Heart Failure (HFrEF) Treatment

Question 1

These drugs reduce Morbidity and Mortality according to GDMT

Answer 1

• RAAS inhibitors
• MRAs
• SGLTs
• Beat-blockers
• Vaso-veno dilators

Question 2

These drugs OLNY reduce morbidity

Answer 2

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

Question 3

What is a general approach to treating HFrEF?

Answer 3

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

Question 4

What are the treatment goals of treating patients with HFrEF?

Answer 4

• 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

Question 5

All patients experiencing HF exascerbations should be put on :

Answer 5

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

Question 6

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

Answer 6

Add/titrate a diuretic agent

Question 7

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

Answer 7

add hydralazine/isosorbice dinitrate

Question 8

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?

Answer 8

add ivabradine

Question 9

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

Answer 9

Add vericiguat

Question 10

ARNI treatment

Answer 10

• 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

Question 11

ARNI/ACEIs/ARBs Doses

Answer 11

* 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

Question 12

MRA Treatment

Answer 12

• 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

Question 13

MRA Dose

Answer 13

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

Question 14

SGLT inhibitors Treatment Plan

Answer 14

• 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

Question 15

SGLT-1/2 inhibitors

Answer 15

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

Question 16

Beta-Blockers treatment plan

Answer 16

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

Question 17

Beta-Blockers Dose

Answer 17

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

Question 18

Loop Diuretics Treatment Plan

Answer 18

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

Question 19

When to add loop diuretic?

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

• 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

Question 22

Loop Diuretic dosing

Answer 22

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

Question 23

Hydralazine/Isosorbide Dinitrate Treatment plan

Answer 23

• 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

Question 24

Vaso/Venodilators Dose

Answer 24

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

Question 25

Ivabradine Treatment plan

Answer 25

* 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 ## Footnote *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

Question 26

Ivabradine Dose

Answer 26

Target-->7.5mg BID

Question 27

Vericiguat Treatment Plan

Answer 27

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

Question 28

Vericiguat Dose

Answer 28

Target--> 10mg QD with food

Question 29

Additioanal therapies to Vericiguat

Answer 29

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

Question 30

When do we add digoxin to the treatment plan?

Answer 30

If patient is already on other GDMT and is still symptomatic

Question 31

Risks associated with digoxin

Answer 31

* Cardiac arrhythmias * GI symptoms: anorexia,nausea,vomiting * Neurological symptoms: visual disturbances, disorientation, confusion

Question 32

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

Answer 32

0.5-0.9ng/mL

Question 33

Medications to avoid in HFrEF

Answer 33

* 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