HF - part 2

Question 1

QUAD therapy for reduced HF

Answer 1

ARNI (ACEi or ARB then sub for ARNI)
Beta-blocker
MRA
SGLT2

Question 2

when would we ideally like to have therapies at target or max tolerated doses by?

Answer 2

3-6 months after diagnosis

Question 3

why quad therapy?

Answer 3

complementary mechanism of actions

Question 4

what add on do we consider if Hr is above 70 bpm and sinus rhythm ?

Answer 4

add ivradine

Question 5

what add on do we consider if recent HF hospitalization?

Answer 5

vericiguat

Question 6

what atherapy we consider if black or unable to tolaerate ARNI/ACEi/ARB

Answer 6

consider H-ISDN

Question 7

what add on do we consider if suboptial contolr for AF and persistent symptoms despite quad therpy?

Answer 7

digoxin

Question 8

if dehydrated what med do we avoid?

Answer 8

Beta blockers.

Dehydration can cause hypotension and beta blaockers can also cause hypotension

Question 9

diruetics role in reduced HF?

what dose should we satrt at

Answer 9

contorl of symtpoms
- no target dose
- dose adjusted as needed

start low then increase until urine output increases and weight decreases

• use lowest effect dose

Question 10

if congestion is not resolved with diuretics what can we do?

Answer 10

we can restrict daily fluid intake

Question 11

what monitoring for toxicity needs to occur with diuretics

where should k levels be?

chcek Scr and K when?

other SE?

Answer 11

Electrolyte depletion
- decreasd K and Mg whihc can cause arrhymthimas
- K should be between 4-5
- concimiitant admin of ACEi or K sapring can prevnt hypokalemia
- check Scr and K within week of giving drug

hypotension and dizziness

Question 12

how do we initate Acei /ARB in reduced HF?

Answer 12

if hospitalized we can increase the dose q 3-7days if outpatient wiat 2-4 weeks

Question 13

when changing Acei /ARB what should we moniotr for?

Answer 13

SCr and K

if Scr increases by more then 30% do not increase dose fruther and consider lowering dose

Question 14

how are Acei /ARB and diuretics dosages linked?

Answer 14

diuretic dose should be optimized because dehydration can worsen the renal effects of ACEi and ARB

also, fluid overload can blunt effects of ACEi and ARB

Question 15

big ADE of ACEi and ARB?

Answer 15

• hypotension
• worsening renal fucntion
• hyperkalameia
  rare
• cough

Question 16

ARNI in reduced

Answer 16

pateinst with new dignosis - satrted on ARNI

Patients already on ACEi/ARB should be switched to ARNI

Question 17

ARNI drug name?

Answer 17

Sacubitril/valsartan

• ARNI has an ARB in it!

Question 18

ARNI dosing consdierations

Answer 18

• can not be combined with ACEi or ARB
• if on ACei need a36 hours washhout periodde due avoid angioedmea
• start low and titrate up
• consider decreasing diuretic dose for 3-4 days when satrt ARNI

Question 19

ARNI ADE and CI

Answer 19

• can cause hypotension, hyperkalemia, and increase SCr

-avoid in patients with history of angioedema

• avoid in patients with eGFR less then 30 ml/min

Question 20

MRAs ADE, interactions

Answer 20

• hyperkalemia - interaction with TXX-SMX
  if K.5.2mmol/L then intervention
• Scr and K monitoring first 3 days then 1 week then monthly for 3 months and then q3 months
• gynecomastia

Question 21

MRA, renal, titration, avoid

Answer 21

renal reduce dose if less than 50, avoid if less than 30ml/min

titration every 2-4 weeks

avoid: NSAIDS

Question 22

which beta blocker in reduced HF and why

Answer 22

Carvedilol, bisoprolol, metoprolol because cardio selective(beta1)

Question 23

dosing for Beta-blockers

Answer 23

satrt low then double dose every 2-4 weeks

Question 24

beta-blockers effect seen when?

Answer 24

clinically in 2-3 months, heart function may improve in 6-12 months

Question 25

Beta-blocker and ADHF

Answer 25

may need to stop the Beta blocker until the patient is stable

Question 26

beta blockers ADR

Answer 26

-hypo
- fluid retention and worsening HF
- Bradycardia and heart blcok
- fatigue and weakness

Question 27

SGLT2i used in reduced HF?

Answer 27

DAPA and EMPA

Question 28

which SGLT2i works better for renal impairment

Answer 28

DAPA less then 25

EMPA less then 20

Question 29

SGLT2i ADE/CI?

Answer 29

• volume depletion
  so monitor might have to adjust diuretic dose, ARNi have additive diuretic effect
• glycemic control
  won’t cause hypo in those that aren’t DM
• UTI
  could increase the number of UTIs

Question 30

SGLT2i titration required?

Answer 30

no!

Question 31

what causes more hypotension, ARNI or ACEi/ARB, and what causes more hyperkalemia and renal dysfunction

Answer 31

more hypotenison: ARNI

more hyperkalamia: ACEi

more renal dysfunction: ACEi