Sowinski Heart Failure Part 2 Flashcards
Which drugs treat mortality or mortality and hospitalization?
-Beta-blockers
-ACEI/ARB/ARNI
-Mineralocorticoid receptor antagonists (MRA)
-Isosorbide/hydralazine
-SGLT2I
Which drugs treat hospitalizations?
-Digoxin
-Ivabradine
Which drugs treat hemodynamic or physical function?
-Digoxin
-Isosorbide/hydralazine
-Inotropes
-Milrinone
-Sodium nitroprusside
-Nesiritide
Which drugs treat QOL or symptoms?
-Digoxin
-Diuretics
-Nesiritide
What are the neurohormonal blockers?
-ARNI/ACE/ARB
-Beta-blockers
-SGLT2i
-MRA
-ISDN/hydralazine
In which patients should ACE inhibitors be used?
Must be used in all who do not have contraindications regardless of etiology or severity of disease
In which patient populations see additional benefits with ACE use?
-IHD
-CKD
-Post-MI
-DM
ACE inhibitor mechanism of action
-Prevents conversion of angiotensin I to angiotensin II
-Blocks the conversion of bradykinin to inactive peptides
Why is it beneficial to block the conversion of bradykinin to inactive peptides?
Allows activation of the bradykinin receptor leading to improved endothelial function
Why is it beneficial to block the conversion of angiotensin I to angiotensin II?
Angiotensin II cause increased afterload disease progression
ACE inhibitor benefit in heart failure
-Improved endothelial function
-Decreased NE
-Inhibition of cardiac hypertrophy
-Improved cardiac hemodynamics
-Reduced aldosterone
-Decreased endothelin-1
-Decreased arginine vasopressin
-Reduced vasoconstriction
-Reduced Na and water retention
Initial dose of enalapril
2.5-5 mg BID
Target dose of enalapril
10 mg BID
Initial dose of captopril
6.25-12.5 mg TID
Target dose of captopril
50 mg TID
Initial dose of lisinopril
2.5-5 mg QD
Target dose of lisinopril
20-40 mg QD
ACE dosing conversions
20 mg E = 150 mg C = 20 mg L
How to dose ACEi
-Titrate dose to target dose
-Start low and double dose every 1-4 weeks
When to be cautious with ACEi use
-Volume depleted
-SBP less than 80
-K over 5
-SeCr over 3
ACEI absolute contraindications
-Pregnancy or intending to become pregnant
-History of angioedema or hypersensitivity
-Bilateral renal artery stenosis
-History of WELL-DOCUMENTED intolerance due to symptomatic hypotension, decline in renal function, hyperkalemia or cough
What to monitor in patients taking ACEi
-Volume status
-Renal function
-Serum potassium
-Blood pressure
-Other adverse effects
ACEi adverse effects
-Hypotension
-Functional renal insufficiency
-Hyperkalemia
-Skin rash and dysgeusia
-Cough
-Angioedema
Losartan initial dose
25-50 mg daily
Losartan target dose
150 mg daily
Valsartan initial dose
20-40 mg BID
Valsartan target dose
160 BID
Candesartan initial dose
4 mg daily
Candesartan target dose
32 mg daily
When to use ARBs
If unable to take ACEi due to cough, angioedema, etc.
Sacubitril/Valsartan indication
Reduce the risk of CV death/hospitalization for HFrEF patients with NYHA Class II-IV
Adverse effects of sacubitril/valsartan
-Hypotension
-Elevations in SeCr, SeK
-Angioedema (rare)
-Pregnancy
-Expensive (~$600/month)
What is more effective ACE or ARNI?
ARNI showed a 20% reduction in primary endpoint
Initial dose of ARNI when switching from a high dose ACEI/ARB
S 49/V 51 mg BID
Max dose of ARNI when switching from a high dose ACEI/ARB
S 97/V 103 mg BID
Initial dose of ARNI when switching from low-to medium dose ACEI/ARB or if the patient is ACEI/ARB naive, EGFR <30, moderate hepatic impairment, or age >75 years
S 24/V 26 mg BID
What is considered a high dose of ACEI?
Greater than E 10 mg/day = C 75 mg/day = L 10-20 mg/day
ARNI contraindications
-Within 36 hours of ACEI use
-Angioedema with an ACEI or ARB previously
-Pregnancy
-Lactation
-Severe hepatic impairment
-Concomitant use of aliskiren in patients with diabetes
-Known hypersensitivity to either ARB or ARNI
Stage B recommendations for ARNi/ACEi/ARB use
-ACEIs
-ARBS: if intolerant to ACEIs
Stage C recommendations for ARNi/ACEi/ARB use
-ARNi: patients with current or previous symptoms (patients with current or previous symptoms who tolerate an ACEi or ARB, replacement with ARNi further reduces mortality)
-ACEi: patients with current or previous symptoms when use of ARNI is not feasible (financial)
-ARBs: If intolerant to ACEis when ARNI is not feasible (ARBs are reasonable alternatives as first-line agents especially if taking an ARB for another indication)
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Which beta-blockers are approved for the treatment of HF?
-Carvedilol
-Metoprolol CL
-Bisoprolol
How do beta-blockers benefit patients with HF?
-Decrease ventricular arrhythmias
-Decrease cardiac hypertrophy and cardiac cell death
-Decrease VC and HR
-Decrease cardiac remodeling
Carvedilol (Coreg) target dosing
25-50 mg BID
Bisoprolol target dosing
10 mg QD
Metoprolol CR/XL target dosing
200 mg QD
Which HF patients are candidates for beta-blocker treatment?
-STABLE and euvolemic patients
-Symptomatic patients should receive diuretics also, especially with current or recent history of fluid retention
-Should be considered in patients with bronchospastic disease and asymptomatic bradycardia, but cautiously
-For hospitalized patients start later in hospital stay
-Do not abruptly discontinue
Carvedilol (Coreg CR) target dosing
80 mg daily
Bisoprolol initial dosing
1.25 mg daily
Carvedilol (Coreg) initial dosing
3.125 mg BID
Carvedilol (Coreg CR) initial dosing
10 mg daily
Metoprolol CR/XL initial dosing
12.5-25 mg daily
How to dose beta-blockers
-Double the dose every 2 weeks and MONITOR closely vital signs and symptoms
-Planned dose increases can be slowed if necessary to manage
-AIM FOR TARGET DOSE in 8-12 weeks or highest tolerated dose
Beta-blocker monitoring
-BP
-HR (Goal HR not defined but aim for around 50-60 bpm)
-Edema and fluid retention
-Fatigue or weakness
Stage B recommendations for beta-blocker use
All patients should be on beta-blocker unless contraindicated
Stage C recommendations for beta-blocker use
All patients should be on beta-blocker unless contraindicated
