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