6024 Mod 9 HF PDF

Vasodilators Hydralazine ● MOA ○ Same as NTG + acts on Ca channels (dilates arteries ONLY) ● SE ○ HA ○ reflex HTN/tachy ○ Nausea ● Indications ○ HTN ○ HFrEF especially in people of color ● Contraindications ○ Renal failure ○ pregnancy?? ● Monitoring ○ HR/BP ● Facts/Population Considerations ○ Risk o...

Vasodilators Hydralazine ● MOA ○ Same as NTG + acts on Ca channels (dilates arteries ONLY) ● SE ○ HA ○ reflex HTN/tachy ○ Nausea ● Indications ○ HTN ○ HFrEF especially in people of color ● Contraindications ○ Renal failure ○ pregnancy?? ● Monitoring ○ HR/BP ● Facts/Population Considerations ○ Risk of SLE Sodium Nitroprusside ● MOA ○ Same as hydralazine ● SE ○ Cyanide toxicity→ delirium, psychotic behavior ○ Brady; hypo ○ Heart blocks; HF ● Indications ○ HTN urgency/emergency ○ GMDT for acute diastolic HF exacerbation ● Contraindications ○ Renal failure ● Monitoring ○ Needs to be in ICU Anginal Medications/vasodilators for acute & chronic angina NTG ● MOA ○ Act directly on smooth muscle of arterioles via nitric oxide→ relaxation→ decreased afterload→ decreased O2 demand→ dilation of venous system ● SE ○ Hypotension ○ HA, flushing ○ Reflex tachy→ palpitations ● Indications ○ Angina ● Contraindications ○ Glaucoma, migraines, ED (on meds), CVA, CrCl < 50 ● Monitoring ○ HR/BP. Nitro free time (to prevent tolerance), edema, renal ● Facts/Population Considerations ○ For MI, avoid morphine & oxygen but keep ASA and NTG Isosorbide Mononitrate ● MOA ○ Directly relax smooth muscles to cause vasodilation including coronary arteries ● SE ● ● ● ● ○ HA, dizziness ○ Postural Hypotension, reflex tachy ○ Worsen angina ○ Dry mouth, hot flashes Indications ○ Chronic angina Contraindications ○ ACUTE angina Monitoring ○ BP ○ Tolerance Facts/Population Considerations ○ Pt should take in AM ○ For extended release→ stop slowly Hydralazine + Isosorbide Dinitrate ● MOA ○ Hydralazine vasodilates smooth muscle and isosorbide restores nitric oxide and dilates arteries & veins ● SE ○ Hypotension, tachy ○ HA, dizziness, flushing ○ SLE flare ups ● Indications ○ Chronic angina ● Contraindications ○ Acute angina ○ Sildenafil with ED ● Monitoring ○ BP ○ Tolerance ● Facts/Population Considerations ○ Stop med if having SLE flare up CCB for Angina ● Use if unable to tolerate BB ● Nifedipine = drug of choice bc it’s long acting ○ Other options: amlodipine, diltiazem, verapamil ● Use amlodipine if pt has angina AND heart failure Ranolazine (Ranexa) ● MOA ○ Disrupts Na & K channels→ decrease HR and O2 demand ● Can be used with nitrates, BB, or CCB ● SE ○ QT prolong ○ Hypo ○ Brady ○ Edema ● Contraindications ○ Not for acute angina ○ Adjust dose if CrCl < 50 Heart Failure ARNI—Sacubitril/Valsartan (Entresto) ● MOA ○ Neprilysin inhibitor (sacubitril) prevents breakdown of natriuretic peptides + MOA of ARB = double blockage of RAAS ● SE ○ Hypotension ○ Angioedema ○ hyperK ○ Increased bradykinin ● Indications ○ HFrEF ● Contraindications ○ Use w/ ACE—need 36 hr washout ○ Pregnancy ○ ESRD ○ Liver failure ● Monitoring ○ BP, renal, liver, K+ ● Facts/Population Considerations ○ Don’t need 36 hr washout if already taking valsartan ○ Hold or reduce dose if CrCl < 30 BB in Heart Failure ● Which 3 ○ Metoprolol succinate, carvedilol, bisoprolol ● GDMT ○ Start low and go slow ○ Better to start when pts are “dry” aka not in acute exacerbation AA/MRA in HF—Spironolactone ● Only if CrCl < 30 and K+ WNL ● Improves blockage of RAAS when used w/ ACE/ARB/ARNI ● If pt has acute diastolic HF and loop diuretic resistance→ add spironolactone ● Watch for endocrine issues: gynecomastia (enlarged breasts) and galactorrhea (milk production unrelated to pregnancy) SGLT2 Inhibitors in HF—-”glifozin” dapaglifozin (farxiga) empagliflozin (jardiance) ● MOA ○ Sodium-glucose cotransporter in proximal tubule that is responsible for 90% of urinary glucose reabsorption→ also cause diuretic effects, weight loss, and lowering BP ● SE ○ Hypoglycemia ○ Electrolyte imbalance ● Indications ○ HFmrEF; HFrEF ● Contraindications ○ ESRD (if CrCl < 20) ● Monitoring ○ Risk for UTI/pyelonephritis ○ BP; BG, electrolytes HF and Diuretics ● Which classes? ○ Loop or thiazide ○ Why is it recommended? ■ Maintain euvolemia, relieve congestion, improve symptoms and prevent worsening HF ● Use in acute and chronic renal disease Heart Failure and Oral Vasodilators ○ Which medications ■ Hydralazine & isosorbide dinitrate ○ Why is it recommended? ■ Afterload reduction and decrease cardiac related deaths ■ Excellent sub for ACE if pt can’t handle the dry cough