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186 Cards in this Set
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Non-pharm HF therapy:
*monitor wgt *worsening symptoms/wgt *Na *drugs to avoid bad habits vaccines vitamin wgt management |
*monitor weight qam after voiding, before eating.
*notify provider if sx worsen or if gain 3 or more lbs/day or 5 in a week *limit Na to 2g/day in moderate to severe HF, and to 1500mg if they also have HTN. *avoid NSAID's, including cox2, due to renal insufficiency and fluid retention -ma huang and ephedrine will kill, don't take them -don't smoke, do illegal rx, limit etoh -get flu and pneumo vaccines yearly -keep bmi under 30, exercise 30 min 3-5 d/wk, as tolerated. losing weight makes the heart's job easier. |
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-anthracyclines esp., traztuzumab, imatinib and docetaxol should be avoided in hf, why?
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anthracyclines are hard on a healthy heart. traztuzumab, imatinib and docetaxol can cause fluid retention.
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should peeps w/ HF take sympathomimetics or other amphetamines?
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no
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which CCBs should be avoided in HF?
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ND-CCB like verapamil and diltiazem can exacerbate HF due to negative inotropic, chronotropic effects.
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avoid which azole in hf? i don't know why
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itraconazole in HF
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antiarrythmics can worsen HF. which 2 may be lower risk?
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amiodarone and dofetilide in HF
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which class of antiarrythmics are not to be used in hf?
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class I antiarrythmics like mexiletine, procainamide, quinidine, disopyramide, tocainamide, flecainamide and propafenone should not be used in HF.
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heart valve disease can be caused
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fenfluramine, dexfenfluramine, ergot derivatives like ergotamine, dihydroergotamine, methysergide and others in HF.
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some immunmodulators can cause/worsen hf
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interferons, etanercept (TNF blockers worsen), rituximab in HG
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HF and NSAID's, including COX-2
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These drugs should be avoided in HF, esp in advanced renal disease. use can worsen renal function, increase fluid retention and worsen hf.
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glucocorticoids
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steroids that can worsen hf
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Triptans in HF
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migrane drugs that are CI in cardiovascular disease or uncontrolled htn
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Thiazolidinediones, esp rosiglitazone (Avandia), pioglitazone (Actos) in HF
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these DM drugs can cause edema, especially if used with insulin
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HF and etoh
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moderate use may be goodk, but excessive is bad
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2 drug class that should be used in every HF patient w/o a CI
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acei and bb's
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EF in HF
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EF less than 40 indicates systolic HF, but EF can be higher in diastolic HF
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BNP (B-type natriuretic peptide) normal range
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normal range <100pg/ml
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ACC/AHA stage 1
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patients at risk of HF, but no structural damage or sx's. htn, chd, dm, fatties, metabolic syndrome
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acc/aha stage 2
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patients have structural damage, but no HF sx's
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ACC/AHA stage of a person with LVH, low EF, MI, valve disease...but no s/s of hf
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acc/aha stage 2
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acc/aha stage 3
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someone with known structural heart disease, with prior or current sx's.
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acc/aha stage of a pt with advanced structural disease and sx's at rest despite ma med tx.
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acc/aha stage 4
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how many acc/aha stages? NYHA classes?
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4/4
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NYHA class of a pt with no limitations of physical activity. ordinary physical activities do not cause problems
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nyha class 1
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nyha class of a pt who is comfortable at rest, but ordinary activities cause symptoms
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nyha class 2
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nyha class of a pt with marked limitations of physical activity. comfortable at rest, but minimal exertion (bathing) brings on sx
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nyha class 3
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nyha class of a pt who has sx at rest and can not do any physical activity without discomfort.
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nyha class 4
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*for RAAS inhibitors, to what do you titrate doses?
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titrate doses to symptoms, not bp with these hf drugs.
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can you do an ace + Arb in HF
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you could combine these, but watch out for hyperkalemia
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when should you use arb's in hf
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drug that can be used 1st line, but generally used when pt can tolerate ace
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RAAS inhibitors cause angioedema. who is at higher risk? what drugs are CI if pt develops angioedema?
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RAAS inhibitors increase risk of this side effect. esp ACEi. blacks are at higher risk. if get angioedema with one, can't use another, I think aliskiren included.
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RAAS inhibitors and KCl
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HF pts on these drugs should not use salt substitutes (KCl), because it puts them at risk of hyperkalemia. cut down on the Na
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Two reasons captopril (Capoten) is not an ideal acei.
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This acei has extra side effects (rash, tast perversions) and dosing is more frequent (inconvenient) at bid to tid.
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acei and arbs reduce what loads?
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both pre and after load are reduced
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acei moa
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blocks the conversion of at1 to at2 via inhibition of the angiotensin? converting enzyme.
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arb mechanism
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they block the angiotensin II receptor
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*acei black box
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pregnacy, stop or don't start
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acei ci's (3)
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*angioedema
*bilateral renal artery stenosis -use in DM when also on aliskiren |
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*ACEI S/E 5
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*Cough
*hyperK *angioedema *hypotension -ARF |
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*ACEI monitorin-4
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*BP, K, renal, s/s hf
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acei pg cat
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HF rx that is cat D
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captopril
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Capoten
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*enalapril, enalaprilat (inj)
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*Vasotec
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fosinopril
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Monopril
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*lisinopril
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*Zestril, Prinivil
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Quinapril
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Accupril
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*ramapril
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Altace*
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trandolapril
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Mavik
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This acei has to be taken an hour before meals
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captopril (Capoten)
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candesartan
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Atacand
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*losartan
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*Cozaar
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*valsartan
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*Diovan
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*ARB black box
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*same as acei, pregnancy
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*ARB 3 CI's
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same as ACEi
*angioedema *bilateral renal artery stenosis -use in DM with Aliskiren |
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Aldosterone receptor antagonists moa
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these drugs inhibit the effects of aldosterone, reducing water and sodium.
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aldosterone receptor antagonist are used in what classes
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III and IV
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why does spironolactone have more SE's than eplenerone?
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eplenerone is a selective aldosterone blocker, spironolactone in non-selective and also blocks androgen and progesterone receptors.
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*ARB 3 CI's
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*angioedema
*bilateral renal artery stenosis -use in dm with aliskiren |
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*ARB 5 SE's
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*angioedema
*hyperK *hypotension -HA and dizziness |
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*ARB monitoring 4
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*BP
*K *renal *s/s hf |
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arb pg cat
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D
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K sparing diuretics used in HF
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spironolactone, eplenerone
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*spironolactone
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*Aldactone
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eplenerone
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Inspra
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This Ksparing diuretic has a black box warning for tumor risk
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Spironolactone, it should only be used as indicated, and unecessary use should be avoid as it has a black box warning for...?
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2 CI to Ksparing diuretics and one specific to eplenerone
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-these are contraindicated in crcl<30, hyperK
-use with 3A4 inhibitors |
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2 warnings for ksparing diuretics with regards to K and renal fx
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-don't start tx if K is greater than 5
-don't use in women with scr over 2, or men with scr over 2.5 |
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*ksparing diuretic SE's (2), and those specific to spironolactone
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*HyperK, increased SCr
*Spironolactone also causes breast tenderness and gynecomastia*, impotence, mentrual problems, impotence, hirsutism |
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*Ksparing diuretic monitoring 4
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*BP, renal, K, s/s of HF
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*5 ways to minimize hyperK with ksparing diuretics
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*CI in crcl less than 30, as risk increases with renal dysfunction
*don't start if if K is over 5 *use low doses, risk higher w/ace and arb *don't use nsaids, not supposed to anyway *counsel pt a/b dehydration (vomit/diarrhea...) |
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Ksparing pg cat
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spironolacte is C, eplenerone B
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Lithium + diuretics
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Lithium should not be used with diuretics as they reduce Li clearance and can cause Li toxicity
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is triple tx with ace, arb, aldosterone antagonist recommended?
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triple therapy increases the risk of hyperK, so no
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This drug class is use to inhibit the SNS.
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bb's
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bb's are recommended in classes...
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II-IV
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start BB's when the patient is...
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these drugs are started when the pt is euvolemic and asymptomatic, otherwise HF can worsen
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What type of bb's should be avoided in HF
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bb with intrinsic sympathomimetic activity, they may worsen survival
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ISA BB's (4)
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CAPP should be avoided in HF
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bisoprolol
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Zebeta
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*metoprolol succinate, extended release
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Toprol XL
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*carvediolol
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*Coreg, Coreg CR
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*3 BB's used in HF
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*bisoprolol, Toprol XL, Carvedilol
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of the 3 HF bb's, which is a non-selective alpha, beta blocker
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carvedilol
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which hf bb has shown benefit, but does not have an indication?
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bisoprolol (Zebeta)
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target dose of this hf bb is 10 qd
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Zebeta(bisoprolol)
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target dose of this hf bb is 200 qd
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Toprol XL (metoprolol succinate)
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carvedilol target doses
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25 BID, or 50 BID if pt >80kg, or 80 mg QD of Coreg CR
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*how should all forms of carvedilol be taken
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*take this bb with food
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Dosing conversions of Coreg to CR
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3.125 BID to 10 qd
6.25 BID to 20 qd 12.5 BID to 40 qd 25 BID to 80 qd |
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BB CI 5
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-sinus bradycardia
-2/3 degree heartblock w/o pacemaker -cardiogenic shock -sick sinus syndrome -do not start if have active bronchospasm |
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*4 common BB SE's
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*bradycardia
*hypotension *fatigue *dizziness |
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6 less commen bb se
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-depression
-decrease libido -impotence -hyperglycemia (non-select can reduce insulin) -increase tgs -reduce hdl |
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*BB monitoring 3
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*HR, BP, s/s HF
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when do you lower bb dose?
when can it increase? |
-lower dose of these drugs when HR is less than 55
-titrate up q 2 wks as tolerated |
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4 BB cautions
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-DM with recurrent hypoclycemia
-asthma -COPD -resting limb ischemia |
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metoprolol tartrate
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Lopressor, not recommended in HF
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BB and hypoglycemia
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BB, mostly the non-selective agents, can cover up the signs of hypoglycemia, exept hunger and sweating
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BB and hypoglyceMICs (insulin, sulfons)
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BBs can enhance the effects of these DM drugs
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BB's and digoxin
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both slow HR
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carvedilol metabolism
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2D6, wathch for interactions
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carvedilol + CSA or digoxin
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carvedilol can increase the concentrations of csa and dig
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hydralazine is a direct ____ vasodilator which reduces ____ ?
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arterial, afterload
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Nitrates are ____ vasodilators and reduce ___?
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venous, preload
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BiDil
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combination of nitrate and hydralazine
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BiDil indication
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indicated for use in black patients w/ class III-IV who are symptomatic despite optimal tx w/ acei and bb's.
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why else might you use hydralazine and nitrates?
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also used in patients who can not tolerate acei, arb due to poor renal fx, angioedema, or hyperkalemia.
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do you use nitrates alone in HF?
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No. They are used in combo with hydralazine, which improves efficacy and to reduce nitrate tolerance.
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BiDil
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isosorbide dinitrate/hydralazine
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*any nitrate tolerance with BiDil
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*No nitrate tolerance with this combo.
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BiDil (20-37.5) target?
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-Start 1 TID, increase to target of 2 TID, if tolerated.
-in other words 75mg hydralazine/40mg ISDN TID. |
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*BiDil is CI with what Rx? what component is the problem?
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*This HF drug is contraindicated for use with PDE-5 drugs due to the nitrate component.
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*among s/e for BiDil are reflex tachy and Lupus like syndrome, what is the cause of this?
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*Hydralazine can cause these s/e.
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*HA and dizziness from BiDil are due to what component?
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*The nitrate component in BiDil can cause these S/E.
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*isosorbide mononitrate
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*Imdur, Monoket
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isosorbide dinitrate
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Isordil, Dilatrate SR
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*Drug CI with BiDil or any of the nitrates.
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*PDE5 inhibitors
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*3 things to monitor when using hydralazine, nitrates, BiDil...
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*HR, BP, s/s HF
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hydralazine target
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75 QID
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mononitrate is given ___ or ___
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daily or bid
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dinitrate is given ___ or ___
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tid or qid
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target dose of hydralazine, not BiDil
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75 qid
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nitrate target dose, not bidil
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40 qid
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*ISMN and ISDN can cause HA and dizziness. what other problem is there?
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*Nitrates, not BiDil, can have tachyphylaxis and need a 10-12 hr nitrate free period.
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What options are there when a diuretic dose becomes ineffective?
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Increase dose, go IV, go continuous infusion, or add metolazone
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*furosemide
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*Lasix
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bumetanide
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?Bumex?
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torsemide
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Demadex
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ethacrynic acid
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Edecrin
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*oral loop dose equivalency of furosemide
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40 mg
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*oral loop dose equivalency of bumetanide
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1 mg
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*oral loop dose equivalency of torsemide
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20 mg
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Loop black box
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profound diuresis and electrolyte depletion is black box warning
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loop CI
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anuria is a CI to these diuretics
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*what electrolytes are affected by loops
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these diuretics reduce K, Ca, Mg, Cl, and Na
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*other than problems with electrolytes, loops have these side effects (6)
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Side effects from this drugs include:
*orthostatic hypotension *metabolic alkylosis *hyperuricemia *hyperglycemia *photosensitivity *ototoxicity (more w/ethacrynic acid) |
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*5 things to monitor when using loops
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when using this rx, monitor:
*renal *fluid status *BP *electrolytes *hearing w/high dose or rapid IV |
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IV loop storage
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IV forms of these drugs should be stored in amber bottles
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furosemide IV:PO ratio
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IV:PO ratio of this drug is 2:1
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what allergy is a concern with using loops? with the exception of___
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sulfa, ethacrynic acid
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loop pg cat
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B for ethacrynic acid and torsemide
C for furosemide and bumetanide |
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Only use loops in combo with these drugs in life threatening situations due to ototoxicity
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Aminoglycosides should not be used with loops due to this s/e. Risk is greater w/ reduced renal fx.
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Li +diuretics
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diuretics should not be used with this drug as they will decrease its clearance and lead to toxicity
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nsaids should not be used in HF anyway, but what problem do they cause w/loops.
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these drugs cause NA and water retention and reduce the effect of loops.
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digoxin MOA
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this drug inhibits a Na/K ATPase pump, acts as a positive inotrope and negative chronotrope
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*digoxin
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*Lanoxin
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*digoxin dose is based on...
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*renal function and current meds
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most patients take this dose of digoxin
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0.125 mg qd
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do you use a LD of digoxin in HF?
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no LD for dig in HF.
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*digoxin therapeutic range in HF
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*0.5-0.9 ng/ml is the therapeutic range for this drug in hf
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digoxin CI (2)
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2/3 degree heart block without a pacemaker, Wolf-Parkinson White syndrome with AFib are CI's
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digoxin s/e (7)
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dizzy, HA
diarrhea, n/v, anorexia mental changes |
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dig monitoring 5
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HR, BP, electrolytes (K, Ca, Mg), renal, ECG if suspect toxicity
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when do you lower dig dose?
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when CrCl is less than 50, reduce the dose of this rx
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if you need to lower dig dose...
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can do 0.125 qod or less frequently
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*s/s of digoxin toxicity...starts with...
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*-toxicity starts with n/v and loss of appetite and bradycardia.
-vision problems like halos, blurred/double vision, color perception, confusion, ab pain -confusion, delirium, -prolonged PR, accelerated junctional rhythm, bidirectional v. tachycardia |
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dig pg cat
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c
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*antidote for dig tox
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*Digifab or digibind are antidotes
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2 other drugs that reduce HR w/ dig
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BB's and non-DHP CB
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dig and renal fx
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it is mostly cleared by kidneys, partly by liver. may need to reduce dose if reduce renal function, or hold dose if ARF.
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being a 3A4 substrate digoxin can increase if used with ___, requiring a dose reduction
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amiodarone, quinidine, verapamil, erythromycin, clarithromycin, azoles anntifungals, CSA, propafenone, PI's
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2 drugs listed that may decrease dig levels
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BAS and St. John's wort could reduce conentrations
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how do levels of K and Ca affect dig toxicity risk
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HypoK (less than 3.5) can increase risk of toxicity as can hypercalcemia
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BNP, pro-BNP indicate...
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indicators of HF exacerabtion, important so that you can rule out other causes of sx, like copd
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If the loop becomes ineffective and you and metolazone, when do you give it.
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Give metolazone 30 min before the loop. i think this allows the metolazone to get to distal tubules
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if not hypotensive, adhf sx can be treated with
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Vasodilators like NG, NP, or nesiritide
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If a pt with adhf is hyptensive (sbp less than 90 or has sx's), these could be used to help with CO
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IV inotropic drugs like dobutamine, or milrinone
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nesiritide moa
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it is a b-type natriuretic peptide that binds smooth muscle, increases cGMP leading to relaxation of vascular, blah, blah
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nesiritide tachyphylaxis
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no tachyphylaxis with this vasodilator
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Concern of increased death and worsening renal with nesiritide?
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ascend-hf trial showed that conclusions of 2 prior meta analysis of nesiritide were incorrect
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NG mostly dilates
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veins
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NP dilates...
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arterial and venous dilation, and has a more pronounced effect on BP
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*nesiritide
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*Natrecor
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*nitroprusside
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*Nitropress
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*of nesiritide, ng, np...
-all 3 are CI if___. Both___ and___ are CI with use of____ and in cases of ____. |
*All 3 are CI if sbp is less than 90
*NG and NP are CI with use of PDE5 inhibitors and in cases of increased intracranial pressure. |
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*2 main se's from nesiritide
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*hypotension and increased scr*
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*hypotension, ha, tachycardia are se's of these 2 vasodilators used in HF
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*NP, NG
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*this vasodilator has a se of tachyphylaxis
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*NG
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*a side effect specific to NP, risk is increased in renal dysfunction
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*cyanide/thiocyanate toxicity*
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*VDilator monitoring
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*for all 3, monitor BP, renal, urine output
*monitor HR for NG and NP * watch for CN toxicity w/ NP, as well as acid/base status |
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*how should NP infusion bag be treated?
*when can you not use it? |
*infusion bag of this drug should be covered w/ an opaque material or aluminum foil.
*if it is blue, you have CN, don't use it |
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why is NG given continuous infusion
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due to short t1/2
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storage of IV NG
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store this iv drug in polyolefin (PAB or EXCEL) as adsorption can occur if use soft plastic (pvc)
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2mcg/kg bolus followed by 0.01mcg/kg/min X48hrs
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dosing for nesiritide (Natrecor)
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why is coreg taken cf?
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to slow adsorption and reduce dizziness, this med is taken cf in all forms.
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what if they can't swallow coreg cr caps?
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they can open and sprinkle them on applesause, and only applesauce, and only cold applesauce, not warm. and they need to eat it right away
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these drugs can increase pain from PVD like pain, numb, cold
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BB's
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