Heart Failure - Management Flashcards
Multimodal treatment of HF generally includes:
○ Dietary and lifestyle changes
○ Treatment of cause (such as ischemic heart disease)
○ Medications (several classes)
○ Device therapy in some Pts (such as CRTs, LVADs, etc.)
○ Heart transplantation in some patients
○ Cardiopulmonary rehabilitation
Short-term goals for Heart Failure treatment:
Relieving symptoms; improving hemodynamics; avoiding
hypokalemia, renal dysfunction, and symptomatic hypotension; and
correcting neurohormonal activation
Long-term goals for Heart Failure treatment:
Correcting hypertension, preventing myocardial infarction
and atherosclerosis, improving cardiac function, reducing hospitalizations,
improving survival, and improving quality of life.
Immediate treatment for Heart failure
may require inpatient hospitalization for acute or worsening heart failure due to certain disorders (acute MI, A-Fib with
rapid ventricular rate, severe HTN, acute valvular regurgitation), as well
as for patients with pulmonary edema, severe symptoms, new-onset HF,
or HF that is unresponsive to outpatient treatment.
Long term Pharmacologic Treatments for Heart failure include:
■ ACE inhibitors / ARBs
■ ARNIs
■ Beta-blockers
■ Aldosterone antagonists
Symptomatic relief Pharmacologic Treatments for Heart failure include:
■ Diuretics (commonly)
■ Vasodilators
■ Digoxin
For medical management, we generally classify HF patients as either
○ Heart Failure with Reduced Ejection Fraction (HFrEF) - 40% or below
○ Heart Failure with Mildly Reduced Ejection Fraction (HFmEF) – 41-49%
○ Heart Failure with Preserved Ejection Fraction (HFpEF) – 50% or higher
○ Heart Failure with improved EF (HFimpEF) – got better, was 40% or below
STAGE A Heart failure treatment:
at-risk for HF
● SGLT-2 inhibitors should be started in pts with DM with or at elevated risk of CV disease
to reduce hospitalization.
● Control co-morbidities
STAGE B heart failure treatment:
pre-HF à focus on GDMT
● CLASS I: (≦ 40%) ACEi or ARB, control co-morbidities, cardio-selective BB (e.g.
carvedilol)
● >40% control so-morbidities
STAGE C & D Heart failure treatment
Symptoms present (see slides)
The most effective class of medication for significantly decreasing
volume status in a HF patient with volume overload
Diuretics
these meds Should be added early to offset the potassium-losing effects of higher-
dose Loop Diuretics
Aldosterone Antagonises (Potassiom-sparing diuretics)
_____ can cause hypovolemia with hypotension, hyponatremia, hypomagnesemia, and severe hypokalemia
Loop diuretics
Examples of aldosterone antagonists
Spironolactone or Eplerenone.
Examples of loop diuretics
Furosemide, Bumetanide, and Torsemide
Examples of thiazide diuretics
Hydrochlorothiazide and Chlorthalidone
T/F All patients with HFrEF should be given oral ACE Inhibitors unless
contraindicated
T
Beneficial effects of ACE inhibitors in regards to HF
■ Reduces production of Angiotensin II and breakdown of bradykinin
■ Slight arterial and venous vasodilation (decreased TPR)
■ Sustained decreases in LV filling pressure during rest and exercise
■ Favorable effects on ventricular remodeling
These have been proven to prolong survival and reduce the number of
hospitalizations for patients with HF
Ace Inhibitors
In ______, ACE inhibitors and ARBs are likely equally as effective
chronic HFrEF,
In _____, ARBs should be used only if they are already being used to
treat HTN, diabetic kidney disease, or microalbuminuria
HFpEF,
Complications of Angiotensin Receptor (Blockers) / Neprilysin Inhibitor (ARNI)
hypotension, hyperkalemia, renal dysfunction, and
angioedema
Angiotensin Receptor (Blockers) / Neprilysin Inhibitor (ARNI) example
Valsartan/Sacubitril (Entresto)
_____ may be very helpful in patients truly
intolerant of ACE inhibitors or ARBs (usually because of significant renal
dysfunction)
Hydralazine plus Isosorbide Dinitrate
______ significantly reduced
the risk of death and hospitalization for HF in those with HF with reduced EF
SGLT2 Inhibitors
Ivabradine (Corlanor)
○ Ivabradine works on a channel in the sinus node and slows the sinus rate.
○ The SHIFT trial revealed that Ivabradine may reduce hospitalization for HF by 18% in
some select patients.
○ Indicated for stable patients with HF and HR of at least 70 bpm who are taking the
maximally tolerated dose of beta-blockers (or can’t take beta-blockers)
Vericiguat (Verquvo)
○ The new medication reduces the risk of
cardiovascular death and HF hospitalization
following HF hospitalization in those with LV EF less than 45%.
Digoxin
○ Digitalis inhibits the sodium-potassium pump, which causes weak positive
inotropy (increases the strength of myocardial contraction)
EKG findings that are characteristic of digitalis toxicity
downsloping “scooped”
ST segments in I and aVL as well as biphasic T waves V5-V6
Dietary Sodium Restriction in HF management
■ Limiting intake of sodium helps limit fluid retention. All patients should
eliminate salt in cooking and at the table, and avoid salty foods. The most
severely ill should limit intake to < 2 g per day
Monitoring Daily Morning Weight in HF management
Monitoring body weight daily helps detect sodium and water retention
early, before it becomes severe. If weight increases > 5 pounds over a few
days, may consider increasing diuretic dose
Regular Light Activity in HF management
■ Activities such as walking is generally encouraged. Formal cardiac
rehabilitation programs are useful for HFrEF especially
Stage A and B are _____ while C and D _____
“at risk of HF,” have HF
When HF patients experience acute
decompensation, signs and symptoms
of left and right heart failure arise, such as:
Dyspnea, orthopnea, PND, fatigue,
peripheral edema, etc
Treatment of acute exacerbations of HF generally revolves around _____
correcting the volume overload by diuresis
Implantable Cardioverter-Defibrillator (ICD)
○ Recommended for patients with otherwise good life expectancy who
experience occasional symptomatic runs of VT or VF.
○ Defibrillates the heart back into normal rhythm
Cardiac Resynchronization Therapy Device (CRT)
○ Essentially a pacemaker which kicks in and initiates depolarization of the
ventricles when the heart is not beating normally.
○ Most helpful for patients with significant conduction defects, such as AV
blocks or Bundle Branch Blocks
Heart transplantation is the treatment of choice for patients ______
under the age of 60 years who have
severe, refractory HF and no other life-
threatening conditions, and who are highly
adherent to management recommendations
Patients who are waiting for a donor heart to
become available have a _____% mortality rate.
12-15
If a donor heart does become available, survival is _____% at 1 year after surgery, with annual mortality of about _____% per year
85-90; 4
Prognosis of heart failure
Generally, patients with heart failure have a poor prognosis unless the cause
is correctable (which is not common)
5-year survival rates after a first-time hospitalization for heart failure is
about ____%, regardless of the patient’s ejection fraction
35
Predictors of poor prognosis in HF
include hypotension, low EF, presence of CAD,
elevated troponins, elevated BUN, reduced GFR, chronic hyponatremia, and poor functional capacity (such as difficulty walking due to symptoms).
● Heart failure usually involves gradual deterioration, interrupted by bouts of
severe decompensation
Patient family education about heart failure
● All patients and families should be taught about the expected and natural
disease progression and the risk of sudden cardiac death.
● For some patients, quality of life is
more important than quantity of life.
○ For this reason, it’s important to
determine the patient’s wishes
about resuscitation if their
condition deteriorates suddenly
