Cardiology Test 3- Montepara HF

Disease states that cause/worsen HF:- Ischemic Cardiomyopathy

coronary artery disease

1) myocardial __ and ___

ischemia, infarction

Disease states that cause/worsen HF-Non-ischemic Cardiomyopathy

dilated cardiomyopathy

1) _____ heart disease

2) arrhythmias

3) alcoholism

4) _____ drugs

valvular, cardiotoxic

Disease states that cause/worsen HF-Non-ischemic Cardiomyopathy

dilated cardiomyopathy

5) _______ disease

6) diabetes

7) sepsis

8) ______ (inflammation of the heart muscle)

thyroid, myocarditis

Disease states that cause/worsen HF-Non-ischemic Cardiomyopathy

dilated cardiomyopathy

9) _____ (inflammation of the pericardium)

10) ______ (weakness of the heart muscle in pregnancy)

11) stress

12) familial

13) idiopathic

pericarditis, peripartum

Disease states that cause/worsen HF-Non-ischemic Cardiomyopathy

hypertrophic cardiomyopathy

1) ____

2) familial

3) idiopathic

hypertension

Disease states that cause/worsen HF-Non-ischemic Cardiomyopathy

restrictive cardiomyopathy

1) amyloidosis

2) _______ (enlargement of lymph nodes)

3) ______ and/or radiation exposure

4) idiopathic

sarcoidosis, chemotherapy

Disease states that cause/worsen HF-Other

pulmonary

1) pulmonary _____

2) pulmonary HTN

3) COPD/asthma

4) sleep _____

embolism, apnea

Medications that cause/worsen HF:

1) ______ (class 1 agents, dronedarone, sotalol)

2) _____ (anthracyclines, trastuzumab, cyclophosphamide)

antiarrhythmics, chemotherapy

Medications that cause/worsen HF:

3) ___-___ ____ (diltiazem, verapamil)

4) ______ (rosiglitazone, pioglitazone)

non-dhp ccb, thiazolidinediones

Medications that cause/worsen HF:

5) ___ ___-__ inhibitors (saxagliptin, sitagliptin)

6) _______

7) ____

8) ___ (excludes aspirin)

dipeptidyl peptidase-4, cilostazol, corticosteroids, NSAIDS

____ HF: less blood fills the ventricles, stiff heart muscle can't relax normally

diastolic

____ HF: less blood pumped out of ventricles, weakened heart muscle can't squeeze as well

systolic

HFpEF = EF ≥ ___%

50

HFmrEF = EF ___-___%

41-49

HFrEF= EF ≤ ___%

40

TTE (transthoracic echo): standard echocardiogram uses sound waves to see the heart's function from just ____ of the chest

outside

TEE (transesophageal echo): uses sound waves to see the heart's function from ____

behind

Left heart failure, think L=______, symptoms include pulmonary congestion, dyspnea, and cough with sputum

lungs

Right heart failure, think R=____ ___ ___, symptoms include impaired liver function, anorexia, GI distress, and edema

rest of body

NYHA functional classification:

I= ______ limitation of physical activity. Ordinary physical activity does not cause HF symptoms

no

NYHA functional classification:

II= ______ limitation of physical activity. Comfortable at rest, but ordinary physical activity results in HF symptoms

slight

NYHA functional classification:

III= ______ limitation of physical activity. Comfortable at rest, but less than ordinary activity results in HF symptoms

marked

NYHA functional classification:

IV= _____ to carry on any physical activity without HF symptoms, or HF symptoms at ___

unable, rest

HF stages

stage A= ___-__ for HF but without current or previous symptoms/signs of HF and without structural/functional heart disease or abnormal biomarkers

at-risk

HF stages

stage B= Pre-heart failure. no signs or symptoms of heart failure but have one of the following:

a) structural heart ____

b) evidence of increased ___ pressures

c) risk factors and increased natriuretic peptide levels or elevated cardiac _____

disease, filling, troponin

HF stages

stage C= symptomatic heart failure. these patients have signs/symptoms of heart failure and this stage is a ___

diagnosis

HF stages

stage D= ____ heart failure. These patients have marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT

advanced

Nonpharm therapy for HF:

-restrict ____ (<1500 mg/day) and ___ (1.5-2 L/day) if signs of congestion

sodium, fluid

Nonpharm therapy for HF:

-monitor and document __ ___ daily

-eat a heart-healthy diet

body weight

Nonpharm therapy for HF:

-improve functional status with ___ or cardiac rehabilitation

-quit ___ and limit alcohol intake

exercise, smoking

Nonpharm therapy for HF:

-continue ___ ___ ___ in patients with HF and sleep apnea

positive airway pressure

What are the 4 pillars to treat HFrEF?

ARNI/ACEi/ARB, Beta blocker, MRA, SGLT2i

can also use ____ as needed in patients with HFrEF

diuretics

the use of ACE inhibitors is beneficial in patients with chronic HFrEF to reduce morbidity and mortality when the use of an ____ is not feasable

ARNI

ACE-I adverse effects:

-dry, hacking ___

-____

-____

-hypotension

-renal dysfunction

-dizziness

-headache

-rash

cough, angioedema, hyperkalemia

ACE-I contraindications:

-history of angioedema

-use of aliskiren in patients with diabetes

-use within 36 hours of neprilysin inhibitor (____)

-bilateral renal artery stenosis

-____ (teratogenic)

sacubitril, pregnancy

ACE-I monitoring:

-BP

-K+

-___ function

-interacts with ARB, ARNI, aliskiren

-increases lithium concentration

renal

the use of ARBs is beneficial in patients with chronic HFrEF to reduce morbidity and mortality when patients are intolerant to ___-__ and when the use of an ____ is not feasable

ace-inhibitors, ARNI

What are the 3 ARBs approved for HFrEF?

candesartan, losartan, valsartan

ARBs adverse effects

-________

-hypotension

-_____ dysfunction

-dizziness

-headache

-rash

-angioedema

hyperkalemia, renal

ARBs Contraindications

-use with aliskiren in patients with diabetes

-bilateral renal artery stenosis

-____ (teratogenic)

pregnancy

ARBs Monitoring

-BP

-potassium

-____ function

-interacts with ARB, ARNI, aliskiren

-increases lithium concentration

renal

In patients with NYHA class II-III HFrEF an _____ is recommended to be used in place of an ACE-I or ARB to further reduce morbidity and mortality

ARNI

the only ARNI is ___/___ (Entresto)

sacubitril/valsartan

ARNI Adverse Effects:

-dry, hacking cough

-angioedema

-____ (higher risk than ACE-I or ARB)

-____ dysfunction

-dizziness

hypotension, renal

ARNI Contraindications:

-concomitant use or use within 36 hours of an ___ ___

-history of angioedema associated with ACE-I or ARB therapy

-concomitant aliskiren use in patients with diabetes

-_____ (teratogenic)

ace inhibitor, pregnancy

ARNI Monitoring:

-BP

-potassium

-____ function

-interacts with ACE-I, ARB, aliskiren

renal

BNP is NOT an ______ marker of fluid volume for patient on Entresto because the sacubitril will cause increased BNP levels

accurate

in stable, ____ (normal fluid status) patients with previous or current symptoms of HFrEF, use 1 of the 3 approved beta blockers to reduce mortality

euvolemic

the timing of when you add beta blockers is important for HFrEF. Wait until the patient is not _____ (ie "fluid is off") before adding it.

congested

what are the 3 approved beta blockers for HFrEF?

bisoprolol, carvedilol (and carvedilol CR), metoprolol succinate

carvedilol is a _____ beta blocker that is the most ____ for HFrEF

nonselective, potent

bisoprolol and metoprolol succinate are ____ beta blockers that are preferred for comorbidities of asthma/COPD

selective

Beta Blockers Adverse Effects

-____

-hypotension

-fatigue

-dizziness

-depression

-impotence/low libido

-mask symptoms of hypoglycemia

bradycardia

Beta Blockers Contraindications

-severe ____

-2nd or 3rd degree AV block or sick sinus syndrome (unless pacemaker)

-cardiogenic ___

bradycardia, shock

Beta Blockers Monitoring

-HR

-BP

-ECG

-signs/symptoms of worsening HF

-blood ____

-interacts with other drugs that lower HR

glucose

in patients with NYHA class II-IV HFrEF with serum potassium < ___ mEq/L and eGFR > __mL/min/1.73 m2, an aldosterone antagonist is recommended to reduce morbidity and mortality

5, 30

What are the 2 aldosterone antagonists for HFrEF?

spironolactone, eplerenone

Aldosterone Antagonists Adverse Effects

-dehydration

-____

-hyponatremia

-dizziness

-spironolactone causes ___, breast tenderness, irregular menses

hyperkalemia, gynecomastia

Aldosterone Antagonists Contraindications

-hyperkalemia

-___

-renal impairment

-concurrent use of potassium-sparing diuretics or potassium supplementation

anuria

Aldosterone Antagonists Monitoring

-BP

-Potassium

-renal function

-interacts with strong ___ inhibitors (eplerenone)

CYP3A4

in patients with symptomatic chronic HFrEF, an SGLT2 inhibitor is recommended to reduce hospitalization for heart failure and cardiovascular mortality, irrespective of the presence of ___ ___ ___

type 2 diabetes

What are the 2 SGLT2 inhibitors for HFrEF?

dapagliflozin, empagliflozin

What is the brand name of dapaglifozin?

Farxiga

What is the brand name of empagliflozin?

Jardiance

____ (inpefa) is an SGLT2 and SGLT1 inhibitor (leads to more diarrhea bc of effects on glucose absorption)

sotagliflozin

SGLT2 Inhibitors Adverse Effects

-dehydration

-urinary tract ___

-genital mycotic ____

-renal dysfunction

-hypoglycemia if used in combination with insulin or a sulfonylurea

infection, infection

SGLT2 Inhibitors Contraindications

-known hypersensitivity to drug

-patients on _____

dialysis

SGLT2 Inhibitors Monitoring

-BP

-volume status

-renal function

-glucose

-caution with ____

diuretics

ensure that the eGFR is ≥ ____ for dapagliflozin

25

ensure that the eGFR is ≥ ____ for empagliflozin

20

for patients of african american race with NYHA class III-IV HFrEF who are receiving optimal medical therapy, the combination of __ and ___ ___ is recommended to improve symptoms and reduce morbidity and mortality

hydralazine, isosorbide dinitrate

a combination of hydralazine and isosorbide dinitrate is also recommended in patients with HFrEF who cannot be given an ARNI, ACE-I, or ARB because of __ __ or __ ___

drug intolerance, kidney dysfunction

Hydralazine Adverse Effects

-headache

-hypotension

-peripheral ___

-reflex ___

-palpitations

-drug induced lupus

edema, tachycardia

Isosorbide Dinitrate Adverse Effects

-hypotension

-headache

-dizziness

-____ (passing out)

syncope

Hydralazine Contraindications

-_____ valve rheumatic heart disease

-coronary ___ disease

mitral, artery

Isosorbide Dinitrate Contraindications

-concurrent use with ___ ____ and ___

PDE5 inhibitors, riociguat

hydralazine and isosorbide dinitrate monitoring

-BP

-HR

-antinuclear antibody (___) titer for hydralazine

-caution with other drugs that lower BP

ANA

in patients with heart failure who have __ ___, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening of heart failure

fluid retention

What are the 3 loop diuretics recommended for heart failure with fluid retention?

bumetanide, furosemide, torsemide

What is the 1 thiazide-like diuretic recommended for heart failure with fluid retention? (only use if loop-diuretic resistant!)

metolazone

relative potency of loop diuretics

furosemide is ___ (PO) and ___ (IV)

40, 20

relative potency of loop diuretics

bumetanide is __

1

relative potency of loop diuretics

torsemide is ___

20

oral:IV potency of loop diuretics

furosemide is __:___

2, 1

oral:IV potency of loop diuretics

bumetanide is __:___

1, 1

oral:IV potency of loop diuretics

torsemide is __:___

1, 1

Loop diuretics adverse effects

1) ____ (ear damage)

2) dehydration

3) hypotension

4) ____ glucose, uric acid, LDL-C, TG

ototoxicity, increased

Loop diuretics adverse effects

5) _____ Na+, K, Ca, Mg, and Cl

6) renal dysfunction

7) photosensitivity

decreased

Loop diuretics Contraindication

-___(low urine production)

-caution with ___ allergy

anuria, sulfa

Loop diuretics Monitoring

-BP

-electrolytes

-renal function

-_____ status (input and output, weight)

-glucose

-uric acid

-interacts by raising Li concentration, raising dofetilide concentration, and with NSAIDs

fluid

in patients with symptomatic HFrEF despite guideline-directed medical therapy, ____ may be considered to decrease hospitalizations for heart failure

digoxin

target dose for digoxin is 0.5-0.9 ng/mL, which is a ___ therapeutic index

narrow

digoxin adverse effects

-N/V/D

-______/AV block

-arrhythmias

-headache

-___ disturbances

-dizziness

bradycardia, mental

digoxin contraindications

-____ fibrillation

ventricular

digoxin monitoring

-HR

-ECG

-electrolytes

-____ function

-_____ digoxin level (bc narrow therapeutic index)

renal, serum

Ivabradine can be beneficial to reduce heart failure hospitalizations for patients with stable HFrEF who are receiving guideline-directed medical therapy (including beta blocker), and who are in normal sinus rythym with a HR of ___bpm or greater at rest

70

What is brand name of Ivabradine?

Corlanor

Ivabradine Adverse Effects

-____ (can increase risk of QT prolongation and ventricular arrhythmias)

-hypertension

-atrial fibrillation

-_____ (sensations of seeing light without an actual light source)

bradycardia, phosphenes

Ivabradine Contraindications

1) _____ (acute decompensated HF)

2) sick sinus syndrome, SA block, or 3rd degree AV block (unless ___)

ADHF, pacemaker