Heart Failure 2 Flashcards
Goals of Therapy for HFpEF Management:
- Reduce HF symptoms
- Increase functional status (NYHA class)
- Reduce hospitalization risk
— lifestyle modification, congestion control, rhythm control, BP and comorbidity management
no evidence that pharm, diet, etc reduce mortality risk for these patients
Ongoing evaluation and monitoring for HFpEF
- F/u every 1-6 months, depending on comorbid conditions, medication response, etc.
- HTN, CAD, CKD, obesity - Chronic disease management
- Exercise, diet, weight loss, and cardiac rehab
what therapy is most effective providing symptomatic relief to pts with HF
Improves both dyspnea and fluid overload
diuretics
what diuretic is used for mild fluid retention in HF?
thiazides
- Hydrochlorothiazide
- Metolazone
- Chlorthalidone
Monitor renal function and potassium
what diuretic therapy is used for severe fluid retention / symptoms in HF?
oral loop diuretic
- Furosemide
- Torsemide
- Bumetanide
MUST monitor renal function and potassium
what is the Rule Of 2s for HF?
no more than 2L of fluids
no more than 2g of Na
if a pt has continued sx from diuretic therapy, what could you do?
- combine thiazide + loop
- Caution - massive diuresis and electrolyte abnormalities
- Metolazone and furosemide MC combo - Oral potassium replacement
- Potassium chloride (KCl, Klor-con, Kdur) - Monitoring
- Daily weights
- BMP within 1 wk of diuretic therapy initiation or dosage change
what medication reduces the risk of cardiovascular death and hospitalization for heart failure, regardless of diabetes status
SGLT2i
Dapagliflozin (Farxiga), empagliflozin (Jardiance), canagliflozin (Invokana), Sotagliflozin (Inpefa)
how do SGLT2i help with HF?
- osmotic diuresis and natriuresis → decreasing arterial pressure and stiffness → shifts to ketone-based myocardial metabolism
- Additional benefits d/t reduction of preload and afterload, blunting of cardiac stress/injury with less hypertrophy and fibrosis
The exact mechanism remains uncertain
what are the Recommended Pharm Classes for HFrEF?
- Loops - sx relief d/t fluid overload
- ACEi or ARBs (1)
- BB (1) - additive to ACEi
- Aldosterone antagonists (1)
- SGLT2i (1)
- Entresto (1)
- Hydralazine/Nitrate combination (1)
- Corlanor (2a)
- Digoxin (2b)
class indications for ARBs
- Class I indication for patients who do not tolerate ACE inhibitors
- Class IIA indication to continue if pt already on an ARB at time of dx of HF
- Class IIB indication to add to ACE inhibitor if aldosterone antagonist is contraindicated
- Class III (harmful) to add to ACE inhibitor and aldosterone antagonist
which BB is LA and is the most effective for HF?
Metoprolol succinate
indication for aldosterone antagonist for HF?
Class I indication - Prolong survival and reduce cardiac remodeling
CI for Aldosterone Antagonists
patients with K > 5 and eGFR < 30
Combination sacubitril and valsartan
a neprilysin inhibitor, which limits the breakdown of natriuretic peptides (ANP, BNP)
what medication is this?
Entresto
indications for Entresto
pts with continued sx after on appropriate doses of ACEI and BB
Used in place of the ACEI or ARB
what is needed before starting entresto?
Will need a 36 hr washout period of ACEI prior to starting Entresto
Start low dose and titrate to max dose over 4-6 weeks
CI to entresto
h/o angioedema with ACEI
SE of entresto
hypotension and hyperkalemia
indication for Hydralazine / Nitrate
in HF?
Class I as addition to ACEi and BB for black pts
In non-black pts, Class IIA as replacement for ACEi or ARB d/t drug intolerance, renal failure
what med inhibits the If channel in the sinus node → specifically slows sinus rate
Ivabradine (Corlanor)
indication for Ivabradine (Corlanor)
Class IIA indication Approved by the FDA for use in stable patients w/ HF
in order to take Ivabradine (Corlanor), the pt must have:
HR ≥70
sinus rhythm
Are taking the max tolerated dose of BB or in pts in whom BB are CI
Class IIB indication – beneficial to add after ACEi, BB, and aldosterone antagonist
Greater negative chronotropic effects than ionotropic
May improve HF sx and control ventricular rate in pts with afib
what med?
Digoxin
what CCBs have been shown to be safe with use in HF, but not beneficial?
which are harmful in pts with HF and should be avoided?
Amlodipine and Felodipine
Verapamil and Diltiazem - Myocardial depressants / negative inotropic effects
what meds to avoid in HF?
- Antiarrhythmics - Flecainide, Propafenone, Sotalol
- NSAIDs
- Thiazolidinediones – Actos (pioglitazone), Avandia (rosiglitazone)
what are the preferred antiarrhythics in HF
Amiodarone and dofetilide (Tikosyn)
Non-Pharmacologic Management
for HF
- exercise training - cardiac rehab
- Cardiac Resynchronization Therapy (CRT)
what non-pharm management is recommended in patients with stable NYHA class II to III HF
Lessens sx, increases exercise capacity, improves quality of life, reduces hospitalizations and improves survival
cardiac rehab
An effective therapy in patients with HF and ventricular dyssynchrony identified as a prolonged QRS
Cardiac Resynchronization Therapy (CRT)
Can improve exercise tolerance, NYHA functional class, and reduce morbidity and mortality
recommendations for Cardiac Resynchronization Therapy (CRT)
LVEF < or = 35%
QRS > 120ms
NYHA class III or IV sx
what is used to prevent Sudden Cardiac Arrest (SCA)
implantable cardioverter defibrillator (ICD)
vary based on etiology of cardiomyopathy and whether for primary or secondary prevention
