29/30 - HFrEF Flashcards
MoA in HF-rEF
ACE-I & ARB
Enalapril / Lisinopril / Ramipril
Valsartan / Candesartan / Losartan
↓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
MoA in HF-rEF
Beta Blockers
Metoprolol SUCCinate/Bisoprolol / Carvedilol
↓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
MoA in HF-rEF
DIURETICS
Loop = Furosemide / Bumetanide / Torsemide
Thiazide = HCTZ / Chlorithalidone / Metazolone
↓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
MoA in HF-rEF
Aldosterone Receptor Antagonist = ARA
Spironolactone / Eplerenone
↓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
MoA in HF-rEF
Sacubatril/Valsartan = ENTRESTO
↓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
MoA in HF-rEF
Ivabradine = CORLANOR
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
HF-rEF Treatment:
ACE INHIBITORS
Place in therapy for All Stages?
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
HF-rEF Treatment:
BETA BLOCKERS
Place in therapy for All Stages?
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
HF-rEF Treatment:
DIURETICS
Place in therapy for All Stages?
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
HF-rEF Treatment:
ARA’s
Spironolactone / Eplerenone
Place in therapy for All Stages?
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
HF-rEF Treatment:
Hydralazine + Isosorbide
Place in therapy for All Stages?
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
HF-rEF Treatment:
ENTRESTO
Sacubutril/Valsartan?
Place in therapy for All Stages?
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*
HF-rEF Treatment:
CORLANOR
Ivabradine
Place in therapy for All Stages?
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***
HF-rEF Treatment:
DIGOXIN
Place in therapy for All Stages?
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
HF-rEF DOSING:
ACE INHIBITORS
- *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
HF-rEF DOSING:
ARBs
- *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
HF-rEF DOSING:
BETA BLOCKERS
- 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
HF-rEF DOSING:
LOOP DIURETICS
- 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
HF-rEF DOSING:
THIAZIDE DIURETIC
- 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
HF-rEF DOSING + WHEN TO AVOID STARTING?
ARA
Spironolactone + Eplerenone
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**
HF-rEF DOSING:
- *HYRALAZINE / ISOSORBIDE**
- *BiDil** = Combo
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
HF-rEF
DOSING + SWITCH CONSIDERATIONS
Sacubutril / Valsartan
ENTRESTO
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
HF-rEF
DOSING + CONSIDERATIONS
IVABRADINE
CORLANOR
- *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
HF-rEF MONITORING & ADR
ACE / ARB
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
HF-rEF
MONITORING & ADR
Beta Blockers
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
HF-rEF
MONITORING & ADR
DIURETICS
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
HF-rEF
MONITORING & ADR
SPIRONOLACTONE / EPLERENONE
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
- *HF-rEF**
- *BETA BLOCKERS**
- *when should we AVOID to START or INCREASE dose?**
- 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
HF-rEF
MONITORING & ADR
SACUBITRIL / VALSARTAN
ANGIOEDEMA
history with ACE / ARB = CONTRAINDICATED
+ 36 hours washout when switching
HYPERKalemia** + **Renal Dysfunction
- *Caution w/ BP <100**
- more ANTI-HTN than ACE/ARB*
HF-rEF
MONITORING & ADR
Ivabradine = Corlanor
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**
HF-rEF
MONITORING & ADR
DIGOXIN
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
Which Beta Blocker would you choose if
HTN is a bigger issue?
AKA
MORE BP LOWERING EFFECT
CARVEDILOL
stronger BP lowering agent
Metoprolol / Bisoprolol
better for patients with hypotension
