HF Flashcards
What is the most common discharge diagnosis for 65+ years?
HF
What are the changes in anatomy and physiology which contribute to HF?
Increased vascular stiffness
Decreased endothelial function
Diminished beta-adrenergic stimulation
Often preserved left ventricular function
What conditions can mimic HF?
Chronic deconditioning
Chronic lung disease
Peripheral edema
What are atypical presentations of HF?
Anorexia
Confusion
Fatigue
Generalized weakness
What is the best way to determine HF in elderly?
LV function echo is best
BNP is high in elderly (less specific test and unclear role in diagnosis)
What is the prognosis of HF?
5 year survival for those 80+ years <25%
What are the primary treatment goals for patients with HF?
Improve QOL
Reduce frequency of HF exacerbations
Extend survival
What are the secondary treatment goals for patients with HF?
Maximize independence
Increase exercise capacity
Enhance emotional well-being
Manage associated costs of care
Which CCBs do we avoid in HF and why?
First generation (nifedipine, verapamil, diltiazem) Increased adverse outcomes
What is stage A HF?
At high risk for HF but w/o structural disease or sx of HF
What is stage B HF?
Structural heart disease but w/o s/sx of HF
What is stage C HF?
Structural heart disease w/prior or current sx of HF
What is stage D HF?
Refractory HF
What do patients with stage A HF have?
HTN Atherosclerotic disease DM Obesity Metabolic syndrome OR Using cardio toxins FH of cardiomyopathy
What are the goals of therapy for stage A HF?
Heart healthy lifestyle
Prevent vascular/coronary disease
Prevent LV structural abnormalities
What are the medications for stage A HF?
ACE/ARB in appropriate patients for vascular disease/DM
Statins as appropriate
What do patients with stage B HF have?
Previous MI
LV remodeling including LVH and low EF
Asymptomatic valvular disease
What are the goals of therapy for patients with stage B HF?
Prevent HF sx
Prevent further cardiac remodeling
What are the medications for stage B HF?
ACE/ARB
BB
What select patients are qualified for stage B?
ICD
Revascularization or valvular surgery as appropriate
What do patients with stage C HF have?
Known structural heart disease and
HF s/sx
What are the goals of HFpEF therapy?
Control sx
Improve HRQOL
Prevent hospitalization
Prevent mortality
What is the treatment of HFpEF?
Diuresis to relieve sx of congestion
Follow guideline driven indications for comorbidities (HTN, AF CAD, DM)
What are the two types of HF?
HFpEF (reserved
HFrEF (reduced)
What are the goals of therapy in HFrEF?
Control sx
Patient education
Prevent hospitalization
Prevent mortality
What drugs are used in HFrEF?
Diuretics for fluid retention
Entresto (ACE/ARB)
BB
Aldosterone antagonists
What do patients have in stage D HF?
Marked HF sx at rest
Recurrent hospitalizations despite GDMT
What are the goals of therapy in stage D HF?
Control sx
Improve HRQOL
Reduce hospital readmissions
Establish patient’s end-of-life goals
What are treatment options for stage D HF?
Advanced care measures Heart transplant Chronic inotropes Temporary/permanent MCS Experimental surgery/drugs Paliative care/hospice ICD deactivation
How do ARNIs work compared to enalapril?
Decreased CV death or HF hospitalizations
What trials were there for BBs?
SENIORS
MERIT-HF
COLA II
OPTIMIZE-HF
What drugs did the SENIORS trial compare?
Nebivolol vs PBO
What was the patient population in the SENIORS trial?
> /= 70 years any EF
What were the results of the SENIORS trial?
Nebivolol decreased mortality and CV hospitalization
No difference between 75-85 or > 85 years
What drugs did the MERIT-HF trial compare?
Metoprolol succinate vs PBO
What patients did the MERIT-HF trial study?
> /= 65 years
What were the results of the MERIT-HF trial?
Post hoc: decreased mortality, sudden death, and hospitalization
Significant benefit > 75 years
What drugs were observed in the COLA II trial?
Carvedilol
What patients were studied in the COLA II trial?
> /= 70 years
What are the results of the COLA II trial?
Majority of patients tolerated for at least 3 months
What drugs did the OPTIMIZE-HF trial compare?
BBs
What type of trial is the OPTIMIZE-HF trial?
Retrospective
What type of patients were studied in the OPTIMIZE-HF trial?
Patient registry and medicare claims data; hospitalized for HF
What were the results of the OPTIMIZE-HF trial?
HFrEF: BB decreased mortality
HFpEF: BB no mortality benefit
What trials were done on ACEi?
Gambassi et al
Flather et al
PEP-CHF
What drugs were studied in the Gambassi et al trial?
ACEi or digoxin
What type of trial was Gambassi et al?
Retrospective
What patients were studied in the Gambassi et al trial?
Nursing home
Avg age 84 (ACEi), 85 (dig);
Enknown EF
What were the results of the Gambassi et al trial?
ACEi decreased mortality vs digoxin
What drugs were studied in the Flather et al trial?
ACEi
What patients were studied in the Flather et al trial?
Systemic overview of 5 prospective trials
HF and post MI
What were the results of the Flather et al trial?
> /= 75 years had smaller mortality benefit than younger patients but still decreased mortality
What drug did the PEP-CHF trial study?
Perinopril
What patients were studied in the PEP-CHF trial?
> /= 70 years with HFpEF?
What were the results of he PEP-CHF trial?
“Trend” towards decreased mortality and hospitalization (did not meet power)
What was the ARNI trial?
PARADIGM-HF
What drugs were investigated in PARADIGM-HF trial?
Valsartan/sacubitril vs enalapril
What were the patients in the PARADIGM-HF trial?
Avg age 63 +/- 1 1 yo
LVEF 29%
70% NYHA class II
Is there any relevant PK difference in ARNIs when given to elderly?
Yes
What would be the results if an ARNI is given with NSAIDs in patients with volume-depleted, compromised renal function?
Possible worsening of renal function, including possible acute renal failure
What trial was used for ivabradine?
SHIFT
What drugs did the SHIFT trial study?
Ivabradine vs PBO
What were the patients studied in the SHIFT trial?
Avg age 60 +/11 yo
NYHA Class II-III
LVEF 29%
Optimized, stable regimen
What were the results of the SHIFT trial?
Decreased composite endpoint (CV death and HF hospitalization) BUT only hospitalization showed benefit individually
No mortality benefit
>/= 65: no clear benefit for composite endpoint
Which elderly patients are more likely to have CIs?
Pacemaker dependence
Use of strong 3A4 inhibitors
What are the trials that study digoxin?
DIG (ACC)
DIG (JAMA)
DIG substudy-Ahmed et al (AJC)
What was digoxin compared to in the DIG (ACC) trial?
PBO
What patients were studied in the DIG (ACC) trial?
Stratified by age
Main study: LVEF = 45%
Ancillary: LVEF > 45%
What were the results of the DIG ACC trial?
InHFrEF: Dig = no mortality benefit, decreased hospitalization, applies to all age groups
Older age = increased toxicity, withdrawal
Insufficient evidence to recommend dig in HFpEF, especially in very old
What patients were in the DIG (JAMA) trial?
Evaluating dig levels
What were the results of the DIG JAMA trial?
Low mortality at 0.5-0.8 mg/dl versus higher concentrations
What drugs were studied in the DIG substudy-Ahmed et al (AJC)?
Digoxin continuation at low SDC vs d/c
What was the patient population of the DIG substudy-Ahmed, et al (AJC)
Avg age = 63 yo
N = 1666 continued on dig
N - 1699 d/c
Low SDC = 0.0 - 0.9 ng/ml
What were the results of the DIG substudy-Ahmed et al (AJC)
Continuation = decreased all-cause mortality, all cause and HF hospitalization Discontinuation = increased all cause and HF hospitalization, no effect on mortality
What is the serum digoxin level?
0.5-0.8 mg/dl
What drugs for HF are on the Beers List?
Spironolactone
Digoxin
What are the renal adjustments with spironolactone?
Avoid if CrCl < 30
How does spironolactone impact potassium levels?
Increased risk of hyperkalemia (especially with ACEi/ARB)
What is the max digoxin daily dose?
Avoid greater than 0.125mg daily
Why do we avoid higher digoxin doses in the elderly?
Increased toxicity with no additional benefit
May be associated with increased mortality
What drugs do we avoid in HF d/t increased risk of fluid retention and/or HF exacerbations?
TZDs NSAIDs COX-2 inhibitors Cilostazol Dronedarone (if severe/decompensated HF) non-DHP CCB (if HFrEF)
