HF Pharmaco Flashcards
Guideline Classes + Recommendations
- Class I: Benefit»_space;> Risk, SHOULD use treatment/procedure
- Class IIa: Benefit»_space; Risk, REASONABLE to perform procedure/treatment
- Class IIb: Benefit >= Risk, MAY CONSIDER treatment/procedure
- Class III: not shown to have any proven benefit, may cause harm or have excessive cost with no worthwhile benefit, DON’T USE/PERFORM
Guideline Levels + Recommendations
- Level A: multiple RCT or meta-analyses
- Level B: data derived from single RCT or nonrandomized studies
- Level C: consensus opinion of experts was primary source of recommendation or case studies
Conditions to Treat + HF
- HTN and lipid disorders should be controlled according to contemporary guidelines to reduce HF risk too (1/A)
- DM, obesity, tobacco use, and other cardiotoxic agents should also be controlled since they may contribute to HF (1/C)
Patient Assessment: EVERY Visit
- NYHA Functional capacity/activity level
- Changes in body weight
- Volume status: edema, JVD, HJR, hepatomegaly, swelling, bloating, dyspnea, DOE, orthopnea, PND
- Vital signs
- History of substance/drug use
- Diet/sodium intake
- Review of medical history
Patient Assessment: Diagnostic Tests
- Initial labs/tests: CBC, serum electrolytes, BUN, SCr, glucose, fasting lipis, liver fxn tests, and TSH, 12-lead ECG, Chest x-ray, ECHO
- Serial monitoring: serum electrolytes and renal fxn when indicated, ECHO for those with change in status or to determine level or response/eligibility for therapy/transplant
Patient Assessment: BNP
- Useful to rule out HF as a cause of dyspnea
- BNP < 100 pg/mL
- NT-proBNP < 300 pg/mL
Patient Education
Provide education on the following:
- Activity level
- Diet
- Discharge medications
- Follow-up appointments
- Weight monitoring
- What to do if symptoms worsen
Weight Monitoring
- Make sure they all have a scale
- Instruct patient to weigh in the morning after first void
- Scale is on hard surface
- Patient should call provider if weight increases by 2lbs/day or 5 lbs/week
- Weight gain has been connected to hospital admission
Sodium Restriction
- Necessary in those with current or prior HF symptoms
- Stages A/B: <1500 mg/day
- Stages C/D: No more than 3000 mg/day
- *Caution with salt substitutes and potassium sparing medications**
Activity Level and Life Habits
- Exercise training to help improve functional status
- Encourage cardiac rehabilitiation: reduces mortality, improves NYHA-FC, QOL, and more
- Encourage weight loss if overweight/obese
- Tobacco cessation
- Avoid alcohol
Worsening Symptoms
- Contact provider if worsening/new symptoms of: dyspnea, orhtopnea, DOE, PND, chest pain/pressure, dizziness, syncope, swelling, or weight gain
- Contact for the weight gain previously defined too
HF Treatment Goals
- Improve signs/symptoms: decrease SOB, weight, BNP levels, edema and improve exercise tolerance/functional class
- Decrease morbidity: prevent hospitalizations and ER visits
- Decrease mortality
Diuretics
-Recommended in HFrEF patients with evidence of fluid retention
Examples
- Loop: Bumetanide, Furosemide, Torsemide
- Thiazide: Chlorothiazide, Chlorthalizonde, Hydrochlorothiazide, Indapamide, Metolazone
Diuretic Effects
- Decrease preload
- Thiazide: good for eGFR > 30, work on distal tubule
- Loop diuretics: ascending loop of henle, QD or BID
- Resistance: use sequential nephron blockade (Loop + Thiazide)
Diuretic Monitoring
- Goal: euvolemia
- Monitor electrolytes, renal fxn, BP, weight, urinary response, and symptoms in first 1-2 weeks
Diuretic Adjustments/Limits
- Titrate dose until urine output increases and weight decreases (0.5-1 kg/daily)
- May need to up to BID for reboudn fluid retention
- K+: 4-5 mEQ/L
- Supplement Mg++ if it drops below 1.6
- Back down dose if having symptomatic hypotension or azotemia (BUN/SCr > 20)
ACE Use
Beneficial for all patients with prior or current symptoms of chronic HFrEF to reduce morbidity/mortality
ACE Monitoring
- BP, BUN/SCr, electrolytes
- Follow-up in 1-2 weeks on same labs and HF symptoms
- Half initial dose if SBP < 100, SCR > 2, or Na+ < 130
- Try to achieve target dose but not at expense of BB therapy
- Avoid NSAIDs and recommend low-dose ASA if necessary (<160 mg)
ACE-I AE
- Cough
- Angioedema
- AKI
ARB Recommendation
Reduce mortality/morbidity in patients with prior/current symptoms of HFrED who are intolerant to ACE-I due to cough/angioedema
ARB Monitoring
- Precautions: renal impairment, hyperkalemia, hypotension, angioedema
- Monitoring is same as ACE-I
ACE-I/ARBs used for HF
ACE-I
- Captopril**
- Enalapril**
- Fosinopril
- Lisinopril**
- Perindopril
- Quinapril
- Ramipril**
- Trandolapril**
ARBs
- Candesartan
- Losartan
- Valsartan
BB Recommendations
Shown to reduce mortality in all stable patients
Worsen EF first, then improvement
BB for HF
- Bisoprolol
- Cardvedilol (CR or not)
- Metoprolol Succinate ER
BB CI
- Allergies
- Reactive airway disease (Asthma)
- Symptomatic bradycardia or >1st degree heart block unless they have a pacemaker
- Evidence of fluid overload or recent requirement for IV inotropic agents
BB Monitoring
- 2 week follow up to assess tolerability
- Monitor HR, BP, weight, volume status, and HF symptoms
- Hold titration if symptomatic hypotension or bradycardia or if experiencing worsening symptoms
BB AE
- Fluid retention/worsening HF (diuretic adjustments)
- Fatigue
- Bradycardia and heart block (decrease dose)
- Hypotension (separate or decrease ACE)
Aldosterone Angtagonist Recommendations
- Recommended for NYHA II-IV with LVEF =< 35%
- Recommended following an acute MI with LVEF =< 40% wtih symptoms of HF or DM
- Examples: Spironolactone, Eplerenone
ARA AE
-Hyperkalemia: avoid NSAIDs/COX-II Inhibitors, D/C reduce K+ supplements, closely monitor
ARA Dosing
ONLY USE IF
- SCr =< 2.5 mg/dL in men or 2.0 in women
- K+ < 5
- eGFR >= 30
ARA Monitoring
-K+ and renal fxn at 3 days, 1 week, monthly for first three months, then every 3 months from then on
ARNI
- Neprilysin is an endopeptidase that breaks down vasoactive peptides like BNP, bradykinin, and adrenomedullin
- Entresto: Sacrubitril (neprilysin inhibitor) + Valsartan
- Recommended for NYHA II/III patients who tolerate an ACE-I or ARB
ARNI AE
- More symptomatic hypotension
- Angioedema
- Start on low dose and titrate as tolerable to avoid AE
- Decrease dosage of loop diuretics
ARNI Dosing
-D/C ACE at least 36 hours prior to starting ARNI
Dosing based on ACE/ARB
- E/L > 10 or R > 5: start at 100 mg BID
- E/L =< 10 or R =< 5: start at 50 mg BID
- If no previous ACE/ARB or eGFR < 30, start at 50 mg BID
- Titrate every 2-4 weeks up to 200 mg BID (target dose)
Hydralazines/Nitrates
- Recommended for black, NYHA III/IV patients
- Can combine the two if the paitent cannot be given an ACE-I/ARB
Hydralazine/Nitrates AE/Monitoring
Monitoring
- Recommend follow-up in 1-2 weeks and with each dose increase to check BP/HR
- AE: HA, dizziness, hypotension
Ivabradine Recommendation
-Recommended to reduce hospitalization in those with symptomatic, stable chronic HFrEF who have a stable rhythm and resting HR >= 70
Ivabradine Dosing
- 5 mg BID or 2.5 mg BID in those who are hemodynamically compromised due to bradycardia
- After 2 weeks, adjust dose to achieve HR between 50-60
- Max: 7.5 mg BID
Ivabradine AE
- Bradycardia
- Luminous phenomena
- Atrial fibrillation
Ivabradine Monitoring
- Follow up in 2 weeks to check resting HR
- Avoid with CYP3A4 inhibitors, grapefruit juice, avoid St. John’s Wort (inducer)
Ivabradine Counseling
- Avoid while pregnant
- Counsel about luminous phenomena
- Tell to contact provider for racing HR or palpitations
- Take with food
Digoxin Hemodynamic Effects
- Increased CO
- Decreased PCWP
- Increased LVEF
Digoxin Neurohormonal Effects
- Vagomimetic action
- Improved baroreceptor sensitivity
- Decreased norepinephrine serum concentration
- Decreased activation of renin-angiotensin system
- Direct sympathoinhibitory effect
- Increased sympathetic CNS outflow at high doses
- Decreased cytokine concentrations
- Increased release of ANP and BNP
Digoxin Electrophysiological Effects
- SA node slowing of sinus rate
- Slowed conduction of AV node
- Possible decreased refractory period in atrium
Digoxin Monitoring
- SDC levels at initiation and if suspecting digoxin toxicity, suspecting nonadherence, or conditions that would alter SDC and predispose to toxicity
- Draw at trough (>6 hours for oral, >4 for IV)
- Ideal SDC: 0.5-0.9
- Interactions: Amiodarone/Quinidine, Dilt., Verapamil, antibiotics, azole antifungals, propafenone
Omega-3 Recommendation
-Reasonable as an adjunctive therapy in patients with NYHA II-IV and HFrEF OR HFpEF unless otherwise CI
HFrEF Summary
- ACE in all patients unless intolerant, then ARB
- BB for all patients
- ADA for NYHA II-IV patients given they meet requirements
- ARNIs with LVEF < 40%, NYHA II/III, and on ACE/ARB and a BB
- ISDN/Hydralazine for those intolerant to ACEI/ARB or if black and NYHA III/IV
- Omega-3 (1000 mg combined EPA/DHA/day)
- Ivabradine if on all others mentioned above, NYHA II/III, LVEF =< 35%, normal sinus rhythm, and HR > 70
- Digoxin for symptomatic patients on optimal therapy
