Chronic Heart Failure Flashcards
When does heart “failure” occur?
Heart “failure” occurs when the heart is not bale to supply sufficient oxygen-rich blood to the body, because of impaired ability of the ventricle to either fill or eject blood
What are the most common causes of heart failure?
Ischemic (due to decreased blood supply, such as from an MI) or non-ischemic, such as from long-standing uncontrolled hypertension
What are less common causes of heart failure?
Less common causes include valvular disease, excessive alcohol intake, illicit drug use, congenital heart defects, viral infections, diabetes and cardiotoxic drugs/chest radition
What are symptoms of HF generally related to?
Symptoms of HF are usually related to fluid overload, which commonly presents as shortness of breath (SOB) and edema
Why do symptoms occur with HF?
Symptoms can occur due to problems with systolic (contraction) or diastolic (relaxation) functions of the heart
What is performed when HF is suspected and why is it important?
An ultrasound of the heart (echocardiography or ECHO) is performed when HF is suspected. It provides an estimate of left ventricular ejection fraction (LVEF)
What is LVEF?
LVEF is a measurement of how much blood is pumped out of the left ventricle (the main pumping chamber of the heart) with each contraction and is used interchangeably with ejection fraction (EF)
What does an EF < 40% indicate?
An EF < 40% indicates systolic dysfunction, or heart failure with reduced ejection fraction (HFrEF)
*Impaired ability to eject blood during systole
What does an EF of 55-70% indicate?
Normal
What does an EF > 50% with diastolic dysfunction indicate?
Heart Failure with Preserved EF (HFpEF)
*Impaired ventricular relaxation and filling during diastole
What does an EF of 41-49% indicate?
Heart Failure with Mildly Reduced EF (HFmrEF)
*Likely mixed systolic and diastolic function
What does an EF < 40% at baseline, then a > 10% increased and second EF > 40% indicate?
Heart Failure with Improved EF (HFimpEF)
*EF improved with treatment; classified separately because treatments for HFrEF should be continued, despite higher EF
Describe the ACC/AHA staging system
The American Heart Association recommend categorizing patients by HF stage. The staging system is used to guide treatment in order to slow progression of structural heart disease in asymptomatic patients or in symptomatic patients
What does biomarkers refer to in the staging system?
Biomarkers in the definitions refer to BNP and NT-proBNP
Describe the NYHA classification system.
HF can also be classified by the level of limitation in physical functioning using NYHA classification system
What does AHA/ACC stage A indicate?
At risk for development of HF, but without symptoms of HF and without structural heart disease or elevated biomarkers (e.g. patients with HTN, ASCVD or DM)
What does ACC/AHA stage B indicate?
Pre-HF; structural heart disease, abnormal cardiac function or elevated biomarkers, but without signs or symptoms of HF (e.g. patients with LVH, low EF, valvular disease)
What does ACC/AHA stage C indicate?
Structural and/or functional cardiac abnormality with prior or current symptoms of HF (e.g. a patient with known structural disease plus SOB, fatigue and reduced exercise tolerance)
What does ACC/AHA stage D indicate?
Advanced HF with severe symptoms, symptoms at rest or recurrent hospitalizations despite maximal treatment (refractory HF requiring specialized interventions)
What does NYHA functional class I indicate?
No limitations of physical activity. Ordinary physical activity does not cause symptoms of HF (e.g. fatigue, palpitations, dyspnea)
What does NYHA functional class II indicate?
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity (e.g. walking up stairs) results. in symptoms of HF
What does NYHA functional class III indicate?
Marked limitation of physical activity. Comfortable at rest but minimal exertion (e.g. bathing, dressing) causes symptoms of HF
What does NYHA functional class IV indicate?
Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest (e.g. SOB while sitting in a chair)
Describe the corresponding ACC/AHA staging system and NYHA functional class system.
- ACC/AHA stage B = NYHA stage I
- ACC/AHA stage C = NYHA stage I/II/III
- ACC/AHA stage D = NYHA stage IV
What are lab/biomarkers indicative of systolic heart failure?
- Increased BNP: normal is < 100 pg/mL
- Increased NT-proBNP: normal is < 300 pg/mL
*BNP and proBNP are used to distinguish between cardiac and non-cardiac causes of dyspnea
What are left-sided signs and symptoms of systolic heart failure?
- Orthopnea: SOB when lying flat
- Paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
- Bibasilar rales: crackling lung sounds head on lung exam
- S3 gallop: abnormal hear sound
- Hypoperfusion (renal impairment, cool extremitiies)
What are general signs and symptoms of systolic heart failure?
Dyspnea (SOB at rest or upon exertion), cough, fatigue, weakness, reduced exercise capacity
What are some right-sided signs and symptoms of systolic heart failure?
- Peripheral edema
- Ascites: abdominal fluid accumulation
- Jugular venous distention (JVD): neck vein distention
- Hepatojugular reflux (HJR): neck vein distortion from pressure placed on the abdomen
- Hepatomegaly: enlarged liver due to fluid congestion
What is cardiac output?
Cardiac output (CO) is the volume of blood that is pumped by the heart in one minute and is determined by heart rate and stroke volume
*CO = HR x SV
What is stroke volume?
Stroke volume is the volume of blood ejected from the left ventricle during one complete heartbeat (cardiac cycle). SV depends on preload, afterload, and contractility
What is the cardiac index?
The cardiac index (CI) relates the CO to the size of the patient, using the body surface area
*CI = CO/BSA
How does the body try and compensate for HFrEF?
HFrEF is a low cardiac output state. The body compensates by activating neurohormonal pathways to increase blood volume or the force or speed of contractions. This can temporarily increase CO, but chronically leads to myocyte damage and cardiac remodeling which causes change in the size, composition and shape of the heart
What are the main pathways that are activated in HF?
The main pathways that are activated in HF are the renin-angiotensin-aldosterone system (RAAS), the sympathetic nervous system (SNS) and vasopressin, The neurohormones that normally balance these systems become insufficient
Describe the steps of RAAs and Vasopressin activation
1) Renin convert angiotensinogen to angiotensin I
2) Angiotensin I is converted to angiotensin II (Ang II) by angiotensin-converting enzyme (ACE)
3) Ang II causes vasoconstriction and stimulates release of aldosterone from the adrenal gland and vasopressin from the pituitary gland
4) Aldosterone causes sodium and water retention and increases potassium excretion
5) Vasopressin causes vasoconstriction and water retention
Describe SNS activation
Norepinephrine (NE) and epinephrine (EPI) release cause an increase in HR, contractility (positive inotropy) and vasoconstriction
What are some lifestyle management counseling points for patients with HF?
- Monitor and document body weight daily, in the morning after voiding and before eating
- Notify the provider if weight increases by 2-4 pounds in one day or 3-5 pounds in one week, or if symptoms worsen
- Restrict sodium intake to < 1500 mg/day in stage A and B HF (maintain some sodium restriction
- Restrict fluid in stage D HF
- Stop smoking. Limit alcohol intake. Do not use illicit drugs
- Obtain recommended vaccines: influenza (annually) and pneumococcal vaccines per ACIP guidelines
- Reduce weight to BMI < 30 kg/m2 to decrease the heart’s workload and preserve function
- Exercise (or perform regular physical activity, if able)
What are some natural products that can help in the management of HF?
- Omega-3 fatty acid (fish oil) supplementation is reasonable to decrease mortality and cardiovascular hospitalizations
- Hawthorn and coenzyme Q10 may improve HF symptoms
- Avoid the use of products containing ephedra (ma huang) or ephedrine
By what mechanism do drugs cause or worsen HF?
Most drugs that cause or worsen HF cause fluid retention/edema, increase blood pressure or have negative inotropic effects
What are key drugs that cause or worsen heart failure?
DPP-4 inhibitors, Immunosuppressants, Non-DHP CCBs, Antiarrhythmics, Thiazolidinediones, Itraconazole, Oncology drugs, NSAIDs
What are the initial medications recommended for all systolic heart failure patients without contraindications?
ACE inhibitors or ARBs or ARNIs, beta-blockers, loop diuretics
What are secondary medications recommended that are added on in select patients with systolic heart failure?
Aldosterone receptor antagonists (ARAs), SGLT2 inhibitors, Hydralazine and nitrates, Ivabradine
What are some additional medications that can be considered in patients with systolic heart failure?
Digoxin, Vericiguat
What is the MOA of loop diuretics?
Loop diuretics block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle. They increase excretion of sodium, potassium, chloride, magnesium, calcium and water
What is the significance of loop diuretics in CHF?
The decrease in fluid volume makes it easier for the heart to pump, reduces congestive symptoms (decreases preload) and restores euvolemia (“dry” weight). They do not improve survival, but are often required for symptom control
What are some examples of loop diuretics?
Furosemide, Bumetanide, Torsemide, Ethacrynic Acid
What is a boxed warning of loop diuretics?
Can cause profound diuresis resulting in fluid and electrolyte depletion
What is a contraindication of loop diuretics?
Anuria
What are some warnings of loop diuretics?
Sulfa allergy (not likely to cross-react); warning does not apply to ethacrynic acid
What are some side effects associated with loop diuretics?
- Decreased electrolytes: K, Mg, Na, Cl, Ca
- Increased electrolytes/labs: HCO3 (metabolic alkalosis), UA, BG, TGs, total cholesterol
- Ototoxicity including hearing loss, tinnitus and vertigo (more with ethacrynic acid or rapid IV administration of any loop diuretic)
- Orthostatic hypotension, photosensitivity, myalgias
What are some monitoring parameters of loop diuretics?
Renal function, fluid status (input/output, weight), BP, electrolytes, audiology testing (with high doses or rapid IV administration), s/sx of HF
What are some notes associated with loop diuretics?
- Take early in the day to avoid nocturia
- Furosemide injection: store at room temperature (refrigeration causes crystals to form, which may dissolve upon warning); solution must be clear, do not use if yellow in color
- Bumetanide and furosemide injections are light-sensitive (store in amber bottles); IV admixtures do not require light protection
What is the oral equivalent dosing of loop diuretics?
Furosemide 40 mg = torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 50 mg
What is the conversion ratio between Furosemide IV to PO?
Furosemide IV:PO 1:2
What is the conversion of Bumetanide and ethacrynic acid IV to PO?
1:1
What are some important loop diuretic drug interactions?
- Avoid NSAIDs; the increased sodium and water retention can decrease the effect of loop diuretics and cause renal impairment
- Use caution with other drugs that decrease blood pressure
- Watch for additive diuresis and electrolyte abnormalities when used in combination with thiazide-type diuretics
- Additive risk for ototoxicity when used with other ototoxic drugs, especially in patients with impaired renal function
- Diuretics can decrease lithium renal clearance and increase risk of lithium toxicity
How do ACE inhibitors work?
ACE inhibitors block the conversion of angiotensin I to Ang II, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin, which may contribute to the vasodilatory effects and the side effects of cough and angioedema
How do ARBs work?
ARBs block Ang II from binding to the angiotensin II type-1 (AT1) receptor. These drugs decrease RAAS activation, resulting in decreased preload and afterload. They decrease cardiac remodeling, improve left ventricular function and decreased morbidity and mortality
What is the dose recommendation for ACE inhibitors and ARBs when treating HF?
The goal is to titrate to the target dose (which is different for every medication), as tolerated, not to target BP
What is the recommendation of the combination of ACE inhibitor, ARBs and ARAs?
Combining an ACE inhibitor or ARB with an ARA has added survival benefits. Triple combination of an ACE inhibitor + ARB + ARA is not recommended due to a higher risk of hyperkalemia and renal insufficiency
Between ACE inhibitors, ARBs and ARAs, which class of medications tend to cause angioedema more frequently?
Angioedema occurs more frequently with ACE inhibitors (than with ARBs) and in black patients. For testing purposes, do not use an ACE inhibitor or ARB in patients with a history of angioedema from use of any of these medications
What are the ACE inhibitors mentioned in the HF guidelines?
Captopril, Enalapril, Fosinopril, Lisinopril, Perindopril, Quinapril, Ramipril, Trandolapril
What are some boxed warnings of ACE inhibitors?
Can cause injury and death to the developing fetus when used in the 2nd and 3rd trimesters; discontinue as soon as pregnancy is detected
What are some contraindications of ACE inhibitors?
- Do not use with history of angioedema
- Do not use within 36 hours of Entresto
- Do not use with aliskiren in diabetes
What are some warnings about ACE inhibitors?
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
What are some side effects of ACE inhibitors?
Generally well-tolerated, can cause cough, hyperkalemia, increased SCr, hypotension/dizziness [increases risk if volume-depleted (e.g. with concurrent diuretic)], headache
What are monitoring parameters of ACE inhibitors?
BP, K, renal function, s/sx of HF and angioedema
What are the ARBs mentioned in the HF guidelines?
Candesartan, Losartan, Valsartan
What are some differences in side effects between ACE inhibitors and ARBs?
ARBs have less cough, less angioedema and no washout period required with sacubitril/valsartan (Entresto)
What is Entresto a combination of?
Entresto is a combination of a neprilysin inhibitor (sacubitril) and an ARB (valsartan)
What is Neprilysin and what is its function in the treatment of HF?
Neprilysin is the enzyme responsible for degradation of several beneficial vasodilatory peptides, including natriuretic peptides, adrenomedullin, substance P and bradykinin. These peptides counteract the effects of RAAS activation and cause vasodilation and diuresis
When is an ARNI indicated?
An ARNI is indicated in NYHA Class II-IV patients to reduce HF hospitalizations and cardiovascular death. It is a preferred first-line treatment in all patients with HFrEF and would be used in place of an ACE inhibitor or ARB
*Entresto should not be used in combination with an ACE inhibitor/ARB)
What is a boxed warning of Entresto?
Can cause injury and death to the developing fetus when used in the 2nd or 3rd trimesters; discontinue as soon as pregnancy is detected
What are some contraindications of Entresto?
- Do not use with or within 36 hours of ACE inhibitors
- Do not use with history of angioedema
- Do not use with aliskiren in diabetes
What are some warnings about Entresto?
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
What are some side effects of Entresto?
Generally well-tolerated, can cause cough, hyperkalemia, increased SCr, hypotension/dizziness [increased risk if volume-depleted (e.g. with concurrent diuretic)]. headache
What are monitoring parameters of Entresto?
BP, K, renal function, s/sx of HF and angioedema
What are some notes about Entresto?
- Do not use with an ACE inhibitor or an ARB
- No washout period required when switching from an ARB; take the first dose of sacubitril/valsartan when the next ARB dose was due
What are some notable ACE inhibitor, ARB and ARNI drug interactions?
- Risk of hyperkalemia; use caution with other drugs that increase potassium. Avoid salt substitutes that contain potassium
- do not use more than one RAAS inhibitor together or triple combination of ACE inhibitor + ARB/ARNI + ARA due to increased risk of renal impairment, hypotension and hyperkalemia
- Use caution with other drugs that decrease blood pressure
- Use with NSAIDs can worsen renal function
- Can decrease lithium renal clearance and increase risk of lithium toxicity
How do beta-adrenergic receptor antagonists (beta-blockers) work?
Beta-blockers antagonize the effects of catecholamines (especially NE) at the beta-1, beta-2 and/or alpha-1 adrenergic receptors. They decrease vasoconstriction, improve cardiac function and decrease morbidity and mortality
What are the only recommended beta-blockers to be used for the treatment of HF?
Bisoprolol, Carvedilol (ER and IR) and Metoprolol Succinate (ER) are recommended in the guidelines
Which medications should not be used concurrently with beta-blockers?
Do not use beta-blockers with intrinsic sympathomimetic activity (ISA)
When should beta-blockers be discontinued?
Only discontinue beta-blockers during acute decompensated HF if hypotension or hypoperfusion is present
What are the beta-1 selective beta-blockers used for the treatment of HF?
Metoprolol succinate ER, Bisoprolol
What is a boxed warning of beta-1 selective beta-blockers?
Do not discontinue abruptly (particularly in patients with CHD/IHD); gradually taper over 1-2 weeks to avoid acute tachycardia, HTN and/or ischemia
What are some contraindications of beta-1 selective beta-blockers?
Severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless a permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
What are some warnings associated with beta-1 selective beta-blockers?
- Caution in diabetes: can worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms
- Use caution with bronchospastic diseases
- Use caution with Raynaud’s/other peripheral vascular diseases and pheochromocytoma
- Can mask signs of hyperthyroidism, can worsen CNS depression
What are some side effects of beta-1 selective beta-blockers?
Bradycardia, fatigue, hypotension, dizziness, depression, impotence, cold extremities (can exacerbate Raynaud’s)
What are some monitoring parameters of beta blockers?
HR (decrease dose if HR < 55 BPM), BP, s/sx of HF
What are some notes about Metoprolol IV?
Metoprolol IV is not equivalent to PO (IV:PO ratio 1:2.5)
What are some notes about Toprol XL?
Can be cut in half; take with or immediately after meals
What are some notes about Kapspargo Sprinkle?
Swallow whole; if needed, the capsule can be opened and the contents sprinkled on a teaspoonful of soft food
What is the only non-selective beta-blocker and alpha-1 blocker used for the treatment of HF?
Carvedilol
What is a contraindication specific to Carvedilol?
Severe hepatic impairment
What is a warning specific to Carvedilol?
Intraoperative floppy iris syndrome has occurred in cataract surgery patients who were on or were previously treated with an alpha-1 blocker
What are some side effects specific to Carvedilol?
Edema, weight gain
What are some notes about Carvedilol?
- Take with food (all forms) to decrease the rate of absorption and the risk of orthostatic hypotension
- Carvedilol CR has less bioavailability than carvedilol IR; dose conversions are not 1:1
What are some important beta-blocker drug interactions?
- Can enhance the hypoglycemic effects of insulin and sulfonylureas and can mask some symptoms of hypoglycemia (e.g. shakiness, palpitations, anxiety)
- Use caution with other drugs that decrease HR (e.g. digoxin, verapimil, diltiazem)
- Carvedilol and metoprolol are CYP450 2D6 substrates; monitor with CYP2D6 inhibitors or inducers
- Carvedilol inhibits P-gp and can increase concentrations of P-gp substrates (e.g. digoxin, cyclosporine, dabigatran, ranolazine)
How do aldosterone receptor antagonists work?
Aldosterone receptor antagonists (ARAs) compete with aldosterone at receptor sites in the distal convoluted tubule and collecting ducts of the nephron. They decrease sodium and water retention, cardiac remodeling (especially in myocardial fibrosis) and the risk of sudden cardiac death
Which medication is a non-selective ARA and which medication is a selective ARA?
Spironolactone is non-selective; it also blocks androgen and exhibits endocrine side effects. Eplenerone is selective and does not exhibit endocrine side effects
What are some contraindications of ARAs?
Do not use if hyperkalemia, severe renal impairment, Addison’s disease or taking strong CYP3A4 inhibitors (eplenerone)
What are some warnings about ARAs?
Do not initiate for HF if K > 5 mEq/L (> 5.5 mEq/L for eplenerone), CrCl (eGFR) < 30 or SCr > 2.0 mg/dL (females) or SCr > 2.5 mg/dL (males)
What are some side effects of ARAs?
- Hyperkalemia, increased SCr, dizziness, hyperchloremic metabolic acidosis (rare)
- Spironolactone: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea
- Eplenerone: increased TGs
What are some monitoring parameters of ARAs?
BP, K, renal function, fluid status, s/sx of HF
What are some notes of CaroSpir?
CaroSpir suspension is not therapeutically equivalent to the tablets; CaroSpir doses > 100 mg can cause higher than expected concentrations; only use tablets when doses > 100 mg are needed
What are some important ARA drug interactions?
- Risk of hyperkalemia; use caution with other drugs that increase potassium
- Do not use triple combination of ACE inhibitor + ARB/ARNI + ARA due to higher risk of hyperkalemia and renal insufficiency
- Use caution with other drugs that decrease blood pressure
- Can decrease lithium renal clearance and increase the risk of lithium toxicity
- Eplenerone is a major substrate of CYP3A4. Do not use with strong CYP3A4 inhibitors
How does hydralazine work?
Hydralazine si a direct arterial vasodilator
How do nitrates work?
Nitrates increase the availability of nitric oxide, causing venous vasodilation and decreased preload
When can the combination of hydralazine and nitrates be used?
The combination improves survival in HF (but to a lesser degree than ACE inhibitors) and can be used as an alternative in patients who cannot tolerate ACE inhibitors or ARBs due to poor renal function, angioedema or hyperkalemia
Who is the combination product BiDil (Hydralazine/Isosorbide Dinitrate) indicated for?
The combination product BiDil is indicated in self-identified black patients with NYHA Class III or IV who are symptomatic despite optimal treatment with ARNI (or ACE inhibitors or ARBs), beta-blockers, ARAs and SGLT2 inhibitors
What are some notes about BiDil?
No nitrate tolerance
What are some contraindications of Hydralazine?
Mitral valve rheumatic heart disease, CAD
What are some warnings associated with hydralazine?
Drug-induced lupus erythematosus (DILE - dose and duration related), peripheral neuritis, blood dyscrasias, hypotension
What are some side effects of Hydralazine?
Peripheral edema/headache/flushing/palpitations/reflex tachycardia, nausea/vomiting
What are some monitoring parameters of Hydralazine?
HR, BP, s/sx of HF, ANA titer
What are some contraindications of Isosorbide dinitrate?
Do not use with PDE-5 inhibitors or riociguat
What are some side effects of Isosorbide?
Hypotension, headache, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 hour nitrate-free interval), syncope
What are some monitoring parameters of Isosorbide?
HR, BP, s/sx of HF
What are some important BiDil drug interactions?
Do not use with PDE-5 inhibitors or riociguat. The combination can cause severe hypotension
How do SGLT2 inhibitors work?
Sodium glucose co-transporter 2 (SGLT2) inhibitors work by reducing glucose reabsorption in the proximal renal tubules. The benefits likely relate to reduced sodium reabsorption, diuresis and a decrease in preload and/or afterload
What are the two SGLT2 inhibitors used for HF treatment?
Dapagliflozin and Empagliflozin
*Dapagliflozin gained FDA approval in patients with HFrEF without diabetes after demonstrating a decrease in mortality and hospitalizations in this population
What are contraindications of SGLT2 inhibitors?
Dialysis
What are some warnings of SGLT2 inhibitors?
Ketoacidosis, hypotension, AKI, genital mycotic infections, urinary tract infections, necrotizing fasciitis of the perineum
What are some side effects of SGLT2 inhibitors?
Weight loss, increased urination, increased thirst, hypoglycemia, Mg/PO4
How does Digoxin work?
Digoxin inhibits the Na-K-ATPase pump, causing a positive inotropic effect (increased CO), and exerts a parasympathetic effect, which causes negative chronotropy (decreased HR). It does not improve survival but does improve symptoms, exercise tolerance and quality of life
How do you dose Digoxin?
The starting dose is based on renal function, body size, age and gender (lower dose if renal insufficiency, smaller, older or female). The dose is adjusted to maintain a serum concentration < 1 ng/mL in HF. Since hypokalemia and hypomagnesemia increase the risk for digoxin toxicity, maintain potassium between 4-5 mEw/L and magnesium > 2 mEq/L
What are contraindications of Digoxin?
Ventricular fibrillation
What are some warnings of Digoxin?
2nd/3rd degree heart block without pacemaker, Wolff-Parkinson-White syndrome with AFib, vesicant (avoid extravasation)
What are some side effects of Digoxin?
Dizziness, mental disturbances, headache, N/V, diarrhea
What are some monitoring parameters of Digoxin?
Electrolytes, renal function, HR, ECG, BP, and digoxin level (draw 12-24 hours after dose)
What are the s/sx of digoxin toxicity?
- Initial s/sx: N/V, loss of appetite and bradycardia
- Severe s/sx: blurred/double vision, greenish-yellow halos around lights or objects, altered color perception, abdominal pain, confusion, delirium, arrhythmias
What is the antidote to Digoxin?
DigiFab
What are some important digoxin drug interactions?
- Use caution with other drugs that decrease HR
- Hypokalemia, hypomagnesemia and hypercalcemia increase risk of digoxin toxicity
- Hypothyroidism can increase digoxin levels
- Digoxin is a substrate of P-gp and CYP3A4 (minor). P-gp inhibitors will increase digoxin levels
- Reduce digoxin dose by 50% when starting amiodarone or dronedarorne
How does Ivabradine work?
Ivabradine belongs to a class of drugs known as hyperpolarization-activated cyclic nucleotide-gated channel blockers. It disrupts the “funny “ current in the SA node, resulting in decreased rate of firing and ultimately decrease HR
When is Ivabradine recommended?
It is recommended as adjunct treatment in symptomatic (NYHA Class II-III) stable chronic HF (EF < 35%). Patients must already be on mortality-reducing medications, including target or maximally-tolerated doses of beta-blockers and be in sinus rhythm with a resting HR > 70 BPM
What are some contraindications of Ivabradine?
ADHF; sick sinus syndrome, SA block or 3rd degree AV block (unless a permanent pacemaker is in place); clinically significant hypotension or bradycardia; HR maintained and exclusively by a pacemaker; severe hepatic impairment; use with strong CYP3A4 inhibitors
What are some warnings associated with Ivabradine?
- Can cause bradycardia which can increase risk of QT prolongation and ventricular arrhythmias; not recommended in 2nd degree AV block
- Increased risk of atrial fibrillation
- Fetal toxicity
What are some side effects of Ivabradine?
Bradycardia, hypertension, atrial fibrillation, luminous phenomena (phosphenes - seeing flashes of light)
What are some monitoring parameters of Ivabradine?
HR, ECG, BP
What are some important Ivabradine drug interactions?
- Do not use with moderate or strong CYP3A4 inhibitors or strong CYP3A4 inducers
- Use caution with other drugs that decrease HR
How does Vericiguat work?
Vericiguat is a soluble guanylate cyclase stimulator, which increases cyclic GMP and leads to smooth muscle relaxation and vasodilation
What is Vericiguat indicated for?
It is FDA-approved to reduce the risk of cardiovascular death and HF hospitalizations following a hospitalization for HF or need for IV diuretics in patients with chronic symptomatic heart failure (EF < 45%)
What is a boxed warning of Vericiguat?
Do not use if pregnant. Contraception required during use and for one month after stopping treatment
What is a contraindication of Vericiguat?
Do not use with riociguat
What are some side effects of Vericiguat?
Hypotension, anemia, dyspepsia
What are some important Vericiguat drug interactions?
- Do not use with other soluble guanylate cyclase stimulators
- Vericiguat may enhance the hypotensive effects of PDE-5 inhibitors; this combination should be avoided
- Patients taking long-acting nitrates were excluded from studies because of the potential for increased hypotension
Why are fluctuations in potassium levels common in HF?
Fluctuations in potassium levels are common in HF due to the use of drugs that decrease (loop diuretics) or increase (RAAS inhibitors, ARAs) potassium levels
Why is maintenance of potassium levels in HF patients important?
Maintenance of normal potassium levels is essentials to reduce the already elevated arrhythmia risk
How often should potassium levels be checked in HF patients?
It should be checked with changes in renal function and after any change in diuretic, ACE inhibitor, ARB or ARA dose
What should be checked prior to correcting potassium?
Magnesium deficiency can aggravate hypokalemia. Magnesium should be checked and corrected (as needed) prior to correcting the potassium level
What are some examples of potassium oral supplementation?
Potassium chloride, Klor-con, MicroK, K tab
What are contraindications of potassium oral supplementation?
Severe renal impairment, hyperkalemia
- Solid oral formulations: do not use in patients with delayed or obstructed passage through the GI tract
What are some warnings associated with potassium oral supplementation?
Abdominal pain/cramping, diarrhea, nausea, flatulence, hyperkalemia
What are some monitoring parameters of potassium oral supplementation?
K, Mg, Cl, pH, urine output
What are some notes associated with potassium oral supplementation?
- Take with meals and a full glass of water to minimize the risk of GI irritation
- Injection: concentrated electrolyte, high-alert medication
What is an important note about Micro-K, Klor-Con Sprinkle?
Capsule contents can be sprinkled on a small amount of applesauce or pudding
What is an important note about K-tab, Klor-con?
Swallow whole; do not chew, crush, cut or suck on the tablet
What is an important note about Klor-Con M?
If difficult to swallow whole, it can be cut in half or dissolved in water (stir for 2 minutes and drink immediately); do not chew, crush or suck on the tablet
What is an important note about the potassium oral packets?
Dissolve contents in water and drink immediately
What is an important note about potassium oral solution?
- KCl 10% = 20 mEq/15 mL
- Mix each 15 mL with 6 oz of water
For the CHF management/action plan, what do the colors green, yellow, and red represent?
- Green means go: follow medication, weight and diet advice
- Yellow means caution: you may need to change your medications
- Red means danger: get help from a doctor today (call 911)
What indicates green in the CHF management/action plan?
No SOB, usual amount of swelling in legs, no weight gain, no chest pain, no change in usual activity
What is the recommendation when an HF patient is in the green zone?
Weigh yourself every, eat a low salt diet, take all your medications, go to your doctor appointments
What indicates yellow in the CHF management/action plan?
- Weight gain of 2-4 pounds in 1 day or 3-5 pounds in a week
- Increased number of pillows to sleep
- Increased swelling or coughing
- Shortness of breath with activity
What is the recommendation when an HF patient is in the yellow zone?
- You may need to change your medications (e.g. double the dose of your loop diuretic)
- Call your doctor for instructions
What indicates red in the CHF management/action plan?
- Weight gain of more than 5 pounds in 1 week
- Dizziness or falling
- Waking at night due to shortness of breath
- Shortness of breath at rest, chest tightness or wheezing
What is the recommendation when an HF patient is in the red zone?
- Call your doctor today to report symptoms and request an appointment
- Call 911 if having severe chest pain
How does ADHF or acute decompensated HF present as?
ADHF presents with either worsening congestion and/or hypoperfusion
What does treatment consist of for the treatment of ADHF?
Treatment consists of IV loop diuretics, vaasodilators and/or inotropes
What is the main cause of HF hospitalizations?
Many HF hospitalizations are due to nonadherence with medications and/or lifestyle recommendations
What are key counseling points for all patients with heart failure?
- Monitor and record body weight daily, in the morning after using the restroom and before eating
- Limit salt intake. Choose foods with “no sodium added” or “low sodium.” Avoid foods high in sodium such as prepared sauces and condiments, canned vegetables and soups, frozen meals, deli meat, pickles, olives, cheeses, nuts, chips
- Do not use NSAIDs, they can worsen sodium and water retention and reduce the effectiveness of HF medications
What are key counseling points associated with loop diuretics?
- Take this medication early in the day (no later than 4 pm) to avoid getting up at night to use the bathroom
- Can cause orthostasis
What are key counseling points of beta-blockers?
- Do not suddenly stop taking this medication without consulting your healthcare provider
- This medication can mask symptoms of low blood sugar. If you have diabetes, check your blood sugar if you notice symptoms of sweating or hunger
- Can cause sexual dysfunction
- Take Coreg/Coreg CR with food
- Take Toprol XL with or immediately after meals
- The Coreg CR capsule can be opened and the contents sprinkled on a small amount applesauce
- The Kapspargo sprinkle capsule can be opened and the contents sprinkled on a teaspoonful of applesauce, yogurt or pudding
What are some key counseling points of ACE inhibitors, ARBs and ARNIs?
- Avoid in pregnancy (teratogenic)
- Can cause allergy/anaphylaxis
- ACE inhibitors: tell your health care provider if you develop a dry, hacking cough
What are some key counseling points of Digoxin?
- Digoxin levels and kidney function will be monitored
- Avoid dehydration; an overdose can occur more easily if you are dehydrated
- Symptoms of overdose include nausea, vomiting, decreased appetite, vision changes, confusion and delirium
- Many drug interactions
