Treatment Approach: HFrEF Flashcards
Morbidity and Mortality Reducing Drugs
Guideline Directed Medical Therapy
- RAAS Inhibition
ARNI, ACEI,ARB - MRAs
Spironolactone, Eplerenone - SGLT Inhibitors
Empagliflozin, Dapagliflozin, Sotagliflozin - Beta Blockers
Carvedilol, Metoprolol Succinate, Bisoprolol
Morbidity Reducing Drugs
1.Diuretics
* Loop diuretics
2.If Channel Inhibitor
* Ivabradine (Corlanor)
3.Soluble guanylate cyclase stimulator
* Vericiguat (Verquvo)
4.Cardiac Glycoside
* Digoxin (Lanoxin)
General Approach
- Initiate as many mortality reducing drugs as patient can tolerate, then titrate up to target doses
- Target doses of all GDMT = most mortality reduction
- A little of everything is better than a lot of a few things
Treatment Goals
- If de novo HFrEF, achieve maximally tolerated or target doses within 3 months
- If discharged from hospital for HFrEF, achieve maximally tolerated or target doses within 6 weeks
HFrEF treatment
for patients with persistent volume overload
add/titrate diuretic agent (loop diuretics)
HFrEF treatment
persistently symptomatic AA patients on other GDMT
add hydralazine/isosorbide dinitrate (vaso/veno dilators)
HFrEF treatment
patients w/ a resting HR ≥ 70 bpm on maximally tolerated beta- blocker and in sinus rhythm
add ivabradine
don’t need to be symptomatic
HFrEF treatment
patients on GDMT with worsening HF evidenced by hospitalization or requirement for IV diuretics and EF < 45%, confirm patient is not pregnant
add vericiguat
ARNI starting dose requirements
24/26 mg twice daily
- on 10 mg or less of enalapril
- on 160 mg or less of valsartan
- ACEI/ARB naive
- eGFR is less than 30 mL/min/1.73 m2
- 75 yrs old or older
ARNI starting dose requirements
49/51 mg twice daily
- on more than 10 mg enalapril
- on more than 160 mg valsartan
ARNI monitoring criteria
1-2 weeks: assess tolerability, monitor BP, electrolytes, renal function
ARNI target dose
97/103 mg twice daily
every 1-2 wks, increase dose step wise to this dose
ACEI/ARB monitoring criteria
1-2 weeks: assess tolerability, monitor BP, electrolytes, renal function
ACEI starting dose
lisinopril 2.5-5 mg daily
ACEI target dose
20-40 mg daily
ARB starting dose
valsartan 40 mg twice daily
ARB target dose
160 mg twice daily
every 1-2 weeks, increase dose stepwise to target doses
MRA monitoring criteria
- 7 days: assess tolerability, monitor BP, electrolytes, renal function
- after stable dose: check monthly for 3 months then every 3 months out to a year
MRA contraindications
- eGFR < 30 mL/min/1.73 m2
- creatinine > 2.5 mg/dL in men
- creatinine > 2 mg/dL in women
MRA starting dose
spironolactone 12.5-25 mg daily
MRA target dose
25-50 mg daily
increase dose stepwise at least every 2 weeks to target dose
SGLT inhibitors starting criteria
- ensure eGFR of 25 mg/ml/1.73 m2 for dapagliflozin and sotagliflozin
- contraindicated in patient with T1DM
SGLT2 inhibitors starting and target dose
- dapagliflozin (farxiga) 10 mg daily
- empagliflozin (jardiance) 10 mg daily
SGLT1 inhibitors starting dose
sotagliflozin (inpefa) 200 mg daily
SGLT1 inhibitors target dose
sotagliflozin 400 mg daily
increase dose stepwise to target dosing in 2 weeks
evidence based beta blockers monitoring criteria
monitor HR and BP after initiation and during titration
increase dose every 2 weeks stepwise to target dosing
beta blocker starting dose
bisoprolol (zebeta)
2.5 mg daily
beta blocker target dose
bisoprolol (zebeta)
10 mg daily
beta blocker starting dose
metoprolol succinate (toprol XL)
12.5-25 mg daily
beta blocker target dose
metoprolol succinate (toprol XL)
200 mg daily
beta blocker starting dose
carvedilol (coreg)
3.125-6.25 twice daily
beta blocker target dose
carvedilol (coreg)
- 25 mg twice daily
- > 85 kg: 50 mg twice daily
loop diuretics monitoring criteria
monitor BP, electrolytes and renal function after initiation and during titration
titrate to relief of congestion over days-weeks
when to add loop diurectics
- if patients are experiencing any signs of congestion (hypervolemia)
loop diuretics: threshold
- have to hit a specific drug concentration to make patient urinate some amount that is specific to that patient
- threshold is different for every patient
Increase threshold:
* Chronic use
* AKI/CKD
* Heart failure (gut edema)
loop diuretics: ceiling
- once we reach threshold even if we increase the dose the amount of urine output would only be incremental
- would have to increase dose frequency to get increased urine output
diuretic resistance
1.increased distal sodium reabsorption (chronic loop diuretic use)
* add thiazide to loop
2.poor delivery to site of effect (kidneys): reduced GFR, HF, gut edema
* increase dose of loop diuretic
loop diuretics: dosing
furosemide (oral/iv): 40 mg/20 mg
torsemide (oral/iv): 20 mg/20 mg
bumetanide (oral/iv): 1 mg/1 mg
ethacrynic acid(oral/iv): 50 mg/50 mg
hydralazine/isosorbide dinitrate monitoring criteria
monitor BP after initiation and during titration
hydralazine (apresoline) starting dose
25 mg TID
hydralazine target dose
75 mg TID
isosorbide dinitrate starting dose
20 mg TID
isosorbide dinitrate target dose
40 mg TID
BiDil (20 mg isosorbide nitrate + 37.5 mg hydralazine) starting dose
1 tablet TID
BiDil (20 mg isosorbide nitrate + 37.5 mg hydralazine) target dose
2 tablets TID
titration schedule for vaso/venodilators
increase dose every 2 weeks stepwise to target dosing
ivabradine monitoring criteria
2-4 weeks: reassess HR and increase stepwise to target dosing
how to titrate ivabradine
- HR < 50 bpm or symptoms of bradycardia: reduce dose by 2.5 mg twice daily or discontinue if already at 2.5 mg twice daily
- HR 50-60 bpm: maintain current dose and monitor heart rate
- HR > 60 bpm: increase by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily
take with food
ivabradine (corlanor) starting dose
2.5 mg twice daily with food
ivabradine (corlanor) target dose
7.5 mg twice daily with food
vericiguat (verquvo) monitoring criteria
monitor BP and CBC (anemia) during initiation and titrate
vericiguat titration schedule
double the dose every 2 weeks until target dose is achieved
vericiguat (verquvo) starting dose
2.5 mg daily with food
vericiguat (verquvo) target dose
10 mg daily with food
symptomatic HFrEF
additional therapies
digoxin
HF NYHA II-IV
additional therapies
polyunsaturated fatty acids (PUFA)
HF with hyperkalemia when taking RAASi
additional therapies
potassium binders
when to add digoxin
if already on other GDMT and patient is still symptomatic
risks associated with digoxin
- cardiac arrhythmias
- GI symptoms: anorexia, nausea, vomiting
- neuro symptoms: visual disturbances, disorientation, confusion
digoxin toxicity
- plasma concentration target 0.5-0.9 ng/mL
- patients can still develop toxicity in this range
consequences in HFrEF when administrating Non-DHP CCBs
worsening of EF/CO
consequences in HFrEF when administrating Class IC antiarrhythmic drugs and dronedarone
increased mortality
consequences in HFrEF of administrating thiazolidinediones
worsening HF symptoms and hospitalizations
consequences in HFrEF of administrating DPP-4s (saxagliptin and alogliptin)
increased HF hospitalizations
consequences in HFrEF of administrating NSAIDs
worsen HF symptoms (fluid overload)
