Pharm Exam CHF & Nitrates MW (2/4)

Volume overload and decreased tissue perfusion (heart can’t pump enough blood to meet needs)

CHF

(Weber says “weak pump pumping against a kinked hose”)

What diseases usually lead to CHF?

1. HTN

2. CAD

3. valvular disease & ventricular dysfunction

4. Ischemia

CHF originates from _____ sided ventricular failure

Left

Is this acute or chronic CHF?

-Large % is systolic

- Sudden reduction in CO leading to Pulmonary Edema and systemic hypotension without peripheral edema

Acute CHF

What can cause acute HF?

1. MI

2. ruptured papillary muscles

3. hypertensive crisis

4. Acute aortic insufficiency

What can cause chronic HF?

dilated cardiomyopathy and multivalvular disease

Grade this type of HF..

- without limitations of physical activity.

- No physical activity induced fatigue, palpitation, dyspnea or CP.

Grade I HF (no limitations)

Grade this type of HF..

-Slight limitations of physical activity.

- Comfortable at rest

- Physical activity causes fatigue, palpitation, dyspnea or CP.

Grade II HF

Grade this type of HF..

-Marked Limitation of physical activity.

- Comfortable at rest

-Less than ordinary PE causes fatigue, palpitation, dyspnea or CP.

Grade III HF

(use to go up 12 stairs now can only do 3)

Grade this type of HF..

- Inability to carry on any PE without discomfort

- CP, Fatigue and dyspnea at rest

Grade IV HF

What causes BNP to be released?

1. Salt

2. water retention

3. vasoconstriction

What does BNP cause?

increased GFR

Vasodilator

What is used to monitor how bad HF is?

BNP (>100)

High BNP in a patient means...

bad HF

What are some non-pharm tx for CHF?

A. Low salt diet & NO ETOH

B. fluid restriction

C. daily weight

D. cardiac rehab

E. patient education

F. All of the above

F. All of the above

A. How much sodium for HF grade 1/2?

B. what about 3/4?

A. 3 g

B. < 2 g

Why do we have to weigh ourselves for HF?

fluid levels

- retention

A. People with HF and congestion need to consume less than how much fluid?

B. What if those patients have low sodium < 135?

A. < 2,000

B. < 1,500

What does ETOH do to myocardial contractility ?

decrease

Pt in HF. What will each do?

1. HCT/Hb

2. LFTs

3. Sodium level

4. BNP

1. decrease

2. increase

3. decrease (hyponatremic)

4. Increase

True/False

Must monitor electrolytes and do CXR, EKG and ECHO in pt with CHF

True

What is diagnostic for the etiology for HF?

ECHO

What medications can we use to tx CHF?

A. ACEI or ARBs

B. Diuretics

C. Digitalis

D. Selective BB or anticoagulants

E. All of the above

E. All of the above

What pts get anticoag Tx if they have HF?

A. < 30% EF

B. Afib, Embolic event, Cardiac thrombus

C. bed rest

What do ARBS and ACEi do to each:

1. Arterial diastolic pressure

2. LV end diastolic pressure

3. Systemic resistance & BP

4. LV function & CO

5. Blood flow to renal, coronary and cerebral

1. decrease

2. decrease

3. decrease

4. increase

5. increase

Arbs block more Angiotensin II therefore lowering which hormone level?

aldosterone (increase K+ & decrease Na+)

What effects do beta blockers have?

antihypertensive

antiarrythmic

1. What do beta blockers do for hormonal activation and toxicity?

2. HR?

decrease both

What type of pt does not get Carvedilol?

COPD/Asthma

When do we give carvedilol?

after we use diuretics

Who gets started on a beta blocker ?

mild to moderate HF on ACE or diuretic

Beta blockers are contraindicated in patients with HF if they have what symptoms?

hypotension

bradycardia

pulmonary congestions

This medication inhibits Na/K ATPase causing increase Na+ and decrease K+. It increase Ca2+ in cells increasing contractility.

Cardiac Glycosides such as Lanoxin (Digoxin)/ Digitalis

Weber uses this as his last line in patients with HF and afib?

Digoxin

What does digi do to vagus nerve?

stimulates vagus nerve thus decreasing

1. rate of SA node

2. slows AV conduction

3. decrease HR

T or F: Digi is a negative chronotrop and dromotrop

T

What is the theraputic index of digi?

.8 to 2

Digoxin is NOT removed by ______ because it goes to the tissue NOT the blood

dialysis

What type of patient gets digitalis?

someone with afib, HF and stable BP

What do we do to a patient with Afib, HF and low BP?

cardiovert

What are the AE of digi? (GI, CNS, cardiac)

GI- n/v/f

CNS- yellow/green halo vision, seizures, hallucinations, weakness

Cardiac- V tach, PVCs, tachy-brady arrythmias, AV block

What is the MCC of death from digitalis toxicity?

V fib*

What two drugs can increase Digi levels?

verapamil and quindine

What can digi plus beta blocker cause?

complete heart block

What does antacid and thyroid hormone cause to digi?

decreased levels

Digitalis toxicity can be made worse by?

hypokalemia

How do you tx patient with Digitalis toxicity ?

1. D/C dig

2. Digibind IV over 30m

3. PO/IV K+

4. Correct cardiac arrhythmia

What is the MOA of entresto (sacubitril/valsartan)?

Combo of Neprilysin inhibitor with ARB that decreases the break down of ANP and antagonists ARB.

(HE LOVES THIS SHIT)

What grade HF gets entresto?

2 to 4

(HF with Reduced EF)

What are the AE of entresto?

1. hyperkalemia

2. anaphylxis/angioedema

3. renal failure

4. hypotension

What are the drug interactions for entresto?

cant use ACE/ARB

What are the CI for entresto?

1. RAS

2. renal impairment

3. pregnancy

What are nitrates used for?*

1. HTN

2. Angina

3. CHF

4. MI

These cause systemic vasodilation, decreases preload and myocardial oxygen demand/wall stress.

Nitrates

_____ increase myocardial oxygen supply

nitrates

What is the onset and duration of each:

1. Sublingual Nitroglycerin

2. Nitroglycerin Ointment (Transdermal)

3. Tridal (IV nitro)

1) 30sec; 15-30min

2) 1hr; 6-14hr

3) 1-2 seconds

What is the onset and duration of each oral nitro:

1. Isosorbide dinitrate

2. Isosorbide mononitrate

1) 30min; 4-6hrs

2) 30min; 8-12hrs

Weber likes isosorbide ____________ better because its dosed 1x/day and can be used for prophylaxis and tx of angina (NOT for Acute attacks)

Isosorbide mononitrate*

This type of nitroglycerin is used for Prophylaxis of angina but NOT for acute attacks (takes too long to work)

Nitrodur (transdermal nitro)

Since you can grow a tolerance to Nitrodur (transdermal nitro), how would you instruct pt to use it?

Keep it on for 16 hours and take off for 8 hours

What nitro can you use for prophylaxis of angina and ACUTE attacks?

1. Nitroglingual (nitro spray)

2. S/L Nitrate (Nitroglycerine)

What nitro is good for acute attacks?

1. SL

2. spray

3. IV

For SL and spray nitro, how much can you use it?

3 doses max and 1 dose every 5 minutes

What 2 main DI for nitrates that can cause severe hypotension?

-ED drugs

-CCBs

-ETOH

What are the CI for nitrates?

-recent MI

-hypotension

-hypertrophic cardiomyopathy

What are the AE of nitrates?

1. headache (MC)

2. orthostatic hypotension

3. bradycardia

4. flushing