Treatment Approach: HFpEF, HFmrEF, Exacerbations and Drug Induced HF

Question 1

What is HFpEF?

Answer 1

1. heart failure with preserved ejection fraction
2. “diastolic heart failure”
3. LV doesn’t fill properly but does contract so same % of blood leaves the ventricle but from a smaller starting volume
4. EF > 50%

Question 2

What causes HFpEF?

Answer 2

long standing hypertension leading to myocyte hypertrophy in the LV

Question 3

HFpEF treatment in patient with symptomatic HF and an ejection fraction equal to or more than 50%

Answer 3

1. control hypertension and atrial fibrillation in accordance with guidelines
2. diuretics as needed
3. SGLT2i: decreased HF hospitalizations and CV mortality
4. MRAS: decrease hospitalizations
5. ARBs: decrease hospitalizations
6. ARNIs: decrease hospitalizations

Question 4

HFpEF fluid management

Answer 4

1. loop diuretics to get Na and water excretion

big concern is removal of too much volume leading to even less profusion

Question 5

What is HFmrEF?

Answer 5

1. heart failure with mildly reduced ejection fraction
2. HFpEF getting worse or HFrEF getting better
3. EF 40-50%

Question 6

HFmrEF treatment

Answer 6

1. diuretics as needed
2. SGLT2i: decreased hospitalizations and CV mortality
3. evidenced based beta blockers, ARNI/ACEI/ARB, and MRAs can be considered for HF hospitalizations and CV mortality, especially if EF is on the low end of the spectrum

Question 7

keeping BB,ARNI,ACEI,ARB,MRA with Acute Decompensated HF (ADHF)

exacerbation

Answer 7

1.keep on if at all possible
* if required decrease dose instead of discontinuing the medication
* if hemodynamically unstable/requiring vasopressors, stop medications
* if AKI, hold ARNI/ACEI/ARB/MRA

Question 8

keeping SGLTi with ADHF

Answer 8

1.keep on if at all possible
* stop if euglycemic ketoacidosis or pending procedure/surgery

Question 9

Class I ADHF treatment

warm and dry

Answer 9

DO NOTHING

Question 10

Class II ADHF treatment

warm and wet

Answer 10

1. dry them out
   * diuresis: double home dose as IV
   * no home diuretic: furosemide 40 mg IV or equivalent
2. give one dose of diuretic and assess response
   * good response: 500 mL/hr over first 6 hrs
   * poor response: double dose
   * goal urine output: 1-2 L negative/day

Question 11

Class III ADHF treatment

cold and dry

Answer 11

1.increase perfusion
2.vasodilation: arterial vasodilation makes it easier to move blood forward from LV (decreases afterload)
* for hemodynamically stable patients
* agents:ARNI, ACEI, ARB, hydralazine, IV vasodilators (nitroglycerin, nitroprusside)

3.inotropy: increase squeeze of LV to move blood forward
* for patients with low BP (not in shock)
* agents: dobutamine, milrinone

Question 12

Class IV ADHF treatment

cold and wet

Answer 12

1.increase perfusion first (warm them up)
* vasodilation or inotropy
* vasopressors: provides increased squeeze of the LV and vasoconstriction to keep BP high for hemodynamically unstable patients (norepi, epi, dopa)

2.dry them out
* must be warm first to deliver blood and drug to kidneys
* loop diuretics

Question 12

3 main causes of Drug Induced HF

Answer 12

1. sodium and volume retention
2. direct cardiotoxicity leading to cardiomyopathy
3. negative inotropy

Some drugs or drug classes may contribute to more than one of these mechanisms

Question 13

HF due to sodium and fluid retention

avoid these

Answer 13

1. NSAIDs and steroids
   * avoid but if necessary: minimize dose and duration

2.TZDs
* BBW: avoid in patients with NYHA III-IV HF

Question 14

HF due to cardiomyopathy

avoid these

Answer 14

1.chemo agents
* anthracyclines
* alkylating agents

2.biologic agents
* trastuzumab

3.alcohol
* direct toxic effect on the myocardium

Question 15

anthracycline induced cardiomyopathy

Answer 15

1. most common: doxorubicin, daunorubicin
2. TOP2B is inhibited by above meds which causes DNA breakdown and cell death
3. dexrazoxane binds to TOP2B to prevent anthracycline binding

Question 16

risk factors for anthracycline toxicity

limit lifetime dose to 550 mg/m2

Answer 16

1.treatment related
* cumulative dose > 400 mg/m2
* dosing schedules
* previous anthracycline therapy
* radiation therapy
* co-admin of potentially cardiotoxic agents

2.patient related
* age
* preexisting CV disease or risk factors
* obesity
* smoking
* gender? (women more)

Question 17

trastuzumab induced cardiomyopathy

Answer 17

1.HER2 receptor antagonist used in breast cancer that leads to HF because
* reduced NOS expression
* reduced NO bioavailability
* increased angiotensin II (RAAS)
* increased ROS

2.can be reversed once drug is d/c
* dose adjustments based on LVEF
* dose reduction or d/c if HF develops
* if EF declines use ACEI/ARB/BB

3.risk factors
* advanced age
* presence of CV comorbidities
* previous treatment with anthracyclines

trastuzumab BBW: Associated with symptomatic and asymptomatic reductions in left ventricular ejection fraction (LVEF) and development of HF

Question 18

HF due to negative inotropy

avoid these

Answer 18

1.Non-DHP CCBs
* avoid in patients with EF < 40%

2.beta blockers
* avoid in acute HF exacerbation