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IPC Cardiology 2 > Heart Failure (HFrEF) Treatment > Flashcards

Heart Failure (HFrEF) Treatment Flashcards

1
Q

These drugs reduce Morbidity and Mortality according to GDMT

A
  • RAAS inhibitors
  • MRAs
  • SGLTs
  • Beat-blockers
  • Vaso-veno dilators
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2
Q

These drugs OLNY reduce morbidity

A
  • Loop Diuretics
  • If channel inhibitor(Ivabradine)
  • Soluble guanylate cyclase stimulator(Vericiguat)
  • Cardiac glycoside(Digoxin)
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3
Q

What is a general approach to treating HFrEF?

A

Initiate as many mortality reducing drugs as the patient can tolerate, then titrate up to target doses

Addition of a new class of medications decreases mortality a LOT
Increasing a dose of a mortality decreasing drug decreases mortality a LITTLE
Target doses of all GDMT=most mortality reduction

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4
Q

What are the treatment goals of treating patients with HFrEF?

A
  • If they are newly diagnosed, strive to achieve max tolerated or target doses within THREE(3) MONTHS
  • If discharged from the hospital for HFrEF, achieve max tolerated or target doses within SIX(6) WEEKS
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5
Q

All patients experiencing HF exascerbations should be put on :

A
  • ARNI(ACEI/ARB)
  • Evidence-based beta blocker
  • MRA
  • SGLT inhibitior
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6
Q

Patient present with HFrEF symptoms and has a persistent volume overload, what should be added to their GDMT?

A

Add/titrate a diuretic agent

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7
Q

Patient presents with HFrEF persistent symptoms and is African-American on other GDMT, what should be added to treatment?

A

add hydralazine/isosorbice dinitrate

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8
Q

Patient with HFrEF and has a resting HR more than/equal to 70bpm on max tolerated beta-blocker and in sinus rhythm, what should be added to treatment?

A

add ivabradine

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9
Q

Patients with HFrEF that are on GDMT with worsening HF evidenced by HF hospitilization or requirements for IV diuretics

A

Add vericiguat

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10
Q

ARNI treatment

A
  • If previously on ACEI, allow 36-hour wash out
  • Select appropriate staring dose
  • 1-2 wks: Assess tolerability,monitor BP,electrolytes, renal functions
  • Every 1-2wks: increase dose stepwise to a target of 97/103mg BID

Starting dose:
* 24/26mg QD
—>on daily equivalent of <10mg Enalapril or <160mg valsartan
—->ACEI/ARB naive
—->eGFR< 30mL/min/1.73m2
—-> >75yo
* 49/51mg BID
—-> On equivalent of > 10mg or >160mg valsartan

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11
Q

ARNI/ACEIs/ARBs Doses

A

* ARNI(Sacubitril/Valsartan):
Start–>24/26-49/51mg BID
Target–>97/103mg BID
* ACEI(Lisinopril):
Start–>2.5mg-5mg QD
Target–>20-40mg QD
* ARB(Valsartan):
Start–>40mg BID
Target–>160mg BID

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12
Q

MRA Treatment

A
  • Select approriate starting dose
    * 7 days: Assess tolerability,monitor BP, electrolytes,renal function
  • Increase dose stepwise at least every 2 weeks to target dosing and monitor appropriately

Contraindications: eGFR,30ml/min, Scr in men >2.5mg/dL and in women >2mg/dL
Special monitoring:
–> Electrolytes and renal function 7 days after initiation/titration
–>After stable dose: check monthly for 3 months then evry 3 months out to a year

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13
Q

MRA Dose

A

Spiranolactone
Start–>12.5mg-25mg QD
Target–>25-50mg QD

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14
Q

SGLT inhibitors Treatment Plan

A
  • Ensure eGFR >25mg/mL/1.73m2 for dapagliflozin and sotagliflozin
  • Select appropriate starting dose
  • Sotagliflozin: increase dose stepwise to target dosing in 2 weeks

Empagliflozin has no eGRF cut-off

Contraindications: Patients with type 1 diabetes

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15
Q

SGLT-1/2 inhibitors

A

Dapagliflozin and Empagliflozin
Start and target–> 10mg QD
Sotagliflozin
Start–> 200mg QD
Target–>400mg QD

Dapa and empa do not need to be titrated unless patient has diabetes

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16
Q

Beta-Blockers treatment plan

A
  • Select appropriate starting dose
  • Monitor HR and BP after initiation and during titration
  • Increase dose every 2 weeks stepwise to target dosing
17
Q

Beta-Blockers Dose

A

Bisoprolol
Start–>2.5mg QD
Target–>10mg QD
Metoprolol succinate
Start–>12.5-25mg
Target–>200mg QD
Carvedilol
Start–>3.125mg-6.25mg BID
Target–>25mg BID; >85kg, 50mg BID

18
Q

Loop Diuretics Treatment Plan

A
  • Selec starting dose
  • Monitor BP,electrolytes and renal function after initiation and during titration
  • Titrate to relief of congestion over days-weeks
19
Q

When to add loop diuretic?

A

if patients are experinecing any signs of congestion(hypervolemia)

  • usually start ~20-40mg oral furosemide
  • increase as needed to maintain euvolemia
  • may need to prescribe PO potassium with this
20
Q

What comorbities a patient has that will increase the diuretic threshold?

A
  • Chronic use
  • AKI/CKD
  • Heart failure(gut edema)
21
Q

What if a patient has a diuretic resistance, how do we combat that?

A
  • Increased distal sodium reabsorption(chronic loop diuretic use)–>add thiazide to loop
  • Poor delivery to site of efffect: reduced GFR,HF, gut edema–>increase dose of loop diuretic
22
Q

Loop Diuretic dosing

A

Furosemide
IV–>20mg
Oral–>40mg
Torsemide
IV–>20mg
Oral–>20mg
Bumetanide
IV–>1mg
Oral–>1mg
Ethacrynic acid
IV–>50mg
Oral–>50mg

23
Q

Hydralazine/Isosorbide Dinitrate Treatment plan

A
  • Select appropriate starting dose as separate tablets or fixed-combination
  • Monitor BP after initiaition and during titration
  • Increase dose every 2 weeks stepwise to target dose
24
Q

Vaso/Venodilators Dose

A

Hydarlazine
Target–> 75mg TID
Isosorbide dinitrate
Target–> 40mg TID
BiDil(20mg isosorbide dinitrate =37.5mg Hydral)
Target–> 2 tabs TID

25
Q

Ivabradine Treatment plan

A
  • Confirm beta blocker is at max tolerated /targeted dose,patient is in sinus rhythm
  • Select appropriate starting dose
  • 2-4 weeks: Reassess HR and increase stepwise to target dosing

How to titrate:
* HR <50bpm or symptoms of bradycardia: reduce dose by 2.5mg BID or discontinue if already at 2.5mg BID
* HR 50-60bpm: Maintain current dose and monitor HR
* HR >60bpm: Increase by 2.5mg BID until max dose of 7.5mg BID
Pearl:
* Take with food

26
Q

Ivabradine Dose

A

Target–>7.5mg BID

27
Q

Vericiguat Treatment Plan

A
  • Confirm EF <45%, on max tolerated GDMT and has worsening HF symptoms
  • Confirm patient is not pregnant
  • Select appropriate starting dose
  • Monitor BP and CBC(anemia) during initiation and triturate
  • Double the dose every 2 weeks until a target dose is achieved

Worsening HF symptoms= recent hospitilization or need for IV diuretics
Pearl:
Take with food

28
Q

Vericiguat Dose

A

Target–> 10mg QD with food

29
Q

Additioanal therapies to Vericiguat

A
  • Symptomatic HFrEF(add digoxin)
  • HF NYHA II-IV(add Polyunsaturated fatty acids)
  • HF w/ hyperkalemia when taking RAASi(add Potassium binders)
30
Q

When do we add digoxin to the treatment plan?

A

If patient is already on other GDMT and is still symptomatic

31
Q

Risks associated with digoxin

A
  • Cardiac arrhythmias
  • GI symptoms: anorexia,nausea,vomiting
  • Neurological symptoms: visual disturbances, disorientation, confusion
32
Q

What is the plasma concentration range of digoxin that is target for therapeutic?

A

0.5-0.9ng/mL

33
Q

Medications to avoid in HFrEF

A
  • Non DHP-CCBs(Worsen EC/CO)
  • Class IC antiarrhytmic drugs and dronedarone (increased mortality)
  • Thiazolidinediones (Worsen HF symptoms and hospitilizations)
  • DPP-4s(saxagliptin and alogliptin)–>Increased HF hospitilizations
  • NSAIDs(Worsen HF symptoms)–>fluid overload

IPC Cardiology 2 (6 decks)

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