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B.20 Chronic Heart Failure Treatment Flashcards

1
Q

B.20 Chronic Heart Failure Treatment

What are the first line drugs for HF

A

ACE inhibitors
Beta-blockers
Diuretic
Aldosterone Antagonist/MRA

“ABCDE” of HFrEF

A – ACEi / ARNI

B – Beta-blocker

C – Correct congestion (loop diuretic)

D – Dapagliflozin / Empagliflozin (SGLT2i)

E – Eplerenone / Spironolactone (MRA)
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2
Q

B.20 Chronic Heart Failure Treatment

What are the general principals of pharmacotherapy

A

Titrate medications to the target dosage, even if symptoms improve at lower doses.

Dosages may be adjusted as frequently as every 1–2 weeks.

Most patients with HFimpEF should continue treatment, even if asymptomatic, to prevent relapse and worsening LV dysfunction.

Patients with HFmrEF may benefit from the agents recommended for HFrEF, especially SGLT2i.

Diuretics are recommended for all patients with congestion regardless of LVEF.

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3
Q

B.20 Chronic Heart Failure Treatment

Which of the first line drugs is not recommended for NYHA stage/Class I

A

aldosterone antagonists

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4
Q

B.20 Chronic Heart Failure Treatment

Drugs used in NYHA Class I

A

ACEi/ARNI
beta Blocker
MRA
SGLT2i - Dapagliflozin/Empagliflozin
Loop Diuretic For Fluid Retention

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5
Q

B.20 Chronic Heart Failure Treatment

MRA/Aldosterone Antagonist principles

A

“MRAs like spironolactone or eplerenone are key mortality-reducing agents in HFrEF, used in patients with EF <35% on standard therapy. They block aldosterone to reduce remodeling, but require careful monitoring of potassium and renal function.”

MRAs are a core, first-line therapy in heart failure with reduced ejection fraction (HFrEF, EF <40%), used to:

✅ Reduce mortality
✅ Decrease hospitalizations
✅ Prevent myocardial fibrosis and remodeling

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6
Q

B.20 Chronic Heart Failure Treatment

MRA/Aldosterone Antagonist what drugs are used

A

Spironolactone

Eplerenone

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7
Q

B.20 Chronic Heart Failure Treatment

MRA/Aldosterone Antagonist MOA

A

Mechanism of Action

Block aldosterone receptors in the distal nephron

↓ Sodium and water reabsorption

↑ Potassium retention

Inhibit aldosterone-mediated myocardial fibrosis and vascular inflammation

🧠 Aldosterone contributes to cardiac remodeling, fibrosis, and potassium/magnesium loss – all of which worsen heart failure outcomes.

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8
Q

B.20 Chronic Heart Failure Treatment

Diuretics - principles

A

Initiate treatment using loop diuretics to address volume overload.

essential for symptom relief in HFrEF or HFpEF
DO NOT improve survivial

Thiazides can be included for a synergistic effect.

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9
Q

B.20 Chronic Heart Failure Treatment

MOA Diuretics

A

Furosemide, Bumetanide, Torsemide
Site of action: Thick ascending limb of Loop of Henle

Inhibits the Na⁺-K⁺-2Cl⁻ (NKCC2) transporter
→ Leads to massive natriuresis and diuresis
→ ↓ preload by reducing intravascular volume
→ Relieves pulmonary and peripheral congestion
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10
Q

B.20 Chronic Heart Failure Treatment

What are Thiazide Diuretics

A

A group of diuretic agents that act as Na⁺-Cl⁻ cotransporter inhibitors in the early distal renal tubule. Used mainly to treat hypertension

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11
Q

B.20 Chronic Heart Failure Treatment

MOA of Thiazide Diuretics

A

Hydrochlorothiazide, Metolazone
Site of action: Distal convoluted tubule

Inhibit Na⁺-Cl⁻ symporter
→ Modest diuresis
→ Used as add-on therapy in diuretic resistance to loop diuretics

Metolazone is especially potent when combined with loop diuretics.

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12
Q

B.20 Chronic Heart Failure Treatment

Do loop diuretics improve mortality in HF?

A

→ ❌ No – they improve symptoms only, not survival.

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13
Q

B.20 Chronic Heart Failure Treatment

Can thiazides be used as monotherapy in acute decompensated HF?

A

→ ❌ No – they are not potent enough; used with loop diuretics if needed.

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14
Q

B.20 Chronic Heart Failure Treatment

What electrolyte disturbances can loop diuretics cause?

A

→ Hypokalemia, hyponatremia, hypomagnesemia, metabolic alkalosis

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15
Q

B.20 Chronic Heart Failure Treatment

ACEi prinicples

A

Can improve prognosis and symptoms

Start treatment with ACE inhibitors to decrease preload, lessen afterload, and enhance cardiac output.

If the patient experiences intolerance to the medication (e.g., dry cough), consider switching to ARBs.

Monitor for hypokalemia, hypotension, and elevated creatinine levels (renal impairment).

All patients with ACC/AHA stage B HFrEF
Patients with ACC/AHA stages C and D HFrEF if ARNI is not tolerated or affordable

group of antihypertensive drugs that inhibit the enzyme responsible for the conversion of angiotensin I to angiotensin II.

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16
Q

B.20 Chronic Heart Failure Treatment

What ACEi are used to TX HR

A

Enalapril

Ramipril

Lisinopril

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17
Q

B.20 Chronic Heart Failure Treatment

MOA of ACEi

A

Inhibition of ACE enzyme
 → Prevents conversion of angiotensin I to angiotensin II

  1. ↓ Angiotensin II → multiple effects:↓ Vasoconstriction → ↓ afterload (↓ resistance the LV pumps against)↓ Aldosterone secretion → ↓ sodium and water retention → ↓ preload↓ Sympathetic activation↓ Myocardial remodeling & fibrosis↓ Ventricular hypertrophy and dilation
  2. ↓ Bradykinin breakdown (ACE also degrades bradykinin)
     → ↑ bradykinin → vasodilation → may cause dry cough and angioedema (side effects)
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18
Q

B.20 Chronic Heart Failure Treatment

Do ACE inhibitors improve mortality in HFpEF?

A

→ ❌ No – they do not improve survival in HFpEF (only HFrEF)

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19
Q

B.20 Chronic Heart Failure Treatment

Can ACE inhibitors be used during acute decompensated HF?

A

→ ❌ No – start after stabilization; may worsen hypotension or renal function if given too early

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20
Q

B.20 Chronic Heart Failure Treatment

Should ACEi be stopped if creatinine rises after starting?

A

→ ❌ Not necessarily – a rise up to 30% from baseline is acceptable and expected

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21
Q

B.20 Chronic Heart Failure Treatment

Are ACE inhibitors useful in asymptomatic LV dysfunction (EF <40%)?

A

→ ✅ Yes – they delay onset of symptoms and progression to symptomatic HF

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22
Q

B.20 Chronic Heart Failure Treatment

Beta Blockers general principles

A

Introduce a beta blocker once the patient is stable on ACE inhibitors. This is especially advantageous for patients with hypertension and those who have experienced a post-myocardial infarction. Note that beta blockers are contraindicated in acute decompensated heart failure (ADHF).

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23
Q

B.20 Chronic Heart Failure Treatment

What are the beta blockers used to tx HF

A

Bisoprolol – selective β₁-blocker

Carvedilol – blocks β₁, β₂, and α₁ (vasodilating)

Metoprolol succinate (extended-release, β₁-selective)

24
Q

B.20 Chronic Heart Failure Treatment

MOA of beta blockers in HF

A

Beta-blockers inhibit β₁-adrenergic receptors (primarily in the heart), leading to:

1- ↓ Heart rate (negative chronotropy)
 → Increases diastolic filling time
 → Improves cardiac output and coronary perfusion

  1. ↓ Myocardial contractility (negative inotropy) (initially)
     → But long-term leads to improved LV function
  2. ↓ Myocardial oxygen demand
     → Protects against ischemia and arrhythmias
  3. ↓ Sympathetic overactivation
     → Which normally worsens HF by causing vasoconstriction, tachycardia, and remodeling
     → So beta-blockers reverse maladaptive remodeling, ↓ apoptosis, and ↓ fibrosis
  4. ↑ β-receptor sensitivity and density over time
     → Improves heart’s long-term responsiveness to catecholamines
25
B.20 Chronic Heart Failure Treatment What are the benefits of beta blockers in HFrEF (EF<40%)
✅ ↓ Mortality ✅ ↓ Sudden cardiac death (anti-arrhythmic effect) ✅ ↓ Hospitalizations ✅ Improves LVEF over months of therapy ✅ Slows disease progression
26
B.20 Chronic Heart Failure Treatment Do beta-blockers worsen heart failure?
→ ❌ Not in the long term. They may cause transient worsening but improve outcomes over time.
27
B.20 Chronic Heart Failure Treatment Should beta-blockers be stopped in decompensated HF?
→ ❌ Not unless the patient is hypotensive or bradycardic. Otherwise, continue them.
28
B.20 Chronic Heart Failure Treatment Are all beta-blockers equally effective in HF?
→ ❌ No – only certain ones (bisoprolol, carvedilol, metoprolol succinate) have proven survival benefit.
29
B.20 Chronic Heart Failure Treatment Can beta-blockers be used in HFpEF?
→ ✅ Yes – mainly for rate control in AF or to treat hypertension, but no mortality benefit proven in HFpEF.
30
B.20 Chronic Heart Failure Treatment angiotensin receptor blockers (ARB) - principles
Patients with ACC/AHA stages B, C, and D ARBs are used in heart failure with reduced ejection fraction when: ✅ ACE inhibitors are not tolerated, especially due to cough or angioedema ✅ As part of triple therapy if ACEi is contraindicated ✅ Some guidelines allow ARNI → ARB step-down if ARNI is not tolerated 🧠 ARBs provide similar benefits to ACE inhibitors but do not increase bradykinin, so they are less likely to cause cough and angioedema.
31
B.20 Chronic Heart Failure Treatment ARBs commonly used in HF
Candesartan Valsartan Losartan
32
B.20 Chronic Heart Failure Treatment
blocks AT1 receptors, which decreases the binding of angiotensin II. This decreases vasoconstriction, which lowers the blood pressure. Also leads to decreased secretion of aldosterone, which causes decreased reabsorption of Na+ and water and lowers blood pressure. Block the angiotensin II type 1 (AT₁) receptor → Prevent vasoconstriction, aldosterone release, sodium retention, and remodeling Results in: ↓ Afterload (vasodilation) ↓ Preload (via natriuresis) ↓ Myocardial fibrosis & remodeling ↓ Mortality and hospitalizations
33
B.20 Chronic Heart Failure Treatment Can ARBs be given with ACE inhibitors to double the benefit?
→ ❌ No – combination increases risk of renal dysfunction, hyperkalemia, and hypotension
34
B.20 Chronic Heart Failure Treatment If a patient develops cough on an ACE inhibitor, can you switch to an ARB?
→ ✅ Yes – ARBs do not increase bradykinin and are better tolerated
35
B.20 Chronic Heart Failure Treatment Do ARBs improve survival in HF like ACE inhibitors?
→ ✅ Yes – especially Candesartan and Valsartan have proven mortality benefit
36
B.20 Chronic Heart Failure Treatment Can ARBs be used in HFpEF?
→ ❌ No clear survival benefit in HFpEF — may be used for blood pressure control, but not a core HFpEF therapy
37
B.20 Chronic Heart Failure Treatment SGLT2i principles
They improve survival, reduce hospitalizations, and improve quality of life — even in non-diabetics Patients with any of the following: ACC/AHA stage C NYHA class II-IV HFrEF LVEF ≤ 40%
38
B.20 Chronic Heart Failure Treatment What SGLT2i are used
Dapagliflozin Empaglifloz
39
B.20 Chronic Heart Failure Treatment SGLTi MOA
Inhibit SGLT2 in the proximal renal tubule → ↑ glucose + sodium excretion Leads to: Osmotic diuresis & natriuresis → ↓ preload and afterload ↓ Interstitial fluid volume without major drop in BP ↓ LV wall stress ↑ Hematocrit and oxygen delivery ↓ Cardiac inflammation and fibrosis Improved cardiac energy efficiency (shift to ketone metabolism)
40
B.20 Chronic Heart Failure Treatment angiotensin-receptor neprilysin inhibitor (ARNI) Sacubitril/valsartan - principles
A combination drug used in heart failure with reduced ejection fraction (HFrEF), replacing ACE inhibitors as first-line therapy in many patients. Sacubitril Neprilysin inhibitor → ↑ natriuretic peptides Valsartan Angiotensin II receptor blocker (ARB) → blocks RAAS effects
41
B.20 Chronic Heart Failure Treatment Sacubitril/valsartan MOA
1. Sacubitril (Neprilysin inhibitor): Inhibits breakdown of natriuretic peptides, bradykinin, adrenomedullin → ↑ vasodilation, ↑ natriuresis/diuresis, ↓ fibrosis, ↓ sympathetic tone → ↓ preload, ↓ afterload, ↓ remodeling 2. Valsartan: Blocks AT₁ receptor → ↓ vasoconstriction, ↓ aldosterone, ↓ remodeling 🧠 Combined: Dual neurohormonal blockade → powerful anti-remodeling + natriuretic effects
42
B.20 Chronic Heart Failure Treatment What are second line drugs to tx HF
Ivabradine (works by reducing heart rate) Hydralazine (used for hypertension) Digoxin Angiotensin receptor neprilysin inhibitor Nesiritide (for heart failure management)
43
B.20 Chronic Heart Failure Treatment Ivabradine principles
Indications: If the highest tolerated dose of beta-blockers (BB) is reached and the patient remains symptomatic, or if there is a contraindication to BB Suitable for patients with EF < 35% and sinus rhythm with a resting heart rate > 70 bpm Contraindications: Severe bradycardia Acute decompensated heart failure (ADHF) Severe hepatic dysfunction Benefits Improves symptoms Reduces hospitalization rate
44
B.20 Chronic Heart Failure Treatment Ivabradine MOA
"Ivabradine slows the heart rate by inhibiting the funny current in the SA node, reducing myocardial oxygen demand and improving outcomes in HFrEF patients with high resting heart rate in sinus rhythm." Ivabradine selectively inhibits the funny current (If) in the sinoatrial (SA) node. Funny current (If) = mixed Na⁺/K⁺ inward current responsible for spontaneous depolarization in pacemaker cells Inhibition → ↓ heart rate without affecting myocardial contractility (inotropy), conduction, or blood pressure 🧠 This makes it ideal for patients who need HR control but can’t tolerate higher beta-blocker doses
45
B.20 Chronic Heart Failure Treatment Hydralazine and nitrate
Hydralazine - Mechanism: Affects afterload; combined with nitrates to decrease preload Indications: - Recommended for patients with EF < 40% - Particularly beneficial for African-American patients - Alternative when ACE inhibitors and ARBs are not tolerated Monitoring: - Monitor for volume depletion and hypotension Benefits: - Improves symptoms - May enhance prognosis This combination is used as an alternative or add-on in heart failure with reduced ejection fraction (HFrEF) when: ✅ Patients cannot tolerate ACE inhibitors or ARBs (e.g., due to renal dysfunction, hyperkalemia, or angioedema) ✅ As an add-on to standard therapy (ACEi/BB/MRA) in Black patients with persistent symptoms (NYHA III–IV) 💡 Proven to reduce mortality and hospitalizations, particularly in self-identified Black patients (A-HeFT trial)
46
B.20 Chronic Heart Failure Treatment MOS Hydralazine and nitrate
Hydralazine is a Arterial vasodilator : ↓ afterload → ↓ LV wall stress → ↑ CO Isosorbide dinitrate / mononitrate Venodilator (via NO) :↓ preload → ↓ pulmonary congestion and LV filling pressures 🧠 Combined effect: ↓ preload and afterload → ↓ wall stress, improved symptoms, and survival
47
B.20 Chronic Heart Failure Treatment Digoxin principles
Indications: - Used in heart failure with reduced ejection fraction (HFrEF) - If symptoms persist despite treatment with beta-blockers (BB), ACE inhibitors, diuretics, and mineralocorticoid receptor antagonists (MRA) - Can be administered to control ventricular rate in atrial fibrillation (A. fib) if contraindicated Contraindications: - Not recommended in cases of severe AV block Benefits: - Improves symptoms - Reduces hospitalization rates Used in HFrEF (EF <40%) patients who remain symptomatic despite optimal therapy (ACEi/ARB/ARNI, BB, MRA, SGLT2i) Also used to control ventricular rate in atrial fibrillation with HF Does not improve survival, but may reduce hospitalizations and improve symptoms
48
B.20 Chronic Heart Failure Treatment Digoxin MOA
Dual MOA: Positive inotrope Inhibits Na⁺/K⁺-ATPase in cardiac myocytes → ↑ intracellular Na⁺ → ↓ Na⁺/Ca²⁺ exchange → ↑ intracellular Ca²⁺ → ↑ myocardial contractility Negative chronotrope (via vagal stimulation) ↑ parasympathetic (vagal) tone at the AV node → Slows conduction → useful in AF with rapid ventricular response
49
B.20 Chronic Heart Failure Treatment Digoxin toxicity
Narrow therapeutic window Risk ↑ with: renal failure, hypokalemia, hypomagnesemia, drug interactions (e.g. amiodarone, verapamil) Signs of digoxin toxicity: GI: Nausea, vomiting, anorexia Neuro: Confusion, weakness Visual: Yellow/green vision, blurred vision Cardiac: Arrhythmias — AV block, ventricular ectopy, bradycardia
50
B.20 Chronic Heart Failure Treatment What drugs stop cardiac remodeling
beta blockers ACEi ARBs
51
B.20 Chronic Heart Failure Treatment What drugs stop increased oxygen demand
nitrates ACEi ARBs beta blockers
52
B.20 Chronic Heart Failure Treatment What drugs increase coronary perfusion
beta blockers nitrates
53
B.20 Chronic Heart Failure Treatment what drugs increase cardiac output
digoxin by increasing inotropy
54
B.20 Chronic Heart Failure Treatment what drugs stop increased afterload
ACEi ARBs Hydralazine and BNP - which is upregulated by Neprilysin inhbitiors Nestride
55
B.20 Chronic Heart Failure Treatment What drugs stop increased heart rate
beta blockers Ivabradine
56
B.20 Chronic Heart Failure Treatment What drugs stop increased preload
Thiazides loop diuretics aldosteron antagonists ACEi BNP blocks increased preload and BNP is potentiated by Nesprilysin inhbitors and Nestride
57
B.20 Chronic Heart Failure Treatment what drugs worsen HF
Nondihydropyridine calcium channel blockers: NSAIDs: can worsen HF symptoms Thiazolidinediones (e.g., pioglitazone): increased risk of congestion and hospitalization Antidepressants (e.g., tricyclic antidepressants): Inhalation anesthetics: may induce myocardial depression and peripheral vasodilation, and decrease sympathetic activity Class IC and class III antiarrhythmic drugs: increased mortality DPP-4 inhibitors

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