Module 13: CHF (a)

Question 1

CHF

-Stage A

Answer 1

1. At high risk for HF but w/out structural heart disease or Sx’s of HF
2. Pt Ex: HTN, atherosclerotic dz, DM, obesity, metabolic syndrome
3. Therapy goals — heart healthy lifestyle, prevent vascular coronary dz, prevent LV structural abnormalities
4. Treat w/ ACEi or ARB in appropriate patients for vascular dz or DM — Statins as appropriate

Question 2

CHF

-Stage B

Answer 2

1. Structural heart disease but w/out sings or Sx’s of HF
2. Pt Ex: Previous MI, LV remodeling including LVH and low EF — Asymptomatic valvular dz
3. Therapy — Prevent HF Sx’s — prevent further cardiac remodeling
4. Treat w/ ACEi, ARB as appropriate — Beta blockers
5. In selected Pt’s — ICD, revascularizariam or valvular surgery as appropriate

Question 3

CHF

-Stage C

Answer 3

1. Structural heart disease w/ prior or current Sx’s of HF
2. Pt Ex: Known structural heart disease and HF signs and Sx’s
3. HFpEF and HFrEF

Question 4

CHF

-Stage D

Answer 4

1. Refractory HF

2. Pt Ex: Marked HF Sx’s at rest — recurrent hospitalizations despite GDMT

Question 5

Heart Failure

-Classifications

Answer 5

1. HFrEF is when EF is =40%
2. HFmid-rangeEF EF 41-49%
3. HFpEF is when EF is >/= 50%

Question 6

Drugs NOT to use w/ HF

Answer 6

1. Glucocorticoids — sodium retention
2. NSAIDs — sodium retention
3. CCB’s — Negative inotropy
4. Metformin — Lactic acidosis
5. Thiazolidinediones TZDs — Sodium retention

Question 7

HFrEF

-Treatment Goals

Answer 7

1. Improve Sx’s and health-related quality of life and functional status — decreasing risk of hospitalization
2. Slow or reverse deterioration in myocardial function
3. Reduce mortality

Question 8

HFrEF

-Medications that improve Sx’s

Answer 8

1. Loop Diuretics
2. Beta blockers
3. ACEi, ARB, or ARNI
4. SGLT2i (Dapagliflozin)
5. Hydralazine + nitrate
6. Digoxin
7. Mineralocorticoid receptor antagonist (MRA; aldosterone antagonist)

Question 9

HFrEF

-Meds that prolong survival

Answer 9

1. Beta blockers
2. ACEi or ARNI
3. ARB
4. SGLT2i (dapagliflozin)
5. Hydralazine + nitrate
6. MRA
7. Diuretic therapy (limited evidence of survival benefit)

Question 10

HFrEF

-Initial 3 Pharm Agents?

Answer 10

1. Diuretic therapy (LOOP diuretics) — Treatment of volume overload, dyspnea, peripheral edema
2. Angiotensin system blocker — Either ANRI, ACEi, or ARB
   AND
3. Beta-blocker — Carvedilol, metoprolol, or bisoprolol

Question 11

HFrEF

-Loop Diuretics

Answer 11

1. Furosemide (Lasix) — bumetanide (Bumex) — torsemide (Demadex
2. BBW — fluid and electrolyte depletion - can cause excessive diuresis

Question 12

HFrEF Treatment

-ARNII

Answer 12

ARNI = Angiotensin receptor neprilysin inhibitor

1. Neprilysin inhibitor = Sacubitril
   —ARB = valsartan
2. Combo of Sacubitril-valsartan (Entresto)**
3. MUST be off of ACE at least 36 hours before starting ARNI
4. Can improve Sx’s and reduce mortality in HFrEF — Monitor BP, renal function & Potassium
5. Avoid in hx of Angioedema, pregnancy/lactation

Question 13

HFrEF

-Beta Blockers

Answer 13

1. 3 Beta-blockers recommended for HFrEF
   - Carvedilol
   - Extended-release metoprolol succinate
   - Bisoprolol
2. Begin w/ very low doses w/ titration to optimal doses — Monitor closely as BB initiation may increase Sx’s for 1-2 weeks before improving
3. Monitor BP, HR — Avoid in HR <50-60 (consult cardiology)
4. Weight Gain considerations — Increased diuretic dose or lower BB dose is warranted

Question 14

HFrEF Therapy

-Secondary Therapy Options

Answer 14

1. MRA
2. SGLT2i (dapagliflozin)
3. Hydralazine + nitrate
4. Ivabradine
5. Digoxin

Question 15

HFrEF Secondary Treatments

-MRAs

Answer 15

1. Potassium sparing diuretics — Ex: Spironolactone (cheaper option) & Eplerenone
2. Have relatively weak diuretic activity
3. Check baseline potassium and renal function before starting

A/Es

• Hyperkalemia
• Gynecomastia, menstrual abnormalities, impotence, decreased libido

AVOID in pregnancy

Question 16

HFrEF Secondary Treatments

-SGLT2i

Answer 16

1. Dapagliflozin, empagliflozin, or canagliflozin — Shown to reduce risk of HF hospitalizations in adults w/ T2DM
   - May be considered for pt w/ HF w/out DM
2. Some have been shown to reduce risk of progression of diabetic kidney disease
3. AVOID with
   - risk for DKA
   - symptomatic hypotension
   - Severly impaired or rapidly declining kidney function eGFR <45mL/min

Question 17

HFrEF Secondary Treatments

-Hydralazine + Nitrate

Answer 17

1. Helpful for patients w/ persistent HTN despite compliance w/ other drug therapies for HFrEF
2. Use is limited by verbally poor adherence

Question 18

HFrEF Secondary Treatments

-Ivabradine (Corlanor)

Answer 18

1. Selective Sinus node inhibitor — Decreases HR
2. Consider with HFrEF AND — LVEF = 35%in SR w/ resting HR >/=70 — Who have max tolerated dose of BB or have contraindication to BB.
3. Monitor
   - HR, ECG, Signs and Sx’s of HF — Especially: evidence of volume overload

Question 19

HFrEF Secondary Treatments

-Digoxin

Answer 19

1. Isotrópico effect, increases myocardial Contractility — May also be used for a-fib
2. Can have toxic effects — Monitor serum drug level d/t narrow therapeutic range**TEST
3. Monitor Serum drug levels, Cr, K, electrolytes, HR (bradycardia)

A/Es

• GI (anorexia N/V/D)
• Toxicity — Yellow vision and green halos around lights

Question 20

HFmrEF

-Management

Answer 20

1. Similar management to patients with HFrEF
   - Lifestyle modification
   - Management of associated conditions
   - Med therapy similar to HFrEF

Question 21

HFpEF

-Management

Answer 21

1. The management of HFpEF differs from the management of HFrEF

Question 22

HFpEF

-Management

Answer 22

1. Largely governed by mgmt of ASSOCIATED CONDITION Sx’s — Ex: HTN, CAD, obesity, DM, CKD, anemia, sleep-disordered breathing
2. Diuretics — Used to Tx volume overload — Watch for volume depletion
3. May consider MRA, if pro-BNP is elevated