Heart Failure - Dahl 4 - Follow up/Monitor Flashcards
What are the available doses of ARNI (Entresto: Valsartan/Sacubitril)?
-24/26 mg
-49/51 mg
-97/103 mg
-always twice daily
What directs ARNI dosing in a patient?
-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)
Requirement when changing from ACEi to ARNI
Washout period of at least 36h
-to decrease risk of angioedema
Dose of Lisinopril
Lisinopril (Zestril)
Initial daily dose: 2.5 - 5 mg daily
Target does: 20-40mg daily
Dose of Losartan
Losartan (Cozaar)
Initial daily dose: 25 - 50 mg daily
Target does: 50-150mg daily
Dose of Valsartan
Valsartan (Diovan)
Initial daily dose: 20 - 40 mg daily
Target does: 160mg BID
What to look out for in patients on Beta blockers?
Heart rate
-it takes weeks or months to improve - it may feel worse at the beginning
What are signs of excess fluids?
gained weight, JVD, Hepatojugular Reflux (HJR), crackles, dyspnea, orthopnea, peripheral edema
Adverse effects of ACEi and ARBs
-ACEi: Hypotension, Hyperkalemia, renal dysfunction (prerenal), dry cough
-same for ARBs: except cough
Patients who are not appropriate to treat with ACEi/ARB
-Pregnant
-for ACEi: patients angioedema history -> alternative for these patients -> ARBs (ARNI preferred)
-ARNI has the same
Side effects for ARNI
same as for ARB
-Hypotension, Hyperkalemia, renal dysfunction (prerenal)
-more risk for angioedema
-avoid using duplicate therapy ACEi/ARB/ARNI
Out of ACEi/ARB/ARNI which one is preferred for HF?
ARNI
-the patient can be directly on ARNI or witch from ACEi/ARB to ARNI (if ACEi with washout of at least 36h)
Side effects Beta blocker and what to look out for before starting dosing?
-HR - bradycardia, heart block, hypotension, fatigue
-start once the patient has minimal no-evidence of fluid overload (becomes euvolemic)
Side effects of MRAs
-hypotension
-renal dysfunction
-hyperkalemia
-gynecomastia (growth of breast tissue)
When should MRAs be avoided?
-K > 5
-GFR < 30
What to look out for when giving SGLT2i?
-potential for over-diuresis (especially when given with loops)
-weigh daily -> report changes, huge weight loss is a sign of over-diuresis (drying out)
When to follow up with patients
-1-2 weeks
-GDMT titration (add drugs if needed)
-eventually space out: when BP under control, renal function is stable, euvolemic
Signs of Acute Decompensated HF (ADHF)
-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
What are the subsets of ADHF?
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)
What are the signs of organ hypoperfusion?
Liver: elevated transaminases (ALT)
Renal: upregulation of RAAS
Altered mental status
ADHF
What are possible concomitant CVD’s?
-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)
How to treat Subset II (warm & wet)?
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)
How to treat Subset III (cold & dry)?
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)
How to treat Subset IV (cold & wet)?
cole & wet: low perfusion, too much fluid
Which route to use for diuretics in ADHF and what to do when unresponsive?
-IV, decreased PO absorption due to bowel wall edema
-when unresponsive add a thiazide-like diuretic (more effective and remains effective in GFR < 30)
What are the vasodilators that are used in ADHF?
-Nitroglycerin and Nitroprusside
-avoid if hypotensive
What are the inotropic agents that are used in ADHF?
-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
