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Lippincott Chap 16
Pharm - Heart Failure Drugs
| Question | Answer |
|---|---|
| ACE inhibitor stands for | angiotensin-converting enzyme (ACE) |
| Name the six ACE inhibitors | captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril |
| ARB stands for | angiotensin-receptor blockers (ARBs) |
| Name the four ARBs | candesartan, losartan, telmisartan, valsartan |
| Name the three B-Blockers | atenolol, carvedilol, metoprolol |
| Name the four diurectics | bumetanide, furosemide, hydrochlorothiazide, metolazone |
| Name the three direct vasodilators | hydrolazine, isosorbide dinitrate, sodium nitroprusside |
| Name the five inotropic agents | amrinone, digitoxin, digoxin, dobutamine, milrinone |
| Name the one aldosterone antagonist | spironolactone |
| There are six types of drugs used for heart failure. Name them | renin-angiotensin system blockers (ACE and ARBs), B-adrenoreceptorblockers, diurectics, direct vasodilators, inotropic agents, and aldosterone antagonists |
| What do ACE inhibitors do | block the enzyme that cleaves angiotensin I to form the potent vasoconstrictor angiotensin II. ACE inhibitors also diminish the rate of bradykinin inactivation (bradykinin helps vasodilation) |
| What do ACE inhibitors do for the heart (3 things) | decrease vascular resistance, venous tone, and blood pressure |
| All ACE inhibitors should be taken how | on an empty stomach (food decreases absorption) |
| Which two ACE inhibitors can be taken once a day | ramipril and fosinopril |
| Which ACE inhibitor does NOT require activation by hydrolysis of hepatic enzymes | captopril |
| Which ACE inhibitor does NOT require renal elimination | fosinopril |
| Name the five main adverse effects from taking ACE inhibitors | postural hypotension, renal insufficiency, hyperkalemia, angioedema, and a persistent dry cough |
| What patient should never take ACE inhibitors | pregnant women because these drugs are fetotoxic |
| What do ARBs do | they are antagonists of the angiotensin type 1 receptor |
| Why do ARBs do a better job blockading the angiotensin action than ACE inhibitors? | because ARBs blockade all the enzymes responsible for the production of angiotensin II |
| Do ARBs affect the bradykinin levels? | No. only the ACE inhibitors do. |
| What is the main thing ARBs are approved for | lowering blood pressure |
| How many times a day are ARBs taken | once a day |
| What is the main difference in the adverse effects in ACE inhibitors vs the ARBs | ARBs do not produce a cough. Like ACE inhibitors, ARBs should not be used in pregnancy |
| Why would a doctor prescibe an ARB vs an ACE inhibitor? | When a patient has a severe cough or angioedema |
| What do B-blockers do | decrease the heart rate and inhibit the release of renin. In addition, they decrease remodeling, hypertrophy and cell death by preventing the effect of norepinephrine on cardiac muscle fibers |
| Which B-blocker is a nonselective b-adrenoreceptor anatagonist? | carvedilol |
| Which B-blocker is a b1-selective antagonist? | metoprolol |
| B-blockers are recommmended for all patients with heart disease EXCEPT | those who are at high risk but have no symptoms or those who are in acute HF |
| How should treatment be started with B-blockers | low doses and gradually titrated to effective doses based on patient tolerance |
| What do diuretics do? | relieve pulmonary congestion and peripheral edema, reducing symptoms of volume overload (ex orthopnea, paroxysmal nocturnal dyspnea), decrease plasma volume (this decreases venous return to the heart called preload), also may decrease afterload, BP |
| When would thiazide diuretics not work? | when patient creatinine clearance is less than 50mL/min |
| What patients typically use loop diuretics? | patients requiring extensive diuresis and those with renal insufficiency |
| What can overdoses of loop diuretics cause? | hypovolemia |
| What is a common venous dilator for congestive HF | nitrates (a direct vasodilator) |
| If a patient cannot tolerate ACE inhibitors or b-blockers what direct vasodilators are usually given? | hydralazine and isosorbide dinitrate |
| What should be avoided in patients with HF? | calcium-channel blockers |
| What do inotropic drugs do? | enhance cardiac muscle contractility |
| Cardiac glycosides (inotropic drugs) are often called | digitalis or digitalis glycosides because they come from the foxglove plant |
| Why could digitalis glycosides be dangerous? | because there is a small difference between doses that are therapeutic and doses that are toxic or fatal |
| How do digitalis glycosides work | they regulate the cytosolic calcium concentration an increase the force of the contraction of the heart thus reducing heart rate |
| When is digoxin therapy indicated? | in patients with severe left ventricular systolic dysfunction AFTER initiation of ACE inhibitors and diuretics. Usually HF with atrial fibrillation |
| When is digoxin therapy NOT indicated? | in patients with diastolic or right sided HF |
| What inotropic drug can be given by IV? | dobutamine |
| What inotropic drug is the only one available orally? | digoxin |
| What is the half life of digoxin? | 36 hours (nurse needs to watch creatinine clearance) |
| What is the half life of digitoxin (not digoxin) | 5 days. much longer than the 36 hours of digoxin |
| What type of patient may require decreased doses of digitoxin? | those with hepatic disease |
| What is the most common adverse drug reaction of digitalis drugs (digoxin, digitoxin) | toxicity |
| What actions are implemented with digitalis toxicity | discontinue therapy, determine potassium levels (low levels increase toxicity), may need potassium supplements, renal insufficient pts may need dosage adjustment |
| If a patient has ventricular tachycardia from digitalis toxicity, what needs to be administered? | antiarrhythmic drugs and the use of antibodies to digoxin (digoxin immune Fab), which bind and inactivate the drug |
| What other adverse effects besides arrhythmias, are seen with digitalis drugs (digoxin) | GI effects such as anorexia, nausea, and vomiting. CNS effects such as headache, fatigue, confusion, blurred vision, alteration of color perception, and halos on dark objects |
| What type of patient could potentially get digitalis toxicity? | those receiving diuretics, hypercalcemia, hypomagnesemia. Quinidine, verapamil, amiodarone, corticosteroids can cause digitalis toxicity. |
| What other diseases/conditions could contribute to digitalis toxicity? | hypothyroidism, hypoxia, renal failure, and myocarditis |
| There are 3 classes of inotropic drugs. The first is digitalis (digoxin,digitoxin) what is the second and third? | Second is B-adrenergic agonists (dobutamine)IV only. Third is phosphodiesterase inhibitors (amrinone, milrinone)Short term only (IV only) Increased mortality long term use. |
| What circumstances would warrant using dobutamine (inotropic drug)? | Acute HF in the hospital (given by IV) |
| Patients with advanced heart disease have elevated levels of aldosterone. What is a direct antagonist of aldosterone? | spironolactone. |
| What three things does spironolactone help prevent? | salt retention, myocardial hypertrophy, and hypokalemia (promotes potassium retention) Only used for advanced cases of HF. |
| What adverse effects are seen with the use of spironolactone? | gastritis, peptic ulcers, lethargy, confusion, gynecomastia, decreased libido, menstrual irregularities |
| What treatment is implemented with Stage A HF (high risk w/no symptoms) | risk factor reduction, patient education |
| What treatment is implemented with Stage A HF with symptoms such as high BP, cholesterol? | Treat hypertension, diabetes, dyslipidemia, ACE inhibitors and ARBs in some patients |
| What treatment is implemented with Stage B HF (structural heart disease, no symptoms)? | ACE inhibitors or ARBs in all patients; B-blocker in selected patients |
| What treatment is implemented with Stage C HF (structural heart disease, previous or current symptoms)? | ACE inhibitors and B-blockers in all patients if no improvement, dietary sodium restriction, diuretics, and digoxin. |
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