Heart Failure Meds Flashcards
Main classification focus of heart failure medications
- which STAGE of failure?
- what CLASSESS?
aim to treat those in STAGE C: structural heart disease with prior or current symptoms of failure
classes within Stage C: I, II, III, IV
Class 1: no limit on activity and no symptoms
Class 2: fine at rest, mild symptoms with ordinary activity
Class 3: limited activity, okay at rest
Class 4: unable to carry out activity due to symptoms, or symptoms happening at rest
you can change your class but you cannot change stage
Types of HF depending on LVEF
- HFrEF
- HFimpEF
- HFmrEF
- HFpEF
HF with reduced EF: anything with LVEF < or equal to 40%
HF with improved EF: had a HFrEF ( < 40%) then a follow-up measure it is > 40%
HF with midly reduced EF: HF with LVEF between 41-49%
HF with preserved EF: LVEF > 50%
according to GDMT: what are the medications included in Step 1 therapy for HF
what is this based on?
Goal-Directed Medical Thearpy: the medications at specific doses which have been studied to show signifcant reduction in HF symptoms and improve survival
Meds in this Step 1
- ARNI, ACE or ARB
- Beta-Blocker
- Aldosterone-antagonist (MRA)
- SGLT2 inhibitors
- the above medications need to all be loaded onto a patient, but can be done at low dose all together, or sequentially added (how theyre added and titrated depends on the pt. and their factors) usually uptitrated every 2 weeks
loop diuretics as needed if volumer overloaded– if on a LOOP do NOT start a Beta Blocker
additional add-on treatment of hydralasine or isosorbide dinitrate can be used for some, but is not step 1
Treatment for those in Stage A of Heart Failure
Stage A: high risk for heart failure; but no structural disease or symptoms
goal: treat conditions which put these individuals at an increased risk for developing HF in the future
- treat HTN
- treat lipids
Treatment for those in Stage B HF
Stage B: individuals with structrual heart disease but no symptoms of HF
(structural heart disease: meaning left ventricular dysfunction, CAD, valvular disease, left ventricular hypertrophy)
- treat these individuals with…
- Statin: if they have had MI or ACS recently
- ACE: if LVEF < 40%
- Beta Blocker: if LVEF < 40 % and MI or ACS recently
Loop Diueretics in HF
- when are they used
- why do they work
- how does the dosing work
- names & max doses
- monitoring parameters & ADE
Loops work to decrease the pre-load in pts. with volume overload (they have pulmonary congestion or edema or signs of fluid retention) – decrease the preload will decrease the work of the heart to put and relieve pt. of their symptoms
- Loops more potent than thiazides, but watch with crcl < 30
Dosing
- initally, start on low dose & uptitrate until weight decreases and urine output increases (0.5-1kg/daily)
- can continue chronic thearpy if needed to maintain euvolemia
Drugs & Max Dosing
- furosemide: max dose 600mg daily
- torsemide: 200 mg daily
- bumetanide: 10mg daily
Monitoring
follow pts…
- clincial symptoms of volume overload decrease
- I’s & O’s
- weight: increase dose if gaining > 0.5-1 kg/daily
- BP: take sitting and standing
ADE’s
- HYPO-electrolytes (calcemia, kalemia, magnesemia, natrima)
- hypovolemia (see orthostatic hypotension, dehydration)
- hyperuricemia: watch with gout
- hyperglycemia: can be transient
- photosensitivity
how does volume of the pt. influence treatment and titration
- pt on a loop: can start ACE, ARNI or ARB but NOT a beta blocker
- pt. “dry” and has normal HR: can start beta blocker with ACE, ARB or ARNi
once pt. is euvolemic – they remain on the loop for life to stay as the euvolemimc
how do ACE’s work in HF
- mechanism of action (3)
- populations to be careful with using ACEs
- dosing & drugs
- monitoring while on med
- when do you NOT up the dose & actually lower if they’re on it
Angiotension converting enzyme inhibitor: stops the production of AGII shown to reduce mortality and hospitalizations
MOA:
1. reduce AGII: therefore vasodilate; decrease afterload, decrease ventricular hypertrophy (doesnt need to work as hard against an opposite force)
2. reduces aldosterone: which normal uptakes sodium and water; block this reduces sodium and water retention & decreases preload
3. blocks bradykinin degregation: more bradykinin; vasodilation
watch use in…
- those with systolic BP < 100 (already kinda low & this will only lower it)
- those with volume depletion already
- bilateral renal artery stenosis (this can impact pressures in the kidney)
- those with a K > 5.0 meq/L this can increase K and lead to toxic
Dosing & Drugs
- want to start low, and titrate up every 2 weeks untile target
- captopril: max 50mg TID
- Enalapril: 10-20 mg BID
- Lisinopril: 20-40 mg daily
- Ramipril: 10 mg daily
Monitoring…
1. serum K and SCr
- get inital K and SCr levels within 1-2 weeks of starting or up-titrating the dose
- then repeat K and SCr each month for first 3 months
- then repeat K and SCr every 3 months after first 3
- monitor BP
do NOT up-titrate dose, start med AND drop the dose by 50% for 2 weeks if they’re already on it if….
- SBP < 95 or have hypotension
- K > 5.5
- > 30% drop in the eGFR
When are ARBs used in HF
- what do you monitor
- dosing and drug names
- for those who cant tolerate an ACE: bad cough!
Monitoring…. (same as ACE)
- SCr and K & BP
- if SCr increases > 30% or K > 5.5 or Bp of Systolic < 95 –> drop dose or dont start
Max Dosing & Drug Names
- Valsartan: 160 mg BID
- Losartan: 50-150 mg daily
- Candasartan: 32 mg daily
When are ARNI’s used in HF
- what are they a combo of
- perferred in what pt. population
- what must you do between an ACE and this
- contraindications & precautions
ARNI: angiotenstin receptor- neprilysin inhibitor
a combo of an ARB (valsartan) and neprilysin inhibitor (sacubitril)
neprilysin is an enzyme which normally degrades Bradykinin, natrieuretic peptides & other active things which would otherwise kickstart the RAAs system – which we dont want– we want to let go of fluid
- shown to work better than an ACE in HF pts.
Preferred in..
those with class II or III HFrEF
if swithing from an ACE to an ARNI
NEED A 36 HOUR WASHOUT PERIOD before starting ARNI
dont need this is you’re switching from an ARB
Contraindications
- within 36 hours of an ACE
- EVER HAD ANGIOEDEMA with ACE/ARB or ever!!!
- hypersensitivty to ACE/ARB
- pregnany/breastfeeding
- severe liver failure
- cant use with aliskiren for diabetes pts.
caution use with…
- SBP < 100
- bilateral renal artery stenosis
- volume depletion
Dosing of ARNI
- who starts high dose
- who starts low dose
- target dose
- monitoring parameters
start low @ 24/26 mg BID
- have been taking the equlivent of < 10 mg of enalapril or < 160 mg of valsartan
- new to ACE/ARB treatment entirely
- severely renally impaired (eGFR < 30)
- liver impaired
- older than 75
start high @ 49/ 51 mg BID
- for those who have been taking > 10 mg of enalapril or > 160 mg of valsartan
double dose every 2 weeks until reaching target
target dose: 97/103 mg BID
monitoring
- BP, K and SCr (same rules apply as with ACE/ARB)
Beta Blockers and their use in HF
- MOA (3)
- contraindications
- precautions
- dosing and drug names
only bisoprolol, carvedilol & metoprolol succinate are used in HF
- Beta blockers inhibit sympathetic stimulation –> therefore decrease HR & inhibit renin release therefore decreasing reabsorbtion
Contraindications
- uncontroled COPD or asthma
- those with 3rd or 2nd degree heart block (without a pacemaker)
- decompensated HF (acute)
- symptomatic bradycardia or pena
caution in….
- those with a HR < 55
before starting bb, the must be euvolemic and not fluid overloaded – because of the sodium retention of beta blockers
start low dose thearpy and then titrate up after 2 weeks
Doses and Drugs
- Bisoprolol: 10 mg daily
- Carvedilol: < 85 kg = 25 mg BID , > 85 kg = 50 mg BID
- Metoprolol succinate: 200 mg daily
Aldosterone Antagonists (MRA)
- MOA
- adverse drug reactions
- contraindications
- what do you monitor with these
- dosing and drug names
MOA
- reduce aldosterone –> reduces water and salt reabsorbtion –> reduces preload –> reduces fiberosis of the myocytes
- the benefit of the MRA’s is NOT a dieuretic effect, rather its due to their neurohormonal effect
ADE’s
- HYPERkalemia (aldosterone normally excretes this– but you’re blocking in) may want to d/c their potassium supplemetnt when starting this
- increased serum creatitine
- gynecomastia, menstrual irregularities (eplerenone better tolerated with this SE)
Contraindications
- SCr > 2.5 in men, 2.0 in women
- eGFR < 30
- K > 5
Monitor: SCr and K!
- measure SCr and K –> within 1-2 weeks of starting or upping the dose
- then everymonth for the first 3 months
- then every 3 months afterwards
Dosing & Drug names
Eplerenone
- if eGFR > 50 – get to 50 mg daily if K < 5
- if eGFR 30-49 – get to 25 mg daily if K < 5
Spironolactone
- if eGFR > 50 – get to 25 mg BID if K < 5
- if eGFR 30-49 – get to 12.5-25 mg daily if K < 5
anytime K is > 5 you need to reduce dose by 50%
SGLT2 inhibitors use in HF
- which class of HF pts.
- MOA (3)
- Contraindications
- Precautions
- Medications and dosing
- monitoring
for those with class II,III, IV HFrEF
MOA
- gets rid of sugar in urine–> gets rid of water along with it & therefore decreases cardiac preload
- increases the oxygen supply and metabolic activity of the heart –> therefore leads to increased LV function
- reduces the stiffness of arterial walls & resistance –> decreased afterload
Contraindication
- type 1 DM!!
- dialysis
- lactation
Precaution in…
- hypovolemia (the dec. preload can make this worse)
- ketoacidosis (those with T2DM) d/c SGLT2 before surgery
Dosing and Names
- dapagliflozin: 10 mg daily – DO NOT USE if eGFr < 30
- Empagliflozin: 10 mg daily – DO NOT USE if eGFR < 20
monitor
- renal function (can initally worsen)
- volume status
- UTI risk
- ithcy & pain in genitals
when are hydralazine and isosrbide dinitrate used in HFrEF?
- MOA
- population with best use
- avoid use with what
- adverse effects
not used in step 1 treatment
MOA
- vasodilation (decreases preload and afterload)
- hydralizine (arterial vasodilator – decreases afterload)
- isosorbide (venous vasodilator – decreases preload)
- must be used together!!!
Population for use
- AA individuals with class III, IV HF with HFrEF and already on max or target doses of step 1 meds
- can be used inn anyone who cannoy tolerate ARNI, ACE or ARB
Avoid use with…
- PDE5 inhibitors
ADE’s
- headaches, dizzy, lupus
taken 3x daily
