46

Minimal dose

Front 47

Overdiuresis can cause _____ and _____

Back 47

prerenal azotemia and electrolyte abnormalities

Front 48

where does loop diuretics act on?

Back 48

on the ascending loop of Henle to inhibit sodium and K reabsorption and increase excretion

ex: Furosemide and Torsemide

Front 49

What can thiazide cause?

Back 49

tachyphylaxis (rapid loss of drug effect)

initial natriuresis but effect quickly stabilizes

ex: HTCZ

Front 50

what are SE of diuretics?

Back 50

Hypokalemia

hypomagenesemia

frequent urination

avoid sun exposure

muscle cramps

weakness

thirstness

Front 51

Eplerenone and Spironolactone are what type of drugs?

Back 51

aldosterone antagonists

Front 52

what's the MOA of aldosterone antagonists?

Back 52

prevent sodium reabsorption and potassium excretion

Front 53

when should you use aldosterone antagonists?

Back 53

in al pts w/ class III-IV HF esp. Post-MI

Front 54

______ can increase digoxin plasma concentrations

Back 54

Spironolactone

Front 55

what are other SE of spironalactone?

Back 55

hyperkalemia

gynecomastia

Front 56

what should you monitor when using aldosterone antagonists?

Back 56

serum Creatinine <2.5 in men and <2 in women

serum potassium <5

Front 57

what's an absolute D/I in spironolactone?

Back 57

non-selective BB

Front 58

Digoxin is what type of drug?

Back 58

Iontropic drug

but very little iontropic effect

Front 59

MOA of digoxin

Back 59

inhibits Na-K Pump = ↑ intracellular calcium

and ↓ SNS

Front 60

T or F: digoxin improves mortality and have symptomatic benefits

Back 60

F. does not improve mortality

Front 61

digoxin toxicity occurs at >___ and may occur at lower levels in _____ , ____, ____ pts

Back 61

>2 ng

elderly, hypokalemia, hypomagenesmia

Front 62

_____ increase the risk digoxin toxicity in the presence of hypokalemia or _______

Back 62

diuretics

hypomagenesemia

Front 63

drugs increasing serum digoxin concentration:

Back 63

cyclosporin

quinidine

verapamil

macrolide abx (erythromycin, clarithormycin)

spironolactone

dixogin clearance is reduced in pts w/ renal insufficeincy

Front 64

drugs that decrease serum digoxin concentration

Back 64

antacids

metoclopramide

cholestyramine

Front 65

which drug has a positive inotropic effect

Back 65

digitalis

Front 66

digiatlis is effective in controlling ______ rate and workload when CHF is complicated by AFIB. it does not reduce ____ but can reduce symptoms

Back 66

ventricular

mortality

Front 67

when do you change dosages for digitalis?

Back 67

renal insufficiency

verapamil

amiodarone

quinidine

proprafenone

many DI**

Front 68

what do you have to monitor when taking digitalis?

Back 68

potassium and magnesium

HF symptoms

renal function

Front 69

pearls about digitalis

Back 69

approx. 60-80% of dose is eliminated by kidney so dosage adjustment is required in pts w/ renal insufficiency

lower doses in elderly or pts w/ low lean body mass

Front 70

which drug vasodilates and diureses w/o stiulating RAS System?

Back 70

Natriuretic Peptides

it has direct natriuretic effect on the kidneys.

Front 71

which drug has shown a possible increase in mortality but further studies are needed and is still felt to be useful in the inpatient setting?

Back 71

Nesiritide (Natrecor)

Front 72

what are your inotropic agents?

Back 72

digoxin (lanoxin)

Dobutamine (Dobutrex)

Inamrinone

Milrinone (Primacor)

Front 73

which drug do you use for mod to severe decompensated CHF who are not responding adequately to IV diuretics?

Back 73

Dobutamine

Front 74

MOA of dobutamine

Back 74

beta agonist and ↑ contractility and vasodilates at low doses decreasing afterload

-may decrease BP

-may increase arrhythmias and mortality

Front 75

what is the 1st line drug to increase CO while in septic shock

Back 75

Dopamine

Front 76

name the effects of low and high doses of dopamine

Back 76

low doses: vasodilation and useful in cardiogenic shock and renal perfusion

high doses: vasoconstriction and increase peripheral resistance

useful in septic shock

Front 77

which drug do use in immediate reduction in BP (crisis)?

Back 77

Nitroprusside sodium

it also controls you from bleeding out in sx?

Front 78

MOA of nitroprusside sodium?

Back 78

arterial and venous dilator

1-2 min action start/stop

Front 79

why don't you want to OD on this?

Back 79

cyanide is a metabolite

Front 80

how is nitroprusside sodium packaged?

Back 80

dilute w/ D5 and wrapped in foil or other opaque packaging

Front 81

what meds can cause cardiomyopathy?

Back 81

amphotericin B

cloazpine

doxorubicin

infliximab

itraconazole

mitoxantrone

herceptin

TKI's (Tyrosine kinase inhibitors)

Front 82

what do these drugs have in common?

Cox-2 inhibitors

NSAIDs

Pioglitazone

Rosiglitazone

Sulfonylureas

Back 82

they can all cause fluid overload

Front 83

what 2 drugs mentioned can cause heart valve abnormalities and pulmonary HTN?

Back 83

phentermine

ergotamine: migraines

Front 84

when do you give ACEI or ARBs to all patients? and beta blockers in selected patients?

Back 84

when in stage B- structural heart disease but asymptomatic

Front 85

when do you give ACEI and beta blockers in all patients?

Back 85

stage C- symptomatic

Front 86

when do you give inotropes?

Back 86

Stage D- refractory symptoms requiring special intervention

Front 87

if you have AFIB, you are at increased risk of _____ and increases symptoms of HF by ______ ___ w/ loss of atrial kick.

Back 87

CVA

decreasing CO

Front 88

what's 1st line antiarrhythmic drug? why?

Back 88

amiodarone

does not increase morbidity or mortality in HF pts

Front 89

what 2 classes of meds are hallmark of CHF treatment that have a significant mortality benefit?

Back 89

ACEIs and BB

Front 90

T or F: diuretics have a mortality benefit in CHF treatment

Back 90

False

Front 91

what 2 meds used in combo have shown mortality benefit for CHF tx in AA?

Back 91

Hydralazine and Isordil (ISDN)