Heart Failure (HFrEF) Treatment Flashcards
These drugs reduce Morbidity and Mortality according to GDMT
- RAAS inhibitors
- MRAs
- SGLTs
- Beat-blockers
- Vaso-veno dilators
These drugs OLNY reduce morbidity
- Loop Diuretics
- If channel inhibitor(Ivabradine)
- Soluble guanylate cyclase stimulator(Vericiguat)
- Cardiac glycoside(Digoxin)
What is a general approach to treating HFrEF?
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
What are the treatment goals of treating patients with HFrEF?
- 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
All patients experiencing HF exascerbations should be put on :
- ARNI(ACEI/ARB)
- Evidence-based beta blocker
- MRA
- SGLT inhibitior
Patient present with HFrEF symptoms and has a persistent volume overload, what should be added to their GDMT?
Add/titrate a diuretic agent
Patient presents with HFrEF persistent symptoms and is African-American on other GDMT, what should be added to treatment?
add hydralazine/isosorbice dinitrate
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?
add ivabradine
Patients with HFrEF that are on GDMT with worsening HF evidenced by HF hospitilization or requirements for IV diuretics
Add vericiguat
ARNI treatment
- 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
ARNI/ACEIs/ARBs Doses
* 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
MRA Treatment
- 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
MRA Dose
Spiranolactone
Start–>12.5mg-25mg QD
Target–>25-50mg QD
SGLT inhibitors Treatment Plan
- 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
SGLT-1/2 inhibitors
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
Beta-Blockers treatment plan
- Select appropriate starting dose
- Monitor HR and BP after initiation and during titration
- Increase dose every 2 weeks stepwise to target dosing
Beta-Blockers Dose
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
Loop Diuretics Treatment Plan
- Selec starting dose
- Monitor BP,electrolytes and renal function after initiation and during titration
- Titrate to relief of congestion over days-weeks
When to add loop diuretic?
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
What comorbities a patient has that will increase the diuretic threshold?
- Chronic use
- AKI/CKD
- Heart failure(gut edema)
What if a patient has a diuretic resistance, how do we combat that?
- 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
Loop Diuretic dosing
Furosemide
IV–>20mg
Oral–>40mg
Torsemide
IV–>20mg
Oral–>20mg
Bumetanide
IV–>1mg
Oral–>1mg
Ethacrynic acid
IV–>50mg
Oral–>50mg
Hydralazine/Isosorbide Dinitrate Treatment plan
- 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
Vaso/Venodilators Dose
Hydarlazine
Target–> 75mg TID
Isosorbide dinitrate
Target–> 40mg TID
BiDil(20mg isosorbide dinitrate =37.5mg Hydral)
Target–> 2 tabs TID
Ivabradine Treatment plan
- 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
Ivabradine Dose
Target–>7.5mg BID
Vericiguat Treatment Plan
- 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
Vericiguat Dose
Target–> 10mg QD with food
Additioanal therapies to Vericiguat
- Symptomatic HFrEF(add digoxin)
- HF NYHA II-IV(add Polyunsaturated fatty acids)
- HF w/ hyperkalemia when taking RAASi(add Potassium binders)
When do we add digoxin to the treatment plan?
If patient is already on other GDMT and is still symptomatic
Risks associated with digoxin
- Cardiac arrhythmias
- GI symptoms: anorexia,nausea,vomiting
- Neurological symptoms: visual disturbances, disorientation, confusion
What is the plasma concentration range of digoxin that is target for therapeutic?
0.5-0.9ng/mL
Medications to avoid in HFrEF
- 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
