W13 Heart Failure Flashcards
HF: what are the three main neurohormonal compensation mechanisms ?
● Neurohormonal compensation
○ SANS (↑ HR BP, contractility)
○ RAAS (↑ BP, fluid retention)
○ ↑ cardiac workload
● CARDIAC REMODELING worsens heart failure
SANS = sympathetic autonomic nervous system?
What are the 4 heart failure classifications?
Know %
Defined by left ventricular ejection fraction
● Heart failure reduced ejection fraction (HFrEF)
○ LVEF ≤ 40%
● Heart failure preserved ejection fraction (HFpEF)
○ LVEF ≥ 50%
● Mildly reduced ejection fraction (HFmrEF)
○ LVEF 41-49%
● Improved ejection fraction (HFimpEF)
○ Previous LVEF ≤ 40%, but follow-up measurement
LVEF > 40%
HFrEF
HFpEF
What is happening to the myocardium?
Causes?
HFrEF
“Systolic Heart Failure”
LVEF ≤ 40%
● Weakened myocardium → poor ejection during systole
● Causes:
○ Coronary artery disease
○ Valvular regurgitation
○ Dilated cardiomyopathy
○ Arrhythmias
○ Toxins (e.g. methamphetamine, Chaga’s disease)
HFpEF
“Diastolic Heart Failure”
LVEF ≥ 50%
● Stiffened heart myocardium → poor filling during diastole
● Causes: “chronic”
○ HTN
○ Obesity
○ Diabetes
○ Age
○ Aortic stenosis
○ Restrictive cardiomyopathy
ACC/AHA heart failure staging
A-D
What is happening at each stage
Which medications are recommended?
Stage A: “at risk”
• BP Management (≤130/80)
• SGLT-2I for T2D + CVD or high risk CVD
Stage B: structural heart disease, NO symptoms
• ACE-I/ARB
• Beta blockers
• SGLT-2I for T2D + CVD or high risk CVD
Stage C: structure heart disease WITH symptoms
• ACEI or ARB (NYHA II-IV) / ARNI (NYHA II-III)
• Beta blockers
• SGLT-2I
• ➕ Diuretics for symptomatic management (fluid retention)
• ➕ Aldosterone antagonists (fluid retention)
• ➕ Hydralazine/nitrates (African Americans)
Stage D
• Heart transplant
• assistive devices
• experimental surgery or drugs
• Palliative care
NY heart association functional class
HF diagnosis
Complaints:
● Exercise intolerance
● ⭐️Rapid weight gain
(~5lbs/week or 2-3 lb/24h)
● Swollen legs, arms, scrotum
● Difficulty breathing at night
● Fatigue
● Cough
● Abdominal pain
Physical Exam:
● Pitting Edema
● Jugular vein distention
● Shortness of breath, wheezing, rales
● Pale, cold, sweaty
● Pink, frothy sputum
● Abdominal distention
How do you diagnose HF?
Labs 4
Other
Labs:
● ⭐️NT-proBNP > 300 pg/mL
● ⭐️ or BNP > 100 pg/mL
● Renal dysfunction: ↑ SCr, ↑ BUN
● Hepatic congestion: ↑AST, ALT, TBili
Other:
● CXR: pulmonary edema, pleural effusions, cardiomegaly
● EKG/ECG Abnormalities: arrhythmias
● Echocardiogram: assess for LVEF, LV size, wall motion abnormalities
● Right Heart Catheterization (invasive)
● Exercise stress test
HF: non-pharm recommendations
What are the goals in these categories?
Volume restriction
Toxin exposure
Comorbidities
⭐️ Which exacerbating drugs
Goals:
Symptomatic management, prevent HF progression & hospitalization, reduce mortality
1. Volume Restriction
● Sodium Restriction: < ⭐️1.5-2 g/day
● Fluid Restriction: < ⭐️2 L /day → ALL FLUIDS (e.g. water, juice, coffee)
2. Reduce cardiotoxin exposure
● Stop illicit drug use (e.g. methamphetamines)
● Smoking cessation
● Limit EtOH Intake
3. Manage other comorbidities
● Immunizations (e.g. influenza, pneumococcal, Covid-19)
● Moderate exercise
● DM: A1C < 7%
● HTN: <130/80
4. ⭐️Avoid exacerbating drugs ⭐️
● Negative inotropes: ↓ contractility → ↓ cardiac output
—Non-DHP calcium channel blockers (e.g. diltiazem, verapamil)
—Certain antiarrhythmics (e.g. flecainide, propafenone, disopyramide, sotalol)
—✅ Amiodarone & dofetilide are ok
● Na/H2O Retention: ↑ fluid retention → ↑ BP → ↑ work on heart
—NSAIDs
—Glucocorticoids
—Thiazolidinediones (TZDs) → pioglitazone, rosiglitazone
HFrEF treatment guideline directed medical therapy
4 big ones
6 overall
- ACEI/ARB
- ARNI
- BB
- MRA
Where medications act — reference
Loop diuretics
Place in therapy
MOA
FDA indications
Note
Caution
Go to for fluid overload state
⭐️Meds:
• furosemide 20mg IV / 40mg PO(Lasix) ⭐️ know dose
• bumetanide (Bumex)
• torsemide (Demadex)
• ethacrynic acid (Edecrin)
Place in GDMT:
• primarily for symptomatic management, ⭐️ no effect on mortality
• MOA: inhibits the Na-K-2Cl cotransporter in the ascending
loop of Henle in the kidneys → ⭐️ ↑ Na & H2O excretion
• FDA Indications:
o Heart Failure
o HTN
o Hepatic & renal disease
● Note:
○ Exacerbations: initiate at 1-2.5x home diuretic dose
intravenously
○ Ethacrynic acid used for patients with severe
sulfa/sulfonamide allergies
C/I: Anuria, Hypersensitivity rxns
ADRs
Electrolyte abnormalities
● ↓ Na, K, Mg, Ca⭐️
● ↑ uric acid
Ototoxicity/tinnitus
● ⭐️ Especially IV furosemide when given too quickly or at
very high doses
CV: hypotension (volume depletion)
Renal: ↑ urination, acute kidney injury (↑SCr, BUN)
Thiazide Diuretics
Place in therapy
MOA
FDA indications
Note
Caution
Meds (adjunct to loop diuretics)
● ⭐️ hydrochlorothiazide (Microzide)
● ⭐️ chlorthalidone (Hygroton/Thalitone)
● ⭐️ chlorothiazide (Diuril)
● ⭐️ metolazone (Zaroxolyn)
⭐️ Place in GDMT ⭐️
● symptomatic management, no effect on mortality, adjunct therapy to loop diuretics
○ Consider HCTZ or chlorthalidone in HTN + HF with mild edema
○ Consider chlorothiazide or metolazone for refractory edema
MOA:
● inhibits the NCC cotransporter in the distal convoluted tubule
→ ⭐️ ↑ Na & H2O excretion⭐️
FDA Indications:
○ Heart Failure
○ HTN
○ Hepatic & renal disease
Note:
○ Administer 30 mins prior to loop diuretics
○ Chlorothiazide is the only IV thiazide
○ ⭐️ CrCl < 30 mL/min → diminished diuretic effect unless
combined with loop diuretics ⭐️
● 🔺Caution in gout: ↑ uric acid reabsorption (> than loop
diuretics) 🔺
C/I
Anuria
Hypersensitivity rxns
Metolazone: hepatic coma
ADRS
Electrolyte abnormalities
● ↓ Na, K, Mg
● ⭐️ ↑ Ca, uric acid ⭐️
CV: hypotension (volume depletion)
Renal: ↑ urination, acute kidney injury (↑SCr, BUN)
Beta Blockers
↓ SANS & RAAS, ↓ contractility, ↓ HR
⭐️Meds ⭐️
● metoprolol succinate (Toprol XL)
● carvedilol (Coreg, Coreg CR)
● bisoprolol (Zebeta)
Place in GDMT:
● Pre-HF Stage B, HF Stage C & D, ⭐️ reduces
mortality, hospitalizations, & ↓ cardiac remodeling ⭐️
MOA:
● blocks β-adrenergic receptors on blood vessels, heart,
& kidneys → ↓ vasoconstriction, ↓ HR, ↓ renin secretion,
↓ contractility → ⭐️ ↓ cardiac workload/stress
FDA Indications:
○ Heart Failure
○ ACS
○ HTN
○ (off-label) AFib
⭐️ Note ⭐️:
○ Do not abruptly discontinue → withdrawal → unstable angina & myocardial infarction
○ Carvedilol is less β1-selective & has ɑ1 antagonism → not the best for patients with respiratory
issues (e.g. COPD, asthma), use metoprolol succinate or bisoprolol instead
C/Is
Sinus bradycardia
Heart block
Decompensated HF
Cardiogenic shock
ADRs
CV: bradycardia, hypotension
CNS: depression, dizziness
Endocrine: mask hypoglycemia symptoms
Respiratory: (less likely) bronchospasms → most HF beta blockers are β1 selective except for
carvedilol
Question for reference
The 3 recommended beta blockers are
Metoprolol succinate XL
Carvedilol (Coreg)
Bisoprolol
They are the only three that were tested in clinical trials
ARNI
Meds
• ⭐️sacubitril/valsartan (Entresto)
⭐️ Place in GDMT ⭐️:
• HF Stage C & D, reduces mortality, hospitalizations, & ↓ cardiac remodeling
*preferred over ACEi/ARB
MOA: [sacubitril]
• inhibits neprilysin enzyme → increases
vasodilatory peptides → vasodilation & diuresis/ [valsartan]
angiotensin receptor blocker → ⭐️ ↓ cardiac workload/stress ⭐️
FDA Indications:
o Heart Failure
Note:
○ Requires a 36 hour-washout period when switching ACEi → ARNi (↑ risk for angioedema)
■ No need for washout if ARB → ARNi
○ $550/month → Brand only, consider issues with coverage
⭐️Caution ⭐️:
○ Renal insufficiency (SCr ≥ 3 mg/dL, CrCl < 30 mL/min, K ≥ 5 mEq/L)
C/I
🔺pregnancy: BBW Fetal toxicity 🔺
Angioedema (> ARB, early vs. delayed presentation)
Bilateral renal artery stenosis
Concomitant use with Entresto
Concomitant use with aliskiren in patients with DM
Hypotension
ADRS
Hyperkalemia
Acute kidney injury (↑SCr, BUN)
Potent hypotension (ARNi>ACEi/ARB)
Question for reference
ACEI ~pril
lisinopril (Zestril/Prinivil), enalapril (Vasotec), captopril (Capoten), fosinopril (Monopril)
perindopril (Aceon), quinapril (Accupril), ramipril (Altace), trandolapril (Mavik)
⭐️Place in GDMT ⭐️:
Pre-HF Stage B, HF Stage C & D, reduces mortality, hospitalizations, & ↓ cardiac remodeling
ACEi preferred over ARB unless intolerant
MOA:
○ inhibits ACE →↓ angiotensin II → ↑ vasodilation & Na excretion, ↓ aldosterone release
FDA Indications:
o Heart Failure
o HTN
o ACS
Note:
○ Can use any ACEi but guidelines have recommended doses for the above
Caution:
○ ⭐️ Renal insufficiency (SCr > 3 mg/dL, CrCl < 30 mL/min, K > 5mg/dL)
C/I
○ Angioedema (> ARB, early vs. delayed presentation)
○ Bilateral renal artery stenosis
○ 🔺Pregnancy (BBW: fetal toxicity) 🔺
ADRS
○ Dry cough
○ Angioedema
○ Hyperkalemia
○ Acute kidney injury (↑SCr, BUN)
○ Hypotension (ARNi>ACEi/ARB)
○ Concomitant use with Entresto
○ Concomitant use with aliskiren in patients with DM
ARB ~sartan
Meds
losartan (Cozaar)
valsartan (Diovan)
candesartan (Atacand)
Place in GDMT:
• Pre-HF Stage B, HF Stage C & D, reduces mortality, hospitalizations, & ↓ cardiac remodeling
*alternative to ACEi
MOA:
• blocks angiotensin II from binding to angiotensin I receptors → ↑ vasodilation, Na excretion,
↓ aldosterone release
FDA Indications:
o Heart Failure
o HTN
o ACS
Note:
caution & contraindications very similar to ACEi; does not require washout period with Entresto
losartan (Cozaar), valsartan (Diovan), candesartan (Atacand)
contraindications and ADRs not accurate
Question for reference
MRAs
Meds
—spironolactone (Aldactone)
—eplerenone (Inspra) —selective MRA
Place in GDMT: HF Stage C & D, reduces mortality, hospitalizations, & ↓ cardiac remodeling
⭐️Add on when:
⭐️ CrCl ≥ 30 mL/min
⭐️ SCr ≤ 2.5 mg/dL in MEN or SCr ≤ 2 in WOMEN
⭐️ K+ < 5 mEq/L
• MOA: aka “potassium-sparing diuretic”, antagonizes aldosterone receptors in the distal
convoluted tubule & collecting ducts of the kidneys → ↓ Na & H2O reabsorption
• FDA Indications:
o Heart Failure
o Ascites due to cirrhosis
o HTN
• Note:
o Spironolactone blocks androgen receptors whereas eplerenone is selective for mineralocorticoid receptors (spironolactone $50 for 30-day supply vs. eplerenone $150 for 30-day supply)
o 🔺 K+ ≥ 5.5 mEq/L → discontinue drug 🔺
C/I
⚠️ Addison’s disease
⚠️ Hyperkalemia
ADRs
o Hyperkalemia (especially when combined with
o RAASi agents or in renal insufficiency)
o 🔺 Gynecomastia (spironolactone) 🔺
o Hypotension
Question reference
RAAS inhibiting agents and spironolactone can increase K+
SGLT2
Meds — ↓ fluid retention
• dapagliflozin (Farxiga)
• empagliflozin (Jardiance)
Place in GDMT:
• Stage A & B in patients with diabetes, HF Stage C & D regardless of diabetes, reduces
mortality, hospitalizations, symptoms
MOA:
• inhibits sodium-glucose cotransporter 2 in the PCT of kidneys → ↓ Na & glucose reabsorption →
↑ glycosuria, diuresis, & natriuresis
FDA Indications:
o Heart Failure
o Type 2 diabetes
● Note:
○ Dapagliflozin (~$551/month), Empagliflozin (~$578/month)
○ Caution use in patients with recurrent UTIs, possible
risk factors for diabetic ketoacidosis
○ HF dosing is different from DM dosing
C/Is
• severe renal impairment
• dialysis
ADRs
• Infections (e.g. UTI, necrotizing fasciitis/Fournier’s
gangrene)
• Euglycemic diabetic ketoacidosis
- risk factors: missing meals, EtOH, infections
• Increased urination
• Hypotension
• Acute kidney injury
Nitrates/Hydralazine
↓ preload (nitrate) & ↓ afterload (hydralazine)
Meds
isosorbide dinitrate/hydralazine (BiDil)
isosorbide dinitrate (Isordil) + hydralazine (Apresoline)
Place in GDMT:
• Self-identified African American patients with NYHA Class III-IV HFrEF intolerant of
ARNi/ACEi/ARB or already on optimal GDMT, reduces mortality, hospitalizations, & ↓ symptoms in select
patient population
o Intolerance: renal insufficiency, hyperkalemia
MOA:
• [nitrates] increases nitric oxide in blood vessels → venous vasodilation & ↓ preload;
• [hydralazine] direct arterial vasodilator that ↓ afterload →↓ cardiac work
Indications
• BiDil: Heart Failure
• Hydralazine: HTN
• Isosorbide dinitrate: angina
C/I
• Concomitant use with PDE-5 inhibitors & riociguat
• Severe hypotension
• Myocardial ischemia
ADRs
• Hypotension
• Lupus-like reaction (hydralazine)
• Flushing
• Tachycardia
Notes
• Bidil (~$401) → separate into 2 medications → isosorbide dinitrate + hydralazine
• Counsel on risk for hypotension
Digoxin
Ivabradine
EF?
Plus which other criteria?
MOA
C/I
DDIs
Vericiguat
HFrEF GDMT initiation
HFpEF treatment
Guideline recommendations
HFmrEF treatment
HFimpEF treatment
Guideline recommendations
Summary of HF
