Chronic HF Flashcards
LVEF
Left ventricular ejection fraction term is interchanged with EF,
An EF <40% indicates systolic dysfunction or heart failure with reduced ejection fraction HFrEF
EF
55-70%
Term: Normal
Primary Problem: normal
EF
>=50%
Term: heart failure with preserved EF (HFpEF)
diastolic dysfunction
Primary Problem: impaired ventricular relaxation and filling during diastole
EF
41-49%
Term: heart failure with Mildly reduced EF (HFmrEF)
Primary Problem: likely mixed systolic and diastolic dysfunction
EF
<=40%
Term: heart failure with reduced EF (HFrEF)
systolic dysfunction
Primary Problem: impaired ability to eject blood during systole
EF
<= 40% at baseline, then >=10%
increased and second EF >40%
Term: heart failure with improved (HFimpEF)
Primary Problem: Ef improved w/tx ; classified separately because tx for HFrEF should be continued, despite higher EF
ACC/AHA staging system
A. At risk for developing HF- HTN, ASCVD, or DM
B. Pre-HF Structural Heart Disease- LVH, low EF, valvular disease, abnormal cardiac or biomarkers
C. structural and/or functional cardiac abnormality with prior or current symptoms of HF (SOB, LVH, fatigue and reduced exercise tolerance)
D. advanced HF, severe symptoms, symptoms are rest or recurrent hospitalization…
NYHA functional class
I. No limitations to physical activity. does not cause HF symptoms
II. Slight limitations of physical activity, comfortable at rest, but ordinary physical activity (walking up stairs) results in symptom of HF
III. marked limitations, comfortable at rest but minimal exertion (bathing, dressing) causes symptoms of HF
IV. unable to carry on physical activity w/o symptoms of HF at rest (SOB in chair lol)
systolic HF signs
Labs/biomarkers
- increased BNP, normal <100pg/ml
- increased NT-proBNP normal <300 pg/ml
systolic HF signs
General signs/ and symptoms
- Dyspnea (SOB at rest or upon exertion)
- Cough
- Fatigue, Weakness
- Reduced exercise capacity
systolic HF signs
left side signs and symptoms
orthopnea: SOB when lying flat
paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB
Bibasilar rales: crackling lungs sound
S3 gallop: abnormal heart sound
Hypoperfusion (renal impairment, cool extremities)
systolic HF signs
right-sided signs and symptoms
peripheral edema
ascites: abdominal fluid accumulation
Jugular venous distention (JVD): neck vein distention
Hepatojugular reflux (HJR): neck vein distent from pressure placed on the abdomen
Hepatomegaly: enlarged liver due to fluid congestion
CO
CO= HR x SV
CI
CI= CO/BSA
cardiac index
body surface area
Drug Information NATION
drugs that cause or worsen HF
Dipeptidyl peptidase 4 inhibits (alogliptin, saxagliptin)
Immunosuppressants TNF inhibitors (adalimumab, etanercept) and interferons
Non-DHP CCBs (diltiazem and verapamil in systolic HF)
Antiarrhythmics Class I agents (quinidine, flecainide) and dronedarone. (amiodarone and dofetilide ad preferred in pt with HF)
Thiazolidinediones (increased edema risk)
Itraconazole
Oncology drugs (anthracyclines- doxorubicin, daunorubicin)
NSAIDs (all including celecoxib)
initial medications, recommended for all pt without contraindication
HF
- ARNI, ACE inhibitor, or ARBS
- Beta-blockers
- Loop Diuretics
Secondary meds, add on in select pts
HF
- ARAs
- SGLT2 inhibits
- Hydralazine and nitrates (BiDil)
- Ivabradine (Corlanor)
Additional meds
HF
- digoxin
- Vericiguat, a soluble guanylate cyclase (sGC) stimulator
Sacubitril/Valsartan
Entresto
start: 50-100mg
target 200mg BID
50mg 24/26
100mg 49/51
200mg 97/103
Entresto
- injury to developing fetus, stop if prego
- do not sue with ace or arbs
- no wash out period required with arbs
- do not use withing 36 hr of ace inhibitions
- SE: angioedema, hyperkalemia, bilateral renal artery senosis
- do not use w/hisotry of angioedema
Enalapril
vasotec
start 2.5 mg BID
target dose: 10-20 mg BID
Lisinopril
Prinivil, Zestril
Qbrelis oral solution
start 2.5mg -5mg daily
target 20-40 mg daily
Quinapril
Accupril
start 5mg BID
target dose 20mg BID
Ramiril
Altace
start 1.25-2.5 mg daily
target 10mg daily
Losartan
Cozaar
start 25-50mg daily
target 50-150mg daily
Valsartan
Diovan
start 40mg BID
Target 160mg BID
ARNI, ACE inhibitors, ARBs
remember hyperkalemia risk
Metoprolol succinate
Toprol XL
target 200mg daily
Carvedilol
Coreg, Coreg CR
target
<85 kg 25mg BID
>85 kg 50mg BID
controlled release
target 80mg daily
Furosemide
Lasix
20-40mg daily or bid
IV:PO 1:2
stored at room temp
- loop diuretics
Bumetanide
bumex
.5-1mg daily or bid
max 10mg/daily
IV: \PO 1:1
- loop diuretics
toresemide
10-20mg daily
max 200mg/daily
- loop diuretics
ethacrynic acid
Edecrin
50-200mg daily or divided
IV:P0 1:1
- loop diuretics
Loop diuretics
oral equivalent dosing
furosemide 40mg= torsemide 20mg= bumetanide 1mg= ethacrynic acid 50mg
Loop diuretics monitor
causes decrease in K, Mg, Na, Cl, Ca (different with thiazide witch increase Ca)
increase HCO3 (metabolic alkalosis), UA, BG, TG, and total cholesterol
Spironolactone
Aldactone
target 25mg daily or BID
gynecomastia, breast tenderness, impotence
do not use if hyperkalemia, Addison’s disease
Eplerenone
Inspra
target 50mg daily
avoid strong cyp3A4 inhibitors
increases TG
Dapagliflozin
Farxiga
10mg daily in the morning
eGFR <25 initiations not recommended
Empagliflozin
Jardiance
10mg daily in the morning
eGFR <30 initiations not recommended
Hydralazine/ Isosorbide Dinitrate
BiDil
start 20/37.5mg TID (1tab TID)
target 40/75mg TID (2 tab TID)
Ivabradine
Corlanor
target rest HR between 50-60 BPM
use in pt with normal sinus rhythm but HR>70
increased risk of QT prolongation and ventricular arrhythmias
not recommended in 2nd degree AV block, or 3rd or SA block or ADHF
Digoxin
inhibits Na-K-ATPase pump, causing a positive inotropic effect (increase CO) which causes negative chronotropic (decrease HR)
0.125-0.25 mg daily
CrCl<50 decreases dose
.5-.9ng/ml therapeutic rang
hypokalemia, hypomagnesemia, and hypercalcemia
toxicity signs: loss of appetite and bradycardia and blurred/double vision, green-yellow halos
