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PDAT5 CV > 29/30 - HFrEF > Flashcards

29/30 - HFrEF Flashcards

1
Q

MoA in HF-rEF

ACE-I & ARB
Enalapril / Lisinopril / Ramipril
Valsartan / Candesartan / Losartan

A

↓Preload - ↓Afterload - Cardiac Remodeling

ACE/ARB

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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2
Q

MoA in HF-rEF

Beta Blockers
Metoprolol SUCCinate/Bisoprolol / Carvedilol

A

↓Afterload - Cardiac Remodeling

BETA BLOCKERS

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis -↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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3
Q

MoA in HF-rEF

DIURETICS
Loop = Furosemide / Bumetanide / Torsemide
Thiazide = HCTZ / Chlorithalidone / Metazolone

A

↓Preload

DIURETICS

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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4
Q

MoA in HF-rEF

Aldosterone Receptor Antagonist = ARA
Spironolactone / Eplerenone

A

↓Preload - Cardiac Remodeling

ARA = Spironolactone / Eplerenone

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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5
Q

MoA in HF-rEF

Sacubatril/Valsartan = ENTRESTO

A

↓Preload - ↓Afterload - Cardiac Remodeling

Sacubatril/Valsartan = Entresto
SAME AS ACE/ARB + additional VASODILATION

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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6
Q

MoA in HF-rEF

Ivabradine = CORLANOR

A

INDIRECTLY –> Lowers HEART RATE

Ivabradine = Corlanor

AT2 + Aldosterone –> Na + H2O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO2 ↓Stroke Volume

NE –> SNS Excess
Apoptosis -↑MVO2

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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7
Q

HF-rEF Treatment:
ACE INHIBITORS

Place in therapy for All Stages?

A

ALL Pts in Stage C/D
+
ALL ASx pts in Stage B
DELAYS onset of Sxs & 1st HF hospitilization

High Risk Patients in Stage A (just at risk, no SXs)
Vascular Disease = PAD / PVD / Stroke
DM + 1 CV Risk Factor
OR
DM + Smoking / MicroAlbuminuria

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8
Q

HF-rEF Treatment:
BETA BLOCKERS

Place in therapy for All Stages?

A

ALL Pts in Stage B/C/D
↓ HF symptoms + ↓Hospitalizations
SLOWS HF Progression:
↓incidence of sudden death (Ventricular fibrillation)

HIGH DOSE:
↓ mortality/hospitalizations, ↑ ejection fraction

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9
Q

HF-rEF Treatment:
DIURETICS

Place in therapy for All Stages?

A

Management of FLUID OVERLOAD** in **Stage C+D
Most LOOP diuretics
Thiazides for MILD fluid overload = better HTN drug

Clinical Benefit:

  • *SYMPTOMATIC ONLY**
  • no effect on MORTALITY*

Stage A + B –> only for HTN

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10
Q

HF-rEF Treatment:
ARA’s
Spironolactone / Eplerenone

Place in therapy for All Stages?

A

STAGE C/D
NYHA FC 2-3 w/ SYMPTOMS
&
Stage B/C
Post MI / EF<40 / HF Symptoms or DM

Clinical Benefits:
↓ hospitalizations, mortality
IMPROVED SYMPTOMS
decreases fibrosis/remodeling

consider in STAGE B resistant HTN

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11
Q

HF-rEF Treatment:
Hydralazine + Isosorbide

Place in therapy for All Stages?

A

AFRICAN AMERICANS
In addition to OPTIMAL THERAPY of RAAS-1 + BB in Class 3-4
↓ mortality & ↓ hospitalizations for HF

Alternate Therapy for those UNABLE to take ACE/ARB
due to intolerance or contraindication
Ex. Pregnancy / Angioadema / Advanced Kidney Disease

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12
Q

HF-rEF Treatment:
ENTRESTO
Sacubutril/Valsartan?

Place in therapy for All Stages?

A

REPLACES ACE/ARB
for patients with:
SYMPTOMATIC HFr-EF Class 2-3
↓ hospitalizations from HF + ↓CV mortality

  • *Need BP >100mmHg**
  • due to greater DROP in BP*
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13
Q

HF-rEF Treatment:
CORLANOR
Ivabradine

Place in therapy for All Stages?

A

ADD to Std therapy (ACE/ARB + BB)
BB should be at TARGET or MAX tolerated dose
in patients with:
Symptomatic HFr-EF FC2-3
AND:
RESTING HR > 70bpm

  • *↓ hospitalizations and death from HF
  • No overall mortality benefit***
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14
Q

HF-rEF Treatment:
DIGOXIN

Place in therapy for All Stages?

A

Added to Std of Care in SYMPTOMATIC HFr-EF
NOT ADDRESSED in 2017 GUIDELINES
only studies are from OLD treatment protocols

↓Hospitilizations
BUT:
NO effect on MORTALITY

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15
Q

HF-rEF DOSING:

ACE INHIBITORS

A
  • *ENALAPRIL**
  • *2.5-5** BID > 10mg BID
  • *LISINOPRIL**
  • *2.5-5 qd** > 20-40mg qd
  • *Ramipril**
  • *1.25-2.5 qd > 10mg qd**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

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16
Q

HF-rEF DOSING:

ARBs

A
  • *VALSARTAN**
  • *40 BID > 160 BID**

CANDESARTAN
4-8 qd > 32 qd

  • *LOSARTAN**
  • *25-50 qd > 150 qd**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

17
Q

HF-rEF DOSING:

BETA BLOCKERS

A
  • ONLY these 3 DRUGS have proven Benefit*
  • *DOUBLE the DOSE every 2 WEEKS as tolerated**
  • *METOPROLOL SUCCINATE**
  • *12.5-25 qd > 200 qd**
  • *BISOPROLOL
    1. 25 qd > 10 qd**
  • *CARVEDILOL**
  • *3.125-6.25 BID > 25-50 BID**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

18
Q

HF-rEF DOSING:

LOOP DIURETICS

A
  • NO TARGET DOSE* –> SYMPTOMATIC ONLY
  • *INITIAL DOSE** > Maintanence dose
  • need to get FLUID OUT ASAP*
  • *BUMETANIDE**
  • *0.5-1** qd OR bid -> max= 10
  • *FUROSEMIDE**
  • *20-40** qd OR bid -> max= 600
  • *TORSEMIDE**
  • *10-20** qd OR bid -> max= 200
19
Q

HF-rEF DOSING:

THIAZIDE DIURETIC

A
  • NO TARGET DOSE* –> SYMPTOMATIC ONLY
  • *INITIAL DOSE** > Maintanence dose
  • need to get FLUID OUT ASAP*
  • *HCTZ**
  • *25 qd** -> max= 200
  • *Chlorthalidone**
  • *12-25 qd** -> max= 100
  • *Metolazone**
  • *2.5 qd** -> max= 20
20
Q

HF-rEF DOSING + WHEN TO AVOID STARTING?

ARA
Spironolactone + Eplerenone

A

Can start at the TARGET DOSE
Avoid Starting if:
K ≥ 5 mEq/L or
SCr ≥ 2.5 mg/dL or
CrCl < 30 ml/min
Likely will need to ↓ or d/c K supplements

  • *SPIRONOLACTONE**
  • *25 qd - Target**
  • *Eplerenone**
  • *50 qd - Target**
21
Q

HF-rEF DOSING:

  • *HYRALAZINE / ISOSORBIDE**
  • *BiDil** = Combo
A

Initial Dose:
Hydralazine 25-50** + **ISDN 20-30 TID or QID
Bidil is diff concentration TID

Target Dose:
Hydralazine 300mg** + **ISDN 120mg in div doses

Monitor:
BP + Adherence

ADR = Headache

22
Q

HF-rEF
DOSING + SWITCH CONSIDERATIONS

Sacubutril / Valsartan
ENTRESTO

A

Titrate q2 weeks to TARGET as tolerated
MORE HYPOTENTION –> more CAUTIOUS w/ dosing
36 HOUR WASHOUT
when switching from ACE-I, need to take back old med
due to increased risk of ANGIOEDEMA

Dose is Converted from current ACE/ARB dose

49/51 -> 97/103

23
Q

HF-rEF
DOSING + CONSIDERATIONS

IVABRADINE
CORLANOR

A
  • *BetaBlocker needs to be @Target or @MAX**
  • *HR > 70 bpm** BEFORE starting

Ivabradine initial start:

  • *5mg BID**
  • *TAKE WITH FOOD = Better Bioavailability**

HEART RATE MONITORING
every 2 weeks after dose adjustment & q4 months

24
Q

HF-rEF MONITORING & ADR

ACE / ARB

A

RENAL FXN** + **K-Potassium
within 1-2 weeks: of start & after dose increases
q6 months in stable pts

  • Contraindicated in PREGNANCY*
  • -> use Hydralazine/Isosorbide

Symptomatic HypoTension = BP
low BP is FINE, just watch out for SYMPTOMS

Cough / ANGIOEDEMA
more common in ACE-I

25
Q

HF-rEF
MONITORING & ADR

Beta Blockers

A

May initially WORSEN SYMPTOMS
reason for slow titration up

  • *Carvedilol**
  • better for HTN** + *more dizzyness + diarrhea

Metoprolol + Bisoprolol
good for reactive airway disease
Carvedilol switch to Metoprolol if symptomatic Hypotension (less BP effect)

ADR:
SOB / EDEMA = worsening HF, need to slow titration
Symptomatic Bradycardia –> need to lower dose/slow

26
Q

HF-rEF
MONITORING & ADR

DIURETICS

A

DIURETIC RESISTANCE
declining response dispite INCREASING doses
Na+ Diet / NSAIDs / Renal Fxn
can COMBINE LOOP + THIAZIDE/Metolazone for SYNERGISTIC EFFECT

Safety/Efficacy:

  • *Daily Weight / HF Symptoms**
  • *ELECTROLYTES_ + _RENAL FUNCTION**
  • *OTOTOXICITY** = only @ high dose/rapid IV push
27
Q

HF-rEF
MONITORING & ADR

SPIRONOLACTONE / EPLERENONE

A

RENAL FXN** + **K-POTASSIUM
within 3 days & 1 week after initiation
monthly for 1st 3 months –> 3-4months after

K > 5.5 counseling:
avoid K+ foods / NSAIDS / Salt
D/C supplements or Drug
K-BINDER for severe elevation > 6
ECG IF NEW BRADYCARDIA
life threatening HYPERkalemia

28
Q
  • *HF-rEF**
  • *BETA BLOCKERS**
  • *when should we AVOID to START or INCREASE dose?**
A
  • avoid starting / increasing dose of BB if…*
  • *ACUTE EXACERBATION**
  • *Volume Overload / Worsening signs**

BB is initially a NEGATIVE INOTROPE
can worsen symptoms at first

no NEED to WAIT for reaching TARGET ACE/ARB DOSE
before initiating

29
Q

HF-rEF
MONITORING & ADR

SACUBITRIL / VALSARTAN

A

ANGIOEDEMA
history with ACE / ARB = CONTRAINDICATED
+ 36 hours washout when switching

HYPERKalemia** + **Renal Dysfunction

  • *Caution w/ BP <100**
  • more ANTI-HTN than ACE/ARB*
30
Q

HF-rEF
MONITORING & ADR

Ivabradine = Corlanor

A

HR MONITORING
can reduce HR by 10bpm during rest/exercise
need HR > 70bpm b4 start
2 weeks after dose adjustments / q4 months

ADR:

  • *AFIB** - new start
  • *Luminous Phenomena** = bright spots
  • *Bradycardia**
31
Q

HF-rEF
MONITORING & ADR

DIGOXIN

A

Elimination
RENAL + P-Gp Interactions

AVOID Pg-P Inhibitors + Other AV nodal Blockers

  • *CrCl + IBW DOSING**
  • *K + Mag low**

Suspected Toxicity:
ECG + Visual Changes (green-yellow)
CONFUSION
NVD

32
Q

Which Beta Blocker would you choose if

HTN is a bigger issue?
AKA
MORE BP LOWERING EFFECT

A

CARVEDILOL
stronger BP lowering agent

Metoprolol / Bisoprolol
better for patients with hypotension

PDAT5 CV (30 decks)

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