E2: HF Flashcards
HFpEF Symptoms
Symptoms and signs of HF
LVEF >50%
Cardiac structural and/or functional abnormalities
Includes elevated natriuretic peptides
(pitting) edema
Symptoms of HF
- Dyspnea
- Fatigue
- Exercise intolerance
- Fluid overload
- Hypoperfusion (end organ damage, cool/clammy skin)
HFrEF Symptoms
Symptoms and signs of HF
LVEF <40%
NO elevated BNP
Drug classes indicated for treatment of HFpEF
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
What do BNP values indicate
Normal value
Likely HF vlaue
Indicates if there is fluid overload
Normal = <100 pg/mL
Likely HF = >500 pg/mL
4 pillars of HFrEF treatment and examples of each
ARNI: sacubitril/valsartan
BB: metoprolol succinate, bisoprolol, carvedilol
MRA: spironolactone, eplerenone
SLGT2i: dapagliflozin (Farxiga), empagliflozin (Jardiance)
What is the general rule for dosing for heart failure? (I.e. starting dose)
Start low and go slow
Beta-blockers
Examples (3)
Titrate doses q___ weeks to target or maximally tolerated dose
Monitoring:
Caution:
Metoprolol succinate, bisoprolol, carvedilol
Titrate q2 weeks
Monitor: HR, BP, symptoms worsening after initiation
Caution: do not initiate until stable
ARNI
Example (1)
Titrate dose q2 weeks based on tolerability
Starting dose may be dependent on baseline __________
Monitoring:
Caution:
Baseline ACEi/ARB dose
Monitoring: BP, K+, kidney function , angioedema
Caution: 36 hour washout required when switching form ACEi
May reduce diuretic requirement
ACEi/ARB
Example (ACEi 2, no ARBs specifically listed)
Monitoring:
Caution
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
MRAs
Example
Monitoring
Caution
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
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
Bidil (hydralazine/isosorbide)
Monitor BP
Lower level recommendation than previous therapies
Purpose of diuretics in HR
Monitoring
Pearl fact
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
PO and IV dose of the following
Furosemide
Torsemide
Bumetanide
Furosemide: 40mg PO, 20mg IV
Torsemide: 20mg PO, 20mg IV
Bumetanide: 1mg PO, 1mg IV
When to use Digoxin in heart failure
_______ w/rapid ventricular rate ______ to other options or if other agents limited by hypotension
Monitoring
Caution
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
When do use CCB (Non-DHP or DHP) in HF
Not indicated
Non-DHP associated w/worst outcomes and specifically contraindicated in HFrEF
DHP may muddy picture w/edema ADR
4 causes of HF exacerbation
- dietary indiscretion
- Medication non-adherence
- noncardiac illness
- recent dose titrations
We typically want patients to be _____ and _____ (warm or cold and wet or dry)
Warm and dry
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
1 liter net loss per day
Insensible losses ~700mL/day
Increase dose of diuretic/disease modifying therapy
If a patient is on a home dose of 20mg furosemide, what is their dose in the hospital?
1 to 2 times daily oral dose
20-40mg
Why should a patient monitor their weight daily and when should they call their provider/doctor
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
