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What drugs are usually used to treat Tachycardia caused by receded CO?
BBs
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What drugs are usually used to treat Increased preload caused by receded CO?
ACEIs and Diuretics
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What drugs have Negative inotropic effects on HF?
- Antiarrhythmics
- Beta-blockers (other than the 3)
- CCB (non-dihydropyridine CI in Systolic HF)
- Intraconazole
- Terbinafine
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What drugs have Cardiotoxic effects on HF?
- Doxorubicin
- Daunomycin
- Cyclophosphamide
- Trastuzumab
- Ethanol
- Amphetamines
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What drugs have Na/Water retention effects in HF?
- NSAIDs
- COX-2 Inhibitors
- TZD’s
- Glucocorticoids
- Androgens/estrogens
- Na-containing drugs
- Imatinib
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What CCB’s are always CI in Systolic HF?
Non-dihydropyridine CCB (verapamil and diltiazem)
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Do Diuretics provide a mortality benefit for HF?
No, symptom relief only
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What aspects of HF are Diuretics used to treat in HF?
- Symptoms only:
- Improve exercise tolerance
- Improve QOL
- Reduce hospitilizations
- Reduce preload (main mechanism)
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How should you initiate a diuretic in HF?
- Start low
- Adjust based on s/s
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How should you monitor Diuretic use in HF?
- By s/s (i.e. body weight)
- See HCP if:
- More than 1 lb/day weight gain for several consecutive days
- More than 3lb/week
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What is the main diuretic used in HF?
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What is the peak effect time from time of dosing for Loops?
30-90 minutes after admin
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What is the benefit of Loops over other diuretics?
Maintain efficacy in Renal impairment
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What Loops have a long DOA?
Torsemide
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What loops have a short DOA?
Butenamide and Furosemide
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What is the MOA of loops?
Inhibit Na-K transporter in the ascending loop of henle
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What is the usually PO dose of Furosemide?
20-160 mg QD
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What is the Ceiling dose for Furosemide in Normal renal function, CrCl 20-50 and CrCl <20?
- Normal renal function: 80-160 mg
- CrCL 20-50 mL/min: 160 mg
- CrCL < 20 mL/min: 400 mg
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What is the DOS for Furosemide?
6-8 hours
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What are the beneficial Mechanisms of ACEIs in HF?
- Decrease BP: reduce AgII and aldosterone
- Prevent RAAS mediated worsening of myocardial function and remodeling
- Decrease preload and afterload
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What are the benefits of ACEIs in HF?
- Mortality benefit
- Reduce reinfarction, hospitalizations, symptoms, QOL, NYHA functional class and Exercise tolerance
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Do ACEIs have a mortality benefit for HF?
Yes
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What should you monitor when giving and ACEI to a HF patient?
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Should patients stop their ACEI if they are symptomatic?
No, should be on for the rest of their lives
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Should a patient be on an ACEI if they have renal insufficiency?
Yes, benefits outweigh the risks
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What are the potential adverse reactions of ACEIs in HF?
- HYPOtension
- Renal insufficiency
- Hyperklaemia
- Cough
- Angioedma
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What are the indications for ACEIs in Stage A HF?
Atherosclerotic disease (PAD or CAD) or DM and HTN
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What stages are ACEIs indicated for in HF?
All
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What are the indications for ACEIs in Stage B HF?
- History of MI and EF < 40%
- EF < 40%
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What are the indications for ACEIs in Stage C HF?
EF < 40%
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What are the indications for ACEIs in Stage D HF?
Continue only if tolerating
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What are the BBs with a mortality benefit in HF?
- Carvedilol
- Metoprolol succinate
- Bisoprolol
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What is the MOA of BBs in HF?
- Antagonize Sympathetic NS effects
- Antiarrhythmic effects
- Decrease HR/ventricular wall stress
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What are the benefits of BBs in HF?
- Mortality benefit
- Hospitilizations
- LV systolic function
- Reverses remodeling
- Helps with: symptoms, QOL and exercise tolerance
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Do BBs have a mortality benefit?
Yes
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If a patient is having a symptomatic exacerbation to a BB, what would you do?
- Temorarily reduce dose
- Only stop dose under dire situations
- Don’t start a BB under these conditions
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What are the key adverse events realetd to BB use in HF?
- Fluid retention and worseneinf HF
- Fatigue
- Bradycardia
- HYPOtension
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What are the CIs for BB in HF?
- Bronchospastic disease
- Severe bradycardia
- Heart Block
- Very severe acute decompensated HF
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What diseases are BBs precautioned in, but should be used unless symptoms make impossible?
DM, COPD, asthma and PVD
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What is the difference in MOA of the various BBs for HF?
- Metoprolol succinate and Bisoprolol: Only B1 antagonist
- Carvedilol: B1, B2 and a1 antagonist
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Why might Carvedilol cause more BP lower than Metoprolol succinate and Bisoprolol?
B/C it is an a1, B1 and B2 antagonist and the others are just B1
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What is the Initial dose of Carvedilol CR?
10 mg QD
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What is the target dose of Carvedilol?
80 mg QD
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At what interval should you push up the dose of BB?
Q2weeks, unless symptomatic, then wait, maybe a month
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Typically, should you initiate a BB or ACEI first?
ACEI first
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What stage of HF should you use BBs in?
- Stage B: History of MI and EF <40% or <40%
- Stage C: all patient with <40%
- Stage D if tolerated
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When should you initiate a BB before and ACEI?
- Excessive SNS activity (high HR)
- ACEI CI due to renal dysfunction or K concentration
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Why might you stop a BB in Stage D?
Makes you feel pretty groggy and sluggish sometimes and Stage D, we just want patients to be comfortable
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What are the core agents for HF?
ACEI and BB
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What ARBs are usually used in HF clinical trials?
Valsartan and Candesartan
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What are the benefits of ARBs in HF?
- Mortality benefit
- Reduction in hospitalizations
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What is the MOA of ARBs in HF?
- BP control by blocking Ag II and aldosterone
- Prevents RAAS mediated worsening of myocardial function
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How should you monitor ARBs?
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