Learn: Chapter 31. CHF

What are 2 common causes of CHF?

• MI (ischemic)

• long-standing uncontrolled HTN (non-ischemic)

What is the staging system used for?

to guide treatment to slow progression of left ventricular hypertrophy (LVH), low EF (structural heart disease)

At what stage of the ACC/AHA system does a patient become symptomatic?

C

How does the NYHA classification system organize HF classes?

by limitation in physical functioning

ACC/AHA Stages

• A - At risk for HF

• B - pre-HF: structural heart disease, but no s/sx

• C - structure/fxnl cardiac abnormalities with sx

• D - Advanced HF with severe sx/hospitalizations

NYHA Functional Classes

• I -no limitations of physical activity

• II - ordinary physical activity (stairs) = sx (comfy at rest)

• III - comfy at rest but minimal exertion (bath/dress) = sx

• IV - no physical activity without sx of HF or sx at rest

Labs/Biomarkers of CHF

• increased BNP (normal

Left-Sided s/sx

• Orthopnea: SOB when lying flat

• Paroxysmal nocturnal dypsnea (PND)

• Bibasilar rales: crackling lung sounds on exam

• S3 gallop: abnormal heart sound

• Hypoperfusion (renal impairment, cool extremities)

General CHF s/sx

• Dypsnea (SOB @ rest or exertion)

• Cough

• fatigue, weakness

• reduced exercise capacity

Right-Sided s/sx

• Peripheral edema

• Ascites

• JVD

• Hepatojugular reflex (neck distention from abdomen pressure)

• Hepatomegaly

How is cardiac output calculated?

CO = SV x HR

How is cardiac index calculated?

CI = CO/BSA

How does the body compensate for HFrEF that ends up leading to damaging cardiac remodeling?

• neurohormonal pathways increase blood volume

• force/speed contractions increased

What systems are mainly activated in HF?

• RAAS

• SNS

• Vasopressin

Which neurohormones typically balance the systems involved in HF?

• natriuretic peptides

What does ANG II cause?

vasoconstriction; stimulates aldosterone release from adrenal gland and vasopressin from pituitary

What are the effects of aldosterone?

sodium and H2O retention

What are the effects of vasopressin?

• vasoconstriction

• H2O retention

What does SNS (NE and Epi) activation cause?

increased HR, contractility (positive inotropy), and vasoconstriction

Natural products that patients use for HF?

• Omega-3 fatty acid (fish oil) -> reasonable to dec. mortality and CV hospitalizations

• Hawthorn (sx)

• Coenzyme Q 10 (sx)

Lifestyle mgmt of HF

• Monitor body weight daily

• Notify provider if weight increased by 2-4 pounds in a day or 5 lbs in a week

• avoid excessive sodium (

Key Drugs that Worsen HF

• DPP-4 Inhibitors

- alogliptin, saxagliptin

• Immunosuppresants

- TNF inhibitors i.e. adalimumab

• Non-DHP CCBs

- diltiazem and verapamil (if EF

What 4 drug classes are GDMT?

• ARNI, ACE, ARB

- dec. morbidity and mortality

• BB

- dec. mortality and hospitalizations

• ARA

- dec morbidity and mortality in NYHA class II-IV\

• SGLT2 inhibitor

- dec hospitalizations and mortality

Additional add on medications in select patients

• Loops (dec sx)

• Hydralazine and Nitrate - african american with NYHA III-IV

• Ivabradine

- dec risk of hospitalization and CV death in stable class NYHA II-III w/ resting heart rate at least 70bpm in NSR on max dose of BB

• Digoxin (small inc in CO)

- dec. hopitalizations

- good for pts w sx and cannot tolerate 1st line tx

• Vericiguat

- dec CV death and hospitalization risk after recetn HF hospitalization or need for IV diuretics

- pts getting worse despite first-line tx

What drug class is recommended even for patients with HFpEF or HFmrEF?

SGLT2 inhibitors

Sacubitril in Entresto is what class of medication?

neprilysin inhibitor (enzyme that is responsible for degradation of several beneficial vasodilatory pepties)

An ARNI is indicated in NYHA Class II-IV patients to decrease __________ and _________.

HF hospitalizations and CV death

Preferred in HFrEF over ACE or ARB

What is the target dose of Entresto?

97/103 mg BID

Contraindications to Entresto

• Use within 36 hours of ACE

• Hx of angioedema

Boxed Warning for Entresto

Injury and death to developing fetus (dsc as soon as pregnancy detected)

Warnings/Side effects of Entresto

• cough

• angioedema

• hyperkalemia

• renal impairment (bilateral renal artery stenosis (avoid use))

• hypotension

Monitoring with Entresto

• BP

• K

• Renal fxn (increased SCr)

• s/sx of HF

What is the result of both ACEs and ARBs?

Decreased vasoconstriction and aldosterone secretion

ACE also blocks degradation of bradykinin

ACE inhibitors have same boxed warning, contraindications, warnings/side effects, and monitoring as what drug?

Entresto

Enalapril brand name

Vasotec

Lisinopril brand name

Zestril

Quinapril brand name

Accupril

Ramipril brand name

Altace

Losartan brand name

Cozaar

Valsartan brand name

Diovan

Target dose of ACE inhibitors for HF

• Lisinopril (Zestril): 20-40 mg daily

• Enalapril (Vasotec): 10-20mg BID

• Ramipril (Altace): 10 mg daily

• Quinipril (accupril): 20 mg BID

Why should more than one RAAS inhibitor NOT be used together?

renal impairment and hyperkalemia risk

How do BBs improve HF?

• antagonize effects of catecholamines (especially NE)

• decrease morbidity and mortality

What BBs are recommended in HF for all patients?

• bisoprolol

• metoprolol succinate (XL)

• carvedilol IR and ER

big myo cardium

What is the target dose of Metoprolol succinate XL?

200mg daily

Carvedilol brand name

Coreg, Coreg CR

Carvedilol MOA

non-selective BB and alpha 1 blocker

Target dose of IR and CR Carvedilol

IR: ≤85 kg = 25mg BID, >85kg = 50mg BID

CR: 80 mg daily

Where do ARAs work in the kidney?

DCT and Collecting Duct

Which ARA is selective and dose NOT exhibit endocrine side effects (ie gynecomastia, impotence)?

eplerenone

spironolactone is non-selective and has endocrine side effects

Side effects of ARAs?

• hyperkalemia

• increased SCr

• dizziness

How do SGLT2 inhbiitors affect HF?

decreased mortality and hospitalizations

How do ARAs affect HF?

decreased morbidity and mortality

Which SGLT2s are used in HF?

• Dapagliflozin (Farxiga)

• Empagliflozin (Jardiance)

*both 10mg daily*

Loop diuretic MOA

Block Na and Cl reabsorption in TAL in loop of Henle

How do loops affect electrolytes?

• Decrease: K, Mg, Na, Cl, Ca, and H2O

• Decrease in fluid volume = decrease in preload

• Increase: HCO3 (metabolic alkalosis), UA, BG, TGs/TC

• Do not improve survival, but used for sx control

How do loops and thiazides differ?

Thiazides INCREASE Ca - Loops DECREASE

Monitoring for loop diuretics

• renal fxn

• fluid status (input/output, weight)

• BP

• Electrolytes

• s/sx HF

Side effects/warnings of loop diuretics

• orthostatic hypotension

• photosensitivity

• ototoxicity

• AKI

• Caution w/ sulfa allergy (does NOT apply w ethacrynic acid)

Which diuretic may cause ototoxicity, including hearing loss with rapid IV administration?

ethacrynic acid (loop)

ORAL Loop Diuretic equivalent dosing

Furosemide 40mg

Torsemide 20mg

Bumetanide 1mg

Ethacrynic Acid 50mg

Furosemide IV:PO ratio

1:2

i.e. 20mg IV = 40mg PO

What drug should be avoided with concurrent loop diuretic use?

NSAIDs

Loop diuretics _____________ lithium.

can increase leading to toxicity

How should furosemide injection be stored?

at room temperature

Isosorbide dinatrate/hydralazine brand name

BiDil

Hydralazine MOA

direct arterial vasodilator

decreases afterload

Nitrates MOA

vasodilation and decreased preload (opposite of hydralazine)

Warnings/side effects of Hydralazine

• DILE

• Peripheral edema

• Headache

• Flushing

• Palpitations

• Reflex Tachycardia

When can hydralazine/nitrate combo be used?

• improves survival

• Alternative to those who cannot tolerate ARNI/ACE/ARB

- poor renal fxn, hyperkalemia, angioedema

When is BiDil indicated?

self-identified black pts with NYHA Class III or IV who are symptomatic despite optimal tx

Contraindications to using a nitrate product

concomitant PDE-5 ihibitors

Side effects of Isosorbide dinitrate

• Hypotension

• Headache

• Dizziness

• Tachyphylaxis (need 10-12 hr nitrate free interval)

• Syncope

How does ivabradine decrease risks in HF?

decreased hospitalizations; decreases HR

What are the requirements for a patient to receive Ivabradine?

• receiving GDMT, including BB

• Sinus rhythm with resting HR ≥70 BPM

Target resting HR with Ivabradine

50-60

Warnings/Side effects of ivabradine

• brady cardia

• increase risk of AFib

• Hypertension

Digoxin inhibits the _________ pump, causing __________.

• Na-K-ATPase pump in myocardial cells

• Causing a positive inotropic effect (increased CO) and negative chronotropic effect (decreased HR)

• Does not improve survival

• decrease HF related hospitalizations

Why is digoxin added to GDMT?

improve sx, exercise tolerance, and QOL

When should the dose of digoxin be lowered?

• renal insufficiency (

• smaller

• older

Digoxin therapeutic range for HF

0.5-0.9 ng/mL

higher for A. Fib

Dose adjustment for Digoxin from IV to PO

Decrease PO dose by 20-25% when switching to IV

Monitoring for digoxin

• levels

• electrolytes

• renal fxn

• HR

Digoxin Toxicity sx

• N/V, loss of appetite

• Blurred/double vision

• Greenish-yellow halos

• Bradycardia

• Life-threatening arrhythmias

*increased risk with low K, Mg, Ca

What is the antidote for Digoxin toxicity?

DigiFab

Stay hydrated to prevent

What is the typical PO dose of digoxin?

0.125-0.25 mg daily

Digoxin is a substrate of _____.

PGP

Digoxin should be ______ by _______% when starting Amiodarone/Dronedarone.

decreased by 50%

Vericiguat MOA

Solubale guanylate cyclase stimulator

Side effects of vericiguat

• hypotension

• do not use w riociguat

When should K levels be checked?

• Changes in renal fxn

• Changes in any diuretic, ARNI, ACE, ARB, or ARA

Which electrolyte should be checked and corrected prior to correct potassium?

magnesium

Potassium chloride injection is a .......

high alert medication (concentrated electrolyte)

Digoxin brand name

• Digitek

• Lanoxin

Potassium chloride oral packet brand

Klor-Con

Potassium chloride ER tablet brands

• K-Tab

• Klor-Con

• Klor-Con 10

• Klor-Con M10/M15/M20

Concentration of Potassium Chloride oral solution 10%

20 mEq/15mL

Which potassium chloride XR tablet can be cut in half or dissolved in water (stir for 2 min and drink); do not chew/crush/suck?

Klor-Con M

Which potassium chloride XR tablets must be swallowed whole?

• K-Tab

• Klor-Con

Oral packet (Klor-Con) counseling

dissolve in water and drink immediately