Chronic Heart Failure Flashcards
Signs and Sx’s are 2ndary to a lack of forward blood flow
For each, state what happens in each body system
- Backward failure (Back up of blood from the heart)
-Pulmonary
-heart
-Hepatic
-Abdomen
-Feet - Forward Failure (LACK of blood delivery from the heart)
-Brain
-Heart
-liver
-Kidney
-SKin
- -Back up of blood to the pulm vasculature
-incr volume of blood in ventricles (INCR PRELOAD)
-Backup of fluid to hepatic vein
-Back up of fluid to abdomen
-back up of fluid in feet - Decr perfusion to brain
- decr coronary blood flow
-decr perfusion to liver
-decr perfusion to kidneys
-Decr perfusion to SKIN
What are the sx’s of backward failure?
(Lungs, abdomen, feet)
What are sx’s of forward failure?
(brain, heart, kidneys, skin)
- Dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea
-Abdom swelling , cramps, weight gain
-Swelling in feet and ankles - Fatigue or confusion
-irreg heart beats, exercise intolerance
-decr urine output
-Cold skin
Signs of backward failure
-Lung specific? (3)
-Heart specific? (3)
-Hepatic? (2)
-Legs?
What’s the value of the elevated jugular venous pressure or JVP?
In HF, what might the BNP and NTproBNP values be?
Signs of FORWARD failure
-Heart specific ?
-Liver specific?
-Kidney speciifc?
- rales, crackles, pleural effusion
- Elevated BNP, NTproBNP, S3 heart sound
- Elevated INR, Hepatojug reflex
- Pitting edema
-JVP >= 5 cm H20
BNP > 100-400 pg/mL
NTproBNP > 900 pg/mL
- Tachycardia, arrhythmia
- Elevated AST and ALT
- Elevated creatinine
- If pt has HFrEF, whats the EF?
-what kind of dysnfunction ? - If pt has HFmrEF whats EF?
-Kind of dysfunction ? - If pt has HFpEF whats EF?
-What kinda dysfunction? - If pt has HFimpEF whats EF?
- EF<= 40%
-systolic. Cant pump out well - Midrange EF 41-49%
-Either or both dysfunction - EF >= 50%
-Diastolic , cant fill well - Previously <=40%, but now improved to > 40%
NYHA Classification System
Class 1
2
3
4
- Asx’s
- Syptomatic with physical activity (exercise)
- Sx’s with ordinary activities (doing dishes, folding clothes)
- Sx at rest
AHA/ACC Stages of HF
Stage A
Stage B
Stage C
Stage D
a. at risk for HF (pt’s without sx’s or structural hd)
b. Pre-HF
-Pts without current or prev sx’s but have structural HD or elevated filling pressures in LV
c. Symptomatic HF
-pt’s with current or previous sx’s/signs of HF
d. Advanced HF
-pt’s with sx’s and recurrent hospitalizations despite optimal med therapy
What to ask when interviewing pt with Heart Failure :
- S
- Difficulty ___
- Wake from ___
- Can you ___
- ___ in feet or ankles
- Home ____
- Home ___ trends
- Missed ___
- SOB
- laying down flat
- sleep, gasping for air
- Can you climb a flight of stairs?
- Swelling
- weight trends
- BP and HR
- Missed doses of meds
Non Pharm TX and Home monitoring
- What are some interventions? (6)
- What should pt’s avoid? (4)
- exercise
-immunizations
-salt ~2gm/day
-Fluids <2L/day
-Weigh daily (call clinic if u gain more than 2 pounds in 1day or > 5 pounds in 1 week)
-Daily BP and HR - Nsaids, tobacco, execessive alc, NON DHP CCBS
ACEi’s for HfrEF :
1. They reduce ___ and ___
2. AceI Dosing ? For enalapril or Lisiniprol?
3. How often do u titrate?
4. Whats the target dose?
5. AE’s? (5)
6. CI’s? (2)
7. What should u check in 2 weeks after starting or incr dose?
- mortality and hf hospitalizations
- Enalapril (vasotec) is 2.5 mg BID
Lisinopril : 2.5-5 mg daily - double dose every 2 weeks until target dose
- enal 10-20 mg BID
Lisinopril : 20-40 mg DAILY - Hyperkalemia, cough, angioedema, AKI, Sx’s of hypotension
- Preg, hx of angioedema
- serum potassium and creatinine
ARB for HFrEF :
1. Reduces __ and __
2. Dosing ? Losartan ? For rest see chart *
3.Titrate by ? Whats losartan target dose ?
4. ARB AE’s (4) ?
5. ARB CI? (2)
Check serum creatinine and potassium 2 weeks after starting or incr dose
- mortality and HF hospitalizations
- 25-50 mg daily
- double dose evry 2 weeks
- 50-150 mg daily - Hyperkalemia
angioedema
aki
sx’s of hypotension - preg and history of angioedema with an ARB, but can still use if only hx of angioedema with ACEI
ARNI : Entresto (Sacubitril/Valsartan) for HFrEF
- What can it reduce?
- Initial Dose?
-titrate by doubling dose every 2 weeks - target Dose?
- Reduces HF hospitalizations better than ACEI or ARB, Reduces mortality BETTER than ACEI or ARB
- 24/26 mg BID
- 97/103 mg BID
ARNI : Transition from LOW DOSE ACEI or ARB
1) if on low dose ACEI, how do u switch?
2) If on Low dose ARB or no ACEI/ARB, how do u switch?
3) Whats a low dose ACEI?
4) Low dose ARB?
- wait 36 hrs then switch to 24/26 mg BID
- Switch immed to 24/26 mg BID
- Total daily dose of <= 10 mg enalapril equivs (lisinopril <=10 mg, ramipril <= 5 mg)
- Total daily dose <=160 mg valsartan equivs (Losartan <= 50 mg, candesartan <=16 mg)
ARNI transition from HIGH DOSE ACEI OR ARB
1) If high dose ACEI?
2) If high dose ARB?
3) WHats high dose ACEI?
4) High dose ARB?
5) the 36 hr wait reduces risk for?
- wait 36 hrs , then 49/51 mg BID
- SWITCH IMMED 49/51 mg BID
- Total daily dose of >10 mg enal, lisino > 10, ramipril > 5 mg
- Total daily dose > 160 mg valsart, Losartan > 50 mg, candesartan > 16 mg
- ANGIOEDEMA. If u dont stop ACEI and add on entresto right away u have a build up of bradykinin
ARNI AE’s? (4)
CI? (2)
Check serum creatinine and potassium ~2weeks!!
Hyperkalemia, ANGIOEDEMA, AKI, Hypotension
Preg, hx of angioedema w/ either ACEI or ARB
MRA : HfrEF Dosing
1) Reduces ? (2)
2) Whats the starting eplerenone dose ? Spironolactone?
-titrate by doubling dose q2weeks
3) Whats the target dose?
- HF hospitalizations, mortality
- 25 mg daily
-25 mg daily if egfr > 50, 12.5 mg daily if egfr 30-50*** - Eplerenone 50 mg daily
Spirono 25-50 mg daily
MRA : monitoring
- AE’s (5)
- CI? 4 for spirono, 2 for eplerenone
- DDI’s for eplerenone only ?
- Hyperkalemia
hyponatremia
Gynecomastia (more with spiro)
Dysmenorrhea (more with spiro)
Dehydration (Mild diuretic effect) - Spiro : preg,
egfr < 30,
Scr>2.5 men, and 2 for women ,
potassium > 5 meq/L
Epler : ClCR < 30 mL,min
-Potassium > 5.5 meq/L
- Strong CYP 3A4 inhibs and inducers
Beta Blockers : HFrEF
1. Reduces? (2)
2. Initial Dose for Carvedilol and Metoprolol Succinate?
Target Dose?
3. Monitoring for AE’s (5)
4. CI? (2)
- HF hospitalizations, mortality
- Carved : 3.125 mg BID
Target : 25-50 mg BID
Metoprolol : 12.5-25 mg daily
target : 200 mg daily - -Bradycardia
-Fatigue/drowsiness
-can worsen congestive sx’s if NOT euvolemic (ONLY START OR TITRATE UP if EUVOLEMIC)
-sx’s of hypotension
-beta blocker withdrawal - Acute decomp HF !!
-Active airway disease (asthma copd)
SGLT2I : HFrEF
1) Reduces ___and ___
2) Dosing Dapa, Empag, Sota
3) AE’s (3)
4) CI’s:
For ALL? (1)
For DAPA?
-NO RENAL LIMITS with empag or sota
- hf hospitalizations, mortality
- Dapa 10 mg po daily
Empag 10 mg po daily
Sota 200 mg po daily (titrate to 400 mg daily in 2 weeks) - genitourinary tract infections
-euglycemic ketoacidosis
-dehydration - Recurrent UTI’s
DAPA :
Dont start if eGFR < 25 , ok to continue if on therapy and eGFR decreases to < 25
What 4 meds are considered guideline directed medical therapy (GDMT) ?
make the effort to titrate up all 4 med classes, but how many changes should u make at a time?
- Beta blocks
ACEI/ARB/ARNI
MRA
SGLT2I - only 1-2 changes at a time
What do loop Diuretics do for HFrEF :
1) treat sx’s of ?
2) DONT PROVIDE!!!!!
3) Initial Dosing for Lasix, Torsemide, Bumetanide, Ethacrynic acid
4) What should be monitored? (3)
Dose Titration
1) If they arent producing goal urine output and they’re not losing enough weight, how should the dose be titrated?
- congestion
- Mortality benefit
- lasix : 20-40 mg po daily
Tors : 10-20 mg PO daily
Bumex : 0.5-1 mg po daily
Etha : 25-50 mg PO daily - Weight loss, resolution of congestive sx’s, urine output
The dose should be DOUBLED until goal is met, THEN U CAN CONSIDER incr freq of dosing
LOOP Diuretics : Monitoring
1) AE’s ?
Hypo (4)
D
A
M
O
2) CI? (1)
- Hypo kalemia, natremia, magnesemia, chloremia
-Dehydration
-AKI
-Metab alkalosis
-ototoxicity - sulfa allergy (Ok to use ethacrynic acid)
Describe the stepwise approach to overcoming loop diuretic resistance :
1) WHats the PO conversion of 40 mg furosemide into torsemide, bumex, and ethacrynic acid ?
2) IV conversion from 20 mg furosemide to tors, to bumex, to etha?
If taking Furosemide, SWITCH IT TO ANOTHER
–> then, add Thiazide Diuretic –> COnsider IV admin
40 mg lasix = 20 mg tors = 1 mg bumex = 50 mg ethacyrnic acid
20 mg furo = 20 mg tors = 1 mg bumex = 50 mg etha
Thiazide Diuretics : HFrEF
1. Treat sx’s of ___ but do not provide __
2. Dosing for Metolazone and Chlorothiazide
3. Give thiazide diuretics with __ for sequential nephron blockade
4. Thiazides AE’s? (6)
5. When should you consider giving Thiazides?
- congestion, mortality benefit
- Metol : 2.5-10 mg PO daily or in divided doses, admin 30 min before loop
Chlor: 250-1000 mg IV DAIlLY or BID, admin 30 min before Loop
- Loops diuretics
- Hypokalemia (LOTS)
-HYPOnatremia, magnesemia , chloremia, dehydration and AKI - If pt is volume overloaded on :
-80 mg lasix PO daily/BID
-4mg Bumex PO Daily/BID
-80 mg Torsemide PO daily/BID
Hydralazine/Isosorbide Dinitrate : HFrEF
in pt’s who are :
intolerant to ACEI/ARNI/ARB or
Black and on max backbone drugs, or
Sx HFrEF EF <= 40%
- it reduces ___ AND reduces ___
- Whats the initial dose? dont need to know
-Titrate by doubling dose q2weeks until target dose - Whats the target dose?
-Can be given as ___ or __
- hf hospitalizations, mortality
- 25/20 mg PO TID
3.100/40 mg PO TID
Separate pills, as combo pill
