HF pt 5 Flashcards
sowinski pg 146-177 (titration strategies/misc)
when should all drugs be started?
at 4 weeks after admission, visit 1, diagonsis
at 42 days, what should be inititaed/titrated?
maintenance or additional titration of four foundational therapies
consideration of EP device therapies or transcatheter mitral valve repair
consideration of add-on medications or advanced therapy if refractory
manage comorbidities
what are important clinical parameters of RASi and MRAs?
SBP over 100
SeK under 5.4
eGFR over 30
what are follow-up lab and clinical parameters of RASi and MRAs?
symptoms of Postural hypotension (PH), SeCr, SeK
when should reduction or d/c of RASi/MRAs be considered?
symptomatic postural hypotension
SeCr increase by 30% within 4 weeks
SeK over 5.4
what are important clinical parameters of BB?
SBP over 100
HR over 60
what should reduction or d/c of BB be considered?
HR under 50
symptomatic PH
what are important clinical parameters of SGLT2i?
SBP over 100
eGFR over 20
what are follow-up lab and clinical parameters of SGLT2i?
symptoms of PH, SeCr, SeK
DM monitoring
genital mycotic infections
when should reduction or d/c of SGLT2i be considered?
symptomatic PH
SeCr increase by over 30% within 4 weeks
development of ketones/lactate if AHF
what is the main purpose of ISDN/hydralazine?
balanced vasodilatory effects, causing reduction in both preload na afterload to reduce mortality
what is the brand name of ISDN/hydralazine?
BiDil
when is BiDil indicated?
for treatment of HF in black pts as an adj to standard therapy
what are the AE of BiDil?
HA, N
flushing, dizziness, tachycardia
lupus-like syndrome
hypotension
increased HR
myocardial ischemia
fluid retention
why is the usage of BiDil limited?
AE are significant
what is the dosing of hydralazine only?
initial: 25 mg TID
target: 75 mg TID
max: 100 mg TID
what is the dosing of ISDN only?
initial: 20 mg TID
target: 40 mg TID
max: 80 mg TID
what is the dosing of BiDil?
initial: 20/37.5 mg TID
max/target: 40/75 mg TID
why is the combination product of ISDN/hydralazine good?
has different sites of action
hydralazine - arteriolar VD
ISDN - venous VD
when should ISDN/hydralazine be recommended?
stage C in black pts to improve symptoms and reduce M/M
pts with symptoms who can receive ARNi, ACEi, or ARB due to drug intolerance or renal insufficiency might be considered
what is an example of a drug intolerance that might switch someone from an ARNI, ACEi, or ARB to ISDN/Hydralazine?
persistent hyperkalemia
when is ivabradine indicated?
reduce the risk of hospitalization (worsening HF) in HFrEF in normal sinus rhythmn in max tolerated BB or with CI
what is the dosing of ivabradine?
initial: 2.5-5mg BID
max: 7.5 mg BID
adj q2 weeks based on HR
if HR is over 60, what should ivabradine dose be?
increase dose by 2.5 mg up to max dose
if HR is between 50-60, what should ivabradine dose be?
maintain current dose
if HR is under 50 or S/S bradycardia, what should ivabradine dose be?
decrease dose by 2.5 mg
if current dose is 2.5mg BID, d/c
what are the AE of ivabradine?
fetal toxicity
atrial fibrillation
bradycardia and conduction disturbances
how does ivabradine being a CYP3A substrate affect it?
fairly substantial drug-drug interactions
CI with KTZ
avoid diltiazem, verapamil, GFJ
what drugs are cardiac glucosides?
digoxin
digitalis glycosides
what is the major benefits of digoxin?
increase parasympathetic activity
vagolytic effects at the AV and SA nodes to reduce HR at rest and slow AVN conduction (afib tx)
re-sensitization of baroreceptors
how do cardiac glycosides affect the Na/K ATPase pump?
inhibits it to alter excitation-contraction coupling
increases intracellular Ca2+
enhance force of contraction
relatively mild positive inotrope
when is digoxin considered in HF?
pts who have symptomatic HFrEF despite optimized GDMT or who can’t tolerate GDMT to decrease hospitalization for HF
controversial
how is digoxin dosed?
empirically based on goal serum digoxin concentration (SDC)
0.125-0.25 mg daily with most being on lower dose
what is goal SDC?
between 0.5-0.9 ng/mL
when should lower doses of digoxin be considered?
pts over 70 yrs, impaired renal function, low weight
what drugs have interaction with digoxin?
amiodarone
quinidine
verapamil
itra/KTZ
increases digoxin concentration x2
what are non cardiac AE of digoxin?
anorexia, NV, abdominal pain
visual disturbances
fatigue, weakness, dizziness, HA, neuralgias, confusion, delirium, psychosis
what are the ventricular AE of digoxin?
PVCs
bigeminy
trigeminy
VT
VF
what are cardiac AE of digoxin?
ventricular
1,2,3 degree AV block
AV junctional escape rhythms, junctional tachycardia
atrial arrhythmias with slowed AV conduction or AV block
sinus bradycardia
what type of drug is vericiguat?
soluble guanylate cyclase stimulator
what are AE and CI of vericiguat?
CI in pregnancy
AE – hypotension and anemia
when should vericiguat be considered?
in selected high-risk pts with recent worsening with symptomatic HFrEF despite optimized GDMt
used to decrease hospitalization for HF and CV death
what is the role of PUFA in HF?
omega-3 polyunsaturated FA
may reduce risk in HF (II-IV) pts
reasonable as adjunctive therapy
what is the role of antiplatelets in HF tx?
long term therapy with aspirin is recommended in pts with HF and IHD/CAD/ASCVD only
not recommended for routine use
what is the role of anti-coags in HF?
not recommended unless
pt with other indication (hx of systemic or pulmonary embolism), in HF with Afib with one addition R/F
what is the role of CCBs in HF?
do not use diltiazem, verapamil, and nifedipine
felodipine and amlodipine may be useful in managing angina/HTN if not effectively managed by other HF therapies
when would an ICD be implanted?
LVEF under 35% with 40 days post MI, NYHA II-III
LVEF under 30% at least 40 days post MI, NYHA I
when is cardiac resynchronization therapy recommended in HF?
NYHA II-IV pts on optimal medical therapy with QRS duration over 150 milliseconds and LVEF under 35%
what are other therapies that show no benefit or conflicting benefit?
coenzyme Q10
nutritional therapies
hormonal therapies
