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HFrEF is defined as having a LVEF<____. 2/3 of cases are attributable to __________ and 1/3 cases are attributable to ________________ (HTN, thyroid dz, obesity, stress, cardiotoxins (EtOH, certain chemo agents, cocaine), myocarditis, idiopathic, tachycardia, peripartum)
- HFrEF is defined as having a LVEF<40%. 2/3 of cases are attributable
- to coronary heart dz (CHD) and 1/3 cases are attributable to nonischemic
HFpEF is defined as having LVEF>_____ with the most common cause being ________ (60-89%)
HFpEF is defined as having LVEF>50% with the most common cause being HTN (60-89%)
4 primary sx's of HF include:
- 1. SOB
- 2. Fatigue
- 3. Exercise intolerance
- 4. Edema
Wut r the differences in NYHA class I, II, III, and IV?
I - no limitations in phys activity caused by HF sx's
II - Sx of HF w/normal level of activity
III - Marked limitation in phys activity b/c of HF sx's
IV - Sx of HF at rest
Diuretics like loops and thiazides inhibit reabsorption of Na in which parts of the kidney?
Loops - ascending limb of Henle
Thiazides - distal tubule
In outpt setting, wut is goal wt loss per day for pt w/fluid overload with usage of diuretics?
1-2 lbs wt loss/day
To reduce risk of arrhythmias, K and Mg should be maintained at wut levels with use of diuretics for fluid overload?
Mg>2.0mEq/L (NL: 1.4-1.8 mEq/L; 1.7-2.3mg/dL)
Of the 4 loops, which one has longest DOA (12-16hrs) n is therefore the only one that isnt dosed BID? Which doesnt have a sulfa grp?
Wut r the initial n max doses of loops (d/t ceiling efx)?
Bumetanide 0.5-1mg qd or BID (MAX 10mg TDD)
Torsemide 10-20mg daily (MAX 200mg daily) [longest DOA]
Furosemide 20-40mg qd or BID (MAX 600mg TDD)
Ethacrynic acid 25-50mg qd or BID (MAX 200mg TDD) [No sulfa grp]
FYI all available as IV
Wut r 2 important mechanisms of action of ACEs that help with HF?
1. Blocks production of angiotensin II (which decreases sympathetic stimulation)
2. Inc bradykinin (which may affect myocardial remodeling)
In cases with high and low dose lisinopril, what results were seen for HF pts in comparison?
High dose had no diff in mortality but had a significantly lower risk of death or hospitalizations, compared to low doses of lisinopril
In wut 2 instances should ACE's be absolutely avoided in?
In what 4 instances should ACEs be used in caution?
2. SCr >3 (FYI may rise to 20%, which is acceptable, b/c of renal efferent artery dilation)
4. Bilateral renal stenosis
If pt using ACEs for HF experience angioedema, what 2 drug choices can be used as alternative? (HINT: 1 is a drug class)
1. ARBs (cross reactivity is 2.5%)
2. Hydralazine/isosorbide dinitrate
The following ACEs are recommended for HF use. Wuts the initial and target dose of bolded?
Enalapril: 2.5mg BID, target 10mg BID
Lisinopril: 2.5-5mg qd, target 20mg qd
Ramipril: 1.25-2.5mg qd, target 10mg qd
[RLE? 1.25, 2.5-5, 2.5 BID // target 10, 20, 10 BID]
In wut instance is an ARB considered to be added onto an ACE in HF? (2)
Must have both:
- 1. Taking both ACE and BB and persistently sx'atic
- 2. Ald antagonist not tolerated/indicated
Wut r the 3 ARBs recommended for HF use? Wut r their initial and target doses?
CLV (target x 4/3/4 of initial)
Candesartan: 4-8mg qd, target 32mg qd
Losartan: 25-50mg qd, target 150mg qd
Valsartan: 20-40mg BID, target 160mg BID
Which 2 drug classes are recommended in ALL HFrEF pt unless contraindicated? Of the 2, which produces greater sx improvement and reduction in risk of death at higher doses?
2. BB - produces greater sx improvement and reduction in risk of death at higher doses than ACE
BB blocks efx of NE and other sympathetic NTs on heart and vascular system, which has what 2 important mech of action in HF?
1. Dec ventricular arrhythmias
2. Dec cardiac hypertrophy and cardiac cell death
B/c carvedilol differs from other B1-selective blockers from blocking ___ and ____, what are the 2 results that make it superior than Toprol?
Carvedilol also blocks beta-2 and alpha-1 receptors
Blocking alpha-1 decreases SVR (afterload) AND has greater reduction in BP over Toprol
Wut r the 3 BBs recommended in HF? Explain if they should be initiated in following situations:
1. HF sx unstable
2. Fluid overloaded
3. Reactive airway dz
4. Asymptomatic bradycardia
Bisoprolol, carvedilol IR and ER, metoprolol succinate
- 1. HF sx unstable (wait til stable)
- 2. Fluid overloaded (wait til euvolemic)
- 3. Reactive airway dz
- 4. Asymptomatic bradycardia
Wut r 3 adverse efx that should be monitored during initiation of BB for HF?
1. BP/HR (sx of hypotension) fyi reduce dose of ACE if hypotension occurs, as higher doses of BB is ass'd w/gr8r mortality reduction
2. Inc'd edema/fluid retention (fyi but responds to diuretic inc)
3. Fatigue/weakness (fyi usually resolves spontaneously in several wks but may req dosage dec or DC. Also can be attributed to overdiuresis, sleep apnea, or depression)
Wut r the initial and target doses for the 4 BBs for HFrEF?
Bisoprolol (Zebeta) - 1.25mg qd, target 10mg qd
Carvedilol IR - 3.125mg BID, target 25mg BID (50mg BID in >85kg)
Carvedilol CR - 10mg qd, target 80mg qd
Metoprolol succinate - 12.5-25mg qd, target 200mg qd (FYI tartrate has few or no data in HF)
When are aldosterone antagonists recommended in class III-IV HF? In class II HF? In pt after MI, all to reduce M&M?
Class III-IV: LVEF<35%
Class II HF: LVEF<35%, with either hx of CV hospitalization OR elevated BNP levels
After MI: LVEF<40% with sx of HF OR hx of DM
In wut pt populations can benefit be seen with use of eplerenone? With spironolactone?
Eplerenone: Benefits seen in Class II HF, and LV dysf(x) after MI
Spironolactone: Benefits seen in Class III and IV HF
Aldosterone antagonists has 2 important mechs of actions that are helpful in HF, which are....?
1. Dec K and Mg loss, which dec ventricular arrhythmia (as does BB)
2. Dec Na retention and thus fluid retention
Ald Antagonists should be added to ACE/ARB AND BB's, but should be absolutely avoided in wut 3 instances?
1. SCr>2.5 in males (2.0 in females)
3. K>5.0 (fyi, supplemental K is NOT rec'd when K>4.0 with ald antagonist)
If painful gynecomastia occurs w/ald antagonist use in HF, which one is considered over the other?
Eplerenone >> spironolactone
Wut r the initial and target doses of the ald antagonists for HF?
Eplerenone: 25mg qd, target 50mg qd
Spironolactone: 12.5-25mg qd, target 25mg qd or BID
Wut r the only 2 drugs/drug classes rec'd in HFrEF that improve exercise tolerance but has no effect on mortality?
2. Digoxin (fyi dec hospitalizations)
For digoxin in HF, most pts achieve serum [ ] with dose of _______ daily. Consider dosing ____________ in those >70yo, impaired renal f(x), and low lean body mass.
- For digoxin in HF, most pts achieve serum [ ] with dose of 0.125mg
- daily. Consider dosing 0.125mg qod in those >70yo, impaired renal
- f(x), and low lean body mass.
FYI dose CrCL<50 q36hrs, CrCL<10 q48hrs
Digoxin levels are increased with concomitant admin of what 10 drugs (5 same drug categories)?
1. Clarithro, Erythro (Macrolides)
2. Amiodarone, dronedarone
3. Itraconazole, posaconazole, voriconazole (azoles)
4. Cyclosporine, tacrolimus (txplant agents)
Wut r the 3 signs of toxicity with digoxin? Why does one monitor serum level digoxin b/w 0.5-0.8ng/mL?
Monitor to minimize risk of adverse efx and ventricular arrhthymias asso'd w/inc'd [ ]
Risk of digoxin toxicity increases with what 2 factors? With what 3 labs?
- Increases with:
- Renal dysf(x)
Wut r the 4 drug classes/agents that decrease mortality in HFrEF?
- 1. ACE/ARB
- 2. BB
- 3. Ald Antag
- 4. Hydralazine/Isosorbide Dinitrate
In wut 2 scenarios is hydralazine/isosorbide dinitrate recommended for HFrEF?
1. African American w/Class III or IV HF in addition to ACE AND BB
2. Useful in pt with current HF sx who are unable to tolerate ACE/ARB
Wut is each MOA of hydralazine and isosorbide dinitrate, which is useful in HF?
Hydralazine (Apresoline): Arterial vasodilator that reduces afterload
Isosorbide dinitrate (Isordil): Reduces preload
Wuts the dosing for hydralazine and isosorbide dinitrate for HF? Wuts the fixed dose pill dosing?
- Hydralazine 25-75mg TID-QID
- Isosorbide dinitrate 10-40mg TID
BiDil (Hydralazine 37.5mg/Isosorbide Dinitrate 20mg) 1 tab TID with goal 2 tabs TID
Wut r 3 adverse efx that may limit use of hydralazine/isosorbide dinitrate and therefore should b monitored?
3. Drug-induced lupus w/hydralazine
When is anticoagulation recommended in HF pts?
When pt ALSO has permanent/persistent/paroxysmal AF
FYI not rec in absence of AF, prior stroke, or cardioembolic source
Whats the monitoring parameter for Na and fluid in HF pts?
Explain how both hypo and hyperthyroidism affects HF or vice versa.
Hypothyroidism may be masked by HF sx
Hyperthyroidism will worsen systolic dysf(x)
Wut 4 drug class/agents should be avoided in HF pts d/t its ability to retain fluid ?
What 4 drug classes/agents should be avoided in HF pts d/t its negative inotropic activity? Wut r a couple of exceptions in 2 of the drug classes?
1. Class I antiarrhythmics
2. Class III antiarrhythmics (only amiodarone and dofetilide is ok to use in HF!) FYI dronedarone is CI in HF pts
3. CCBs (except for amlodipine and felodipine, which are proven safe in HF)
Which of these drugs should be avoided in HF for causing....
1. Atrial and ventricular arrhythmias
2. Inhibition of PDE-3 (inhibits vasodilation)
3. Lower extremity edema, HF exacerbation
1. Amphetamines - Atrial and ventricular arrhythmias
2. Cilostazol - Inhibition of PDE-3 (inhibits vasodilation)
3. Pregabalin - Lower extremity edema, HF exacerbation
Wut r the 4 general tx goals of HFpEF?
1. Control HTN (impairs myocardial relaxation, promotes cardiac hypertrophy)
2. Control tachycardia (dec's time for ventricles and coronary arteries to fill w/blood)
3. Reduce preload (fyi sx of breathlessness can be relieved using diuretics or nitrates)
4. Treat myocardial ischemia (impairs ventricular relaxation)
Describe the benefits/use of the following drug classes in HFpEF:
3. Non-DHP CCB
1. ACE/ARB - reduces hosp, and treats HTN
2. BB - sx relief (tachycardia)
3. Non-DHP CCB - sx relief (tachycardia)
4. Digoxin - no effect on mortality/hosp
5. Diuretics - can relieve breathlessness
6. Nitrates - can relieve breathlessness