Relative contraindications for using its inhibitor includes_________,_________,_________, _________, and _________.
Unilateral renal arterial stenosis, renal insufficiency, hypertension, hyperkalemia, and cough
Ace inhibitors should be used in patients with serum creatinine less than _________ to_________.
2.5 to 3 mg/dL
A small increase of _________ is possible with the addition of any ace inhibitor, it usually becomes transient or becomes patients new serum creatinine baseline level
Ace inhibitor should be held if the serum potassium increases above _________.
5 mEq per liter
Cough is coming soon with its inhibitors and may be related to chelation of tissue_________
In patients truly intolerant or contraindicated to ace inhibitors or ARB's the combination of _________and _________should be considered.
Hydralazine and isosorbide dinitrate
Nitrates reduce presented by causing primarily venous vasodilation to reactivation of _________and _________in vascular smooth muscle
guanylate cyclase and cGMP vascular smooth muscle.
The beneficial effect of external nitric oxide source may be more appropriate and_________ population.
Combination therapy with hydralazine and isosorbide dinitrate is an appropriate substitute for a key to antagonists and those who are unable to tolerate an ace inhibitor or ARB or as add-on therapy and African-Americans. True or false.
Isosorbide dinitrate is given_________ times per day.
3 to 4 times daily at 40 mg.
Hydralazine was given _________ times per day
3 to 4 times at 75 mg
Hydralazine is also associated with a dose-dependent risk for_________.
Instead of giving isosorbide dinitrate 2 to 4 times daily to increase patient adherence _________ could be given once daily.
A nitrate free interval is still required when using nitrates for heart failure. true or false
Beta adrenergic antagonists are also called_________.
Beta blockers competitively blocks the influence of the SNS at the _________site.
As recently as 15 years ago, beta blockers were thought to be detrimental in heart failure due to their negative inotropic actions. True or false
Chronic beta blockade reduces _________mass, improves _________shape, and reduces _________volumes.
VentricularventricularLeth ventricle in systolic and diastolic pressures
Beta blockers improve ejection fraction, reduce all causes and heart failure related hospitalizations, and decrease all cause mortality in patients with diastolic heart failure. True or false
False systolic heart failure , not diastolic
Beta blockers also exhibit antiarrhythmic effects, slow or reverse catecholamine induced ventricular remodeling, decrease myocyte death from catecholamine induced necrosis or apoptosis, and prevent myocardial fetal gene expression. True or false
The three beta blockers that have been shown to reduce mortality and systolic heart failure include bisoprolol (selective or nonselective), metoprolol succininate (selective or nonselective), and carvedilol (selective or nonselective).
Selective for metoprolol succinate and bisoprolol
Nonselective beta-1 beta-2 and alpha-1 antagonists carvedilol
The key to utilizing beta blockers and systolic heart failure is initiation with high doses and fast hydration to target over days. True or false
False, start low and go slow over weeks to months
Beta blockade should begin with the lowest possible dose, after which the dose may be double every 2 to 4 weeks, depending on the left ventricular ejection fraction and short-term worsening of heart failure symptoms upon each dose titration. True or false
If the left ventricle ejection fraction is less than 20% metoprolol succinate or carvedilol would be a better choice?
Metoprolol succinate because it is more selective
In patients with higher blood pressure and heart failure would be better to start metoprolol succinate or carvedilol?
Carvedilol may provide additional antihypertensive efficacy
Beta blockers should be used with patients who display active respiratory system symptoms. True or false
False, however, they still can be used if the patient is not exhibiting active symptoms
Metoprolol and carvedilol are metabolized by the liver through the cytochrome P450. Beta blockers should not be used in patients with severe hepatic failure. True or false
Aldosterone antagonists available are _________and _________.
Spironolactone and eplerenone
Aldosterone antagonists inhibit aldosterone, thus producing week diuretic effects while sparing potassium concentrations. True or false
_________aldosterone antagonists is selective for mineralocorticoid receptor and hence does not exhibit the endocrine adverse effect profile, seen with_________.
_________Should be given to patients with a New York heart Association III to IV,_________ given directly to post MI patients with evidence of LV dysfunction.
The major risk related to aldosterone antagonists is _________.
Two parameters that must be assessed before and within one week of initiating aldosterone antagonist therapy include _________and _________
BMP to assess serum creatinine and potassium
Dosing spironolactone starts at 12.5 225 mg daily, or occasionally _________days for patients with baseline renal insufficiency.
Dosing of aldosterone antagonist should be cut in half or alternate day dosing. If cretin clearance falls below _________ milliliters per minute.
Creatinine clearance less than 50
When taking aldosterone antagonist potassium supplementation is often decreased or stopped and patient should be counseled to avoid high potassium foods. True or false
Spironolactone has adverse effects, including _________for men and _________ for one and
Gynecomastia for men and breast tenderness and menstrual irregularities for women
eplereonne is a CYP3A4 substrate and should not be used with other strong inhibitors of 3A4. True or false
Digoxin was shown to slow down heart failure progression and increase survival, but not to decrease heart failure related hospitalizations. True or false
False. Digoxin has shown to decrease hospitalizations. However, it does not halt the progression of heart failure or increase mortality
Digoxin is initiated at a dose of 0.125 to 0.25 mg daily depending on age, renal function, weight, and risk for toxicity. True or false
Digoxin should be given at the lower dose. If the patient satisfies any of the following criteria; over 65 years of age, creating clearance less than 60 mL per minute, ideal body weight less than 70 kg. Dosing can also be every other day in patients with moderate to severe renal failure. True or false
The desired concentration range for digoxin is _________to _________. Preferably with concentrations at or less than _________.
0.5 to 1.2 ng/mL
Digoxin toxicity may manifest as nonspecific findings such as fatigue, or weakness, and other CNS effects such as confusion, delirium, and psychosis. True or false
In patients with life-threatening toxicity due to cardiac or other findings while on digoxin administration of _________therapy usually reverses adverse effects within an hour. In most cases.
Administration of digoxin specific Fab anti-body fragments
Amlodipine and felodipine is the most extensively studied dihydropyridine. Calcium channel blockers for systolic heart failure. They have been shown to have a positive effect on patient survival. True or false
False. They have neither positive or negative patient survival effects. However, they can be safely using heart failure patients to treat uncontrolled hypertension or angina. Once all other appropriate drugs are maximized
Fish oils or omega-3 fatty acids have been recently studied for heart failure and found to mildly decreased cardiovascular permissions and mortality without significant adverse effects. True or false
Hawthorn has been studied in heart failure and is shown to increase exercise capacity and reduce heart failure symptoms. True or false
Treatment of heart failure with preserved left ventricular ejection fraction lacks trials and studies to show optimal treatment. True or false
The current treatment approach for diastolic dysfunction or heart failure with preserved with intricate ejection fraction is correction control of underlying ideologies such as hypertension, CAD and maintenance of normal sinus rhythm, reduction of cardiac filling pressures at rest and enduring in section and increased diastolic filling time. True or false
peripartum cardiomyopathy is defined as clinical and echocardiographic evidence for new onset heart failure occurring during pregnancy and up to six months after delivery. True or false
False all other ideologies need to be excluded
The leading hypothesis for peripartum cardiomyopathy is that it is caused by myocarditis via viral infection or abnormal immune response to pregnancy. True or false
Treatment of peripartum cardiomyopathy is similar to that of regular heart failure patients except for _________.
The use of ace inhibitors and ARB's
Patients with peripartum cardiomyopathy at high risk of thromboembolism. Treatment options during pregnancy are limited to _________ and _________.
Unfractionated heparin and low molecular weight heparin. Warfarin is contraindicated
After pregnancy with patients with peripartum cardiomyopathy anticoagulation is recommended in patients with LVEF of less than _________ percent.
Types of drugs that may precipitate or exacerbate heart failure
Agents causing negative inotropic effects
Agents causing sodium retention
Agents causing negative inotropic effects that may exacerbate HF
Antiarrhythmic's such as recognized, beta blockers, calcium channel blockers(verapamil and diltiazem) itraconazole, terminafine
What are some cardiotoxic agents that can exacerbate HF
Doxorubicin daunomycin cyclophosphamide
Agents causing sodium retention of water that exacerbate HF
NSAIDs, Cox two inhibitors, glucocorticoids, engines, questions, salicylates (high doses), TZDs (rosi and pioglitazone)
Name the 18 symptoms of heart failure
Dyspnea, orthopnea, shortness of breath, paroxysmal nocturnal dyspnea, kidnapped, cough, fatigue, bacteria and or polyuria, and offices, abdominal pain, anorexia, nausea, bloating, ascites, mental status changes, weakness, lethargy
What are the 13 signs of heart failure
Pulmonary rails, pulmonary edema, S3 gallop, plural effusions, Cheyne–Stokes respiration, tachycardia, cardiomegaly, peripheral edema, jugular venous distention, hepatojugular reflux, hepatomegaly, cyanosis of the digits, pallor or cold extremes
Acute HF Subset 1 (warm and dry)
-CI ____ and pulmonary capillary wedge pressure less than ______
-Pt considered well compensated and perfused without evidence of congestion
no immediate interventions necessary except to maximize oral meds
CI greater than 2.2 L/min/m2PCWP less than 18 mmHg
Acute HF Subset 2 (warm and wet)
-CI greater than _____ and PCWP less than _____
-patients adequately perfused and display signs and symptoms of _____
-mail goal is to reduce _____ with ______
- >2.2 CI and >18 mmHg PCWP
-preload (PCWP) with loop diuretics and vasodilators
Acute HF Subset 3 (cool and dry)
-CI ____ 2.2 L/min/m2 PCPW ____ 18 mmHg
-Pt are inadequately perfused and not congested
-Tx focuses on increasing ____ with ____ agents and replacing fluids
-fluid replacement must be done conservatively
CI LESS than 2.2 and PCPW GREATER
tx focuses on increasing CO with positive inotropic agents
Subset IV (cool and wet)
-CI ____ 2.2 L/min/m2 PCWP _____ 18 mmHg
-Pts are inadequately ____ and ____
-____ are used to maintain blood pressure
-CI less than 2.2 and PCWP less than 18
-perfused and congested
Treatment of AHF targets relief of congestion and optimization of cardiac output, utilizing oral and IV_________, IV_________, and when appropriate allotropes based on presenting hemodynamics.
IV diuretics and IV vasodilators
Diuretics reduce_________, but do not increase cardiac index, as do positive inotropes and arterial vasodilators