Lecture 1: Heart Failure Flashcards
Diastolic HF
Thick heart walls are a sign
HFpEF > 50%
Systolic HF
Thin heart walls are a sign
HFrEF < 40%
HF w/ mid-range ejection fraction
HFmEF 40-49%
HF w/ recovered EF
used to have rEF but improved to > 50%
Most important risk for HF?
HTN
Preventative measures for HF?
- Maintain BP at desired target < 130/80
- Control DM and lipids
- Aerobic activity 20-30 min 3-5 x wk
- BMI < 30
- Stop smoking
- Max sodium 2-3g/day
- Limit alcohol to 1-2 drink/day (m) and 1 drink/day (w)
4 determinants of Cardiac Output
HR
Preload
Afterload
Contractility
Stage A
At risk for HF
Stage B
Pre-heart failure (newly added)
Stage C
Symptomatic HF
Stage D
Advanced HF
Stage A drugs
ACEi or ARB appropriate for vascular disease or diabetes
Stains as appropriate
Stage B drugs
ACEi or ARB
B-Blockers
Statins as appropriate
select patients: ICD or revascularization or valvular surgery
Goal Directed Medication Therapy (GDMT)
ACEi/ARB/ARNi + B-Blocker+ Mineralocorticoid Antagonist + SGLT2i
Meds to be used on Stage C (1st line)
ACEi/ARB/ARNi + B-Blocker + Mineralocorticoid Antagonist + SGLT2i
diuretics as needed
Lisinopril Dosing Info
Initial Daily Dose: 2.5-5mg QD
Target Dose: 20-40mg QD
Mean Doses Achieve in CT: 32.5-35mg QD
Losartan Dosing info
Initial Daily Dose: 25-50mg QD
Target Dose: 50-150mg QD
Mean Doses Achieved in CT: 129 mg QD
Sacubitril - Valsartan (ARNi) Dosing Info
Initial Daily Dose: 49mg Sacubitril + 51mg valsartan BID ( can start on 24mg/26 mg BID)
Target Dose: 97mg Sacubitril + 103mg Valsartan BID
Mean Doses Achieved in CT: 182mg Sacubitril + 193 valsartan QD
Carvedilol Dosing info
Initial Daily Dose: 3.125 mg QD
Target Dose: 25-50mg QD
Mean Doses achieved in CT: 37 mg QD
Metoprolol succinate CR/XL Dosing info
Initial Daily Dose: 12.5-25 mg QD
Target Dose: 200mg QD
Mean Doses achieved in CT: 159mg QD
Spironolactone Dosing info
Initial Daily Dose: 12.5mg-25mg QD
Target Dose: 25-50mg QD
Mean Doses achieved in CT: 26mg QD
Dapagliflozin Dosing Info
Initial Daily dose: 10 mg QD
Target Dose: 10mg QD
Mean Doses achieved in CT: 9.8mg QD
Empagliflozin Dosing Info
Initial Daily dose: 10 mg QD
Target Dose: 10mg QD
How often should you titrate these therapies?
Guidelines recommend titrating dose at 2 wk intervals until at max tolerated or target dose
ACEi info
No differences between available ACEi
Caution:
Cough - 20%
Angioedema
Monitor SCr and K
most recommended over ARBs
Natriuretic Peptides
ANP + BNP
BNP secreted by ventricles in response to wall stress, used to detect presence of or worsening of HF + Overall lvl increased in HF
ANP + BNP promotes Natriuresis and Diuresis
Neprilysin
Breaks down NPs
Inhibiting Neprilysin will inc BNP conc
AT2 is substrate for Neprilysin, so AT2 targeting agent required for co-admin….ARB
Why cant combine Neprilysin w/ ACEi?
led to more angioedema
Entresto reduced dose is…
24/26mg BID
It is for those that haven’t been on ACEi or ARB before
Severe renal impairment
CI of Entresto
Concomitant ACEi therapy….don’t admin within 36hrs of ACEi due to risk of angioedema
Concomitant use of aliskiren w/ diabetes w/ Entresto
Previous Angioedema w/ ACEi or ARBs
Carvedilol vs Metoprolol Succinate
Carvediolol = A/B block…impacts BP
Metoprolol is ony B Block, minimal BP effect
Which Beta-blockers are best….
Carvedilol
Metoprolol
Bisoprolol
Beta-blocker considerations
- Use studied agents only
- Start at low dose, titrate up every 2 weeks, reach optimal dose in 8-12 weeks
- Start/titrate when pt is stable
- Monitor HR, caution < 55 bpm
- If pt “congested” best to start ARNi/ARB/ACEi if not already
Aldosterone Antagonist recommended in pts w/
NYHA Class II - 4 HF with systolic HF (LVEF < 35%) unless CI
Aldosterone Antagonist Cautions
Renal impairment, SCr should be < 2.5 m, < 2.0 w
K+ should be less than 5 mEq
GFR cut off for Dapagliflozin
> 30ml/min
GFR cute off Empagliflozin
> 20ml/min
Role of Aldosterone Antagonist is to…
antagonist effects of aldosterone on ventricular remodeling
not used for diuresis effects
Diuretics Equivalents
Bumetanide 1mg = Torsemide 20mg = Furosemide 40 mg (oral)
IV vs PO Furosemide
20mg = 40mg
Which diuretic highest albumin bound? lowest?
Highest = furosemide Lowest = Bumetanide
Metolazone often used as…
“pre-diuretic” before loop ~ 30min or same time
cautions with high dose metolazone in elderly, recommended 2.5mg 2-3 times weekly
Why is metolazone used prior to loop diuretic
By giving thiazide you’ll clear what leaves in the proximal, increasing what gets filtered in the loop.
Maximizes absorption/removal from descending loop to Henle
Oral Nitrates and Hydralazine
1st approved for self-ID black pt due to sign mortality benefit
can be used in place of ACEi or ARB in intolerant patients or those with sig renal dysfunction precluding use of an ACEi/ARB
Oral Nitrates an Hydralazine combo recommended to…
reduce morbidity and mortality for self-described AA with NYHA Class 3-4 receiving optimal therapy with ACEi/B-Blocker unless CI
Isosorbide dinitrate + Hydralazine Dosing
20mg (DN) + 37.5mg (Hyd)
Target: 40mg + 75mg
Ivabradine (Corlanor) indication
only in pt with Stable HF, EF < 35% and a resting HR of at least 70 bpm on maximally tolerated B-Blockers
Ivabradine Dose
2.5mg BID to 7.5 mg BID
Maximally tolerated B-Blockade
When you cant go up in dose due to side effects and cant handle it
Digoxin can be beneficial in patients with….
Systolic HF to decrease hospitalizations for HF
Most beneficial in pts in Classes 3-4 with lower EFs
Nitrates + Vasodilator therapy, Ivabradine, Digoxin, and Vericiguat are all used as….
add ons the the original 4 if you can increase any of those therapies
Vericiguat indicated for….
Pts in NYHA Class 2 - 4, on GDMT still experiencing elevated BNP lvls > 300, or NT pro-BNP > 1000
Vericiguat Caution
Combo with nitrates and/or PDE-5i give profound risk of hypotension
