Heart Failure - Dahl 4 - Follow up/Monitor

Question 1

What are the available doses of ARNI (Entresto: Valsartan/Sacubitril)?

Answer 1

-24/26 mg
-49/51 mg
-97/103 mg

-always twice daily

Question 2

What directs ARNI dosing in a patient?

Answer 2

-if the patient ACEi/ARBs naive or not
if yes: start 49/51 mg twice daily, 24/26 mg if GFR < 30

-if previously on ACEi/ARB start based on equivalent (Lexi-comb)

Question 3

Requirement when changing from ACEi to ARNI

Answer 3

Washout period of at least 36h
-to decrease risk of angioedema

Question 4

Dose of Lisinopril

Answer 4

Lisinopril (Zestril)

Initial daily dose: 2.5 - 5 mg daily

Target does: 20-40mg daily

Question 5

Dose of Losartan

Answer 5

Losartan (Cozaar)

Initial daily dose: 25 - 50 mg daily

Target does: 50-150mg daily

Question 6

Dose of Valsartan

Answer 6

Valsartan (Diovan)

Initial daily dose: 20 - 40 mg daily

Target does: 160mg BID

Question 7

What to look out for in patients on Beta blockers?

Answer 7

Heart rate
-it takes weeks or months to improve - it may feel worse at the beginning

Question 8

What are signs of excess fluids?

Answer 8

gained weight, JVD, Hepatojugular Reflux (HJR), crackles, dyspnea, orthopnea, peripheral edema

Question 9

Adverse effects of ACEi and ARBs

Answer 9

-ACEi: Hypotension, Hyperkalemia, renal dysfunction (prerenal), dry cough

-same for ARBs: except cough

Question 10

Patients who are not appropriate to treat with ACEi/ARB

Answer 10

-Pregnant

-for ACEi: patients angioedema history -> alternative for these patients -> ARBs (ARNI preferred)

-ARNI has the same

Question 11

Side effects for ARNI

Answer 11

same as for ARB
-Hypotension, Hyperkalemia, renal dysfunction (prerenal)

-more risk for angioedema

-avoid using duplicate therapy ACEi/ARB/ARNI

Question 12

Out of ACEi/ARB/ARNI which one is preferred for HF?

Answer 12

ARNI
-the patient can be directly on ARNI or witch from ACEi/ARB to ARNI (if ACEi with washout of at least 36h)

Question 13

Side effects Beta blocker and what to look out for before starting dosing?

Answer 13

-HR - bradycardia, heart block, hypotension, fatigue

-start once the patient has minimal no-evidence of fluid overload (becomes euvolemic)

Question 14

Side effects of MRAs

Answer 14

-hypotension
-renal dysfunction
-hyperkalemia
-gynecomastia (growth of breast tissue)

Question 15

When should MRAs be avoided?

Answer 15

-K > 5

-GFR < 30

Question 16

What to look out for when giving SGLT2i?

Answer 16

-potential for over-diuresis (especially when given with loops)

-weigh daily -> report changes, huge weight loss is a sign of over-diuresis (drying out)

Question 17

When to follow up with patients

Answer 17

-1-2 weeks
-GDMT titration (add drugs if needed)

-eventually space out: when BP under control, renal function is stable, euvolemic

Question 18

Signs of Acute Decompensated HF (ADHF)

Answer 18

-petting edema (>2mm)
-crackles on lungs
-PCWP > 18 mmHg
-increased right atrial pressure
-increased body weight
-elevated BNP (high)

-the heart’s inability to pump blood
-(intravascular) hypovolemic state -> third space
-congestion

Question 19

What are the subsets of ADHF?

Answer 19

I: Warm & Dry II: Warm & Wet

III: Cold & Dry IV: Cold & Wet

Warm: cardiac index above 2.2 –> perfusion is OK
Cold: cardiac index below 2.2

Wet: pulmonary capillary wedge pressure (PCWP, invasive measurement) over 18: volume overload
Dry: PCWP below 18: Euvolemic

IV: challenge to remove fluid but also get fluid to the organs (bc perfusion is low)

Question 20

What are the signs of organ hypoperfusion?

Answer 20

Liver: elevated transaminases (ALT)

Renal: upregulation of RAAS

Altered mental status

Question 21

ADHF
What are possible concomitant CVD’s?

Answer 21

-uncontrolled HTN
-MI or cardiac ischemia
-valvular diseease (stenosis)
-arrhythmias (Afib + RVR rapid ventricular response -> response to the rapid contractions of the atria)

others: severe low K or Mg, COPD exacerbation, pneumonia, HYPO/HYPERthyorid, meds with inotropes (Non-DHP, diltiazem)

Question 22

How to treat Subset II (warm & wet)?

Answer 22

warm & wet: well perfused but hypervolemic

-loop diuretic, if symptom relief -> back to Subset I

-if no relief:
-> diuretic resistant: increase the dose and frequency,
if still resistant: add distal diuretic: THIAZIDE (bc the body compensates the Na block by reabsorbing more on the distal tube)

Question 23

How to treat Subset III (cold & dry)?

Answer 23

Cold & dry: low perfusion, low volume (might be too low)

-if PCWP is below 15mmHg: too dry -> give fluid to get more fluid to the intravascular space to perfuse the kidney

if PCWP is 15-18 + SBP under 90 (low): give IV inotrope (+ vasopressor if needed) to increase SBP
if it doesn’t work: MCS (mechanical circulatory support)

if PCWP is 15-18 and SBP is >90: give IV vasodilator (nitroglycerin)

Question 24

How to treat Subset IV (cold & wet)?

Answer 24

cole & wet: low perfusion, too much fluid

Question 25

Which route to use for diuretics in ADHF and what to do when unresponsive?

Answer 25

-IV, decreased PO absorption due to bowel wall edema

-when unresponsive add a thiazide-like diuretic (more effective and remains effective in GFR < 30)

Question 26

What are the vasodilators that are used in ADHF?

Answer 26

-Nitroglycerin and Nitroprusside
-avoid if hypotensive

Question 27

What are the inotropic agents that are used in ADHF?

Answer 27

-Milrinone
-Dobutamine
-Dopamine

-use of long-term, continuous or intermittent IV inotropic support is potentially harmful - only used for palliative care or bridge to advanced therapy

advanced therapies: temporary mechanical circulatory support (MCS), left ventricle assist device, cardiac transplant