29/30 - HFrEF Flashcards by Karlo Sison

MoA in HF-rEF

ACE-I & ARB
Enalapril / Lisinopril / Ramipril
Valsartan / Candesartan / Losartan

↓Preload - ↓Afterload - Cardiac Remodeling

ACE/ARB

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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MoA in HF-rEF

Beta Blockers
Metoprolol SUCCinate/Bisoprolol / Carvedilol

↓Afterload - Cardiac Remodeling

BETA BLOCKERS

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis -↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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MoA in HF-rEF

DIURETICS
Loop = Furosemide / Bumetanide / Torsemide
Thiazide = HCTZ / Chlorithalidone / Metazolone

↓Preload

DIURETICS

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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MoA in HF-rEF

Aldosterone Receptor Antagonist = ARA
Spironolactone / Eplerenone

↓Preload - Cardiac Remodeling

ARA = Spironolactone / Eplerenone

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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MoA in HF-rEF

Sacubatril/Valsartan = ENTRESTO

↓Preload - ↓Afterload - Cardiac Remodeling

Sacubatril/Valsartan = Entresto
SAME AS ACE/ARB + additional VASODILATION

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis - ↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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MoA in HF-rEF

Ivabradine = CORLANOR

INDIRECTLY –> Lowers HEART RATE

Ivabradine = Corlanor

AT2 + Aldosterone –> Na + H₂O Retention
↑Preload - Vascular Congestion

AT2 + NE –> Vasoconstriction
↑Afterload ↑MVO₂ ↓Stroke Volume

NE –> SNS Excess
Apoptosis -↑MVO₂

AT2 + Aldosterone + NE –> Cardiac Remodeling
↓CO - Arrhythmias

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HF-rEF Treatment:
ACE INHIBITORS

Place in therapy for All Stages?

ALL Pts in Stage C/D
+
ALL ASx pts in Stage B
DELAYS onset of Sxs & 1st HF hospitilization

High Risk Patients in Stage A (just at risk, no SXs)
Vascular Disease = PAD / PVD / Stroke
DM + 1 CV Risk Factor
OR
DM + Smoking / MicroAlbuminuria

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HF-rEF Treatment:
BETA BLOCKERS

Place in therapy for All Stages?

ALL Pts in Stage B/C/D
↓ HF symptoms + ↓Hospitalizations
SLOWS HF Progression:
↓incidence of sudden death (Ventricular fibrillation)

HIGH DOSE:
↓ mortality/hospitalizations, ↑ ejection fraction

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HF-rEF Treatment:
DIURETICS

Place in therapy for All Stages?

Management of FLUID OVERLOAD** in **Stage C+D
Most LOOP diuretics
Thiazides for MILD fluid overload = better HTN drug

Clinical Benefit:

*SYMPTOMATIC ONLY**
no effect on MORTALITY*

Stage A + B –> only for HTN

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HF-rEF Treatment:
ARA’s
Spironolactone / Eplerenone

Place in therapy for All Stages?

STAGE C/D
NYHA FC 2-3 w/ SYMPTOMS
&
Stage B/C
Post MI / EF<40 / HF Symptoms or DM

Clinical Benefits:
↓ hospitalizations, mortality
IMPROVED SYMPTOMS
decreases fibrosis/remodeling

consider in STAGE B resistant HTN

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HF-rEF Treatment:
Hydralazine + Isosorbide

Place in therapy for All Stages?

AFRICAN AMERICANS
In addition to OPTIMAL THERAPY of RAAS-1 + BB in Class 3-4
↓ mortality & ↓ hospitalizations for HF

Alternate Therapy for those UNABLE to take ACE/ARB
due to intolerance or contraindication
Ex. Pregnancy / Angioadema / Advanced Kidney Disease

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HF-rEF Treatment:
ENTRESTO
Sacubutril/Valsartan?

Place in therapy for All Stages?

REPLACES ACE/ARB
for patients with:
SYMPTOMATIC HFr-EF Class 2-3
↓ hospitalizations from HF + ↓CV mortality

*Need BP >100mmHg**
due to greater DROP in BP*

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HF-rEF Treatment:
CORLANOR
Ivabradine

Place in therapy for All Stages?

ADD to Std therapy (ACE/ARB + BB)
BB should be at TARGET or MAX tolerated dose
in patients with:
Symptomatic HFr-EF FC2-3
AND:
RESTING HR > 70bpm

*↓ hospitalizations and death from HF
No overall mortality benefit***

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HF-rEF Treatment:
DIGOXIN

Place in therapy for All Stages?

Added to Std of Care in SYMPTOMATIC HFr-EF
NOT ADDRESSED in 2017 GUIDELINES
only studies are from OLD treatment protocols

↓Hospitilizations
BUT:
NO effect on MORTALITY

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HF-rEF DOSING:

ACE INHIBITORS

*ENALAPRIL**
*2.5-5** BID > 10mg BID
*LISINOPRIL**
*2.5-5 qd** > 20-40mg qd
*Ramipril**
*1.25-2.5 qd > 10mg qd**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

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HF-rEF DOSING:

ARBs

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*VALSARTAN**
*40 BID > 160 BID**

CANDESARTAN
4-8 qd > 32 qd

*LOSARTAN**
*25-50 qd > 150 qd**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

HF-rEF DOSING:

BETA BLOCKERS

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ONLY these 3 DRUGS have proven Benefit*
*DOUBLE the DOSE every 2 WEEKS as tolerated**
*METOPROLOL SUCCINATE**
*12.5-25 qd > 200 qd**
*BISOPROLOL
1. 25 qd > 10 qd**
*CARVEDILOL**
*3.125-6.25 BID > 25-50 BID**

MAXIMIZE DOSE EVEN IF BP IS NORMAL
STILL A REDUCTION IN MORTALITY

HF-rEF DOSING:

LOOP DIURETICS

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NO TARGET DOSE* –> SYMPTOMATIC ONLY
*INITIAL DOSE** > Maintanence dose
need to get FLUID OUT ASAP*
*BUMETANIDE**
*0.5-1** qd OR bid -> max= 10
*FUROSEMIDE**
*20-40** qd OR bid -> max= 600
*TORSEMIDE**
*10-20** qd OR bid -> max= 200

HF-rEF DOSING:

THIAZIDE DIURETIC

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NO TARGET DOSE* –> SYMPTOMATIC ONLY
*INITIAL DOSE** > Maintanence dose
need to get FLUID OUT ASAP*
*HCTZ**
*25 qd** -> max= 200
*Chlorthalidone**
*12-25 qd** -> max= 100
*Metolazone**
*2.5 qd** -> max= 20

HF-rEF DOSING + WHEN TO AVOID STARTING?

ARA
Spironolactone + Eplerenone

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Can start at the TARGET DOSE
Avoid Starting if:
K ≥ 5 mEq/L or
SCr ≥ 2.5 mg/dL or
CrCl < 30 ml/min
Likely will need to ↓ or d/c K supplements

*SPIRONOLACTONE**
*25 qd - Target**
*Eplerenone**
*50 qd - Target**

HF-rEF DOSING:

*HYRALAZINE / ISOSORBIDE**
*BiDil** = Combo

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Initial Dose:
Hydralazine 25-50** + **ISDN 20-30 TID or QID
Bidil is diff concentration TID

Target Dose:
Hydralazine 300mg** + **ISDN 120mg in div doses

Monitor:
BP + Adherence

ADR = Headache

HF-rEF
DOSING + SWITCH CONSIDERATIONS

Sacubutril / Valsartan
ENTRESTO

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Titrate q2 weeks to TARGET as tolerated
MORE HYPOTENTION –> more CAUTIOUS w/ dosing
36 HOUR WASHOUT
when switching from ACE-I, need to take back old med
due to increased risk of ANGIOEDEMA

Dose is Converted from current ACE/ARB dose

49/51 -> 97/103

HF-rEF
DOSING + CONSIDERATIONS

IVABRADINE
CORLANOR

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*BetaBlocker needs to be @Target or @MAX**
*HR > 70 bpm** BEFORE starting

Ivabradine initial start:

*5mg BID**
*TAKE WITH FOOD = Better Bioavailability**

HEART RATE MONITORING
every 2 weeks after dose adjustment & q4 months

HF-rEF MONITORING & ADR

ACE / ARB

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RENAL FXN** + **K-Potassium
within 1-2 weeks: of start & after dose increases
q6 months in stable pts

Contraindicated in PREGNANCY*
-> use Hydralazine/Isosorbide

Symptomatic HypoTension = BP
low BP is FINE, just watch out for SYMPTOMS

Cough / ANGIOEDEMA
more common in ACE-I

**HF-rEF MONITORING & ADR** **_Beta Blockers_**

**_May initially WORSEN SYMPTOMS_** reason for *slow titration up* * *_Carvedilol_** * *better for HTN** + ***more dizzyness*** + **diarrhea** **_Metoprolol + Bisoprolol_** good for reactive airway disease **Carvedilol switch to Metoprolol if _symptomatic Hypotension_** (*less BP effect)* ADR: **SOB / EDEMA = worsening HF, need to slow titration Symptomatic Bradycardia --\> need to lower dose/slow**

**HF-rEF MONITORING & ADR** **_DIURETICS_**

**_DIURETIC RESISTANCE_** *declining response dispite INCREASING doses* **Na+ Diet / NSAIDs / Renal Fxn** can **COMBINE LOOP + THIAZIDE/Metolazone for _SYNERGISTIC EFFECT_** Safety/Efficacy: * *Daily Weight / HF Symptoms** * *_ELECTROLYTES**_ + _**RENAL FUNCTION_** * *_OTOTOXICITY_** = *only @ high dose/rapid IV push*

**HF-rEF MONITORING & ADR** **_SPIRONOLACTONE / EPLERENONE_**

**_RENAL FXN**_ + _**K-POTASSIUM_** within **3 days** & **1 week after initiation** **monthly for 1st 3 months** --\> 3-4months after **_K \> 5.5_** **_counseling:_** **avoid K+ foods / NSAIDS / Salt D/C supplements or Drug _K-BINDER_** for severe elevation \> 6 **_ECG IF NEW BRADYCARDIA_** life threatening HYPERkalemia

* *HF-rEF** * *_BETA BLOCKERS_** * *when should we AVOID to START or INCREASE dose?**

* avoid starting / increasing dose of BB if...* * *_ACUTE EXACERBATION_** * *Volume Overload / Worsening signs** **BB is _initially a NEGATIVE INOTROPE_** can worsen symptoms at first ***_no NEED to WAIT for reaching TARGET ACE/ARB DOSE_*** before initiating

**HF-rEF MONITORING & ADR** **_SACUBITRIL / VALSARTAN_**

**_ANGIOEDEMA_** **history with ACE / ARB = CONTRAINDICATED** + **36 hours washout when switching** **_HYPERKalemia**_ + _**Renal Dysfunction_** * *Caution w/ BP \<100** * more ANTI-HTN than ACE/ARB*

**HF-rEF MONITORING & ADR** **_Ivabradine = Corlanor_**

**_HR MONITORING_** **can reduce HR by 10bpm during rest/exercise** need **HR \> 70bpm b4 start** 2 weeks after dose adjustments / q4 months ADR: * *_AFIB_** - new start * *_Luminous Phenomena_** = **bright spots** * *Bradycardia**

**HF-rEF MONITORING & ADR** **_DIGOXIN_**

_Elimination_ **RENAL** + **P-Gp Interactions** **AVOID Pg-P Inhibitors + Other AV nodal Blockers** * *_CrCl + IBW DOSING_** * *K + Mag low** Suspected Toxicity: **ECG + Visual Changes (green-yellow)** **CONFUSION NVD**

**Which Beta Blocker would you choose if** **HTN is a bigger issue?** AKA MORE BP LOWERING EFFECT

**_CARVEDILOL_** stronger **BP lowering agent** ***_Metoprolol / Bisoprolol_*** better for **patients with hypotension**

29/30 - HFrEF Flashcards

(32 cards)