Heart Failure Part 2 Flashcards
What are the goals of therapy for HFpEF
- Reduce HF symptoms
- Increase functional status (NYHA class)
- Reduce hospitalization risk
No clear evidence that pharmacologic therapy, diet, or other therapies reduce mortality risk for these patients
How is hospitalization risk reduced?
- Lifestyle modification (exercise, decreased fat and sodium diet)
- Congestion control
- Rhythm control
- BP and comorbidity management
What are the key components of management of HFpEF?
- Ongoing evaluation and monitoring
- Follow up visits every 1-6 months, depending on comorbid conditions (HTN, CAD, CKD, obesity), medication response, etc.
- Chronic disease management
- Lifestyle changes
Overall, what recommendations would you make for a patient with HFpEF?
- Weight and blood pressure log
- Exercise training
- Caloric restriction (specifically sodium following rule of 2s–> <2 mg Na, <2 L fluid)
- Coronary revascularization in presence of significant disease
- Appropriate pharmacologic therapy
- Cardiac rehab
What medications can be considered for management of HFpEF?
- Diuretics for congestion and edema
- SGLT2i
- ACEi, ARB, thiazides, MRAs, ARNis (for HTN)
- BBs for HTN, HR, and rhythm control
How would you manage common comorbidities of HFpEF?
- Ischemia –> appropriate management
- Dyslipidemia–> statins
- DM –> appropriate agent
What are the SGLT2i?
- Jardiance
- Farxiga
- Invokana
- Inpefa
According to the AHA/ACC guidelines, what medication should be started first as needed for HFpEF?
Diuretics –> thiazides or loops
A patient with an ejection fraction of >50% who is symptomatic is started on a thiazide diuretic and maxed out. The provider is now thinking about adding another medication. Which medications could be added that are 2a recommendations?
SGLT2i
* Jardiance
* Farxiga
If a patient has an ejection fraction >50%, they have HFpEF
A patient with an ejection fraction of >50% who is symptomatic is maxed out on Jardiance and a thiazide diuretic. The provider is now considering adding another medication to their regimen. Which medications are 2b recommendations and could be added?
ARNis
* Entresto
MRA
* Spironolactone
* Eplerenone
ARB
* -sartans
What medication is the most effective means of providing symptomatic relief to patients with heart failure through improvement of dyspnea and fluid overload
Diuretic therapy
What diuretics should be used for mild fluid retention?
Thiazides
* Hydrochlorothiazide
* Metolazone
* Chlorthalidone
What should be monitored with thiazide diuretics?
- Renal function
- Potassium
What diuretics should be used with severe fluid retention/symptoms?
Oral loop diuretics
* Furosemide
* Torsemide
* Bumetanide
What is the BBW for loop diuretics?
Profound diuresis and electrolyte abnormalities
What do you need to monitor with use of loop diuretics?
- Renal function
- Potassium
If symptoms continue and you have a patient on a diuretic, what can you do? What should you be aware of when doing this?
- You can combine a thiazide with a loop if continued symptoms
- Be cautious of massive diuresis and electrolyte abnormalities
What is the most common combo of loop and thiazide diuretics for severe HFpEF?
- Metolazone and furosemide
What should be initiated with diuretic therapy?
Oral potassium (potassium chloride)
What needs to be monitored with diuretic therapy?
- Daily weight to assess diuresis
- BMP within 1 week of diuretic therapy initiation or dosage change
What are the SGLT2is?
-gliflozins
Dapagliflozin, Empagliflozin, canagliflozin, sotagliflozin
What is the function of SGLT2i in HF?
Reduces risk of CV death and hospitalization for HF regardless of diabetes status through uncertain mechanism
What is the mechanism of action of SGLT2i in HF?
- Leads to osmotic diuresis and natriuresis –> decreasing arterial pressure and stiffness –> shifts to ketone-based myocardial metabolism
- Reduction of preload and afterload, blunting of cardiac stress/injury with less hypertrophy and fibrosis
What are the goals of therapy for HFrEF?
- Clinical improvement, stabilization, and reduction in risk of morbidity and mortality
How is HFrEF managed overall?
- Correction of systemic disorders or underlying causes (thyroid, DM, HTN, COPD, valvular disease, CAD)
- Lifestyle modifications/nonpharmacologic therapies
- Pharmacologic management
What are lifestyle modifications/nonpharmacologic therapies for HFrEF management?
- Tobacco and alcohol cessation
- Sodium restriction
- Daily weight monitoring
- Weight loss in obese patients
- Increase exercise/cardiac rehab
What are the goals of pharmacologic management of HFrEF?
- Improve symptoms
- Slow or reverse deterioration in myocardial function
- Reduce mortality
How should pharmacologic therapy be initiated for HFrEF?
- Initiated at low doses and titrated to target doses based on tolerability
What is the first step in pharmacologic treatment of HFrEF (LVEF <40%)?
Establish diagnosis, address congestion, and initiate GDMT–> all class I and can start all at once or add over time
* ARNi in NYHA II-III; ACEi or ARB in NYHA II-IV
* Beta blocker
* MRA
* SGLT2i
* Diuretics as needed
A patient is initiated on one of the class I recommendations previously mentioned for HFrEF and now has a LVEF >40, what should you do?
Reassess and optimize dosing, compliance and patient education
A patient is initiated on one of the class I recommendations for HFrEF and still has a LVEF of <40%. What should you do now?
- Give a nitrate if AA
- If >1 year survival and LVEF <35%, NYHA 1-III recommend ICD
- If NYHA II-III; ambulatory IV; LVEF <35%; NSR and QRS >150 ms with LBBB CRT-D
CRT-D = cardioresynchronization therapy
If a patient is started on 1st line medications for HFrEF and specific patient scenarios are considered and they continue to have refractory HF stage D, what will you do?
- Durable MCS
- Cardiac transplant
- Palliative care
- Investigational studies
MCS = mechanical circulatory support
What are recommended classes in HFrEF pharmacologic therapy that are class 1?
- Loop diuretics
- ACE inhibitors or ARBs
- Beta blockers
- Aldosterone antagonists
- SGLT2i
- Entresto
- Hydralazine/nitrate combination
What are recommended drugs for HFrEF that are class 2 recommendations?
- Corlanor (2a)
- Digoxin (2b)
What is the use of loop diuretics in HFrEF?
Symptom relief due to fluid overload
What are the common loop diuretics used in HFrEF?
- Furosemide
- Torsemide
- Bumetanide
What is the function of ACE inhibitors in HFrEF?
Improve survival (class I indication)
What are common ACE inhibitors that are used for HFrEF?
- Enalapril
- Captopril
- Lisinopril
How should you dose ACE inhibitors for HFrEF?
- Start low and titrate over one to two week intervals
What should be monitored with ACE inhibitor use in HFrEF?
BMP at baseline to evaluate potassium level and renal function, then again in 1-2 weeks
When are ARBs a class I indication in HFrEF?
Only if patients do not tolerate ACE inhibitors
When are ARBs a class II indication?
- If patient already on an ARB at time of diagnosis of HF (IIA)
- IIB to add to ACE inhibitor if aldosterone antagonist contraindicated
When are ARBs a class III (harmful) indication?
To add to ACE inhibitor and aldosterone antagonist
WILL CAUSE KIDNEY FAILURE DO NOT DO THIS
What is the function of BB in HFrEF?
Improves survival, class I indication, as additive to ACE inhibitors
Which beta blockers are used in HFrEF?
- Carvedilol
- Metoprolol succinate
- Bisoprolol
When would you use caution with beta blockers?
- Bradycardia
- First degree AVB
- Hx of asthma or symptomatic hypotension
How should you dose beta blockers for HFrEF?
start low and titrate up
This medication is a class I indication and prolongs survival and reduces cardiac remodeling
Aldosterone antagonists
What are common aldosterone antagonists used in HFrEF?
Spironolactone and eplerenone
When are aldosterone antagonists contraindicated?
- Patients with potassium >5 and eGFR <30
What is entresto?
- Combination sacubitril and valsartan
- Neprilysin inhibitor, which limits breakdown of natriuretic peptides
When is entresto contraindicated?
If h/o angioedema with ACEI
When would entresto be added to a drug regimen for HFrEF?
- For patients with continued symptoms after an appropriate dose of ACEI and BB
- Used in place of ACEI or ARB
How long do you have to wait after use of ACEI to start entresto?
- 36 hour washout period prior to starting entresto
What are benefits and risks of entresto?
- Reduces hospitalizations and HF death
- Can lead to hypotension and hyperkalemia
When could hydralazine/nitrate be added to a drug regimen for HFrEF?
- Class I indication as addition to ACE inhibitor and beta blocker therapy for black patients
- Class IIa indication as replacement for ACEi or ARB due to drug intolerance or renal failure in non-black patients
What hydralazine/nitrate medications could be added for black patients with HF?
- Hydralazine
- Isosorbide dinitrate
What is the mechanism of action of ivabradine (corlanor)
Inhibits the If channel in the sinus node to slow the sinus rate
When could ivabradine be used for HFrEF?
- Class IIA indication for stable patients with HF
What must patients have before initiation of Ivabradine (Corlanor)?
- Heart rate >70 bpm
- Sinus rhythm
- Taking maximally tolerated dose of beta blockers or in patients in whom beta-blockers are contraindicated
What is the benefit of ivabradine (corlanor)?
Shown to reduce hospitalizations and CV death
When could digoxin be considered as a therapy?
- Class IIB indication
- Can be beneficial to add to therapy after ACE inhibitor, BB, and aldosterone antagonist
What effect does digoxin have on HF?
- Negative chronotropic effects greater than ionotropic
- May improve symptoms and control ventricular rate in patients with afib
What medications should you use caution with HF?
- CCB: amlodipine and felodipine are safe, but not beneficial
- Verapamil and diltiazem are harmful in HF and should be avoided due to myocardial depression/negative inotropic effects
- Certain antiarrhythmics
- NSAIDs
- Thiazolidinones
What are the preferred antiarrhythmics in HF? Which ones should be avoided?
- Preferred: amiodarone and dofetilide
- Avoid: flecainide, propafenone, sotalol
What thiazolidinediones can be used in HF?
- Actos
- Avandia
What non-pharmacologic therapy can be considered in HF?
- Exercise training
- Cardiac resynchronization therapy
- ICD/lifevest
What are guidelines for cardiac rehab in HF?
- Recommended in stable NYHA class II to III HF
What are benefits of cardiac rehab in HF?
- Lessens symptoms
- Increases exercise capacity
- Improves quality of life
- Reduces hospitalizations
- Improves survival
When would cardiac resynchronization therapy be indicated?
- HF and ventricular dyssynchrony identified as prolonged QRS
- LVEF < or = 35%
- QRS >120 ms
- NYHA class III or IV
What are benefits of cardiac resynchronization therapy in HF?
- Improved exercise tolerance and NYHA functional class
- Reduced morbidity and mortality
What ventricular arrhythmias are common in patients with HF and cardiomyopathy?
- Asymptomatic PVCs to sustained VT or VF
what determines recommendations for implantable cardioverter defibrillator to prevent sudden cardiac arrest?
- etiology of cardiomyopathy
- whether for primary or secondary prevention
What are primary prevention recommendations for ICD?
- For those who have not suffered SCD to prevent sudden cardiac arrest
- After optimal medial therapy
- Ischemic CM: ICD recommended for LVEF <35% with class II or III HF symptoms and >40 days post-MI or revascularization
- Nonischemic CM: LVEF <35% with NYHA class II or III HF symptoms, >90 days post dx, and reasonable likelihood of >1 year survival
What are indications for ICD for secondary prevention of SCA?
- Patients with HF and cardiomyopathy who have survived an episode of SCD
- OR sustained VT without obvious reversible causes
What is an additional indication for an ICD in HF other than primary or secondary prevention?
- Patients with LVEF <30% an unexplained syncope
What should be done while waiting 90 days for an ICD?
- Lifevest: wearable defibrillator as bridge to ICD
What is acute decompensated HF?
- Common and potentially fatal cause of acute respiratory distress
- May be new HF or exacerbation of chronic HF
What are causes of acute decompensated HF?
- Medication noncompliance
- Myocardial infarction/ischemia
- Tachyarrhythmias
- Excessive salt intake
What are characteristics of acute decompensated HF?
- Rapid accumulation of fluid that requires rapid assessment and stabilization
What is the presentation of acute decompensated HF?
- Acute pulmonary edema
- Severe dyspnea
- Production of pink, frothy sputum
- Diaphoresis and cyanosis likely present
- Inspiratory rales
- Wheezes and rhonchi also common
What are diagnostic tests that can be performed in acute decompensated HF?
- Echo
- CXR
- BNP
- CMP
- Cardiac enzymes
- CBC
- EKG
How is acute decompensated HF managed?
Stabilization/management measures:
* Airway/oxygenation assessment
* Vital signs
* Cardiac monitoring
* IV access
* Diuretic therapy
* Vasodilator therapy
* Urine output monitoring
How/when should supplemental oxygen be administered in acute decompensated HF?
- If needed, not in absence of hypoxia ox sat >94% goal
- Keep patient upright
- Non-rebreather with high-flow O2
- Noninvasive PPV preferred for respiratory distress, acidosis, or hypoxia
- If fail NPPV or don’t tolerate, intubate and initiate mechanical ventilation
How should a patient with acute decompensated HF be managed with diuretic therapy?
- Start ASAP
- IV recommended bc greater availability
- Loop diuretics are first line (furosemide, torsemide, bumetanide)
What are dosing tips for diuretics in acute decompensated HF?
- Individualize and titrate based on response
- If on chronic oral therapy, IV should be equal or greater
- Peak diuresis = 30 mins after admin
- No single regimen is superior (bolus vs continuous or high vs low dose)
What should be monitored while a patient with acute decompensated HF is on diuretic therapy?
- Vital signs
- Fluid status: daily weights and Is/Os
- Renal function
- Electrolytes
What should be kept in mind with diuretic therapy and renal function?
- Diurese regardless of changes in GFR if severely symptomatic
- Reduce dose or hold if elevation and signs of intravascular volume depletion
- Cardiorenal syndrome can occur due to elevated venous pressure and reduced cardiac output but is actually improved with diuresis
What can you do if there is an inadequate response to diuretic therapy?
- Sodium restriction
- Water restriction in patients with hyponatremia
- Addition of a second diuretic
What additional diuretics can be added if there is an inadequate response to loop diuretic therapy in acute decompensated HF?
- Chlorothiazide (IV)
- HCTZ
- Metolazone
- Aldosterone antagonist
Which additional diuretic is the addition of choice with renal failure because it inhibits reabsorption of Na in distal tubules, thereby increasing excretion of water, Na, K, and H
Metolazone
What is the benefit of adding an aldosterone antagonist to a loop in acute decompensated HF?
- Enhances diuresis and minimizes potassium wasting
When is a vasodilator recommended in acute decompensated HF?
- No hypotension
- Severe symptomatic fluid overload
How is vasodilator therapy for acute decompensated HF administered and what is monitored?
- Continuous IV infusion of nitroglycerin or nitroprusside or morphine
- Frequent BP monitoring required
What is the MOA of nitroglycerin?
- Reduces LV filling pressures via venodilation
- Lowers systemic afterload at higher doses
What are the effects of nitroprusside?
- Vasodilator with venous and arteriolar effects
When is nitroprusside used?
- When pronounced afterload reduction is needed
- HTN emergency, acute AR, acute MR
Why could nitroprusside be dangerous?
Metabolizes to cyanide, accumulation/toxicity can be fatal
May cause reflex tachycardia
How much nitroprusside can be given?
Limit to 24-48 hrs especially with renal failure
What is morphine highly effective as a vasodilator in treating for acute decompensated HF?
Pulmonary edema
What is the mechanism of action of morphine in acute decompensated HF?
- Increases venous and arterial dilation, lowering LA pressure
- Relieves anxiety which can reduce efficacy of ventilation
However, may reduce ventilatory drive
What is the mechanism of action of nisiritide?
- Recombinant BNP
- Vasodilator with no benefits over nitro or nitroprusside
What are some things to keep in mind with nesiritide use?
- Longer half-life, so hypotension and arrhythmias persist longer
- Costly and not sufficient data to support use
What are 2 medications that can be initiated for acute decompensated HF once the patient is stable?
- ACE inhibitors/ARBs
- Beta blockers (hold if severely decompensated or hypotensive and on chronic therapy)
What inotropic agents are indicated for patients with severe LV systolic dysfunction ot maintain systemic perfusion and preserve end-organ performance?
- Milrinone
- Dobutamine
What is the MOA of milrinone?
- PDE3
- Inotropic
- Vasodilation
What is the MOA of dobutamine?
- Stimulates B1 receptors to increase BP, HR, but also vasodilate
What are side effects of milrinone and dobutamine (inotropic agents for acute decompensated HF)?
- May lead to hypotension (milrinone)
- Hypertension (dobutamine)
- Tachyarrhythmias
Patients with ADHF who are hospitalized are at a higher risk for what vascular event? What will you give them for this?
- VTE
- Heparin, LMWH, or fondaparinux
- SCDs if A/C contraindicated
SCD = sequential compression device
What is an additonal therapy for acute decompensated HF that is used to remove excess fluid without major hemodynamic compromise or impact on electrolytes
- Ultrafiltration
What is an additional therapy for acute decompensated HF that is considered for patients in cardiogenic shock?
- mechanical cardiac assistance
What are the 2 major devices used in mechanical cardiac assistance?
- Intraaortic balloon counterpulsation
- Internally implanted left ventricular assist device
What criteria do patients have to meet to get mechanical cardiac assistance?
cardiac index less than 2.0 L/min
Systolic artery pressure <90 mmhg
pulmonary wedge pressure >18 mmHg
What is the definition of cardiogenic shock?
- Signs of reduced cardiac output and hemodynamic findings
What are the clinical signs of reduced cardiac output?
- Cool extremities
- Weak distal pulses
- Altered mental status
- Diminished urinary output
What are hemodynamic findings of cardiogenic shock?
- Hypotension
- PCWP of >15 mmHg which excludes hypovolemia
- Cardiac index <2.2 L/min/m2
What is a cardiac index?
- Cardiac output per square meter of body surface area
- Provides info on left ventricular function
- Normal ranges from 2.6-4.2
- CO/BSA = CI
What are causes of cardiogenic shock?
- AMI
- End-stage severe cardiomyopathies
- Acute myocarditis
- Stress cardiomyopathy
- Endocarine disease: brady or tachyarrhthymias
- Secondary to medications
- Posttraumatic
What is the pathophysiology of cardiogenic shock?
- Principle feature = hypotension with evidence of end-organ hypoperfusion
- Low cardiac output –> sympathetic stimulation –> tachycardia and increased myocardial contractility and peripheral vasoconstriction
What is the classic presentatio of a cardiogenic shock patinet?
- Peripheral vasoconstriction (cool, moist skin) and tachycardia
What are diagnostic labs in cardiogenic shock?
- Elevated cardiac enzymes (if MI)
- Elevated CR, ALT, AST (in renal and hepatic hypoperfusion)
- Coag abnormalities (in hepatic congestion/hypoperfusion
- Anion gap acidosis and/or serum lactate elevation
- BNP (for degree of fluid overload
What are imaging studies for cardiogenic shock?
- EKG for underlying cause (MI, arrhythmia)
- Stat transthoracic echo
- CXR for cardiomegaly, pulmonary congestion
What procedures can be considered for management of cardiogenic shock?
- UA with insertion of foley catheter for UO measurement
- +/- pulmonary artery catheter placement (if diagnosis questionable, pt on inotropes/pressors, or patient not responding to treatment)
- +/- left heart catheterization
- Pulmonary capillary wedge pressure with Swanz Ganz catheter: if elevated, supports pulmonary edema diagnosis
What is the treatment of cardiogenic shock?
- Oxygen supplementation; intubation, ventilation
- Vasopressors/inotropes
- +/- intra-aortic balloon pump
- Suspected MI –> ASA, Heparin, urgent cath, revascularization
what should you consider with vasopressors/inotropes in cardiogenic shock?
- IV fluids arterial line and pulmonary artery catheter insertion to guide management
- correct underlying causes of acidemia
What is the function of inotropic/vasopressor agents in cardiogenic shock?
- Increase contractility of heart, HR, and peripheral vascular tone
- Can also increase myocardial oxygen demand
What should you keep in mind when using inotropic/vasopressor agents?
- beta agonists can precipitate tachyarrhythmias
- alpha agonists can lead to dangerous vasoconstriction and ischemia in vital organ beds
- attention should be given to patient as whole not desired arterial pressure
What are the inotropic/vasopressor agents used in cardiogenic shock?
- Dopamine
- Dobutamine
- Norepinephrine
How does dopamine work as an inotropic/vasopressor agent?
- Catecholamine with varying effect at different doses
- Low doses: dilate renal arterioles/vascular bed
- Intermediate doses: B1 receptor stimulation and enhanced myocardial contractility
- High doses: alpha receptor stimulation in addition to B1 stimulation and tachycardia
What is the MOA of dobutamine?
Strong B1 and weak B2 effects resulting in increased cardiac output, blood pressure, and heart rate, decreased peripheral vascular resistance
What are the 2 ways dobutamine differs from dopamine?
- Does not cause renal vasodilation
- Stronger B2 effect
What is the MOA of norepinephrine (Levophed)?
- Strong B1 and alpha-adrenergic effects and moderate B2 effects
- Increases CO and HR, decreases renal perfusion, decreases peripheral vascular resistance
- BP effects vary
How is norepinephrine usually used?
Typically added to dopamine if patient still hypotensive
How do you choose a inotropic/vasopressor agent?
- Choose based on need, while looking at HR, MAP, and patient clinical status
- Titrate single agent to max tolerate dose before adding additional agent
- Most should be administered through a central line because peripheral extravasation into surrounding tissue can lead to vasoconstriction and skin necrosis
What are the 2 circulatory support devices used in cardiogenic shock?
- Intra-aortic balloon pump and left-ventricular assist device (LVAD)
How is intra-aortic balloon pump used in cardiogenic shock?
- Temporary support system
- Patient anticoagulated with IV heparin due to risk of thrombosis
- Benefits of decreased afterload without increases in myocardial demand
How is Left-ventricular assist device usually used in cardiogenic shock?
As bridge to cardiac transplant
