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IPC CARDIOLOGY 2 JEN > Heart Failure Treatment Slides > Flashcards

Heart Failure Treatment Slides Flashcards

1
Q

General Approach for drugs via HF treatment

A

Try to initiate AS MANY mortality reducing drugs as the patient can tolerate, then titrate up to the target doses

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2
Q

The addition of a new class of medications decreases…

A

Mortality A LOT

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3
Q

Increasing a dose of a mortality decreasing drug decreases…

A

Mortality A LITTLE

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4
Q

Target doses of all GDMT=

A

Most mortality reduction
A little bit of everything is better than a lot of a few things

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5
Q

Treatment goals: If ‘de novo’ (newly diagnosed) HFrEF, achieve maximally tolerated or target doses within…

A

3 months

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6
Q

Treatment goals: If discharged from the hospital for HFrEF, achieve maximally tolerated or target doses within…

A

6 weeks

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7
Q

HFrEF Treatment GDMT

A

ARNI (or ACEI/ARB) +
Evidence-based
beta-blocker + MRA
+ SGLT inhibitor

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8
Q

HFrEF Treatment GDMT: What to do for patients with persistent volume overload?

A

Add/titrate a diuretic agent (usually a loop diuretic)
(very common)

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9
Q

HFrEF Treatment GDMT: What to do for patients with persistently symptomatic African-American patients on other GDMT?

A

Add hydralazine/isosorbide dinitrate
(decreases mortality but only in a certain population)

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10
Q

HFrEF Treatment GDMT: What to do for patients with a resting HR ≥ 70 bpm on maximally tolerated beta-blocker and in sinus rhythm

A

Add Ivabradine (Corlanor)

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11
Q

HFrEF Treatment GDMT: What to do for patients on on GDMT with worsening HF evidenced by HF hospitalization or requirement for IV diuretics

A

Add Vericiguat (Verquvo)

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12
Q

ARNI wash out

A

If previously on ACEI, allow 36-hour
wash out then select appropriate dose

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13
Q

How many weeks to monitoring for ARNI?

A

1-2 weeks! Assess tolerability, monitor BP, electrolytes, renal function

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14
Q

How many weeks to increase dose for ARNI?

A

Every 1-2 weeks increase dose stepwise to a target of 97/103 mg twice daily

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15
Q

Starting Dose of ARNI

A

24/26 mg twice daily
o On daily equivalent of ≤ 10 mg enalapril or ≤ 160 mg valsartan
o ACEI/ARB naive
o eGFR < 30 mL/min/1.73 m2
o ≥ 75 years old

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16
Q

Other starting dose of ARNI

A

49/51 mg twice daily
o On equivalent of > 10 mg enalapril or > 160 mg valsartan

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17
Q

Every patient that has HF is typically on an…

A

ARNI

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18
Q

When would an ACEI/ARB be used instead of an ARNI?

A

Cost can be an issue for some patients or BID may be tough with the ARNI for some patients

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19
Q

How many weeks to monitoring for ACEI/ARB?

A

1-2 weeks! Assess tolerability, monitor BP, electrolytes, renal function

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20
Q

How many weeks to increase dose for ACEI/ARB?

A

Every 1-2 weeks increase dose stepwise target doses

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21
Q

Sacubitril/Valsartan (Entresto) starting dose?

A

24/26 mg- 49/51 mg BID

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22
Q

Sacubitril/Valsartan (Entresto) target dose?

A

97/103 mg BID

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23
Q

Lisinopril starting dose?

A

2.5-5 mg daily

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24
Q

Lisinopril target dose?

A

20-40 mg daily

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25
Q

Valsartan starting dose?

A

40 mg BID

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26
Q

Valsartan target dose?

A

160 mg BID

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27
Q

What is the monitoring time for a MRA?

A

7 days! Assess tolerability, monitor BP, electrolytes, renal function

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28
Q

What are MRAs at high risk for?

A

HYPERKALEMIA

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29
Q

Contraindications for MRAs?

A

eGFR <30 mL/min/1.73 m2, or creatinine >2.5 mg/dL in men or
creatinine >2 mg/dL in women

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30
Q

For MRAs, for stable dose, check…

A

Monthly for 3 months and then every 3 months out to a year

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31
Q

Spironolactone starting dose?

A

12.5-25 mg daily

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32
Q

Spironolactone target dose?

A

25-50 mg daily

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33
Q

To initiate SGLT ensure eGFR…

A

Ensure eGFR ≥ 25mg/mL/1.73m2 for dapagliflozin and sotagliflozin

34
Q

For Sotagliflozin, increase dose…

A

stepwise to target dosing in 2 weeks

35
Q

Starting and Target Doses for Dapagliflozin and Empagliflozin?

A

10 mg daily

36
Q

Starting dose for Sotagliflozin

A

200 mg daily

37
Q

Target dose for Sotagliflozin

A

400 mg daily

38
Q

There is no renal cutoff for…

A

Empagliflozin

39
Q

Contraindications for SGLT Inhibitors?

A

Patients with Type 1 diabetes

40
Q

What is the monitoring time for a Beta-Blocker?

A

Monitor HR and BP after initiation and during titration

41
Q

For Beta-Blockers increase dose…

A

Every 2 weeks stepwise to target dosing

42
Q

Bisoprolol starting dose?

A

2.5 mg daily

43
Q

Bisoprolol target dose?

A

10 mg daily

44
Q

Metoprolol Succinate starting dose?

A

12.5-25 mg daily

45
Q

Metoprolol Succinate target dose?

A

200 mg daily

46
Q

Carvedilol starting dose?

A

3.125-6.25 mg BID

47
Q

Carvedilol target dose?

A

25 mg BID
**85 kg: 50 mg BID
Be sure to watch for patients weight!

48
Q

What is the monitoring time for a Loop Diuretic?

A

Monitor BP, electrolytes, and renal function after initiation and during titration

49
Q

For a Loop Diuretic titrate until…

A

Titrate until the relief of congestion over days-weeks

50
Q

Furosemide IV dose

51
Q

Furosemide oral dose?

52
Q

Torsemide IV and oral dose?

53
Q

Bumetanide IV and oral dose?

54
Q

Ethacrynic Acid IV and oral dose?

55
Q

Add loop diuretics if patients are experiencing any signs of…

A

Congestion (hypervolemia)

56
Q

For starting a loop diuretic, usually start at…

A

20-40 mg Furosemide (or equivalent)
-Increase as needed for hypervolemia
-Frequent clinic visits until titrated to optimal effect

57
Q

When taking a loop diuretic what is a common side effect/ADR

A

HYPOKALEMIA (peeing out a lot of potassium)

58
Q

What may need to be prescribed by mouth with a loop diuretic?

A

Potassium in conjunction

59
Q

Which drugs are the Vaso/venodilators?

A

Hydralazine
Isosorbide Dinitrate

60
Q

For these vaso/venodilators how do you select starting doses?

A

As separate tablets or fixed combination

61
Q

When do you monitor BP for these vaso/venodilators?

A

After initation and during titration

62
Q

How often do you increase the dose for hydralazine and isosorbide dinitrate?

A

Every 2 weeks stepwise to target dosing

63
Q

Target dose of Hydralazine?

64
Q

Target dose of Isosorbide Dinitrate?

65
Q

Starting dose of BiDil (20 mg isosorbide dinitrate + 37.5 mg Hydral)?

A

2 tablets TID

66
Q

When can Ivabradine be started?

A

After confirming that beta-blocker is at maximally tolerated/target dose, patient is in sinus rhythm

67
Q

When should you be reassessed for Ivabradine?

A

2-4 weeks…Reasess HR and increse stepwise to target dosing

68
Q

Ivabradine starting dose?

A

2.5 mg BID with food

69
Q

Ivabradine target dose?

A

7.5 mg daily with food

70
Q

Titrating for Ivabradine: What to do for HR < 50 bpm or symptoms of bradycardia?

A

Reduce dose by 2.5 mg BID or d/c if already at 2.5 mg BID

71
Q

Titrating for Ivabradine: HR > 60 bpm

A

Increase by 2.5 mg BID until maximum dose of 7.5 mg BID

71
Q

Titrating for Ivabradine: HR 50-60 bpm?

A

Maintain current dose and monitor HR

72
Q

Which drug do you need to see a negative pregnancy test with?

A

Vericiguat

73
Q

When can Vericiguat be started?

A

Confirm EF < 45%, on maximally
tolerated GDMT and has worsening HF symptoms

74
Q

When do you monitor for Vericiguat?

A

Monitor BP and CBC (anemia) during initiation and titrate

75
Q

How does increasing the dose work for Vericiguat?

A

Double the dose every 2 weeks until a target dose is achieved

76
Q

Vericiguat target dose?

A

10 mg daily with food

77
Q

Additional Therapies: What to take with symptomatic HFrEF?

A

Consider adding Digoxin

78
Q

Medication Classes to Avoid In HFrEF

A

Non-DHP CCBs, Class IC Antiarrhythmic Drugs, and Dronedarone, Thiazolidinediones, DPP4s, NSAIDs

IPC CARDIOLOGY 2 JEN (6 decks)

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