4 - Chronic Heart Failure

What are the 4 compensatory mechanisms & targets for drug therapy of heart failure?

1. tachycardia and increased contractility

2. fluid retention and increased preload

3. vasoconstriction and increased afterload

4. ventricular hypertrophy & remodeling

What are the hallmark manifestations of heart failure?

• dyspnea

• fatigue

• fluid retention

• abdominal pain/bloating

What are the clinical presentations of heart failure?

• tachycardia

• tachypnea

• cyanosis

• abnormal S3 & S4 heart sounds

• elevated BNP

• pulmonary rales (crackling)

• peripheral edema

• pulmonary edema

What is the gold standard diagnostic criteria for HF?

echocardiogram - can determine EF, wall thickness, valve function, chamber size

What are is stage A HF?

at risk w/o s/s

• htn

• cvd

• diabetes

• obesity

• etc.

What is stage B HF?

patients w/o s/s of HF but 1 of the following:

• structural heart disease

• increased filling pressures

• risk factors and increased BNP or cardiac troponin

What is stage C HF?

current or previous s/s of HF

What is stage D HF?

marked symptoms that interfere with daily life & recurrent hospitalizations despite treatment

What is class I HF?

• no limitation of physical activity

• ordinary activity does not cause undue fatigue, palpitation, sob

What is class II HF?

• slight limitation of physical activity

• comfortable at rest

• ordinary activity results in fatigue, palpitation, sob, chest pain

What is class III HF?

• marked limitation of physical activity

• comfortable at rest

• less than ordinary activity causes fatigue, palpitation, sob, chest pain

What is class IV HF?

• symptoms at rest

• further discomfort with physical activity

What classification is an LVEF ≧50%?

HF w/ preserved EF (HFpEF)

What classification is an LVEF = 41-49%?

HF w/ mildly reduced EF (HFmrEF)

What classification is an LVEF≦40%, but >40% on follow up?

HF w/ improved EF (HFimpEF)

What classification is an LVEF ≦40%?

HF w/ reduced EF (HFrEF)

What is the assessment approach for HF?

stage → class → LVEF%

What are the treatment goals for HF?

• improve quality of life

• relieve or reduce symptoms

• prevent or minimize hospitalization

• slow or reverse disease progression

• prolong survival & reduce mortality

What medications may worsen HF?

• NSAIDs

• COX2 inh

• thiazolidinediones

• DPP4 inh

• disopyramide

• sotalol

• dronaderone

• doxazosin

• CCBs

What is the guideline-directed medication therapy (GDMT) for HFrEF?

• meds shown to improve morbidity & mortality

• four main pillars:

1. angiotensin-receptor blocker-neprilysin inhibitor (ARNI)

2. beta blocker

3. mineralcorticoid receptor antagonist (MRA)

4. SGLT2 inhibitor

What is a key consideration of the 4 pillars in CHF?

all classes should be used & titrated to target doses

What agent is an ARNI?

sacubitril-valsartan (entresto)

In what class/LVEF of HF are ARNIs used?

II-III, HFrEF

What is the substitute for ARNI if not tolerated?

ACEi or ARB, ARNI costs more

What is the initial dosing of entresto?

sacubitril 24mg/valsartan 26mg BID

What is a drug interaction of entresto?

ACEi - angioedema risk

• must washout 36hr between

What is the target dose of entresto?

sacubitril 97mg/valsartan 103mg

What should be monitored when taking entresto?

• BP, HR

• K+

• SCr

In what class/LVEF are ACEi/ARBs used when sub for entresto?

II-IV, HFrEF

What ACEi could be used in place of entresto? (initial & target dose)

lisinopril (prinivil, zestril)

• 2.5-5mg qd

• 20-40mg qd

What ARB could be used in place of entresto? (initial & target dose)

irbesartan (avapro)

• 12.5-37.5mg qd

• 150mg qd

What beta-blocker agents reduce mortality in HFrEF?

• bisoprolol

• carvedilol

• metoprolol succinate

What is a clinical consideration of beta blockers?

• start low, titrate slowly

• be cautious in ADHF or fluid retention → could worsen HF exacerbation

What are the monitoring parameters for beta blockers?

• BP, HR

• s/s worsening HF

What is the initial & target dose of carvedilol for HF?

• 3.125mg BID

• 25mg BID

What is the initial & target dose of toprol-xl for HF?

• 12.5-25mg qd

• 200mg qd

What is the initial & target dose of cardicor for HF?

• 1.25mg qd

• 10mg qd

What class/LVEF are mineralcorticoid receptor agonists used for?

II-IV, HFrEF

24-34% reduction in mortality

What is a consideration of MRAs?

use caution to minimize hyperkalemia risk

What should be monitored when taking an MRA?

• serum potassium and creatinine

• BP

What are the ADE of MRAs?

• gynecomastia

• menstrual irregularity

What agents are MRAs?

• aldactone (spironolactone)

• inspra (eplerenone)

What is the initial & target dose of spironolactone?

• 12.5-25mg qd

• 25-50mg qd

What is the initial & target dose of eplerenone?

• 25mg qd

• 50mg qd

What is a consideration of SGLT2s?

• generally safe to add last

• may need to decrease doses of diuretics

What should be monitored when taking SGLT2s?

• BP, HR

• electrolytes

• renal function

• volume depletion

• AKI

• genital mycotic infection, UTI

• blood glucose (DM)

What are the SGLT2 agents?

• dapagliflozin (farxiga)

• empagliflozin (jardiance)

What is the initial & target dose of SGLT2s?

10mg qd

What is the 1st line diuretic class for HF?

loop, may also use thiazides

What should be monitored when taking diuretics?

• daily weight (fluid buildup)

• BP, HR

• renal function

• electrolytes (K+)

What is the course of action when increased diuretic resistance or reaching ceiling doses of loop diuretic?

• increase frequency

• switch to alternative loop diuretic

• add thiazide

What is the equivalent bumetanide & torsemide dosing for furosemide 40mg?

furosemide 40mg = bumetanide 1mg = torsemide 20mg

What is the initial dose & maximum dose of lasix?

• 20-40mg qd/bid

• 600mg

What is the initial dose & maximum dose of bumex?

• 0.5-1mg qd/bid

• 10mg

What is the initial dose & maximum dose of demadex?

• 10-20mg qd

• 200mg

What is the duration of action of lasix?

6-8hr

What is the duration of action of bumex?

4-6hr

What is the duration of action of demadex?

12-16hr

When is hydralazine-isosorbide dinitrate (bidil) considered?

in african-american patients who are persistently symptomatic despite GDMT

What is the dose of bidil?

hydralazine 37.5mg/isosorbide dinitrate 20mg TID

What are the ADE of bidil?

• headache

• dizziness

• flushing

• drug-induced lupus

When is ivabradine (corlanor) suggested for therapy?

• class II-IV

• sinus rhythm

• LVEF% ≦35%

• max tolerated beta blocker or beta blocker contraindicated

When is vericiguate (verquvo) recommended for therapy?

GDMT w/ worsening HF (hospitalization, IV diuretics)

What is an ADE of verquvo?

hypotension

What should be monitored while taking verquvo?

• BBW pregnancy

• patients must be on contraception during therapy & for 1 month after discontinuation

What is the target dosing of lanoxin?

0.5-0.9ng/mL