CHF Drugs Flashcards
medication classes used to treat HFrEF
*use “BAANDAIDS”:
-beta blockers
-ACE inhibitors
-angiotensin receptor blockers (ARBs)
-neprilysin inhibitors/ARB combination
-diuretics
-aldosterone antagonists
-ivabradine
-digoxin
-SGLT-2 inhibitors
cornerstone (most important) medication classes used to treat HFrEF
- beta blockers (only metoprolol, carvedilol, and bisoprolol)
- anti-RAAS agents (ACEi, ARBs, ARNI [ARB/Neprilysin inhibitor combination])
- aldosterone antagonists
- SGLT-2 inhibitors
*improve cardiovascular outcomes (improve survival), either alone or in combination
beta blockers for HFrEF - MOA
*blockade of antiarrhythmic effects
*antiarrhythmic effects
*blunts cardiotoxic effects of catecholamines
role of beta blockers in HFrEF
*favorable long term benefit
*improve functional status
*decreased risk of sudden cardiac death
beta blockers used for HFrEF - only 3 are shown to be beneficial in heart failure
- bisoprolol (long-acting formulation)
- metoprolol
- carvedilol [probably the best]
bisoprolol - HFrEF class uses
*class II-III/stage B-D
metoprolol - HFrEF class uses
*class II-IV/stage B-D
carvedilol - HFrEF class uses
*class II-IV/stage B-D
guide to using beta blockers in pts with HFrEF
*select an agent with survival benefit (carvedilol, metoprolol, or bisoprolol)
*use when patients are EUVOLEMIC (NOT in fluid overload)
*monitor BP/MAP, HR, CNS, pulmonary side effects
anti-RAAS agents - 3 classes
- ACE inhibitors
- ARBs
- ARNI (ARB/Neprilysin inhibitor combination)
ACE inhibitors - HFrEF class uses
*any HFrEF in which the goal is to decrease afterload and decrease blood pressure
*class I-IV, stages A-D
*examples: captopril, enalapril, lisinopril, ramipril
*compelling indication: HTN + heart failure
angiotensin II receptor blockers (ARBs) - HFrEF class uses
*any HFrEF in which the goal is to decrease afterload and decrease blood pressure
*class I-IV, stages A-D
*examples: losartan, valsartan
*compelling indication: HTN + heart failure
ARB/Neprilysin Inhibitor combination (ARNI) - MOA
*combination of valsartan (ARB) + sacubitril (neprilysin inhibitor)
*aka Entresto
*sacubitril prevents the degradation of bradykinin, ANP, BNP → decreased sympathetic nervous system outflow, decreased vasoconstriction (DRAMATIC AFTERLOAD + BP REDUCTION), decreased release of aldosterone, increased diuresis & natriuresis
ARB/Neprilysin Inhibitor combination (ARNI) - ADEs
*hypotension
*hyperkalemia
*acute kidney injury
*angioedema
guide to using anti-RAAS agents in patients with HFrEF
*select ONE agent from: ACEi, ARB, or ARNI
*if pt is hypertensive, probably use ARNI; if lower BP, probably use ACEi or ARB
*monitor BP, MAP, SCr, K+
if a patient develops ACEi-induced angioedema, can you use an ARNI? can you use an ARB?
*ARNI: NO (risk of cross-reactivity)
*ARB: probably safe
diuretics - urine output comparison
loop diuretics > thiazides > acetazolamide
*loop diuretics produce the largest increase in urine output
use of diuretics in HFrEF
*not proven to improve survival
*however, still an important component of management due to reduction of symptoms when they have volume overload
classes of diuretics used in HFrEF
*loop diuretics
*thiazide diuretics
*aldosterone antagonists
acetazolamide - drug class, MOA
*carbonic anhydrase inhibitor
*MOA: inhibits resorption of HCO3- by tubular cells (increased HCO3- in tubular lumen → loss of HCO3-, loss of increased sodium)
acetazolamide - ADEs
*hyponatremia (low sodium)
*hypokalemia (low potassium)
*hyperuricemia
*metabolic acidosis
thiazide diuretics for HFrEF
*METOLAZONE is the most potent
*hydrochlorothiazide (HCTZ), chlorthalidone, and chlorothiazide are approved for use in HFrEF too
aldosterone antagonists - MOA in HFrEF
*block the effects of aldosterone in the body
1. prevent progression of atherosclerosis, LV stiffening, progression of heart failure
*shown to IMPROVE SURVIVAL in HFrEF patients
aldosterone antagonists - uses in HFrEF
*class III-IV, stage C-D
*aka mineralocorticoid receptor antagonists (MRAs)
ivabradine - MOA & ADEs
*selectively inhibits “funny” sodium channels (If) → prolongs slow depolarization (phase IV) → decreases HR
*ADEs: bradycardia, visual disturbances
digoxin - MOA
*direct inhibition of Na+/K+ ATPase → indirect inhibition of Na/Ca2+ exchanger
*stimulates vagus nerve → decreased HR
*increases calcium concentration → INCREASES LEFT AND RIGHT VENTRICULAR CONTRACTILITY (MARGINALLY)
digoxin - ADEs
*N/V/D
*mental status changes
*confusion
*bradycardia
*visual disturbances - YELLOW VISION
*brady- or tachyarrhythmias
digoxin - metabolism
*cleared by the KIDNEYS (do NOT use in patients with renal dysfunction)
SGLT-2 inhibitors - examples
*dapagliflozin
*empaglifozin
*canagliflozin
SGLT-2 inhibitors - MOA
*inhibit the sodium-glucose co-transporter-2, located in the proximal convoluted tubule
*leads to reduced glucose reabsorption
*may work as an indirect diuretic
SGLT-2 inhibitors - ADEs
*hypoglycemia
*hypovolemia
*hypotension
*UTIs
*yeast infections
HFrEF meds if patient can’t tolerate ACEI/ARB/ARNI
*hydralazine + nitrates
-hydralazine = arterial vasodilator (decreases afterload/BP)
-nitrates = venous dilators (decrease preload & relax blood vessels)
HFrEF med combination shown to be beneficial in African American patients, stacked on top of background HF therapy
*hydralazine + nitrates [in addition to background HF patients]
-hydralazine = arterial vasodilator (decreases afterload/BP)
-nitrates = venous dilators (decrease preload & relax blood vessels)
treatment strategy for treating HFrEF - sequentially
1st: anti-RAAS agent
2nd: add beta blocker if/when needed
3rd: add aldosterone antagonist if/when needed
4th: add SGLT2 inhibitor if/when needed
*deliver maximally tolerated dose
*initiate, titrate, discontinue based on symptoms/comorbidities
advanced HF strategies: parental inotrope therapy
*dobutamine (beta1 receptor agonist → increases contractility, cardiac output, HR, decreases SVR)
*milrinone (PDE inhibitor, selective in cardiac and vascular beds → increases cardiac output & HR, decreases SVR)
drugs to AVOID in HFrEF
*NSAIDs
*COX-2 inhibitors (celebrex)
*corticosteroids
*most antiarrhythmics [safer = dofetilide & amiodarone]
*most calcium channel blockers [safer = amlodipine & felodipine]
medications used for HFpEF
*SGLT2 inhibitors are the only one demonstrated to be beneficial in HFpEF
*diuretics, aldosterone antagonists, anti-RAAS agents, beta blockers?
