Module 13: CHF (a) Flashcards
1
Q
CHF
-Stage A
A
- At high risk for HF but w/out structural heart disease or Sx’s of HF
- Pt Ex: HTN, atherosclerotic dz, DM, obesity, metabolic syndrome
- Therapy goals — heart healthy lifestyle, prevent vascular coronary dz, prevent LV structural abnormalities
- Treat w/ ACEi or ARB in appropriate patients for vascular dz or DM — Statins as appropriate
2
Q
CHF
-Stage B
A
- Structural heart disease but w/out sings or Sx’s of HF
- Pt Ex: Previous MI, LV remodeling including LVH and low EF — Asymptomatic valvular dz
- Therapy — Prevent HF Sx’s — prevent further cardiac remodeling
- Treat w/ ACEi, ARB as appropriate — Beta blockers
- In selected Pt’s — ICD, revascularizariam or valvular surgery as appropriate
3
Q
CHF
-Stage C
A
- Structural heart disease w/ prior or current Sx’s of HF
- Pt Ex: Known structural heart disease and HF signs and Sx’s
- HFpEF and HFrEF
4
Q
CHF
-Stage D
A
- Refractory HF
2. Pt Ex: Marked HF Sx’s at rest — recurrent hospitalizations despite GDMT
5
Q
Heart Failure
-Classifications
A
- HFrEF is when EF is =40%
- HFmid-rangeEF EF 41-49%
- HFpEF is when EF is >/= 50%
6
Q
Drugs NOT to use w/ HF
A
- Glucocorticoids — sodium retention
- NSAIDs — sodium retention
- CCB’s — Negative inotropy
- Metformin — Lactic acidosis
- Thiazolidinediones TZDs — Sodium retention
7
Q
HFrEF
-Treatment Goals
A
- Improve Sx’s and health-related quality of life and functional status — decreasing risk of hospitalization
- Slow or reverse deterioration in myocardial function
- Reduce mortality
8
Q
HFrEF
-Medications that improve Sx’s
A
- Loop Diuretics
- Beta blockers
- ACEi, ARB, or ARNI
- SGLT2i (Dapagliflozin)
- Hydralazine + nitrate
- Digoxin
- Mineralocorticoid receptor antagonist (MRA; aldosterone antagonist)
9
Q
HFrEF
-Meds that prolong survival
A
- Beta blockers
- ACEi or ARNI
- ARB
- SGLT2i (dapagliflozin)
- Hydralazine + nitrate
- MRA
- Diuretic therapy (limited evidence of survival benefit)
10
Q
HFrEF
-Initial 3 Pharm Agents?
A
- Diuretic therapy (LOOP diuretics) — Treatment of volume overload, dyspnea, peripheral edema
- Angiotensin system blocker — Either ANRI, ACEi, or ARB
AND - Beta-blocker — Carvedilol, metoprolol, or bisoprolol
11
Q
HFrEF
-Loop Diuretics
A
- Furosemide (Lasix) — bumetanide (Bumex) — torsemide (Demadex
- BBW — fluid and electrolyte depletion - can cause excessive diuresis
12
Q
HFrEF Treatment
-ARNII
A
ARNI = Angiotensin receptor neprilysin inhibitor
- Neprilysin inhibitor = Sacubitril
—ARB = valsartan - Combo of Sacubitril-valsartan (Entresto)**
- MUST be off of ACE at least 36 hours before starting ARNI
- Can improve Sx’s and reduce mortality in HFrEF — Monitor BP, renal function & Potassium
- Avoid in hx of Angioedema, pregnancy/lactation
13
Q
HFrEF
-Beta Blockers
A
- 3 Beta-blockers recommended for HFrEF
- Carvedilol
- Extended-release metoprolol succinate
- Bisoprolol - 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
- Monitor BP, HR — Avoid in HR <50-60 (consult cardiology)
- Weight Gain considerations — Increased diuretic dose or lower BB dose is warranted
14
Q
HFrEF Therapy
-Secondary Therapy Options
A
- MRA
- SGLT2i (dapagliflozin)
- Hydralazine + nitrate
- Ivabradine
- Digoxin
15
Q
HFrEF Secondary Treatments
-MRAs
A
- Potassium sparing diuretics — Ex: Spironolactone (cheaper option) & Eplerenone
- Have relatively weak diuretic activity
- Check baseline potassium and renal function before starting
A/Es
- Hyperkalemia
- Gynecomastia, menstrual abnormalities, impotence, decreased libido
AVOID in pregnancy
16
Q
HFrEF Secondary Treatments
-SGLT2i
A
- 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 - Some have been shown to reduce risk of progression of diabetic kidney disease
- AVOID with
- risk for DKA
- symptomatic hypotension
- Severly impaired or rapidly declining kidney function eGFR <45mL/min
17
Q
HFrEF Secondary Treatments
-Hydralazine + Nitrate
A
- Helpful for patients w/ persistent HTN despite compliance w/ other drug therapies for HFrEF
- Use is limited by verbally poor adherence
18
Q
HFrEF Secondary Treatments
-Ivabradine (Corlanor)
A
- Selective Sinus node inhibitor — Decreases HR
- Consider with HFrEF AND — LVEF = 35%in SR w/ resting HR >/=70 — Who have max tolerated dose of BB or have contraindication to BB.
- Monitor
- HR, ECG, Signs and Sx’s of HF — Especially: evidence of volume overload
19
Q
HFrEF Secondary Treatments
-Digoxin
A
- Isotrópico effect, increases myocardial Contractility — May also be used for a-fib
- Can have toxic effects — Monitor serum drug level d/t narrow therapeutic range**TEST
- Monitor Serum drug levels, Cr, K, electrolytes, HR (bradycardia)
A/Es
- GI (anorexia N/V/D)
- Toxicity — Yellow vision and green halos around lights
20
Q
HFmrEF
-Management
A
- Similar management to patients with HFrEF
- Lifestyle modification
- Management of associated conditions
- Med therapy similar to HFrEF
21
Q
HFpEF
-Management
A
- The management of HFpEF differs from the management of HFrEF
22
Q
HFpEF
-Management
A
- Largely governed by mgmt of ASSOCIATED CONDITION Sx’s — Ex: HTN, CAD, obesity, DM, CKD, anemia, sleep-disordered breathing
- Diuretics — Used to Tx volume overload — Watch for volume depletion
- May consider MRA, if pro-BNP is elevated
