Sowinski Heart Failure Flashcards
What is the definition of Heart Failure?
- Classified as an abnormality of myocardial function that is responsible for the failure if the heart to pump blood at a rate commensurate with requirements of the metabolizing tissues
What are the types of Heart Failure?
- HFrEF and HFpEF
What is HFrEF?
Heart Failure with Reduced Ejection Fraction
-Heart Failure symptoms with Ejection Fraction of <40%
-Systolic Dysfunction: DECREASED contractility
-Caused by Dilated Ventricles
What is HFpEF?
Herat Failure with Preserved Ejection Fraction
-Heart Failure symptoms with Ejection Fraction of >50%
-HTN is the most common cause
What are the other type of HFpEF?
-HFpEF, Boarderline: EF of 41-49 [Similar to HFrEF]
-HFpEF, Improved: EF > 40 [Had HFrEF before]
What is the way that we calculate Ejection Fraction?
-EF = [(EDV-ESV)/EDV] x 100%
Come back to slide 9
What is the most common precipitating or worsening factor for Heart Failure?
- LACK OF COMPLIANCE [most common], HTN, Arrhythmias,…
What are some of the drugs that can induced Heart Faliure?
-Antiarrhythmias, Beta-Blockers, CCBs, Cancer Medications, NSAIDS,…
What is the way that Antiarrhythmics, Beta-Blockers, and CCBs may cause Drug Induced Heart Failure?
- They cause a reduction in the HEART RATE [Negative Inotrope]
- Are reversible
What are the ways that some Cancer Drugs and Monoclonal antibodies may cause Drug Induced Heart Failure?
- They cause a build up of Ca2+ resulting in a weaken heart muscle.
- Irreversible
What is the way that the drugs that increase Na+ and Retain Water may cause Heart Failure?
- With drugs that increase the Na+ and Fluid retention, its going to cause possible EDEMA
What medication class could exacerbate HFrEF?
- Any CCB [DHP: “-pines”? or NONDHP: Verapamil/Diltiazem
What are some of the clinical presentations associated with Heart Failure?
- Shortness of Breath, Swelling of the Feet and Legs, Fatigue, Hard to sleep at night, Cough [Frothy Sputum], Increased Urination, Confusion…
What is the difference between RIGHT ventricular failure and LEFT ventricular failure?
RIGHT
- Venous Congestion
- Symptoms: Nausea, Vomiting, Constipation
- Signs: Edema, JVD, HJR
LEFT
- Pulmonary Congestion
- Symptoms: Othropnea, PND, Cough
- Signs: Rales, PULMONARY EDEMA,…
What are the major signs of Systemic Venous Congestion?
- PERIPHERAL EDEMA [1+, 2+, 3+, 4+]
- Jugular Venous Distentsion [JVD]: lying on their back can see their jugular vein
- Hepatojugular Reflex [HJR]: push on patients liver the fluid will go up their jugular vein
What are the major signs of pulmonary congestion?
- PULMONARY EDEMA
- Exertional Dyspnea [DOE]
- Paroxysmal Nocturnal Dyspnea [PND]: Need pillows at night to help breathe
What is the NYHA FC?
-It is the way that we classify a patients Heart Failure and determine what therapy is needed to treat them
What is the NYHA Class I?
-Patients with cardiac disease but WITHOUT RESULTING LIMITATION OF PHYSICAL ACTIVITY
-Asymptomatic
What is the NYHA Class II?
-Patients with cardiac disease resulting in SLIGHT LIMITATION OF PHYSICAL ACTIVITY
-Symptomatic
What is the NYHA Class III?
- Patients with cardiac disease resulting LIMITATION OF PHYSICAL ACTIVITY
- Symptomatic
What is the NYHA Class IV?
- Patients with cardiac disease resulting in INABILITY TO CARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT
- Symptomatic
What are the stages that we classify patients with CHF?
- Stage A, B, C, D
How do we classify a patient with Stage A CHF?
- These patients are at HIGH RISK of developing HF; There is no structural or functional abnomalitles of cardiac muscle
- EX: HTN, CAD, DM,…
How Do we classify a patient with Stage B CHF?
-There is STRUCTURAL HEART DISEASE that is associated with HF but NO signs and symptoms of HF
-Fibrosis, LV dilatation, previous MI,…
How do we classify a patient with Stage C CHF?
- They have CURRENT sign and symptoms of HF with underlying structural heart disease
- Fatigue due to HFrEF, Receiving treatment for prior HF symptoms
How do we classify a patient with Stage D CHF?
- ADVANCED heart disease and HAVE marked symptoms of HF; even at rest
- A lot of hospitalizations and CANNOT be discharged, need heart transplant,…
What is the therapy based on stage for HF?
- HIGH RISK: Stage A
- Asymptomatic rEF: Stage B; NYHA FCI
- HFrEF: Stage C & D; NYHA FC II-IV
What are some of the Non-pharmacological things patients can do for HF? [Think lab]
-Reduce Sodium [2-3g/day], Alcohol [2 drinks in men and 1 drink in women/day], Fluid [<2L/day], Increased exercise
What are some of the potential pharmacologic strategies used?
-Reduce intravascular volume [Diuretics]
-Increase myocardial contractility [+ Inotrope]
-Decrease ventricular afterload [ACEi, Vasodilator]
-Neurohormonal Blockade [ARNi, BB, ACEi, MRA,…]
What is the way that we treat a patient that falls in STAGE A CHF?
- ACEi [or ARBs]: if atherosclerotic disease
What is the way that we treat a patient that falls in STAGE B CHF?
- ACEi [or ARBs] & Beta-Blockers (class I indication): used if previous MI or asymptomatic rEF
What is the summary of treatment used for STAGE C CHF [symptomatic]?
- Diuretics, ARNi/ACEi/ARBs, Beta-Blockers, MRA, SGLT-2i
- OTHERS: ISDN/Hydralazine, Digoxin, Ivabradine, Amlodipine/felodipine
What medication class would be considered FIRST LINE in HF patients?
- Diuretics
Who should get a diuretic within HF?
- ANY and ALL patients with signs/symptoms of FLUID RETENTION [symptomatic] = NO SYMPTOMS, NO DIURETICS
- They dont improve mortality
What is the Mechanism of Action for Diuretics?
- Increase sodium and water excretion by reducing sodium reabsorption at a variety of sites in the nephron [NEED to get into the nephron to work]
What are the classes of Diuretics that we use for HF?
- Loop Diuretics and Thiazide Diuretics
What are the Loop Diuretics?
- POTENT diuretics that block the Na and Cl reabsorption in the ascending limb of the Loop of Henle.
What are the Loop Diuretics that are possibly used in HF?
- Furosemide, Torsemide, Bumetanide, Ethacrynic Acid
What is some of the dosing for Loop Diuretucs?
- F: Initial: 20-40mg qd or bid. Max: 20-160mg qd or BID
- T: Initial: 10-20 mg qd. Max: 10-80mg qd
- B: Initial 0.5-1mg qd or bid. Max: 1-2mg qd or bid
- EA: Initial 25-50mg qd or bid
What is the approximate equivalent dose foe the Loop diuretics?
F 40mg = B 1mg = T 20mg = EA 50mg
What are the Thiazide Diuretics?
-Relatively weak agents that block Na and Cl reabsorption in the DCT [used with Loops if need]
What are the Thiazide diuretics that we might used in HF?
- HCTZ: 25mg/day to 100mg/day
- Metolazone: 2.5mg/day to 10mg/day
- Chlorthalidone: 12.5-25mg/day to 50mg/day
What are some of the side effects for the Diuretics in HF?
- Increase Uric Acid, Increase Ca2+, Decrease K+, Decrease Mg2+
What should the patient monitor while using Diuretics?
- Fluid intake, Urine output, Electrolytes [K >4 and Mg >2], Renal Function
What is the mechanism of action for the ACEi?
-They inhibit the conversion of Angiotensin I to Angiotensin II [Inhibiting Vasoconstriction]
-Stop the break down of Bradykinin [Promoting Vasodilation]
Why is it important to use ACEi during HF?
- They reduce any symptoms, improve the NYHA score, and most important improve mortality.
What are the ACEi’s mostly used in HF?
- Lisinopril: 2.5-5mg qd to 20-40mg qd
- Enalapril: 2.5mg bid to 10mg bid
- Capropril: 6.25-12.5mg tid to 50mg tid
Why are the ACEi underdosed and underused?
- CKD needs a lower dose & trying to avoid Hypotension
When shouldn’t a patient use ACEi for HF?
-Volume depleted, SBP<80, K>5, SeCr>3 [may increase by 30%]
-Cough [switch to ARB]
-PREGNANT
-ANGIOEDEMA [switch to ARB]
What is the difference between ACEi and ARBs?
- No real difference; ARBs inhibit some of the Angiotension II activity on the AT1 receptor [decreasing BP and damage to the heart]
- NO COUGH & LESS ANGIOEDEMA
What are the ARBs that we may used in HF?
- Losartan: 25-50mg qd to 150mg qd
- Valsartan: 20-40mg bid to 160 bid
- Candesartan: 4mg qd to 32mg qd
What is the ARNi?
[Entresto]
- Sacubitril: Neprilysin Inhibitor
- Valsartan: ARBs
What is the mechanism of action ARNi?
The MOA is two things: [Decrease blood pressure]
- Sacubitril is the Neprilysin Inhibitor, which stops the break down of the natriuetic peptide, increasing the excretion of Na and Water
- Valsartan is the ARB, stoping the binding of Angiotension II to the AT1 receptor
What are some of the side effect of ARNi?
-Very similar to ACEi and ARBs; Hypotension, Increased SeCr, Increased K, Angioedema, Pregnancy
-VERY EXPENSIVE
What clinical trail showed the efficacy of ARNi vs ACEi/ARBs?
- PARADIGM-HF: Showed that ARNi was better than ACEi for preventing death from CV or reducing HF hospitlizations
What is the dosing for ARNi?
- Low: 24/27mg bid
- High: 49/51mg bid
- Max: 97/103mg bid
What is the best way to convert between ACEi/ARBs and ARNi?
- Stop ACEi/ARBs 36hours before starting ARNi
- Low ACEi/ARBs to Low ARNi
*Enalapril 20mg = Captopril 150mg = Lisinopril 20-40mg
What is the recommendation per STAGE for ARNi/ACEi/ARB?
- Stage B: ACEi [ARB if intolerant to ACEi]
- Stage C: ARNi [1st line]; ACEi [when ARNi cant work]; ARB [when ACEi and ARNi do not work]
What is one medication class that shouldn’t be used in patients that have Heart Failure
- CCBs
What is the mechanism of action of the Beta-Blockers?
-They block the beta receptor from Norepi/Epi/Dopa, which will wont activate AC, decreasing cAMP levels and cause relaxation
What is the proposed benefit of Beta-Blockers?
- Help reverse remodeling; the problems have resulted in the remodeling
What are the ONLY 3 beta-blockers used in heart failure?
- Metoprolol: 12.5-25mg qd to 200mg qd
- Carvedilol: 3.125mg bid to 25-50 mg bid
- Bisoprolol: 1.25-2.5mg qd to10mg qd
What patient population should receive a Beta-Blocker for heart failure?
- Those that are STABLE and EUVOLEMIC [the patient shouldn’t have any fluid retention]: give diuretic
- Considered with bronchospastic disease and asymptomatic bradycardia
What is the monitoring parameters for Beta-blockers for heart failure?
-Blood Pressure & Heart Rate [Dairy]
-Edema [Increase diuretic if need be]
-Fatigue
What is the recommendation per STAGE for Beta-Blockers in Heart Failure?
-Stage B: ALL patient should get one [reduce mortality]
-Stage C: ALL patient should get one [reduce mortality]
Why is it important to inhibit ALDOSTERONE in heart failure?
Elevated aldosterone in HF may cause:
-Sympathetic Activation [increase HR]
-Parasympathetic inhibition [Increase HR]
-Remodeling
What are the two Aldosterone Receptor Antagonists [MRA] that are used in Heart Failure?
- Spironolactone: 12.5-25mg qd to 25mg qd
- Eplerenone: 25mg qd to 50mg qd
What do the MRAs help against?
- Decrease K and Mg losses
- Decrease Na Retention [move fluids out]
- Decrease sympathetic simulation [Low HR]
Explain Spironolactone?
- Non Selective Agent
- AE: gynecomastia, importance, menstrual irregularities, antiandrogenic effects
Explain Eplerenone?
-Selective Agent with greater affinity
- AE: NO antiandrogenic effects
When should MRAs be used in therapy for HF?
-Should be added to ACEi/ARB/ARNi and Beta-Blocker
-AVOID: NSAIDS and High dosed ACEi/ARB
-AVOID: SeCR > 2.5 [CrCl < 30] and K > 5
What is the recommendation per STAGE for MRAs for HF?
-Stage B: No use
-Stage C: Patients with HFrEF and NYHA II-IV & GFR>30 and K<5 [K<5.5 discontinue]
What is the indication for the SGLT-2 Inhibitors for HF?
- Reduce the risk of CV death or hospitalization for HFrEF patients with NYHA Class II-IV [HFpEF]
What are the SGLT-2 inhibitors for HF?
- Dapagliflozin 10mg once daily
- Empagliflozin 10mg once daily
what is the recommendation per STAGE for SGLT-2 Inhibitors for HF?
- Recommended for patients that have chronic HFrEF to reduce hospitalization and mortality
What does ISDN/Hydralazine do within HF?
- It is a combination product that tries to balance the VD[?] effects, causing a decrease in preload [ISDN] and afterload [Hydralazine]
What are some of the adverse effects for ISDN/Hydralazine in HF?
-Headache, Nausea, Flushing, Dizziness, Tachycardia, Lupus-like syndrome, Hypotension,…
Should we worry about nitrate tolerance dosing for ISDN/Hydralazine for HF?
- NO, do not need to worry about that
What is the dosing for ISDN/Hydralazine for HF?
- Initial: 20/37.5mg tid
- Max: 40/75mg tid
What is important to know about ISDN/Hydralazine for HF?
- It works better in African American populations? [no one is sure why, maybe something to do with the nitric oxide?]
What is the recommendations per STAGE for ISDN/Hydralazine for HF?
-Stage B: no
-Stage C: Black patients with NYHA III-IV getting optimal therapy to improve symptoms and reduce mortality
What is the indication for Ivabradine for HF?
- Reduce the risk of hospitalization for symptomatic HF, EF<35% in NSR with rHF>70 in MAX tolerated beta-blocker
What is the Dosing for Ivabradine in HF?
-Initial: 2.5-5mg bid
-Max: 7.5mg bid
Adjustments:
-HR >60: increase by 2.5mg to 7.5mg
-HR 50-60: no change
-HR <50: deacrease by 2.5mg or discontinue
What are some of the side effects with Ivabradine for HF?
-Fetal toxicity, Afib, Bradycardia
What is the mechanism of action for Digoxin in HF?
-Inhibit the Na+/K+ ATPase, causing a decrease in Na+ coming in and Ca2+ leaving, increasing the intracellular Ca2+, resulting in greater contraction [Positive Inotrope]
What is Digoxin’s place in therapy for HF?
- its good a decreasing hospitalization but NOT good at reducing mortality
- When their optimized on max GDMT; add digoxin
What is the dosing for Digoxin in HF?
-0.125mg [need 0.5-0.9 digoxin conc to use]
What are the adverse effects of digoxin in HF?
- Noncardiac: Anorexia, nuasea, vomiting, visual problems, fatigue, dizziness,…
- Cardiac: PVCs, Av Block
What is the mechanism of action of Vericiguat in HF?
-Guanylate cyclase inhibitor [Symptomatic HFrEF]
What is the dosing for Vericiguat in HF?
- Initial:2.5mg qd to 10mg qd
