144 Heart Failure Tx Flashcards
Prevent Heart Failure
•Control blood pressure
- Control diabetes mellitus
- Control lipids
- Smoking cessation
- Weight control
- Early recognition and treatment of acute coronary syndromes
HF: Selected Diagnostic Testing
Chronic Medical Treatment of HF with Reduced EF (EF<40%)
Vasodilator Drugs: venodilator, mixed, arteriolar dilator
Drugs that target: Renin-Angiotensin-Aldosterone System
Spironolactone
–Cheap, generic
–Side Effects: Hyperkalemia, Relatively nonselective: sex steroid hormone effects à gynecomastia, irregular menses
–Prodrug. Has active metabolites with long half-lives: long time to steady state
Sacubutril
•Sacubutril: Neprilysin Inhibitor: only formulation is sacubutril/valsartan
–sacubutril/valsartan aka “ARNI” Angiotensin Receptor Blocker Neprilysin Inhibitor
Aliskiren
B-blockers mechanism in HF
Beta-blockers improve beta-receptor sensitivity in the long run, improving myocardial performance
Failing Heart: Toxic Neurohormonal Milieu
Failing Desensitized Heart: Enter Metoprolol: Sensitivity Restored, Accounts for Efficacy in Left Ventricular Systolic Dysfunction (HFrEF)
Specific B-blockers for HF
Mineralocorticoid Receptor Antagonist Mechanism
-
•Spironolactone:
- –Cheap, generic
- –Side Effects: Hyperkalemia, Relatively nonselective: sex steroid hormone effects à gynecomastia, irregular menses
- –Prodrug. Has active metabolites with long half-lives: long time to steady state
-
•Eplerenone:
- –Quite selective for mineralocorticoid receptor (MR)
- –Side Effects: Hyperkalemia.
- –Often used post-myocardial infarction (based on trial data)
- •Other CV Indications (mostly spiro): HTN, HF with preserved EF
Nitrates mech and use in HF
Eplerenone
–Quite selective for mineralocorticoid receptor (MR)
–Side Effects: Hyperkalemia.
–Often used post-myocardial infarction (based on trial data)
for HFrEF
Hydralazine
Hydralazine / Isosorbide Mononitrate combination therapy
-
•Nitrates:
- –Side Effect: Headache, hypotension
- –Exhibits tachyphylaxis (effect wanes with time)
- –Isosorbide Dinitrate (TID dosing) is the evidence-based HF choice
-
•Hydralazine:
- –Side Effect: Headache, tachycardia
- –TID dosing
-
•Clinical Use:
- –Evidence for benefit in all patient populations, particularly African-Americans
- –Use also in patients who can’t tolerate ACE-I or ARB
- –Three times daily dosing (TID) can be hard to adhere to
Ivabradine Mechanism
HF
Diurectic sites of action
Chronic Medical Treatment of HF with Preserved EF (EF>50%)
- •Volume Control
- •Blood Pressure Control
- •Spironolactone: Near-evidence based therapy (TOPCAT)
- •Weight management (inflammatory adipokines)
- •Exercise
HF subtypes
•Signs of congestion: any of the following
–Orthopnea, +JVP, rales, ascites, leg swelling
•Signs of poor perfusion: any of the following
–Cool extremities, ¯BP, ¯pulse pressure, sleepy/obtunded, worsening renal function, ¯urine output
HF subtypes treatments
Treatment of acute pulmonary edema
–Phosphodiesterase 3 inhibitors (milrinone)
used in stage IV heart failure
IV inotropes
