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IPC Cardiology > Treatment Approach: HFrEF > Flashcards

Treatment Approach: HFrEF Flashcards

1
Q

Morbidity and Mortality Reducing Drugs

Guideline Directed Medical Therapy

A
  1. RAAS Inhibition
    ARNI, ACEI,ARB
  2. MRAs
    Spironolactone, Eplerenone
  3. SGLT Inhibitors
    Empagliflozin, Dapagliflozin, Sotagliflozin
  4. Beta Blockers
    Carvedilol, Metoprolol Succinate, Bisoprolol
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2
Q

Morbidity Reducing Drugs

A

1.Diuretics
* Loop diuretics

2.If Channel Inhibitor
* Ivabradine (Corlanor)

3.Soluble guanylate cyclase stimulator
* Vericiguat (Verquvo)

4.Cardiac Glycoside
* Digoxin (Lanoxin)

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3
Q

General Approach

A
  1. Initiate as many mortality reducing drugs as patient can tolerate, then titrate up to target doses
  2. Target doses of all GDMT = most mortality reduction
  3. A little of everything is better than a lot of a few things
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4
Q

Treatment Goals

A
  1. If de novo HFrEF, achieve maximally tolerated or target doses within 3 months
  2. If discharged from hospital for HFrEF, achieve maximally tolerated or target doses within 6 weeks
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5
Q

HFrEF treatment

for patients with persistent volume overload

A

add/titrate diuretic agent (loop diuretics)

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6
Q

HFrEF treatment

persistently symptomatic AA patients on other GDMT

A

add hydralazine/isosorbide dinitrate (vaso/veno dilators)

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7
Q

HFrEF treatment

patients w/ a resting HR ≥ 70 bpm on maximally tolerated beta- blocker and in sinus rhythm

A

add ivabradine

don’t need to be symptomatic

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8
Q

HFrEF treatment

patients on GDMT with worsening HF evidenced by hospitalization or requirement for IV diuretics and EF < 45%, confirm patient is not pregnant

A

add vericiguat

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9
Q

ARNI starting dose requirements

24/26 mg twice daily

A
  • 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
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10
Q

ARNI starting dose requirements

49/51 mg twice daily

A
  • on more than 10 mg enalapril
  • on more than 160 mg valsartan
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11
Q

ARNI monitoring criteria

A

1-2 weeks: assess tolerability, monitor BP, electrolytes, renal function

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12
Q

ARNI target dose

A

97/103 mg twice daily

every 1-2 wks, increase dose step wise to this dose

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13
Q

ACEI/ARB monitoring criteria

A

1-2 weeks: assess tolerability, monitor BP, electrolytes, renal function

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14
Q

ACEI starting dose

A

lisinopril 2.5-5 mg daily

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15
Q

ACEI target dose

A

20-40 mg daily

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16
Q

ARB starting dose

A

valsartan 40 mg twice daily

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17
Q

ARB target dose

A

160 mg twice daily

every 1-2 weeks, increase dose stepwise to target doses

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18
Q

MRA monitoring criteria

A
  • 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
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19
Q

MRA contraindications

A
  • eGFR < 30 mL/min/1.73 m2
  • creatinine > 2.5 mg/dL in men
  • creatinine > 2 mg/dL in women
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20
Q

MRA starting dose

A

spironolactone 12.5-25 mg daily

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21
Q

MRA target dose

A

25-50 mg daily

increase dose stepwise at least every 2 weeks to target dose

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22
Q

SGLT inhibitors starting criteria

A
  • ensure eGFR of 25 mg/ml/1.73 m2 for dapagliflozin and sotagliflozin
  • contraindicated in patient with T1DM
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23
Q

SGLT2 inhibitors starting and target dose

A
  • dapagliflozin (farxiga) 10 mg daily
  • empagliflozin (jardiance) 10 mg daily
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24
Q

SGLT1 inhibitors starting dose

A

sotagliflozin (inpefa) 200 mg daily

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25
Q

SGLT1 inhibitors target dose

A

sotagliflozin 400 mg daily

increase dose stepwise to target dosing in 2 weeks

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26
Q

evidence based beta blockers monitoring criteria

A

monitor HR and BP after initiation and during titration

increase dose every 2 weeks stepwise to target dosing

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27
Q

beta blocker starting dose

bisoprolol (zebeta)

A

2.5 mg daily

28
Q

beta blocker target dose

bisoprolol (zebeta)

A

10 mg daily

29
Q

beta blocker starting dose

metoprolol succinate (toprol XL)

A

12.5-25 mg daily

30
Q

beta blocker target dose

metoprolol succinate (toprol XL)

A

200 mg daily

31
Q

beta blocker starting dose

carvedilol (coreg)

A

3.125-6.25 twice daily

32
Q

beta blocker target dose

carvedilol (coreg)

A
  • 25 mg twice daily
  • > 85 kg: 50 mg twice daily
33
Q

loop diuretics monitoring criteria

A

monitor BP, electrolytes and renal function after initiation and during titration

titrate to relief of congestion over days-weeks

34
Q

when to add loop diurectics

A
  • if patients are experiencing any signs of congestion (hypervolemia)
35
Q

loop diuretics: threshold

A
  • 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)

36
Q

loop diuretics: ceiling

A
  • 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
37
Q

diuretic resistance

A

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

38
Q

loop diuretics: dosing

A

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

39
Q

hydralazine/isosorbide dinitrate monitoring criteria

A

monitor BP after initiation and during titration

40
Q

hydralazine (apresoline) starting dose

A

25 mg TID

41
Q

hydralazine target dose

A

75 mg TID

42
Q

isosorbide dinitrate starting dose

A

20 mg TID

43
Q

isosorbide dinitrate target dose

A

40 mg TID

44
Q

BiDil (20 mg isosorbide nitrate + 37.5 mg hydralazine) starting dose

A

1 tablet TID

45
Q

BiDil (20 mg isosorbide nitrate + 37.5 mg hydralazine) target dose

A

2 tablets TID

46
Q

titration schedule for vaso/venodilators

A

increase dose every 2 weeks stepwise to target dosing

47
Q

ivabradine monitoring criteria

A

2-4 weeks: reassess HR and increase stepwise to target dosing

48
Q

how to titrate ivabradine

A
  • 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

49
Q

ivabradine (corlanor) starting dose

A

2.5 mg twice daily with food

50
Q

ivabradine (corlanor) target dose

A

7.5 mg twice daily with food

51
Q

vericiguat (verquvo) monitoring criteria

A

monitor BP and CBC (anemia) during initiation and titrate

52
Q

vericiguat titration schedule

A

double the dose every 2 weeks until target dose is achieved

53
Q

vericiguat (verquvo) starting dose

A

2.5 mg daily with food

54
Q

vericiguat (verquvo) target dose

A

10 mg daily with food

55
Q

symptomatic HFrEF

additional therapies

A

digoxin

56
Q

HF NYHA II-IV

additional therapies

A

polyunsaturated fatty acids (PUFA)

57
Q

HF with hyperkalemia when taking RAASi

additional therapies

A

potassium binders

58
Q

when to add digoxin

A

if already on other GDMT and patient is still symptomatic

59
Q

risks associated with digoxin

A
  1. cardiac arrhythmias
  2. GI symptoms: anorexia, nausea, vomiting
  3. neuro symptoms: visual disturbances, disorientation, confusion
60
Q

digoxin toxicity

A
  1. plasma concentration target 0.5-0.9 ng/mL
  2. patients can still develop toxicity in this range
61
Q

consequences in HFrEF when administrating Non-DHP CCBs

A

worsening of EF/CO

62
Q

consequences in HFrEF when administrating Class IC antiarrhythmic drugs and dronedarone

A

increased mortality

63
Q

consequences in HFrEF of administrating thiazolidinediones

A

worsening HF symptoms and hospitalizations

64
Q

consequences in HFrEF of administrating DPP-4s (saxagliptin and alogliptin)

A

increased HF hospitalizations

65
Q

consequences in HFrEF of administrating NSAIDs

A

worsen HF symptoms (fluid overload)

IPC Cardiology (6 decks)

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