E2: HF

Question 1

HFpEF Symptoms

Answer 1

Symptoms and signs of HF

LVEF >50%

Cardiac structural and/or functional abnormalities

Includes elevated natriuretic peptides

(pitting) edema

Question 2

Symptoms of HF

Answer 2

1. Dyspnea
2. Fatigue
3. Exercise intolerance
4. Fluid overload
5. Hypoperfusion (end organ damage, cool/clammy skin)

Question 3

HFrEF Symptoms

Answer 3

Symptoms and signs of HF

LVEF <40%
NO elevated BNP

Question 4

Drug classes indicated for treatment of HFpEF

Answer 4

Diuretics (loop or thiazide) to reduce symptoms of fluid overload
SGLT-2 Inhibitors (Dapagliflozin/Farxiga, Empagliflozin/Jardiance) to reduce HF hospitalization; benefits regardless of diabetes status

Question 5

What do BNP values indicate
Normal value
Likely HF vlaue

Answer 5

Indicates if there is fluid overload

Normal = <100 pg/mL
Likely HF = >500 pg/mL

Question 6

4 pillars of HFrEF treatment and examples of each

Answer 6

ARNI: sacubitril/valsartan
BB: metoprolol succinate, bisoprolol, carvedilol
MRA: spironolactone, eplerenone
SLGT2i: dapagliflozin (Farxiga), empagliflozin (Jardiance)

Question 7

What is the general rule for dosing for heart failure? (I.e. starting dose)

Answer 7

Start low and go slow

Question 8

Beta-blockers
Examples (3)
Titrate doses q___ weeks to target or maximally tolerated dose
Monitoring:
Caution:

Answer 8

Metoprolol succinate, bisoprolol, carvedilol
Titrate q2 weeks
Monitor: HR, BP, symptoms worsening after initiation
Caution: do not initiate until stable

Question 9

ARNI
Example (1)
Titrate dose q2 weeks based on tolerability
Starting dose may be dependent on baseline __________
Monitoring:
Caution:

Answer 9

Baseline ACEi/ARB dose
Monitoring: BP, K+, kidney function , angioedema
Caution: 36 hour washout required when switching form ACEi
May reduce diuretic requirement

Question 10

ACEi/ARB
Example (ACEi 2, no ARBs specifically listed)
Monitoring:
Caution

Answer 10

Lisinopril, captopril
Titrate q2 weeks to target or maximally tolerated dose
Monitoring: BP, K+, Scr, angioedema, dry cough
Caution: Impaired renal function, hyperkalemia, NSAID DI

Question 11

MRAs
Example
Monitoring
Caution

Answer 11

Ex: Spironolactone, eplerenone
Titrate q2 weeks to target or maximally tolerated dose
Monitoring: BP, K+, renal function, gynecomastia (lower gynecomastia risk in eplerenone)
Caution: hyperkalemia, renal insufficiency

Question 12

What drug is used in persistent symptomatic black patients on optimized therapy as an alternative to ACEi/ARB therapy?
What is the drug’s monitoring?
What line agent is this

Answer 12

Bidil (hydralazine/isosorbide)
Monitor BP
Lower level recommendation than previous therapies

Question 13

Purpose of diuretics in HR
Monitoring
Pearl fact

Answer 13

reduce signs and symptoms of congestion
Reduce signs and symptoms of congestion
Monitoring: BP, electrolytes (K+, Na), renal function (BUN/SCr)
Pearls: diuretic resistance; consider addition of thiazide type diuretic if on 80 or more mg furosemide along with thiazide

Question 14

PO and IV dose of the following
Furosemide
Torsemide
Bumetanide

Answer 14

Furosemide: 40mg PO, 20mg IV
Torsemide: 20mg PO, 20mg IV
Bumetanide: 1mg PO, 1mg IV

Question 15

When to use Digoxin in heart failure
_______ w/rapid ventricular rate ______ to other options or if other agents limited by hypotension

Monitoring
Caution

Answer 15

A. fib w/rapid ventricular rate refractory to other options if other agents limited by hypotension
Monitoring: Serum levels <1.2, K+, kidney function, visual disturbances, N/V
Caution: Narrow therapeutic index (especially elderly, kidney dysfunction, hypokalemia

Question 16

When do use CCB (Non-DHP or DHP) in HF

Answer 16

Not indicated
Non-DHP associated w/worst outcomes and specifically contraindicated in HFrEF

DHP may muddy picture w/edema ADR

Question 17

4 causes of HF exacerbation

Answer 17

1. dietary indiscretion
2. Medication non-adherence
3. noncardiac illness
4. recent dose titrations

Question 18

We typically want patients to be _____ and _____ (warm or cold and wet or dry)

Answer 18

Warm and dry

Question 19

Target net loss per day to manage HF exacerbation is _______
We also want to alleviate symptoms by improving congestion and perfusion
Insensible losses account for ~____ mL/day
When can we do to increase loss

Answer 19

1 liter net loss per day
Insensible losses ~700mL/day
Increase dose of diuretic/disease modifying therapy

Question 20

If a patient is on a home dose of 20mg furosemide, what is their dose in the hospital?

Answer 20

1 to 2 times daily oral dose
20-40mg

Question 21

Why should a patient monitor their weight daily and when should they call their provider/doctor

Answer 21

The body may retain fluid as an early sign of heart failure exacerbation
Call provider if:
1. More than 2-3 pounds of weight gain in one day
2. More than 5 pounds of weight gain in a week