Heart Failure Study Deck Flashcards
what is the definition of heart failure
abnormality of myocardial function leading to failure of heart to pump blood
what are the two main types of HF
HFrEF and HFpEF
what are the causes of HFrEF
systolic definition
decreased contractility
most closely related to CAD
what are the causes of HFpEF
diastolic dysfunction
impairment w/ventricular relaxation and filling
most closely related to HTN
what are the 3 categories of drug induced HF
negative inotropes
direct cardiac toxins
fluid and sodium retention
what is the definition of asymptomatic rEF
no HF symptoms w/ EF < 40%
what is the definition of HFrEF
HF symptoms w/ EF < 40%
what is the definition of HFimpEF
previous s/sxs of rEF but now improved
what is the definition of HFmrEF
HF symptoms w/ EF 41-49%
what is the definition of HFpEF
HF symptoms w/ EF > 50%
what are the main clinical presentations of HF
shortness of breath
swollen/tender abdomen
swelling of feet/legs
cough/sputum
chronic fatigue
increase urination at night
difficulty sleeping
confusion/impaired memory
major s/sxs of pulmonary congestions
exertional dyspnea
paroxysmal nocturnal dyspnea
pulmonary edema
orthopnea
rales breathing
bendopnea
major s/sxs of systemic congestion
peripheral edema (gravity dependent areas)
jugular venous distention
hepatojugular reflux
hepatomegaly ascites
Initial Labs for HF
-CBC, electrolytes, BUN, TFTs
-electrocardiogram
-chest x-ray
How to evaluate LV function and EF
-echocardiogram
-nuclear testing (MUGA)
-cardiac catheterization
-MRI and CT
NYHA FC I
cardiac disease w/o limitations of physical activity
NYHA FC II
cardiac disease + slight limitations of physical activity
NYHA FC III
cardiac disease + limitations of physical activity
NYHA FC IV
cardiac disease + inability to carry on activity w/o discomfort
AHA staging A
high risk of developing HF. no identified abnormalities or symptoms of HF
AHA stage B
structural heart disease but no s/sx of HF
AHA stage C
HF symptoms current or prior
AHA stage D
Advanced heart disease + symptoms HF at rest
what are the goals of therapy for HF
- slow disease progression
- reduce sxs and increase QOL. reduce hospitalizations
- reduce mortality
sodium monitoring in HF
-intake should be 2-3 gram/day
-avoid salty foods
alcohol monitoring in HF
-patients should abstain from alcohol
-no more than 2 drinks/day for men and 1/drink/day for women
fluid monitoring in HF
-restrict to <2 L/day in patients with hyponatremia
-diuretics difficult in maintaining fluid volume
staged based drug therapy A
ACE-i / ARB
stage based drug therapy B
ACE-i / ARB
Beta blockers
stage based drug therapy C/D
ARNi or ACE/ARB
Beta Blocker
MRA
SGLT2i
Diuretics as needed
Additional therapies for C
ISDN/hydralazine
Ivabradine
Digoxin
what effects do diuretics have in HF disease
dont reduce disease just symptoms
no impact on mortality
How potent are loops
potent. block Na and Cl absorption in ascending limb
What drug class blocks loop
NSAIDs. Avoid combination
Loop initiation
start low then double and titrate
adjust off weight and symptoms
overload and reduce weight 1-2 pounds/day
BUN/Cr ratio not >20:1
Loop monitoring
1-2 weeks after start get labs
fluid intake and outtake
BP
serum electrolytes
what is the potassium goal in HF
> 4
what is the magnesium goal in HF
> 2
IV equivalent dosing for loops
furosemide 40mg =
bumetanide 1mg =
torsemide 20mg =
ethacrynic acid 50mg
Adverse Effects of loops
hypomagnesia
hypokalemia
volume depletion
hyponatremia
increase uric acid
increase calcium
What are the RAS inhibitors
ARNi
ACEi
ARB
what is the main actions of RAS inhibitors in HF
stop cell hypertrophy, cell death, fibrosis, and arrhythmias
what HF patients should use ACEi
benefit occurs in all HF and all severity
must be used in all HF w/o contraindication
what is the mechanism of action of ACEi in general
block conversion of angiotensin I to angiotensin II
what is the mechanism of action of ACEi in HF
reduced vasoconstriction
improve cardiac hemodynamics
inhibit hypertrophy
ACEi dosing principles in HF
titrate slowly to target dose
start low and double every 1-4 weeks
when should dosing in ACEi be cautioned in HF
volume depletion
SBP <80
K>5
SCr > 3
lower the dose and monitor closely
Enalapril (vasotec) initial dosing
2.5mg-5mg BID
Enalapril (vasotec) target dosing
10mg BID
Captopril (capoten) initial dosing
6.25-12.5mg TID
Captopril (capoten) target dosing
50mg TID
Lisinopril (Prinivil, Zestril) initial dosing
2.5-5mg QD
Lisinopril (Prinivil, Zestril) target dosing
20-40mg QD
Absolute CI of ACEi
pregnancy
PMH of angioedema
Bilateral Renal Arterial Stenosis
PMH of intolerance due to hypotension
decreased renal function
hyperkalemia
cough
Adverse effects of ACEi
Hypotension
renal insufficiency
hyperkalemia
cough
angioedema
Monitoring for ACEi and ARB
volume status
renal function and K levels
blood pressure
How often should labs be done with ACEi and ARB
1-2 weeks after initiation then every 3-6 months
what is the acceptable amount SCr may increase with ACEi and ARB
less than or equal to 30%
when are ARBs used in HF
in place of ACEi
mechanism of action of ARBs
block angiotensin II at the AT1 receptor
Losartan (Cozaar) initial dosing
25-50mg daily
Losartan (Cozaar) target dosing
150mg daily
Valsartan (Diovan) initial dosing
20-40mg BID
Valsartan (Diovan) target dosing
160 mg BID
Candesartan (Atacand) initial dosing
4mg QD
Candesartan (Atacand) target dosing
24mg QD
when to use ARB in place of ACEi
unable to take ACEi due to cough
ACEi induced angioedema
ARNi mechanism of action
dual NP and RAAS. more beneficial effects
how does ARNi work in HF
reduce risk of CV death/hospitalization for HFrEF patients with NYHA class II-IV
High-Dose ACEi/ARB to initial ARNi dose
S49/V51mg BID
High-Dose ACEi/ARB to max ARNi dose
97/103mg BID
Low to medium dose ACEi or ARB or naive to ARNi dose
24/26 BID
ARNi adverse effects
hypotension
increase in SCr and K+
angioedema (rare)
CI with pregnancy
expensive
ARNi contraindications
within 36hr of ACEi use
pregnancy
hepatic impairment
hypersensitivity to ACEi/ARB
Stage B recommendations for RAS inhibitors
ACEi or ARB
Stage C recommendations for RAS inhibitors
1st: ARNi
2nd: ACEi if arni not possible
3rd: ARB if ACEi intolerant or arni not possible
or replace ace/arb with ARNi
what are the main actions of beta blockers in HF
reverse remodeling
decrease cardiac hypertrophy and cell death
decrease HR and vasoconstriction
what beta blockers can be used in HF
bisoprolol (Zebeta)
Carvedilol (Coreg)
Carvedilol ( Coreg CR)
Metoprolol Succinate (Toprol XL)
initial dose of bisoprolol (zebeta)
1.25mg daily
target dose of bisoprolol (zebeta)
10mg daily
initial dose of Carvedilol (Coreg)
3.125mg BID
target dose of Carvedilol (Coreg)
25-50mg BID
initial dose of metoprolol succ (toprol xl)
12.5mg-25mg daily
target dose of metoprolol succ (toprol xl)
200mg daily
monitoring for BB in HF
BP, HR
not lower than 50bpm
edema and fluid retention
fatigue or weakness
what are the recommendations for BB in HF stage B
all patients should be on beta blocker
what are the recommendations for BB in HF stage C
all patients should be on beta blocker
what are the main actions of MRAs in HF
decrease electrolyte loss
decrease sodium retention
decrease sympathetic stimulation
block direct fibrotic action on myocardium
initial dose of eplerenone with normal crcl
25mg qd
target dose of eplerenone with normal crcl
50mg qd
initial dose of eplerenone with crcl 30-49
25mg every other day
target dose of eplerenone with crcl 30-49
25mg qd
initial dose of spironolactone with normal crcl
12.5mg
target dose of spironolactone with normal crcl
25mg qd
initial dose of spirionolactone with crcl 30-49
12.5mg every other day
target dose of spironolactone with crcl 30-49
25mg every other day
dosing principles of MRAs in HF
added to RASi and BB therapy
avoid if SCr > 2.5 or 2
avoid if K>5
concomitant use with k sparing diuretics should be avoided
avoid NSAID use
monitoring for MRAs in HF
renal effects and k within 3 days - 1wk of initiation then every 3 months
counsel on avoiding salt substitutes and sources of potassiumk
what are the recommendations for MRAs in HF stage B
not recommended
what are the recommendations for MRAs in HF stage c
NYHA II-IV
HFrEF
eGFR >30
K< 5
d/c if K cannot be mainted
what are the main actions of SGLT-2is in HF
decrease the risk of CV death or hospitalization for HFrEF class ii-iv
dosing for SGLT2is in HF
dapagliflozin 10mg qd or
empagliflozin 10mg qd
adverse effects/monitoring of SGLT2-is
volume depletion
ketoacidosis
hypoglycemia
infection risk
recommendations for SGLT2-is in HF
symptomatic chronic HFrEF w/wo DM to reduce hospitalizations and CV mortality
as long as renal function is good
how should ISDN/Hydralazine be used in HF
treatment for HF in black patients as adjunct to GDMT at optimal dose
ISDN/Hydralazine initial dose
25mg hydralazine TID
20mg ISDN TID
20/37.5mg TID (combo)
ISDN/Hydralazine target dose
75mg hydralazine TID
40mg ISDN TID
40/75mg TID (combo)
adverse effects of ISDN/Hydralazine
lupus like syndrome, headache, nvd, hypotension
ivabradine dosing
2.5mg BID then increase by 2.5 up to 7.5mg BID
when to use digoxin in HF
HF + Afib
patients w/ symptomatic HFrEF despite optimized GDMT or can’t tolerate GDMT
digoxin dosing
empically
0.125-0.25mg qd
what is the goal serum for digoxin
0.5-0.9 ng/ml
lower doses when greater than 70 years old
DDIs with digioxin
amiodarone
quinidine
verapamil
itra/KTZ
what is the main goal in HFpEF
control the BP
what drugs are used for symptom relief in HFpEF
diuretics
used for volume overload
what drugs are used to decrease hospitalizations and CV mortality in HFpEF
SGLT-2i
do you use RASi or MRAs in HFpEF
can be considered
may decrease hospitalizations for selected patients