Chronic Heart Failure Flashcards by RICHARD TREAT

Heart Failure vs.

Acute Decompensated Heart Failure

Heart failure is an ongoing situation where the heart cannot fill and empty effectively.

Acute Decompensated HF is NEW or WORSENING signs &amp; symptoms requiring ED visit
Examples:
Exacerbation of HF
Cardiogenic Shock
ADHF + hypotension

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HF can be classified according to sys of dia: systolic HF

Heart failure with 40% or lower ejection fraction (HFrEF)

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HF can be classified according to sys of dia: Diastolic

Heart failure with 50% or more preserved ejection fraction (HFpEF)

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Beta blockers can cause HF if the person also has

fluid overload

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NSAIDs and COX-2 inhibitors can cause HF by

causing fluid retention

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Anti-diabetic meds can cause HF by

causing fluid retention

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Summarize how diuretics help with HF

Provides relief of acute symptoms of congestion and maintenance of euvolemia

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What is a good combination for treating HF

Loops + ACEI, BB and sodium restriction

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Maintenance dose of diuretics is

that which maintains dyspnea-free status (stable dry weight)

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Diuretics do not help improve

mortality

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ACE Inhibitors

Slows progression of disease process
Decreases mortality
Decreases risk of developing new onset HF in pts with CV risk factors
Recommended for all patients with left ventricular dysfunction (unless other CI)
Reduce symptoms -> reduces hospitalizations

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ACE Inhibitors: Slows

progression of disease process

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ACE Inhibitors: Decreases 2 things

mortality and risk of developing new onset HF in people at risk

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ACE Inhibitors: Recommended for all patients with

left ventricular dysfunction (unless other CI)

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ACE Inhibitors: what do you check before titrating the dose

Is the SBP more than 80

Is the K level less than 5.5

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ACE Inhibitors: Contraindications

Pregnant
Severe hepatic instability
Renal insufficiency

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Metolazone (diuretic): 4 things

Synergistic when given with a loop diuretic
Given 30-60 minutes before loop
Monitor electrolytes
Used to avoid high doses of loops

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ARBs: 3 things to know

Alternative for people who can’t use ACEi

ACEI intolerance may not be due to: hypotension, hyperkalemia, or renal insufficiency

Thiazides may be added if diuretic resistant

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ARBs: Alternative

for people who can’t use ACEi

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ARBs: ACEI intolerance may not be due to

hypotension, hyperkalemia, or renal insufficiency

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ARBs: if diuretic resistant,

Thiazides may be added

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Entresto

Brand name of a combination medication. It’s a combination of Sacubitril and Valsartan, which is an ARNI and and ARB

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Entresto (Sacubitril/ Valsartan) implications: Can be used as ___ or ___ therapy

Initial or replacement therapy,

Can be used as initial therapy instead of ACEI/ARB in conjunction with BB and aldosterone antagonists

Can also be used as replacement of an ACEI or ARB in individuals with chronic symptoms

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Entresto (Sacubitril/ Valsartan) implications: Adjust if there is

hepatic or renal problems

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Entresto (Sacubitril/ Valsartan) implications: ARNI should NOT be combined with

ACEI or within 36 hours of switching from or to an ACEI

Entresto (Sacubitril/ Valsartan) implications: results

Less mortality and less hospitalization

Entresto (Sacubitril/ Valsartan) ADRs:

hypotension, hyperkalemia, renal insufficiency, angioedema, increased BNP, and cough

Entresto (Sacubitril/ Valsartan) implications: Contraindications

Previous angioedema with ACEI or ARB | Pregnancy

Beta blockers help with HF by

Inhibit the adverse effects of the sympathetic nervous system activation

Benefits of Beta Blockers

``` decrease mortality and slow disease progression-> decrease hospitalizations Improvement in functional class (What does "functional class mean"?) ```

What is the downside of using Beta Blockers

May lead to symptomatic worsening or decompensation

To whom would you recommend a beta blocker

Recommended for all STABLE individuals with 0-minimal fluid overload and reduced LVEF

What meds would you prescribe with a beta blockers

diuretics and ACEI

How do you start out taking Beta Blockers

Initiate low, double dose every 2 weeks, as tolerated | Patient should be clinically stable and euvolemic at time of initiation

How long does it take for Beta Blockers to be effective

2-3 months

Aldosterone Antagonists or Mineralocorticoid Receptor Antagonists (MRAs): If they have HFrEF (HF with reduced ejection fraction), use these meds for

symptomatic HF or standard therapy Left ventricular dysfunction early after MI

Aldosterone Antagonists or Mineralocorticoid Receptor Antagonists (MRAs): If the have HFpEF (HF with preserved ejection fraction), use these meds for

elevated BNP or HF admission within 1 year to decrease hospitalizations

Aldosterone Antagonists example

Spironolactone

Spironolactone drug class

Aldosterone Antagonist

Eplerenone drug class

Mineralocorticoid Receptor Antagonists

Mineralocorticoid Receptor Antagonist example

Eplerenone drug class

If you combine Eplerenone (a Mineralocorticoid Receptor Antagonist) with a CYP3A4 inhibitor (ketoconazole, itraconazole, nefazodone, ritonavir, nelfinavir, clarithromycin) you can have

hyperkalemia

For Eplerenone (a Mineralocorticoid Receptor Antagonist), watch out for N___, C____, A____ or A____, P____, F____

NSAIDs, COX-2 inhibitors, high doses of ACEI or ARBs, potassium supplements, foods with high potassium (bananas, avocado, raisins, oranges, tomato)

Isosorbide dinitrate/ Hydralazine: outcomes include

Better QOL and decreased EF

Isosorbide dinitrate/ Hydralazine: Two special times you might use these meds

As an alternative to ACEI (when intolerant) In addition to standard therapy in African Americans with symptomatic HF

Isosorbide dinitrate/ Hydralazine: do not use with

sildenafil, tadalafil

Digoxin works by

inhibits Na/K ATPase Neurohormonal modulating effect

What is *not* a benefit of digoxin

doesn't slow the disease progression or decrease mortality

When might you use digoxin

Stage C or D + reduced EF + persistent HF symptoms despite ACEI, BB, and diuretic Chronic A. fib

Digoxin is not recommended for

Management of acute HF exacerbation Individuals with preserved EF

Digoxin exclusion criteria

electrolyte imbalance like hypokalemia

Digoxin: monitor for

toxicity in presence of nausea/vomiting; potassium, magnesium and calcium

Digoxin: for the elderly and renal patients

do not give digoxin 0.25mg; doses must be lower

Drugs that increase Digoxin levels

Clarithromycin/ erythromycin amiodarone/verapamil posaconazole/voriconazole/itraconazole

Digoxin has an interaction with amiodarone/verapamil. What's the implication of this?

You can still give dig with these meds, but you need to reduce the dose to only a half

Drugs that decrease Digoxin levels

Cholestyramine | Antacids -> separate dose by 2-4 hours

Since antacids decrease dig levels,

Don't give them together, wait 2-4 hours

Calcium Channel Blockers: Diltiazem and Verapamil: Avoid with

a patient with decreased LVEF

Calcium Channel Blockers: Diltiazem and Verapamil: These meds are good for

HF with preserved EF

Calcium Channel Blockers: Amlodipine and felodipine: They do not help with

mortality

Calcium Channel Blockers: Amlodipine maybe will improve

symptoms

Ivabradine contraindications

anything other than normal sinus rhythm low BP/low heart rate CYP3A4 inhibitors

Ivabradine is recommended for

Symptomatic, stable, chronic HFrEF on standard therapy including a BB and HR at least 70bpm at rest

Ivabradine ADR

Bradycardia, hypertensiton, A fib