Heart Failure - Dahl 3 - Plan/Implement

Question 1

What are the Non-Pharm/Self-Care recommendations for patients with high-level evidence?

Answer 1

1 A: Multidisciplinary team
1 B-NR: Education and support regarding self-care

2a B-NR: Vaccinate against respiratory illness
2a B-NR: screen for depression, social isolation, frailty, and low health literacy

Question 2

Recommendation for Stage C HF patients

Answer 2

1A: If able, physical activity

2a C-LD: Avoid excessive sodium intake to reduce congestive symptoms (2 – 3 g/d)

Question 3

What determines the ACA/AHH Stage?

Answer 3

-Symptoms
-structural heart disease
-BPN level

Question 4

Stage A

Answer 4

At risk: no symptoms, no structural abnormalities, BNP normal

-may have comorbidities: HTN, T2DM, CVD, genetic cardiomyopathy

Question 5

Stage B

Answer 5

-Pre HF
-no symptoms but 1 of the following:
-structural heart disease
-risk factors + elevated biomarkers (BNP, troponin)
-increased filling pressure

Question 6

What is the GOAL for Stage A patients?

Answer 6

-preventing HF
-control HTN, manage comorbiditeies

-if T2DM and ASCVD or high-risk (>10%) -> treat with SGLT2i !!!

Question 7

GOAl for Stage B

Answer 7

prevent symptomatic HF (Stage C)
-control HTN, manage comorbidities

-if LVEF < 40%: use ACEi or evidence-based beta blocker

Question 8

Which drugs should be avoided in Stage B?

Answer 8

-TZDs (diabetic drugs) -> fluid retention

-non-DHP CCblocker (diltiazem, verapamil): they are cardio-specific (alpha-1) and negatively inotropic

Question 9

Treatment for Stage C: HFrEF

Answer 9

-relief congestion with LOOPS (furosemide-lasix, bumetanide, and torsemide-demadex)
1-BNR evidence

+4 block
-ARNI/ACEi/ARB (switch to ARNI if ACEi/ARB stable) or direct ARNI
-ß-blocker
-MRA
-SGLT2i (farxiga-dapagliflozin, Jardiance (empagliflozin)

ALL 1A EVIDENCE

Question 10

When to consider switching from ACEi/ARB to ARNI

Answer 10

when ACEi/ARB stable

Question 11

When to avoid MRA?

Answer 11

-GFR >30
-K > 5 (bc MRAs are K-sparing)

Question 12

Which dose to use for the ACEi/ARB?

Answer 12

Lisinopril:
Start: 2.5 - 5 mg daily
Target: 20 - 40 mg daily
(data show benefit in mortality with low dose)

Losartan:
Start: 25 - 50 mg daily
Target: 50 - 150 mg daily

Valsartan:
Start: 20 - 40 mg daily
target: 160 mg BID
(data show benefit in mortality with low dose)

Question 13

What are the evidence-based beta-blockers?

Answer 13

-Metoprolol succinate
-Bisoprolol
-Carvedilol

Question 14

After GDMT (5 block) treatment, the patient still has an EF < 40% -> How to great?

Answer 14

persistent HF:
Hydrazaline-isosorbide dinitrate (Bidil)
-> NYHA III - IV and African American

-implementable device
-> NYHA I-III, LVEF <35%

cardiac resynchronization + defribillator

Question 15

How to treat patients with improved EF (at least 10% improved)?

Answer 15

HFimpEF
-continue GDMT
-continue monitor

Question 16

What are the options for patients who can’t tolerate first-line drugs (5 block)?

Answer 16

-Hydralazine-isosorbide dinitrate (Bidil)
-Ivabradine (blocks I(f “funny” channel) pacemaker current)
-Vericiguat

Question 17

When not to use Ivabradine?

Answer 17

when the patient is on max toleratable BB and the heart rate is still over 70

Question 18

When to consider digoxin for HF?

Answer 18

-if symptoms persist and the patient cant tolerate other drugs

Question 19

How to treat Stage D HF

Answer 19

Refractory HFrEF
-mechanical circulation support
-cardiac transplant
-Palliative care

-may use inotropes to bridge them until they get their transplant or in palliative care (not for treatment! - potentially harmful)

Question 20

Treatment for HFmEF patients

Answer 20

with fluid retention:
1A: loops
2b: MRA
for women: all EFs
for men: <55-60%

w/o fluid retention
2b: ACEi/ARB/ARNI
2b: HFrEF BB: when they can’t take ARNI

Question 21

Scoring tool HFpEF

Answer 21

Heavy: BMI over 30 - 2 points
2 or more antihypertensive = 1 point
AFib = 3 points
Pulmonary HTN - 1 point
Elder age (ov 60) - 1 point
Filling pressure increased - 1 point

Question 22

treatment for HFpEF patients

Answer 22

-all should have SGLT2i (2a evidence)

-those with fluid retention:
loops 1A
MRA 2b

ARNI
ARB

Question 23

Doses for Empagliflozin and Dapagliflozine

Answer 23

10 mg

stand alone indications (without T2DM):
CKD
HFrEF
HFpEF

Question 24

How to dose ARNI when started directly?

Answer 24

-middle dose: 49/51 (sacubitril/valsartan)
-if GFR < 30 - low dose: 24/26

-always TWICE daily
-if previously on ACEi/ARB use equivalent dosing + washout period of 36h

Question 25

Why is a washout period required when switching from ACEi to ARNI?

Answer 25

risk of angioedema

Question 26

Doses for Beta-blocker

Answer 26

Carvedilol:
Start: 3.125 mg BID
Target: 25-50 mg BID

Metoprolol succinate:
Start: 12.5 - 25 mg daily
Target: 200 mg daily

Question 27

Doses for MRA

Answer 27

Spironolactone
Start: 12.5 - 25 mg daily
Target: 25 mg daily

Question 28

Drugs that cause harm in HF patients

Answer 28

-NSAIDs
-Ant-arrhythmias: Flecainide/Disopyramide
-Dronedarone
-TZDs
-Saxagliptin/Alogliptin
-Diltiazem/Verapamil
-Nifedipine

Question 29

When to SGLT2i

Answer 29

-in HFrEF:
in Stage A - if T2DM and ASCVD risk
in Stage C - part of 5 block

-in HFpEF (all should have SGLT2i)