HF Medications

Question 1

What is the treatment algorithm for stage A HFrEF?

Answer 1

Control conditions that contribute to HF: HTN, hyperlipidemia, obesity, diabetes

Avoid: tobacco use, cardiotoxic agents

Question 2

What is the treatment algorithm for stage B HFrEF?

Answer 2

NYHA Class I: Start off with an ACE-I or ARB AND BB to prevent symptomatic HF

Question 3

What is the treatment algorithm for stage C HFrEF?

Question 4

B-Adrenergic Blockers
MOA: 
Dosing: 
When to use:
Benefits (2)
Monitor (4)
C/I (3)

Answer 4

MOA: blocks effect of NE on the heart

Dosing: patient must be asymptomatic, stable, and dry (negative inotropic effects), titrate up, double every 2 weeks, even if HR is <70bpm if symptomatic

When to use: AHA/ACC Stage B or higher, NYHA Functional Class 1 or higher

Benefits: decreased mortality, slows ventricular remodeling

Monitor: HR, BP, signs of congestion, dizziness

C/I: cardiogenic shock, 2nd/3rd degree heart block, severe reactive airway disease (asthma, active bronchospasm)

Question 5

What are the starting doses of B-Adrenergic Blockers for HF? (3 drugs)

Answer 5

1. Metoprolol succinate (12.5 - 25mg QD) to target dose of 200mg QD
2. Carvedilol (3.125 mg BID) to 25mg BID if patient is less than 85 kg and 50mg BID if 85 or above
3. Bisoprolol (1.25mg QD) to a target dose of 10mg QD

Question 6

ACE-I
MOA: 
Dosing: 
When to use:
Benefits 
Monitor (3)
C/I (3)

Answer 6

MOA: reduces production of angiotensin II and aldosterone which reduces pre and after load, increases bradykinins which increases vasodilatory prostaglandins

Dosing: start low and titrate every 2 weeks to max tolerated dose

When to use: AHA/ACC Stage B or above, NYHA Functional Class 1 or above

Benefit: decreased mortality, prevents ventricular remodeling, *improves functional class

Monitor: 2 weeks after initiation and dose increase: SrCr, K+, BP, cough, angioedema

C/I: hx of angioedema, current hyperkalemia (K is above 5), pregnancy

Question 7

What are the starting doses for ACE-I?

Answer 7

Captopril, Enalapril, Lisinopril, Ramipril

Lisinopril (2.5-5mg QD) to target dose of 20-40 mg QD

Question 8

ARBs
MOA
Dosing
When to use
Benefits 
Monitor (3)
C/I (3)

Answer 8

MOA: inhibits effects of angiotensin II (decreases afterload and preload)

Dosing: start low and titrated every 1-2 weeks to target dose

When to use: AHA/ACC Stage B or above if can’t tolerate ARB, NYHA Functional Class 1 or above if can’t tolerate ARB

Benefits: decreases mortality in patients not taking ACE-I, improves exercise tolerance

Monitor: 2 weeks after initiation and dose increase: SrCl, K+, BP
C/I: Hx of angioedema, hyperkalemia, pregnancy

Question 9

What are the 3 ARBs used for HF?

Doses and target doses?

Answer 9

1. Losartan (25-50mg QD) to target dose of 150mg QD
2. Valsartan (40mg BID) to target dose of 160mg BID
3. Candesartan (4-8mg QD) to 32mg QD

Question 10

When are you able to use ARBS over ACE-I? (2)

Answer 10

When the patient has:
1. angioedema
2. cough
from an ACE-I, you can use ARB.

Question 11

How do you know to add an ACE-I/ARB or BB first?

Answer 11

1. ACE/ARB: better when patient is “wet”
2. BB: better when patient is “dry” DO NOT START WITH SIGNS OF DECOMPENSATION (SOB, DIZZINESS, PALPITATIONS, FLUID OVERLOAD)

Question 12

What is the treatment algorithm for stage C patients with Class II-IV HF?

Answer 12

ARNI is preferred over an ACE-I or ARB.
Add loop for volume overload.

If NYHA Class II or above:

• CrCl is less than 30 or K is less than 5: add MRA
• Adequate drug-specific eGFR: Add SGLT2 inhibitor
• HR 70 or above on max BB: add ivabradine (NYHA class II-III)
• Intolerance to ACE-I or ARB: switch to ISDN/Hyd

If NYHA class III or above: black ancestry > add ISDN/Hyd

Question 13

What is Entresto?

MOA
Indication
Benefits
Dose 
C/I (5)
Monitoring (5)

Answer 13

Sacubitril/Valsartan

MOA: inhibits neprilysin to increase peptides to specifically natriuretic peptide, no increase in NT-proBNP

Indication: Stage C or above, NYHA II-IV, use instead of ACE-I or ARB

Benefits: decreased mortality, less cough AE, but higher risk of hypotension than ACE-I, make sure patient is NOT volume depleted when initiation, dec. loop diuretic

Dose: Target dose of 97/103 BID

C.I: within 36 hours of ACE-I use, hx of angioedema, pregnancy, use of aliskiren in DM, hepatic renal impairment (Child-Pugh C)

Monitoring: BP (volume depletion SBP is <100 mmHg), SCr, K+, angioedema, cough

Question 14

Do loop diuretics have an effect on mortality?

Answer 14

No, use in patients with fluid retention to decrease sx, pulmonary congestion/JVD> edema, and improve cardiac function and exercise tolerance and ADLs

Question 15

What are the doses for the 3 loop diuretics used in HF?

Answer 15

Furosemide (20-40mg QD or BID) to target dose of 600mg QD
Bumetanide (0.5-1mg QD or BID) to target dose of 10mg QD
Torsemide (10-20mg QD) to target dose of 200mg QD

Furosemide 40mg > bumetanide 1mg > torsemide 20mg

Question 16

What are the goals of loop diuretics in HF?

Answer 16

Decrease volume. Titrate to achieve dry weight over days to weeks:

• 1-2 lbs of weight loss per day
• in an acute exacerbation: goal is to be 1L negative

Question 17

What should you monitor for loop diuretics?

Answer 17

CHF symptom relief, fluid retention, SCr, electrolytes, daily weight, signs of volume depletion (hypotension, dizziness, decreased urine output, increased BUN/SCr)

Question 18

How do you convert loop diuretics from PO to IV?

Answer 18

IV to PO Conversion: 1:2

Patient takes 20mg furosemide at home.
How much should be take at the hospital PO? 40mg
How much should be take if IV? 20mg

Home & IV dosing is the same!

Question 19

Thiazides
MOA
Indication
Benefits
Dose 
C/I (5)
Monitoring (4)

Answer 19

MOA: inhibits NaCl in distal convoluted tubule leading to decreased sodium and chloride reabsorption, increased diuresis

Indication: Add thiazide, once or twice daily, to loop diuretics in patients with persistent fluid retention despite high dose loop diuretic therapy; chronic use discouraged!

Benefits: volume depletion
Dose: titrate within days or weeks to relieve congestion
C/I: ?
Monitoring: hypokalemia, hyponatremia, volume depletion, worsening renal function

Question 20

What thiazide diuretics can be used in patients with compromised renal function?

Answer 20

Metolazone

Indapamide

Question 21

What are the 4 thiazide diuretic doses?

Answer 21

1. Chlorthalidone (12.5-25mg QD) to target dose of 100mg QD
2. Hydrochlorothiazide (25mg QD) to target dose of 200mg QD
3. Metolazone (2.5mg QD) to target dose of 20mg QD
4. Indapamide (2.5mg QD) to target dose of 5mg QD

Question 22

Aldosterone Antagonists
MOA
Indication
Benefits
Dose 
C/I 
Monitoring

Answer 22

MOA: blockers effects of aldosterone in kidneys

Indication: symptomatic stage C, NYHA Class II-IV, K is less than 5, SCR 2.5 or less in males, SCr 2 or less in females

Benefits: reduced mortality

Dose: increase every 2 weeks until maximum tolerated or target dose achieved

Monitoring: SCr and K at baseline, 2-3 after initiation, 1 week after initiation, monthly for 3 months, and then every 3 months [BUN/Scr, gynecomastia)

C/I: Avoid if SCr > 2.5 mg/dL in men and > 2 mg/dL in women (or eGFR <30 mL/min/1.73 m2) or K+ > 5 mEq/L

Question 23

What are the 2 aldosterone antagonists used for HF? Doses & notable facts?

Answer 23

1. Eplerenone (25mg QD) to target dose of 50mg QD
2. Spironolactone (12.5-25mg QD) to 25-50mg QD

Do not use eplerenone with: verapamil, fluconazole, clarithromycin, ketoconazole

Spironolactone: 30% reduction in all cause mortality
Eplerenone: 37% reduction in CV death

Question 24

Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors
MOA
Indication
Benefits
Dose 
C/I 
Monitoring/ADR

Answer 24

MOA: inhibit glucose reabsorption in proximal tubule via inhibition of SGLT2 cotransporter

Indication: NYHA class II_IV with/w/o diabetes, •eGFR > 30 mL/min/1.73 m2 for Dapagliflozin before initiation
•eGFR > 20 mL/min/1.73 m2 for Empagliflozin before initiation

Benefits: reduced mortality, hospitalizations, preload, afterload, hypertrophy and remodeling

Dose: *Dosing is different for Type 2 Diabetes Mellitus without ASCVD or HF

C/I: type 1 diabetes, known hypersensitivity of drug, lactation, dialysis

Caution: pregnancy, ketoacidosis, AKI

Monitoring/ADR: UTI/Yeast infection, increased thirst/urine output, hypotension, euglycemic DKA, transient decrease of eGFR 2-4 weeks after initiation (~ 4-6 mL/min/1.73 m2 decrease)

Question 25

What are the 2 SGLT2 inhibitors used for HF?

Answer 25

1. Dapagliflozin (Farxiga) starting with 10mg daily to 10mg daily as target 2. Empagliflozin (Jardiance) starting with 10mg daily with 10mg daily as a target *Dosing is different for Type 2 Diabetes Mellitus without ASCVD or HF

Question 26

What is Corlanor?

Answer 26

Ivabradine

Question 27

``` Ivabradine MOA Indication Benefits Dose C/I Monitoring ```

Answer 27

MOA: selective inhibitor of the If current (controls spontaneous activity of SA node) prolongs duration of diastole, slows HR Indication: NYHA II-III, on MAX BB, NSR, HR 70 or over, **LVEF 35% Benefits: NONE on contractility or BP, lowered hospitalization Dose: age dependent, if under 75, 5mg BID with meals, if over 75, 2.5 BID with meals, max dose is 7.5mg BID C/I: HFpEF, angina, hepatic impairment (CP-C), acute decompesated HF, BP <90/50, sick sinus rhythm, SA block, **persistent AFib or Aflutter (paroxymal OK), atrial pacemaker dependence Monitoring: HTN, HR prior to initiation, increase dose, or decrease dose, BP, EKG DDI: like everything, cannot use in those with pacemakers set to 60 bpm or above

Question 28

Ivabradine Titration Algorithm

Answer 28

Starting: age dependent, if under 75, 5mg BID with meals, if over 75, 2.5 BID with meals, max dose is 7.5mg BID If HR over 60, increase dose by 2.5mg BID If HR 50-60, continue current dose If HR under 50bpm or s/x of bradycardia: decrease by 2.5mg BID or d/c if that's the dose already MAX DOSE: 7.5mg BID

Question 29

``` Hyralazine/Isosorbide MOA Indication Benefits Dose C/I Monitoring SE ```

Answer 29

MOA: hydralazine (vasodilation of arterioles, decreasing afterload), isosorbide (stimulates NO leading to vasodilation, decreasing preload) Indication: NYHA III-IV (BiDil so not class 2), African Americans with s/x despite ARNI, BB< aldosterone antagonist, SGLT2-I Benefits: decreased mortality in African American patients Dose: titrate up to max tolerable target dose every 2 weeks C/I Monitoring: HR and BP SE: H: HA, GI upset, flushing, SLE (lupus) sx I: HA,. orthostasis, hypotension

Question 30

Hydralazine/Isosorbide Dosing

Answer 30

Hydrazaline (25mg TID) to target of 75mg TID Isosorbide (20mg TID) to target 40mg TID Fixed combo (37.5mg/20mg TID) to 75/40mg TID*** * Because of compliance, try using long acting, once-daily isosorbide mononitrate

Question 31

``` Digoxin MOA Indication Benefits Dose C/I Monitoring (3) w/ 1 important thang SE ```

Answer 31

MOA: inhibits Na+/K+ ATPase pump on cardiac cells, A.Fib(rate control), HF(increased contractility) Indication: HFrEF to control rate in those with low BP Benefits: reduces hospitalizations, NO EFFECT ON MORTALITY Dose: 0.125* to 0.25mg QD, lower is better for those over 70 or those with impaired renal function or low lean body mass, can dose every other day; no loading dose for HF C/I: Monitoring: BUN/SCr, K+ and Mg+, Digoxin levels - **target in HF 0.5-1ng/mL IMP: trough -- must wait until steady state is reached after 5-7 days, must wait until distribution phase is reached 8 hours after PO dose administered SE: digoxin toxicity, cardiac 1, 2, 3, AV block, atrial tachycardia, fibrillation, ventricular arrhythmias, sinus bradycardia

Question 32

What DDI would you decrease the dose of digoxin? Increase?

Answer 32

D: amiodarone, erythromycin, ketoconazole, spironolactone, verapamil, quinidine not diuretics though I: antacids, cholestyramine

Question 33

What is the BP goal of HFrEF and HFpEF?

Answer 33

<130/80

Question 34

What drugs do you use for HFpEF?

Answer 34

ACE-I (improves NYHA class), ARB, digoxin, BB, non-dhp CCB Aldosterone receptor antagonists: with EF 45% or above, elevated BNP levels or HD readmission within 1 year ARNI: maybe EF with 40-57% No to: PDE-5i/nitrates

Question 35

What are some ways to manage HF nonpharmacologically?

Answer 35

1. Lose weight, encourage smoking cessation, minimize alcohol 2. Limit Na to 1.5-2g/day 3. Restrict fluid intake (daily weight monitoring, contact provider if experiencing 2-3lbs weight gain within 24 hours or 5lbs in 1 week)

Question 36

What are the pharmacotherapy options for acute decompensated HF?

Answer 36

Loop diuretics, vasodilators, inotropes Loop diuretics are first line and given IV, if you're still congested increase dose, add second diuretic or add metolazone 2.5-5mg PO daily (preferred in compromised renal function)

Question 37

What is the first line of tx for acute decompensated HF? What do you do when they don't work?

Answer 37

Loop diuretics are first line and given IV, if you're still congested, 1. Na+ and fluid restriction 2. Increase dose (2x) vs frequency 3. Add second diuretic (thiazide) HCTZ 12.5-25mg po QD NOT IF CRCL IS <30mL/min 4. metolazone 2.5-5mg PO daily (preferred in compromised renal function) 5. Continuous infusion of loop diuretic

Question 38

When do you use vasodilators in acute decompensated HF? Benefits?

Answer 38

- in absence of hypotension, addo-on tx, good for HTN or pulmonary edema Benefits: no effect on hospitalization or mortality Caution: increased monitoring due to HFpEF being more volume sensitive

Question 39

What are the vasodilators used for acute decompensated HF? MOA, effects, indications, dosing, elimination, AE

Answer 39

IV nitroglycerin: MOA: mimics nitric oxide stimulation of GC and production of cGMP Effects: venous > arterial vasodilator Indication: tolerance issue Dosing: 5 mcg/min, up by 5 every 5 min to 200mcg/min Elimination: inactive excreted in urine AE: hypotension, reflex tachycardia, HA, tachyphylaxis within 24 hours Na+ Nitroprusside: MOA: nitric oxide mediated conversion of GTP to cGMP Effects: balanced arterial and venous vasodilation Indication: warm and wet Dosing: 0.3-0.5 mcg/kg/min IV up 0.5 to 3 mcg/kg Elimination: cyanide: hepatic, thiocyanate: renal AE: hypotension, cyanide or thiocyanate toxicity

Question 40

What is the classification algorithm for acute decompensated HF?

Answer 40

Cl: 2.2 - if above: warm - if below: cold PCWP: 18 - if above: wet - if below: dry

Question 41

``` Inotropes MOA When to use: cold and wet or cold and dry (only if PCWP > 15mm Hg) Effects Indications Dosing Elimination AE Comments ```

Answer 41

Dobutamine MOA: b1-agonist, converts ATP to cAMP to increase CO Effects: inotropic and chronotropic Dosing: 2-40 mcg/kg/min IV, may titrate to max 40 mcg/kg/min Elimination: hepatic and renal AE: proarrhythmic, tachycardia, ischemia, mortality with long term use Comments: use if hypotensive Milrinone MOA: PDE-I, inhibits cAMP breakdown to increase CO in vascular smooth muscle to decrease SVR Effects: inotropic and lusitropic, NO chronotropic Dosing: 50 mcg/kg IV, then 0.375 mcg/kg/min IV, may titrate to max 0.75 mcg/kg/min Elimination: 90% renal AE: " " Comments: suggested if receiving beta blocker

Question 42

Treatment algorithm for dry and warm subset 1?

Answer 42

Maximize oral therapy by increasing dosing

Question 43

Treatment algorithm for wet and warm subset 2?

Answer 43

Primarily, no inotropes 1. loops first line, if c/i: add thiazides 2. add vasodilator or loop for rapid improvement if HTN 3. may consider inotropes Do not enhance diuresis too much

Question 44

Treatment algorithm for dry and cold subset 3?

Answer 44

Primary goal Let PCWP and systolic blood pressure help guide decision 1) If PCWP is < 15 mm Hg, must give IV fluids to initially optimize CO by assuring adequate filling pressures 2) If PCWP is > 15, assess systolic blood pressure • If SBP < 90 mm Hg, consider IV inotropes • If SBP > 90 mm Hg, consider IV vasodilator

Question 45

Treatment algorithm for wet and cold?

Answer 45

Primary goals 1) Therapy typically involves combination therapy 2) IV diuretics + vasodilator + inotrope 3) Requires careful monitoring

Question 46

What monitoring criteria do you follow with HF?

Answer 46

Weight, fluid intake/output, vital signs, edema, JVD, cough, electrolytes (Na, K, Mg), renal function (BUN, SCr)

Question 47

What are the discharge criteria for all HF patients?

Answer 47

To be addressed with all HF patients - Address exacerbating factors - Achieve near-optimal volume status - Transition from IV to PO diuretics - Provide patient and family education - Near-optimal pharmacologic therapy achieved - Follow-up clinic visit scheduled in 7 – 10 days ``` For recurrent administrations - Oral medication regimen stable for 24 hours - No IV vasodilator or inotropic agent for 24 hours - Ambulation before discharge to assess functional capacity - Plans for post-discharge management ```