Heart Failure Flashcards
Describe: NYHA Functional Classification I
no limitation on physical activity
Describe: NYHA Functional Classification II
slight limitation of physical activity; comfortable at rest, but ordinary activity results in symptoms of HF
Describe: NYHA Functional Classification III
marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes symptoms of HF
Describe: NYHA Functional Classification IV
unable to carry on any physical activity without symptoms of HF or even symptoms of HF at rest
Define: HFrEF
LVEF of 40% or less
Define: HFpEF
LVEF of 50% or greater
What are the goals of therapy for HF treatment?
-reduced mortality
-prevent or minimize hospitalizations
-slow progression of disease
-relieve or reduce symptoms
-improve quality of life
What are the precipitating and exacerbating factors of heart failure?
-nonadherence with medical regimen, sodium and/or fluid retention
-acute myocardial infarction
-uncorrected high blood pressure
-recent addition of negative inotrope
-medications
-excessive alcohol or illicit drug use
-pulmonary embolus
-endocrine abnormalities
-infection
What medication should be avoided in heart failure?
-NSAIDs, COX-2 inhibitors
-thiazolidinediones
-saxagliptin and alogliptin
-antiarrhythmics
-NON dihydropyridine calcium channel blockers (CCBs) (diltiazem and verapamil)
What can be done to control the risk factors of heart failure?
-control BP
-diabetes control with SGLT2i can prevent HF hospitalizations
-adherence to healthy lifestyle (no smoking, physical activity, healthy diet)
-ASCVD (including MI) -> ACEI/ARB, beta blocker, statin
What is the first step of treatment for a patient with established diagnosis of HFrEF?
- ARNI (preferred) or ACEI or ARB
- beta blocker
- mineralocorticoid receptor antagonist (MRA)
- SGLT2 inhibitor
- possible diuretic (as needed)
What drug is an Angiotensin receptor-neprilysin Inhibitor (ARNi) approved for patients with heart failure?
sucubitril (ARNi)/valsartan (ARB) (ENTRESTO)
What is the indication for sucubitril/valsartan (ENTRESTO)?
reduce the risk of CV death and hospitalization for patients with heart failure (HF)
What is the starting dose for sacubitril/valsartan (ENTRESTO)?
49mg/51mg po BID with or without food
What is the target dose of sacubitril/valsartan (ENTRESTO)?
97mg/103mg BID
If a patient is not currently taking an ACEI/ARB or is taking a low dose they should initially take _______ of sucubitril/valsartan (ENTRESTO).
24mg/26mg
If a patient has severe renal impairment (eGFR <30 mL/min/1.73m2) they should initially take _______ of sucubitril/valsartan (ENTRESTO).
24mg/26mg
If a patient has moderate hepatic impairment they should initially take _______ of sucubitril/valsartan (ENTRESTO).
24mg/26mg
If a patient is over the age of 75 years old they should initially take _______ of sucubitril/valsartan (ENTRESTO).
24mg/26mg
What are the contraindications of ARNi/ARB (sucubitril/valsartan) use?
-history of angioedema with ACEI or ARB
-concomitant use or use of an ACEI within 36h (WASHOUT PERIOD REQUIRED) note this is not needed for an ARB
-severe hepatic impairment (not recommended)
What are the warnings/precautions of ARNi/ARB (sucubitril/valsartan) use?
-fetal toxicity (due to ARB)
-angioedema
-hypotension
-impaired renal function, hyperkalemia (high potassium, K+)
What are the adverse effects of ARNI/ARB (sucubitril/valsartan)?
-angioedema
-hypotension
-increased serum creatine
-hyperkalemia
-dizziness
What are the monitoring parameters of ARNI/ARB (sucubitril/valsartan)?
-blood pressure
-renal function
-potassium (K+)
What drugs are Angiotensin Converting Enzyme Inhibitor (ACEI)?
-pril
-LISINOPRIL
-captopril
-enalapril
What is the starting dose for Lisinopril?
2.5-5mg po daily
What is the target dose for Lisinopril?
20-40mg po daily
What are the recommended monitoring parameters after Angiotensin COnverting Enzyme Inhibitor (ACEI) INITIATION?
assess BP, renal function and potassium (K+) 1-2 weeks after therapy initiation and dosage changes, then periodically (3 months, 6 months, or annually- depends on patient)
What are the adverse effects of ACEI?
-hypotension
-increased serum creatine
-increase potassium (K+)
-cough!
-angioedema
What are the contraindications/precautions for ACEI?
-angioedema
-pregnancy
-bilateral renal artery stenosis
-symptomatic hypotension
-hyperkalemia (K+ > 5)
-increased serum creatine
-cough
What is the indication of ACEI in heart failure patients?
HFrEF when ARNi is not feasible in combination with beta blockers
What drugs are Angiotensin Receptor Blockers (ARBs)?
-artan
-losartan
-valsartan
-candesartan
note these are the 3 ARBs in treatment guidelines for HF
What are the adverse effects of Angiotensin Receptor Blockers (ARBs)?
-angioedema
-hyperkalemia (high potassium)
-renal insufficient
-hypotension
risks higher when combined with other inhibitors of renin angiotensin-aldosterone system
What is the indication of ARBs in heart failure patients?
HFrEF with ACEI intolerance when ARNi is not feasible
What is the starting dose for Losartan?
25-50mg po daily
What is the target dose for Losartan?
50-150mg po daily
What is the starting dose of Valsartan?
20-40mg po daily
What is the target dose for Valsartan?
160mg po BID
What drugs are Beta Blockers?
-metoprolol succinate (XL): selective beta1 receptor blocker
-carvedilol: block alpha1, beta1, and beta2
-bisoprolol: selective beta1 receptor blocker
note these are beta blockers that have evidence in HF
What is the starting dose of Metoprolol succinate?
12.5-25mg po daily
What is the target dose of Metoprolol succinate?
200mg po daily
What is the starting dose of Carvedilol?
3.125mg po BID
What is the target dose of Carvedilol?
-85kg or less: 25mg po BID
-more than 85kg: 50mg po BID
What are the contraindications of Beta Blockers?
-acute, decompensated HF
-reactive airway disease
-second or third degree AV block
-sick sinus syndrome
-cardiogenic shock
-severe bradycardia (< 55bpm)
-severe, symptomatic hypotension
What are the risks of treating a patient with Beta Blockers?
-fluid retention and worsening HF (monitor weight!)
-fatigue, but HF also does this…
-bradycardia and heart block
-hypotension
What is the indication of Beta Blockers for patients with heart failure?
all patients with current or prior symptoms of HFrEF UNLESS contraindicated
Describe: RAAS Blockade
ARNi or ACEI or ARB + BETA-BLOCKER
What is the benefit of using diuretics for heart failure treatment?
rapidly provides symptomatic benefit by directly interfering with sodium retention in HF
What is the preferred diuretic in HF patients?
loop diuretics
What drugs are Loop Diuretics?
-furosemide
-torsemide
-bumetanide
What must be monitored in a patient with HF taking Loop Diuretics?
ins and outs, weight
What is the indication for Loop Diuretics for a patient with HF?
pt with fluid retention
What drugs are Mineralocorticoid Receptor Antagonists (MRAs)?
-spironolactone
-eplernone
Patients at risk for ______________ require close monitoring while on Mineralocorticoid Receptor Antagonists (MRAs).
renal dysfunction or hyperkalemia
What are the contraindications for Mineralocorticoid Receptor Antagonists (MRA)?
-eGFR 30ml/min/1.73m2 or less
-K+ 5mEq/L or greater
What is the indication of Mineralocorticoid Receptor Antagonists (MRAs) in patients with HF?
HFrEF unless contraindicated- must monitor renal function and potassium closely
What is the indication for Sodium-Glucose Cotransporter Inhibitor (SGLT2i)
symptomatic HFrEF to reduce hospitalization for HF and death in pt regardless of type 2 diabetes diagnosis
What drugs are SGLT2i?
dapagliflozin and empagliflozin
What is the dosing of Dapagliflozin?
10mg po daily
eGFR must be _______ before initiation of Dapagliflozin.
at least 25mL/min/1.73m2
What are the four pillars for survival in a patient with HF?
-ARNi
-beta blocker
-MRA
-SGLT2i
What is the indication of Nitrates/Hydralazine?
african americans with HFrEF who are receiving optimal medical therapy
What are the risks of Nitrates/Hydralazine treatment?
-adherence difficult
-side effects: headache, GI, hypotension
What is the indication of Ivabradine (Corlanor)?
pt with stable, symptomatic chronic HF with EF < 35% who are in sinus rhythm with resting HR > 70 bpm and who are on maximum tolerated doses of beta blocker or are contraindicated to beta blockers
What is the indication of Digoxin?
potential use in Afib with HF, but is considered last line
What drugs are NOT indicated for HF because they have not been shown to reduce hospitalization or mortality?
-calcium channel blockers (verapamil and diltiazem may make HF worse and amlodipine has no evidence to reduce outcomes)
-antiarrhythmics
What is the indication of Vericiguat?
high-risk patients with HFrEF with recent or worsening HF already on optimized therapy
What are the goals of treatment for a patient with HFpEF?
-alleviate congestion (diuretics)
-manage precipitating factors (hypertension, high HR, Afib, myocardial ischemia)
