Chronic Heart Failure Flashcards
What is CHF?
•Heart is not able to supply sufficient oxygen-rich blood to the body, due to impaired ability of the ventricle to either fill or eject blood
What contributes to CHF?
•Damage from MI (ischemic) or from long lasting HTN (non-ischemic)
What are the symptoms of HF?
•Related to fluid overload
^ SOB
^ Edema
Symptoms can occur due to problems with systolic (contraction) or diastolic (relaxation)
What is performed when HF is suspected?
•Echocardiography or echo
^ Provides an estimate of LVEF: EF <40% indicates systolic dysfunction or HFrEF
EF <40%: impaired ability to eject blood during systole
Clinical diagnosis of HF (category C)
•Structural and/or functional cardiac abnormality with prior or current sx;
I : No limitations of physical activity
II: Ordinary physical activity results in symptoms of HF
III: Minimal exertion causes sx of HF
Clinical diagnosis of HF (category D)
•Advanced HF with severe symptoms, sx at rest or recurrent hospitalizations despite maximal treatment;
IV: Unable to carry on any physical activity without symptoms of HF, or sx of HF at rest
Clinical diagnosis of HF (category A and B)
A: At risk for development of HF, but no sx, without structural heart disease or elevated biomarkers (HTN, DM, ASCVD)
B: Pre-HF; structural heart disease, abnormal cardiac function or elevated biomarkers, but without signs or sx (LVH, low EF, valvular disease)
^ No limitations of physical activity
Labs/Biomarkers of HF
• Increased BNP: normal is <100
• Increased NT-proBNP: normal is <300
BNP and pro-BNP are used to distinguish between cardiac and non-cardiac causes of dyspnea
Left-sided signs and symptoms of HF
• Orthopnea: SOB when lying flat
• Paroxysmal nocturnal dyspnea (PND) nocturnal SOB and cough
• Bibasilar rales: crackling lung sounds heard on lung exam
• S3 gallop: abnormal heart sound
• Hypoperfusion (renal impairment, cool extremities)
General signs and symptoms of HF
• Dyspnea (SOB at rest or upon exertion)
• Cough
• Fatigue, weakness
• Reduced exercise capacity
Right-sided signs and symptoms of HF
• Peripheral edema
• Ascites: abdominal fluid accumulation
• Jugular venous distention (JVD): neck vein distention
• Hepatojugular reflux (HJR): neck vein distention from pressure placed on the abdomen
• Hepatomegaly: enlarged liver due to fluid congestion
How is Cardiac output (CO) determined?
• CO = HR (heart rate) X SV (stroke volume)
OR
• The volume of blood ejected from left ventricle during one complete heartbeat
*Cardiac index (CI) relates the CO to the size of tue patient;
^ CI = CO/BSA
What are compensatory mechanisms?
•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 (temporarily increases CO but chronically leads to cardiac remodeling)
• The main pathway is the RAAS, the SNS and vasopressin
RAAS and Vasopressin Activation
1) Ang I to Ang II by the enzyme ACE
2) Ang II cause vasoconstriction and stimulates aldosterone from adrenal gland and vasopressin from pituitary gland
3) Aldosterone: Na and water retention
4) Vasopressin: vasoconstriction and water retention
Natural products for HF
• Omega-3 fatty acid
• Hawthorne and coenzyme Q10
Drugs that cause or worsen HF
Most drugs cause fluid retention, edema, increase BP or have negative inotropic effects
• Dipeptidyl peptidase 4 inhibitors: Alogliptin, saxagliptin
• Immunosuppressants: TNF inhibitors (adalimumab, etanercept) and interferons
•Non-Dihydropyridine CCBs
• Antiarrythmics: class I (quinidine, flecainide) and dronedarone
• Thiazolidinediones: increases risk of edema
• Itraconazole
• Oncology drugs: anthracyclines (doxorubicin, daunorubocin)
•NSAIDs
Tx for HF (Initial)
1) ACE inhibitors, ARBs or ARNI
^ decreases mortality in HFrEF
^ ARNI preferred over ACE/ARB to further reduce morbidity and mortality
2) BBs
^ provide benefit in controlling HR and reducing arrhythmia risk: decreases mortality in HFrEF
3) Loop Diuretics
^ reduce blood volume, which decreases edema and congestion; most HF pts need a loop diuretic for sx relief
Tx for HF (secondary, add on)
1) ARAs
^ decreases morbidity and mortality in NYHA Class II-IV
^ provide added diuresis; improve sx and EF
^ Must meet eGFR, SCr and K criteria for use
2) SGLT2 Inhibitors
^ decreases morbidity and mortality in NYHA Class II-IV HFrEF with or without DM
^ must meet eGFR criteria for use
3) Hydralazine and nitrates (BiDil)
^ decreases morbidity and mortality in black patients in NYHA III-IV, when added to ACE/ARB and BB or in other pts who cannot tolerate an ACE or ARB
4) Ivabradine (Corlanor)
^ decreases the risk of hospitalization in pts with stable NYHA II-III HF in normal sinus rhythm with a resting HR>=70 BPM on maximally tolerated dose of BB
Tx for HF (additional meds)
1) Digoxin
^ provides a small increase in CO, improves sx and decreases cardiac hospitalizations (does not decrease mortality)
2) Vericiguat, (sGC) stimulator
^ decreases the risk of hospitalization and CV death after HF hospitalization or need for IV diuretics
Loop Diuretics - MOA
•Block Na and Cl reabsorption in the thick ascending limb of the loop of henle. They increase the excretion of Na, K, Mg, Ca and water.
•Decrease in fluid volume makes heart to pump easier and reduces congestive symptoms. These do not improve survival but required for symptom control
Loop Diuretics - drugs
•Furosemide (Lasix)
•Bumetanide (Bumex)
•Torsemide
•Ethacrynic acid (Edecrin)
Loop Diuretics - drug effects
•Warnings: sulfa allergy - does not apply to ethacrynic acid
•SEs:
^ decrease electrolytes: K, Mg, Na, Cl, Ca
^ increase electrolytes: HCO3 (metabolic alkalosis), UA, BG, TG, total cholesterol
^ ototoxicity - more with ethacrynic acid or rapid IV administration
^ orthostatic hypotension, photosensitivity
•Monitoring: renal fx, fluid status, BP, electrolytes, audiology testing, s/sx of HF
NOTES:
^ furosemide injection: store at room temperature
^ PO: furosemide 40 mg = torsemide 20 mg = bumetanide 1 mg = ethacrynic acid 50 mg
^ furosemide IV:PO ratio 1:2
ACE Inhibitors - MOA and drugs
•Block the conversion of Ang I to Ang II which decreases vasoconstriction and aldosterone secretion
*Enalapril (Vasotec): 10-20 mg BID
*Lisinopril (Zestril, Privinil): 20-40 mg daily
*Quinapril (Accupril): 20 mg BID
*Ramipril (Altace): 10 mg daily
*Captopril (Capoten): TID
ACE Inhibitors - drug effects
•Boxed Warnings: teratogenic
•CIs:
^ Do not use with hx of angioedema
^ Do not use within 36hrs of Entresto
•Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis
•Monitoring: BP, K, renal fx, s/sx of HF
ARBs - MOA, drugs and effects
•Block Ang II from binding to the AT1 which decreases morbidity and mortality
*Losartan (Cozaar): 50-150 mg daily
*Valsartan (Diovan): 160 mg BID
•Less cough, less angioedema, no washout period required
•The other effects same as ACE inhibitors
Sacubitril/Valsartan
•Entresto
•Drug effects are same as ACE Inhibitors
•Do not use with ACE inhibitors or ARBs
ACE Inhibitors, ARBs and ARNI DDIs
•Decreases lithium clearance and increases the risk of lithium toxicity
BBs - MOA
•They antagonize the effects of catecholamines (NE)
•Decreases morbidity and mortality
•Do not use BBs with ISA
•Discontinue acute decompensated HF if hypotension or hypoperfusion is present
Beta-1 selective BBs
•Metoprolol succinate ER (Toprol XL)
^ target dose: 200 mg daily
•BW: do not discontinue abruptly
•Warnings:
^ caution in diabetes; can worsen hyperglycemia/hypoglycemia and mask hypoglycemic sx
^ caution with bronchospastic disease
^ caution with Raynaud’s
•SEs: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud’s
•Monitoring: HR, BP, s/sc of HF
NOTES: Toprol XL can be cut in half; take with or immediately after meals
Non-selective BB and Alpha-1 Blocker
•Carvedilol (Coreg, Coreg CR)
^ IR: <= 85 kg: 25 mg BID, >85 kg: 50 mg BID
^ CR: 80 mg daily
** Take with food
** Drug effects are same as Beta- selective BBs
ARAs - MOA
•Works on distal convoluted tubule and collecting ducts.
•Spironolactone is non-selective which blocks androgen and exhibits endocrine side effects.
•Eplerenone is selective and does not exhibit endocrine side effects
•They decrease morbidity and mortality
ARAs - drug and drug effects
•Spironolactone (Aldactone):
^ 25 mg daily or BID
•Eplerenone (Inspra)
- CIs: hyperkalemia, severe renal impairment, Addison’s disease
- Warnings: do not initiate for HF if K>5 mEq/L
- SEs: hyperkalemia, increased SCr, dizziness
^ Spironolactone: gynecomastia, breast tenderness, impotence - Monitoring: BP, K, renal fx, s/sx of HF
ARA DDIs
•Decreases lithium clearance and increases lithium toxicity
Hydralazine/Nitrates - MOA
•Hydralazine: direct arterial vasodilator which decreases afterload
•Nitrates: causes venous vasodilation and decreases preload
•The combination improves survival bit to a lesser degree than ACE and ARBs
•Alternative for those who can’t tolerate ACE and ARBs
•BiDil is indicated in black pts with NYHA class III or IV who are symptomatic despite optimal tx
Hydralazine/Nitrates - drug effects
Hydralazine/ Isosorbide Dinatrate (BiDil)
•Hydralazine:
^ Warning: DILE
^ SEs: peripheral edema/headache/ flushing/palpitations/reflex tachycardia
•Isosorbide dinitrate:
^ CIs: PDE-5 inhibitors
^ SEs: hypotension, headache, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 hr nitrate-free interval), syncope
SGLT2 Inhibitors
- Decreases mortality
•Dapagliflozin (Farxiga): eGFR <30; do not initiate
•Empagliflozin (Jardiance): eGFR<20; do not initiate
- Warnings:
^ ketoacidosis, hypotension, AKI, mycotic infections - SEs: weight loss, thirst, urination
Digoxin - MOA
•Inhibits the Na-K-ATPase pump, causing positive inotropic effect (increases CO) and negative chronotropy (decrease HR)
•It doesn’t improve survival, but reduce HF related hospitalizations
•It is added to mortality-reducing drugs to improve sx, exercise tolerance and quality of life
•Lowe dose if renal insufficiency, smaller, older or female
Digoxin - drug effects
•Digoxin (Digitek, Digox, Lanoxin)
^ typical: 0.125-0.25 mg PO daily
^ CrCl <50: lower dose or frequency
- Lower dose by 20-25% when switching from PO to IV
- Therapeutic range: 0.5-0.9 ng/mL
•Monitoring: electrolytes, renal fx, HR
•Toxicity:
^ initial s/sx: N/V, loss of appetite and bradycardia
^ severe s/sx: blurred/double vision, greenish-yellow halos
Antidote: DigiFab
Digoxin - DDIs
•Use caution with other drugs that decreases HR (BBs, non-DHP CCBs, amiodarone)
•Hypokalemia, hypomagnesemia and hypercalcemia increases the risk of digoxin toxicity
•Digoxin is a substrate of P-gp
^ decrease dose by 50% when starting amiodarone
Ivabradine (Corlanor)
•Decreases HR, reduced hospitalizations but does not affect mortality
•Used when sinus rhythm with a resting HR >=70 BPM
Target: 50-60 BPM
Warnings: bradycardia, increases the risk of QT prolongation and ventricular arrhythmias
SEs: bradycardia, hypertension, Afib
Vericiguat (Verquvo)
•Soluble guanylte cyclase stimulator
•Do not use with riociguat
•SEs: hypotension
Potassium oral supplements
•Potassium should be checked with changes in renal fx and after any change in diuretic, ACE, ARB or ARA dose
•Magnesium should be checked and corrected prior to correcting the K level
•PO solution 10% (20 mEq/15 mL)
Potassium Chloride
1) ER capsules:
^ Micro-K, Klor-Con sprinkle; can be sprinkled on small amount applesauce or pudding
2) ER tablets:
^ K-tab, Klor-con; swallow whole, do not chew, crush, cut or suck on the tablet
^ Klor- Con M; it can be cut in half or dissolved in water (stir for 2 min and drink immediately). Do not chew, crush or suck
3) Oral packet:
^ dissolve contents in water and drink asap
4) Oral solution:
^ KCl 10% = 20 mEq/15 mL
^ mix each 15 ml with 6 oz of water
