prevention of hospitalizations/reduce mortality, control symptoms, and provide optimal patient education
What are the goals of of HF therapy? (3)
control HR, BP, fluid volume
What are the three pillars of medication therapy in HF?
loop diuretics, digoxin, ivabradine
Which drugs don't decrease mortality? (3)
fluid/ sodium restrictoin
What are the two most important things in HF lifestyle changes?
c
Which is the diuretic of choice?
a) thiazides
b) AA/MRAs
c) loop diuretics
d) metolazone
d
Which is extremely potent and used in acute treatment?
a) thiazides
b) AA/MRAs
c) loop diuretics
d) metolazone
a,b
Which are mostly adjunctive?
a) thiazides
b) AA/MRAs
c) loop diuretics
d) metolazone
f; used for symptom control
Loop diuretics have been proven to lower mortality. T/F?
renal function & electrolytes
What are the main monitoring points for Loop diuretics? (2)
MRA + loop or ACE/ARB/ARNI + loop
Which combo of medications used in conjunction with Loops can worsen renal function?
b
Which is the only "true" once daily?
a) bumetadine
b) torsemide
c) furosemide
d) ethacrynic acid
e) furoscix
f) metalozone
c
Which needs to be taken with food?
a) bumetadine
b) torsemide
c) furosemide
d) ethacrynic acid
e) furoscix
f) metalozone
b
Which has the most predictable kinetics?
a) bumetadine
b) torsemide
c) furosemide
d) ethacrynic acid
e) furoscix
f) metalozone
to keep people out of hospital/ED
Why do we give people Furoscix, On-Body Infuser?
e
Which CANNOT be used in an emergency situation?
a) bumetadine
b) torsemide
c) furosemide
d) ethacrynic acid
e) furoscix
f) metalozone
f
Which has the longest half-life?
a) bumetadine
b) torsemide
c) furosemide
d) ethacrynic acid
e) furoscix
f) metalozone
as needed for unresponsive edema
Why is Metolazone prescribed?
30 min before loop; takes longer to peak
When do we give patients Metolazone?
in HF, high amount of sodium reaches distal collecting tubule; this combination reduces this
Why do we give patients thiazides + loops?
increase dose, change loops, add thiazide/mra, split doses, enhance TLC
How can we combat diuretic resistance? (5)
CV safety
All diabetes medications have to be assessed for ________.
lower preload, afterload, and remodeling
How do SGLT2 inhibitors help with HF?
CrCl < 25 ml/min
When do we avoid SGLT2 inhibitors?
in am due to diuresis
When do we give patients SGLT2 inhibitors?
f; most ae's are seen in diabetics
SGLT2 inhibitors cause AE's in all patients. T/F?
2 L of water; 2 gm of salt
How much fluid can HF patients have daily? How much sodium?
BMP, weight, kidneys
What do we have to monitor in patients on Metolazone? (3)
increased glucagon; serves as alternate energy source increasing CO, HR, and blood flow
How do SGLT-2 inhibitors affect metabolism?
inhibit myocardium na/h exhanger; decreases fibrosis/remodeling
How do SGLT-2 inhibitors affect the heart directly?
metoprolol succinate, bisoprolol, carvedilol, nebivolol
Which BB's have been proven to reduce mortality & morbidity? (4)
b,c
Which are better at reducing HR?
a) carvedilol
b) metoprolol succinate
c) bisoprolol
d) nebivolol
a
Which is better at reducing BP?
a) carvedilol
b) metoprolol succinate
c) bisoprolol
d) nebivolol
d
Which is equally efficacious in reducing HR & BP?
a) carvedilol
b) metoprolol succinate
c) bisoprolol
d) nebivolol
a
Which has to be taken with food?
a) carvedilol
b) metoprolol succinate
c) bisoprolol
d) nebivolol
b
Which can be split?
a) carvedilol
b) metoprolol succinate
c) bisoprolol
d) nebivolol
< 1 ng/mL
What is our target serum levels in Digoxin?
60-80% bioavailability, 25% protein binding; no fat distribution, low liver metabolism, p-glycoprotein substrate, long half-life, excreted highly unchanged
Digoxin Kinetics? (6)
thiazides, MRAs, macrolides
Which medications can INCREASE Digoxin concentrations? (3)
antacids, st. john's wort
Which medications can DECREASE Digoxin concentrations? (2)
BBs, CCBs, calcium
Which medications can INCREASE Digoxin therapeutic effects? (3)
thyroid hormones, high fiber diet
What can DECREASE Digoxin therapeutic effects? (2)
6 hours post dose
When should we draw a patient's Digoxin levels?
f; can happen w acute ingestion too
Digoxin toxicity can only occur with chronic ingestion. T/F?
low k+/Mg, dehydration, drug interactions, kidney dysfunction
What are the predisposing factors that make someone more likely to
experience Digoxin toxicity? (4)
hold/reduce dose, activated charcoal, gastric lavage, DigiFab
How can we treat Digoxin toxicity? (4)
yearly, changes in renal function, changes to interacting drugs
When do we check Digoxin levels? (3)
5 mg BID w food; titrate to resting HR of 50-60 bpm; max 7.5 mg BID
Ivabradine dosing?
bradycardia/heart block, pacemaker dependency, CYP3A4 inhibitors, severe hepatic impairment
Contraindications of Ivabradine? (4)
f; very expensive
Ivabradine is a relatively cheap medication. T/F?
patient must be on max tolerated BB, EF <=35%, NYHA class II-IV symptoms, normal sinus rhythm, HR > 70
Ivabradine prescribing requirements? (5)
EF <=40%; class II-IV
What EF & class must a patient be in to receive Entresto?
current ACEI/ARB dose, renal & hepatic function
What is the starting dose based off of when prescribing Entresto? (2)
36 hr; 24 hr
How long is the washout period for an ACEI?
How long for an ARB?
f; AA only
BiDil showed reduction in mortality in all races/ethnicities. T/F?
BID-TID; 5-6 tabs
How often do patients take BiDil? How many tabs?
when an AA patient can't take an ACEi/ARB
When do we give a patient BiDil?
f; HF max dose is 400 mg
Hydralazine's max dose is higher in HTN than HF. T/F?
no generic; most insurance won't cover without a PA
What are socioeconomic concerns to consider when prescribing a patient on BiDil?
SrCr >= 2.5, GFR < 30, K+ >= 5
When do we avoid MRAs/AAs in patients w HF? (3)
3 days--> 7 days--> monthly for 1st 3 months at initiation/dose changes
When do we check a patient's BMP when they are on an MRA/AA?
symptomatic HF; EF < 45%
Vericiguat (Verguvo) is FDA approved in _________ & ________.
pregnancy; contraception required
Contraindication w Vericiguat (Verquvo) ?
BP, CBC, pregnancy
What do we monitor in patients on Verquvo? (3)
farxiga; jardiance
______ & _____ are the only 2 medications shown to lower BOTH mortality and morbidity across all LVEFs.
patients w frequent hospitalizations/symptoms
Who does Verquvo benefit the most?