Heart failure Flashcards
Difference between Systolic (HFrEF) and diastolic (HFpEF) heart failure
- If you have systolic heart failure (reduced EF), it means your heart does not contract effectively with each heartbeat. LVEF <40%
- If you have diastolic heart failure (preserved EF), it means your heart isn’t able to relax normally between beats. Both types of left-sided heart failure can lead to right-sided heart failure. LVEF >50%
Rationale for drug use
Heart failure
Provide symptom relief and improve exercise tolerance.
Prevent hospitalisation and deterioration in left ventricular function.
Reduce mortality.
Non pharmacological treatment
Heart failure
Exercise
diet
Drugs for heart failure management
Standard treatment of HFrEF consists of quadruple therapy with:
ACE inhibitor (or sartan or sacubitril with valsartan)
beta-blocker
aldosterone antagonist (Eplerenone, Spironolactone)
sodium-glucose co‑transporter 2 inhibitor.
Doubutamine
Digoxin
Loop diuretics can be used to relieve symptoms of heart failure
Indication
Dobutamine
Inotropic support in acute heart failure, cardiogenic and septic shock
Pharmacological stress testing of myocardial function
Indication
Digoxin
AF and atrial flutter
Heart failure
ACE inhibitor means …
Angiotensin converting enzyme inhibitor
MOA
ACE inhibitor
- block angiotensin I conversion to angiotensin II
- inhibit breakdown of bradykinin (contribute to vasodilation)
- reduce sodium retention
- reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)
ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP
Indication
ACE inhibitors
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Diabetic nephropathy
Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)
Post MI
Adverse reactions
ACE inhibitors
- hypotension
- headache
- dizziness
- cough (dry / non productive)
- hyperkalaemia
- fatigue
- nausea
- renal impairment
Practice points
*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.
Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*
When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment
Drug class and indication
Captopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)
Drug Class and indication
Enalapril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction
Drug class and indication
Enalapril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Fosinopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Fosinopril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Lisinopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment
Drug class and indication
Perindopril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure
Drug class and indication
Perindopril with amlodipine
ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease
Drug class and indication
Perindopril with indapamide
ACE inhibitor + Thiazide diuretic
* Hypertension
Drug class and indication
Quinapril
ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Quinapril with hydrochlorothiazide
ACE inhibitor + Thiazide diuretic
* hypertension
Drug class and indication
Ramipril
ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors
Drug class and indication
Ramipril with felodipine
ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension
Drug class and indication
Trandolapril
ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction
Generic names of ACE inhibitors
Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril
Drug interactions
ACE inhibitor
Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).
Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.
ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.
Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.
Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.
ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.
SARTANs a.k.a. …
angiotensin receptor agonists (ARA)
MOA
sartans / ARA
Competitively block binding of angiotensin II to type 1 angiotensin (AT1) receptors. They reduce angiotensin II-induced vasoconstriction, sodium reabsorption and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
Indication
sartans / ARAs
- Hypertension
- Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
Adverse effects
sartans
dizziness, headache, hyperkalaemia
Precautions / contradictions
sartans / ARAs
Peripheral vascular disease or atherosclerosis—patients may be more likely to have renal artery stenosis.
Volume or sodium depletion—Monitor combination w/ diuretics (both affect sodium and BP)
Black African or Caribbean descent
Treatment with drugs that can increase potassium concentration,
Practice points
sartans / ARAs
- stop K+ and K+ sparing diuretics
- review use of NSAIDs
- check renal function
- used when ACE inhibitors are not tolerated for HTN and chronic heart failure
You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.
Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.
when starting a sartan:
stop potassium supplements and potassium-sparing diuretics
in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan
review use of NSAIDs (including selective COX‑2 inhibitors)
start with a low dose
check renal function and electrolytes before starting a sartan and review after 1–2 weeks
unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they:
cause less cough than ACE inhibitors
may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence)
maximum antihypertensive effect occurs about 4–6 weeks after starting treatment
encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment
Drug class and indication
Candesartan
sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
Drug class and indication
Candesartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Eprosartan
sartan / ARA
Hypertension
Drug class and indication
Eprosartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Irbesartan
sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)
Drug class and indication
Irbesartan with hydrochlorothiazide
sartan /ARA + thiazide diuretic
Hypertension
Drug class and indication
Losartan
sartan / ARA
* Hypertension
* Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)
Drug class and indication
Olmesartan
sartan / ARA
Hypertension
Drug class and indication
Olmesartan with amlodipine
sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension
Drug class and interaction
Olmesartan with amlodipine and hydrochlorothiazide
sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic
Hypertension
Drug class and interaction
Olmesartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Telmisartan
sartan / ARA
* Hypertension
* Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA
Drug class and indication
Telmisartan with amlodipine
sartan / ARA + Dihydropyridine calcium channel blocker
Hypertension
Drug class and indication
Telmisartan with hydrochlorothiazide
sartan / ARA + thiazide diuretic
Hypertension
Drug class and indication
Valsartan
Sartan / ARA
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
* Left ventricular failure/dysfunction after MI, when clinically stable
Drug class and indication
Valsartan with hydrochlorothiazide
Sartan / ARA + Thiazide diuretic
Hypertension
Generic names of Sartans / ARA
Candesartan
Candesartan with hydrochlorothiazide
Eprosartan
Eprosartan with hydrochlorothiazide
Irbesartan
Irbesartan with hydrochlorothiazide
Losartan
Olmesartan
Olmesartan with amlodipine
Olmesartan with amlodipine and hydrochlorothiazide
Olmesartan with hydrochlorothiazide
Telmisartan
Telmisartan with amlodipine
Telmisartan with hydrochlorothiazide
Valsartan
Valsartan with hydrochlorothiazide
Tripple Whammy
NSAID + Sartan + ACE
Sounds like satan ate enough said
Suffix:
Beta-blocker
lol
Drug class
lol
Beta-blockers
Indication
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Chronic heart failure with reduced ejection fraction as part of standard treatment
Prevention of migraine
MOA
Beta-blocker
Competitively block beta receptors in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver.
Beta-blockers reduce heart rate, BP and cardiac contractility; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.
Precautions / adverse effects
Beta-blockers
Shock (cardiogenic and hypovolaemic)—contraindicated.
Hyperthyroidism—beta-blockers may mask clinical signs, eg tachycardia.
Phaeochromocytoma—beta-blockers may aggravate hypertension; an alpha-blocker should be given first.
History of anaphylactic reactions—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis.
Myasthenic symptoms—may worsen.
CARDIACContraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure.
Respiratory contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD
Myasthenic symptoms (muscle weakness)
Adverse effects
Beta-blockers
- bradycardia,
- hypotension,
- orthostatic hypotension
- bronchospasm,
- dyspnoea,
- fatigue, dizziness
- Mask Hypoglycemia
Can mask signs of hypoglycemia in diabetics
Counselling / practice points
Beta-blockers
Counselling
This medicine may cause dizziness or tiredness
Do not stop taking this medicine suddenly
Practice points
beta-blockers are not usually recommended first line for uncomplicated essential hypertension; they are associated with reduced protection against stroke in the elderly
**when stopping treatment, reduce dosage gradually
Drug class and indication
Atenolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Drug class and indication
Bisoprolol
Beta-blocker
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and Indication
Carvedilol
Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Labetalol
Beta-blocker
Hypertension
Hypertensive emergency
Drug class and Indication
Metoprolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
MI
Prevention of migraine
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and Indication
Nebivolol
Beta-blocker
Hypertension
Chronic heart failure with reduced ejection fraction as part of standard treatment
Drug class and indication
Propranolol
Beta-blocker
Hypertension
Angina
Tachyarrhythmias
Tetralogy of Fallot, seek specialist advice
MI
Prevention of migraine
Essential tremor
Phaeochromocytoma (with an alpha-blocker)
Generic drug names
Beta-blockers
Atenolol
Bisoprolol
Carvedilol
Esmolol
Labetalol
Metoprolol
Nebivolol
Propranolol
Sotalol
Indication
Loop diuretic
Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome
MOA
Loop diuretic
Inhibit reabsorption of sodium and chloride in the ascending limb of the loop of Henle. This site accounts for retention of approximately 20% of filtered sodium; therefore, these are potent diuretics.
Produce a rapid and intense diuresis and have a short duration of action (4–6 hours). They are effective over a wide dose range with a dose-related response.
Precautions
Loop Diuretics
Allergy to the specific loop diuretic—contraindicated (see Comparative information below).
Prostatic obstruction—loop diuretics may precipitate acute urinary retention.
Gout—may be aggravated by diuretic-induced hyperuricaemia. If a regular loop diuretic is started after the target serum urate level has been reached, measure serum urate levels every 2–5 weeks and adjust dose of urate-lowering drugs if necessary.
Treatment with ototoxic drugs—increases risk of ototoxicity with loop diuretics; use combinations carefully, especially in renal impairment.
Adverse effects
Loop diuretics
electrolyte disturbances (eg hyponatraemia, hypokalaemia, hypomagnesaemia, hypochloraemia, hypocalcaemia), dehydration, metabolic alkalosis, increased creatinine concentration, hyperuricaemia, gout, dizziness, orthostatic hypotension, fainting
Nursing considerations
Loop diuretic
Furosemide is the only loop diuretic available in oral and IV formulations.
Bumetanide may be used in patients allergic to furosemide (eg rash) but risk of cross-reactivity cannot be excluded.
Can cause hypotension which can cause dizziness
in case of heart failure:
1. Start with low dose
2. combine with ACE inhibitor
This medicine is usually taken once daily in the morning. If you are taking it twice a day, take the first dose in the morning and the second dose at lunchtime.
You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy.
role of loop diuretics in hypertension is limited to management of excess salt and water retention inadequately controlled by other antihypertensive treatment
**Heart failure
**start with a low dose then adjust according to clinical response; use the lowest effective maintenance dose
combine with an ACE inhibitor
if hypotension occurs decrease dose of diuretic before that of the ACE inhibitor
usually given once daily in the morning although there may be a better clinical response if the drug is given twice daily (second dose is usually given at midday; diuresis may interfere with sleep if given after 6 pm)
higher doses are necessary in refractory heart failure:
a trial of IV furosemide may be more effective than increasing oral doses
increase diuretic effect by adding a thiazide diuretic; use small, intermittent thiazide doses with careful monitoring, seek specialist advice
monitor weight and electrolytes
hypokalaemia is less likely when diuretics are used with ACE inhibitors or sartans than when used alone
Drug class and indication
Bumetanide
Loop diuretic
Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome
Given if furosemide is not tolerated
Drug class and indication
Furosemide
Loop diuretic
Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome
