6: HF Treatment Flashcards
What stage of HF (A, B, C, or D) is usually seen in primary care?
Stage C
At what stage (A, B, C, or D) do patients become symptomatic and focus shifts from primary and secondary prevention to tertiary prevention?
Stage C
Stage A, B, C, or D?
Patients with HTN
Stage A
Stage A, B, C, or D?
Patients with atherosclerotic disease
Stage A
Stage A, B, C, or D?
Patients with metabolic syndrome
Stage A
Stage A, B, C, or D?
Patients using cardiotoxins
Stage A
Stage A, B, C, or D?
Patients with HFx CM
Stage A
Stage A, B, C, or D?
Patients with previous MI
Stage B
Stage A, B, C, or D?
Patients with LV remodeling
Stage B
Stage A, B, C, or D?
Patients with LVH and low EF
Stage B
Stage A, B, C, or D?
Patients with asymptomatic valvular disease
Stage B
Stage A, B, C, or D?
Patients with known structural heart disease and fatigue, SOB, reduced exercise tolerance
Stage C
Stage A, B, C, or D?
Patients who have marked symptoms at rest despite maximal medical therapy
Stage D
What are the goals for this stage?
Stage A
Treat HTN Smoking cessation Treat lipid disorders Encourage regular exercise Discourage alcohol, drugs Control metabolic syndrome
What are the goals for this stage?
Stage B
Same as Stage A
What are the goals for this stage?
Stage C
Same as Stages A/B plus: Dietary salt restriction Drugs for routine use Diuretic for fluid retention ACEs BBs
What are the goals for this stage?
Stage D
Same as Stages A/B/C plus:
Control fluid retention
Referral to HF program for appropriate patients
Decision regarding appropriate level of care
Information regarding inactivating previously implanted defibrillator
At what stage might implantable defibrillators be used?
Selected patients in Stages B and C
What drugs might be used in this stage?
Stage A
ACE or ARB in appropriate patients for vascular disease or diabetes
What drugs might be used in this stage?
Stage B
ACE or ARB in appropriate patients
BB in appropriate patients
What drugs might be used in this stage?
Stage C
Aldosterone antagonist
ARB
Digitalis
Hydralazine/Nitrates
When do options like hospice, heart transplants, experimental measures, and chronic inotropes come into play?
Stage D
Stage A, B, C, or D?
At high risk for HF but without structural heart disease or symptoms of HF.
Stage A
Stage A, B, C, or D?
Structural heart disease but without symptoms of HF.
Stage B
Stage A, B, C, or D?
Structural heart disease with prior or current symptoms of HF.
Stage C
Stage A, B, C, or D?
Refractory HF requiring specialized interventions.
Stage D
What classification of recommendation (1, 2a, 2b, or 3)?
Benefit greatly outweighs risk.
Class 1
What classification of recommendation (1, 2a, 2b, or 3)?
Benefit outweighs risk; additional studies with focused objectives needed.
Class 2a
What classification of recommendation (1, 2a, 2b, or 3)?
Benefit and risk roughly equal; additional data would be helpful.
Class 2b
What classification of recommendation (1, 2a, 2b, or 3)?
Risk greatly outweighs the benefit.
Class 3
What classification of recommendation (1, 2a, 2b, or 3)?
Procedure or treatment should be performed or administered.
Class 1
What classification of recommendation (1, 2a, 2b, or 3)?
It is reasonable to perform the procedure or administer treatment.
Class 2a
What classification of recommendation (1, 2a, 2b, or 3)?
Procedure or treatment may be considered.
Class 2b
What classification of recommendation (1, 2a, 2b, or 3)?
Procedure or treatment should not be performed or administered as it is not helpful and may be harmful.
Class 3
What level of evidence (A, B, C)?
Data derived from multiple randomized clinical trials.
A
What level of evidence (A, B, C)?
Data derived from a single randomized trial, or nonrandomized studies.
B
What level of evidence (A, B, C)?
Consensus opinion of experts.
C
These diuretics are typically used in patients with acute volume overload to rapidly diurese them.
Loop Diuretics
Bumetanide
Furosemide
Torsemide
Weaker diuretics used for maintenance therapy or for hypertensive properties.
Thiazide Diuretics Chlorothiazide Chlorthalidone Hydrochlorothiazide Indapamide Metolazone
Diuretic that is a mainstay in HF patients.
Potassium-Sparing Diuretics
Amiloride
Spironolactone
Triamterene
Diuretic that can be added to loop diuretics for an additional boost.
Sequential Nephron Blockade Diuretics
Metolazone
Hydrochlorothiazide
Chlorothiazide
ACE inhibitors are a Class 1 recommendation in Stage C HF with a level of evidence A. When could they not be used?
Severe renal failure
Hx of hyperkalemia
What is an example of a drug combination that is a Class 3 recommendation with level of evidence C?
Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.
When might an ARB be used in place of an ACE?
If the patient is already taking an ARB
Patient develops ACE cough
Should ACEs and ARBs be combined?
No, combination has not shown any benefits and should not be routinely done.
When are aldosterone antagonists (spironalactone) usually added?
After you’ve already been put on ACEs and BBs to help prevent fluid volume overload in the future.
Which ARBs should be used in Stage C?
Candesartan
Valsartan
Which ARB is preferred in Stage C for patients who are also post MI?
Valsartan
Which aldosterone antagonist is suggested in Stage C?
Spironolactone
Which aldosterone antagonist is suggested for patients who are post MI?
Eplerenone
Which BBs are recommended in Stage C?
Bisoprolol
Carvedilol
Metoprolol Succinate
Which BB is recommended in Stage C for those who are also post MI?
Carvedilol
At what stage is Digoxin recommended in HF?
Stage C
Why is BB use recommended in Stage C?
Reduce mortality
What are some contraindications or cautions for carvedilol?
Nonselective BB with alpha blocking properties so caution in:
Sever pulmonary disease that requires bronchodilators (like COPD) as it can impair bronchodilators
Why is metoprolol succinate (XL) commonly used in HF?
It’s a selective BB
T/F Digoxin is first-line treatment in HF.
False. It used to be. Now it used more selectively and in low doses.
After other meds (ACEs, BBs, etc) have reached target doses, what 2 meds have been shown to be beneficial in the AA population?
Hydralazine
Isosorbide Dinitrate
What med should not be continued in patients with significant symptoms of volume overload or fluid retention?
CCBs
