38 - Heart Failure Flashcards
What defines HFrEF?
LVEF < 40%
symptoms of heart failure
dyspnea, fatigue, fluid retention
non-pharms
- management concomitant disease states
- moderate physical activity in stable patients
- no more than 1 alcoholic drink/day
- restrict sodium intake
- restrict fluid intake
- annual flu vaccine
- pneumococcal vaccine
- monitor daily weight
Who are ICDs for? (implantable cardioverter defibrillators)
for those with NYHA class 2-3 and LVEF < 35% or NYHA class 1 & LVEF < 30%
Who are CRTs for? (cardiac resynchronization therapy)
for those with NYHA class 2-4 despite optimal medication therapy
When using LVADs (left ventricular assist devices) use ____ bridge to transplantation
ASA
When do you use CPAP (continuous positive airway pressure) ?
for those with obstructive sleep apnea
Patients with HFrEF need long-term tx with ____ and ___
ACEi and BB
HFrEF: What class of drug may be preferred to an ACEi in select patients with mild-mod HFrEF ?
ARNI (combined angiotensin receptor/neprilysin inhibitor) such as valsartan/sacubitril
HFrEF:
You can add _____ if patients are still symptomatic despite ACEi and BBs.
MRAs (mineral receptor antagonists) such as spironolactone or eplerenone
HFrEF:
____ can control symptoms of hypervolemia
diuretics
HFrEF:
Recommend ____ for all patients. Start at low doses and titrate at 7-14 day intervals.
ACEi
HFrEF:
What do you need to monitor with ACEi?
SCr, K+ and BP before starting and changing doses.
HFrEF:
When you start an ACEi, an increase of SCr up to ___% is expected and acceptable
30%
HFrEF:
In the ARNI combo valsartan/sacubitril, how does sacubitril affect valsartan?
it increases the bioavailability of valsartan
HFrEF:
If switching between ACEi/ARNI how long do you need to wait and why?
Must wait 36 hours between ACEi and ARNI (and vice versa) to decrease risk of angioedema
HFrEF:
How often do you titrate dose of ARNI’s?
every 2-4 weeks
HFrEF:
Which BBs are indicated for heart failure?
bisoprolol, carvedilol, metoprolol succinate (not in Canada)
HFrEF:
points about BBs?
- start at low dose
- titrate every 2-4 weeks
- monitor BP and HR
- BBs should not be stopped abruptly
HFrEF:
Thiazide diuretics for ____ fluid retention
fluid
HFrEF: \_\_\_\_ diuretics (ex. furosemide) are required in most patients
loop
HFrEF:
Need to ____ doses of furosemide for patients with renal dysfunction
increase
HFrEF:
Thiazide diuretics have poor efficacy if CrCl < ____
50 mL/min
HFrEF:
Monitor what while on diuretics?
SCr and electrolytes
HFrEF:
What do thiazide and loop diuretics deplete?
K+ and Mg2+
HFrEF:
What to keep K+ > _____ while on diuretics?
4 mmol/L
HFrEF:
What can you add to help with hypokalemia and hypomagnesemia?
potassium-sparing diuretics (eplerenone or spironolactone)
HFrEF:
ARBs are an alternative to ACEi if ____ or _____ present
cough or angioedema
HFrEF:
What are MRAs for?
for patients who remain symptomatic despite use of ACEi and BB.
HFrEF:
Do not use MRAs if ???
K+ > 5 mmol/L, sCr > 221 umol/L or CrCl < 30
HFrEF: Which MRA (spironolactone or eplerenone) can cause gynecomastia?
spironolactone
HFrEF:
Who is ivabradine used for?
for those with LVEF < 35% who present with NHYA class 2-3 symptoms, resting HR > 77 despite using BBs or if they cant use BBs
*Target HR 50-60 bpm
HFrEF:
____ can help improve HF symptoms
digoxin
HFrEF:
When should you check digoxin levels and what is the target?
Check digoxin serum levels at least 8 hours after drug administration (target 0.6 - 1 nmol/L)
HFrEF:
Who is ISDN/hydralazine for?
black patients or those who can’t tolerate other options
*nitrates alone do not reduce mortality
HFrEF:
Can use omega 3 FAs but high doses > 3g/day increases risk for ___
bleeds
HFrEF:
Which CCB is safe?
amlodipine is safe but does not decrease mortality/morbidity
HFrEF:
Which anti-arrhythmic can be used to maintain sinus rhythm if they also have A. Fib?
amiodarone
HFrEF:
Reasonable to also consider ____ as add on for cardioprotection
statins
HFpEF:
How do we manage this?
- focus tx on control of risk factors
- consider ACEi or ARB for HRN, esp if DM
- should use MRA.
- Can use BB or diuretics if indicated
- can use verapamil or diltiazem
How do you handle decompensated HF ?
- furosemide
- can add a vasodilator such as nitroglycerin
- for low cardiac output, add milrinone or dobutamine if systolic > 90
- dobutamine is preferred if systolic < 90
- limit use of vasopressors (dopamine or NE)
- may have short-term vasopressin antagonist Tolvaptan
