NAPLEX: Heart Failure

[Define]:

systolic HF

a. impaired contractility or pumping function

b. LVEF ≤ 40%

[Define]:

diastolic HF

a. impaired ability to relax, leads to under filling

b. LVEF > 40%

[Diagnostic]:

HF

↑ B-type Natriuretic Peptide (BNP)

[normal < 100 pg/mL]

[Diagnostic]:

acute decompensated HF [ADHF]

[BNP]: > 500 pg/dL

[normal < 100 pg/mL]

[Signs/Symptoms]:

Heart Failure

1. dyspnea at rest or on exertion

2. weakness/fatigue

3. SOB

4. orthopnea

etc.

[Classification of HF]:

New York Heart Association (NYHA)

[Class I]: LV dysfunction w/o physical limitations

[Class II]: slight limitation of physical activity

[Class III]: minimal activity

[Class IV]: no physical activity, symptom at rest

[Classification of HF]:

American College of Cardiology (ACC) &

American Heart Association (AHA)

[Stage A]: high risk, no structural damage, no symptoms

[Stage B]: structural damage, no symptoms

[Stage C]: structural damage, symptoms of HF

[Stage D]: refractory symptoms at rest

[Classification of HF]:

NYHA vs. ACC/AHA

[NYHA]: can move back & forth btw classes

[ACC/AHA]: can only move from Stage A to D

six (6) Nonpharmacologic therapy for HF...

1. low-intensity exercise

2. Na+ intake = [≤3 g/day]

3. Fluid intake = [

[Pharmacologic Therapy]:

Stage B

(or Class I)

ACEI + β-blocker

[Pharmacologic Therapy]:

Stage C

(or Class II, III, IV)

[acronym: BAD]

ACEI + β-blocker + diuretic

[Alternative Therapy]:

the best time to use "aldosterone receptor antagonists" in HF...

current or recent NYHA Class IV symptoms who are already receiving:

[ACEI (or ARB) + β-blocker + diuretic (± digoxin)]

[Alternative Therapy]:

the best time to use "ARBs" in HF...

a. in patients who cannot tolerate an ACEI d/t cough

b. in patients who remain symptomatic despite optimal therapy with ACEI + β-blocker

[Alternative Therapy]:

the best time to use "digoxin" in HF...

in patient who remain symptomatic despite optimal therapy with:

[ACEI (or ARB) + β-blocker + diuretic]

[Alternative Therapy]:

the best time to use "hydralazine/isosorbide dinitrate" in HF...

a. in patients with CIs [RF, hyperkalemia] to ACEI or ARB

b. AA patients w/ NYHA Class III or IV who remain symptomatic despite optimal therapy with [ACEI (or ARB) + β-blocker]

[MOA]:

loop diuretics

inhibit Na+ reabsorption in the ASCENDING loop of Henly

[in HF]: ↓ preload

[Agents]:

three (3) loop diuretics used in HF...

1. bumetanide (Bumex®)

2. furosemide (Lasix®)

3. torsemide (Demadex®)

[SE]:

ten (10) SEs of loop diuretics...

1. hypokalemia (↓ K+)

2. hypomagnesemia (↓ Mg2+)

3. hyponatremia (↓ Na+)

4. hypocalcemia (↓ Ca2+)

5. hyperuricemia (↑ UA)

6. hyperglycemia (↑ BG)

7. hyperlipidemia (↑ TG, ↑ CH)

8. photosensitivity

9. metabolic alkalosis

0. ototoxicity

[Key Monitoring]:

loop diuretics in HF...

1. BP

2. Electrolytes

3. BUN/SCr

4. BG

5. Uric Acid

6. Fluid status (in's & out's)

7. Weight (↓ by 0.5-1 kg/d initially)

8. Hearing

PO to IV conversion of loop diuretics

IV is 2x more potent than PO

[IV dose = 2x PO dose]

[Benefit of Use in HF]:

loop diuretics...

↓ preload

↓ symptoms

[effects on mortality unknown]

[Med Pearl]:

this class of drug therapy can cause "azotemia'...

loop diuretics:

[BUN/SCr ratio]: >20:1 (causing dehydration)

[Define]:

azotemia...

Azotemia = abnormal high levels of nitrogen-containing compounds (urea, creatinine, various body waste compounds) in the blood. It is largely related to insufficient filtering of blood by the kidneys.

[Drug Interactions]:

All anti-HTN therapy can have additive BP lowering effects. Always carefully monitor BP when adding-on therapy, particularly with this agent...

diuretics

[Patient Counseling in HF]:

when taking loop diuretics...

patients should weight themselves everyday

(the 1st thing in AM after voiding)

[MOA]:

ACEIs (angiotensin-converting enzyme inhibitors)...

inhibit angiotensin-converting enzyme (ACE) & prevent the conversion of angiotensin I (AT I) to angiotensin II (AT II)

[in HF]: ↓ preload, ↓ afterload, ↓ mortality

[Benefit of Use in HF]:

ACEIs...

↓ preload

↓ afterload

↓ mortality

[Med Pearl]:

titration of ACE-I dosage in HF is based on what...

based on symptoms, not BP

[Agents]:

four (4) ACEI used in HF...

1. enalapril (Vasotec®)

2. lisinopril (Prinivil®, Zestril®)

3. quinapril (Accupril®)

4. ramipril (Altace®)

[SEs]:

four (4) common SEs of ACEIs...

1. dry cough (d/t bradykinin release)

2. orthostatic hypotension

3. angioedema

4. hyperkalemia (↑ K+)

[BBW]:

ACEIs, ARBs, & direct renin inhibitor...

can cause injury & death to developing fetus

{d/c as soon as pregnancy is detected}

[Contraindications]:

ACEIs, ARBs, & direct renin inhibitor...

1. angioedema

2. bilateral renal artery stenosis

3. pregnancy

4. hyperkalemia

[Key Monitoring]:

ACEI in HF...

1. BP

2. K+

3. renal failure

4. s/s of HF

[MOA]:

β-blockers

↓ activation of the sympathetic nervous system

[Agents]:

three (3) β-blockers that have been shown to ↓ mortality in systolic HF...

1. bisoprolol (Zebeta®)

2. carvedilol (Coreg®)

3. metoprolol succinate (Toprol XL®)

[Contraindications]:

in HF, β-blockers should NOT be initiated in these two (2) group of patients

1. peripheral edema

2. pulmonary edema

[Dosing]:

target dose of bisoprolol (Zebeta®) in HF...

10mg once daily

[Dosing]:

target dose of carvedilol (Coreg®) in HF...

[if

[Dosing]:

target dose of metoprolol succinate (Toprol XL®) in HF...

200mg once daily

[Benefit of Use in HF]:

β-blockers

↓ mortality

[SEs]:

four (4) SEs of β-blockers...

1. ↓ HR

2. hypotension

3. fatigue

4. dizziness

[Key Monitoring]:

β-blockers in HF...

1. BP

2. HR

3. s/s of HF

[Patient Counseling]:

this β-blocker should be taken with food

carvedilol (Coreg®)

[take with food to minimize the risk of orthostatic hypotension]

[Med Pearl]:

time-frame to achieve target dose of β-blockers in HF...

dose can be doubled every 2-4 weeks to achieve target dose

[Med Pearl]:

worsening symptoms associated with the initiation of β-blockers in HF should be managed by this...

↑ diuretic dose

[Med Pearl]:

the best way to manage "hypotension" while on β-blockers in HF patients...

↓ dose of ACEI, ARB, or other vasodilator

[Med Pearl]:

management of "bradycardia" caused by β-blockers in HF patients...

↓ the dose of β-blockers

[MOA]:

digoxin

1. inhibits Na/K ATP-ase pump

2. (+) inotrope [↑ contraction,↑ CO]

3. (-) chronotrope [↓ HR]

digoxin

Lanoxin®

[SEs]:

primary SE of digoxin (Lanoxin®)

[s/s of digoxin toxicity]:

1. bradycardia

2. N/V

3. anorexia

[Benefit of Use in HF]:

digoxin

↓ symptoms

[No effect on mortality]

[Dosing]:

starting dose of digoxin in HF

0.125 mg daily

[Dosing]:

loading doses of digoxin in HF

there is no LD of digoxin in HF

only in AF

[Toxicity]:

three (3) electrolytes abnormality indicating digoxin toxic effects

[one of the following]

↓ potassium

↓ magnesium

↑ calcium

[Drug Interactions]:

two (2) major DIs with digoxin that can DOUBLE its levels

1. amiodarone (Cordarone®)

2. dronedarone (Multaq®)

[so ↓ digoxin dose by 50%]

[Dosing]:

therapeutic range for digoxin in CHF

0.5 - 1 ng/mL

[↑ mortality if >1 ng/mL]

[Med Pearl]:

abrupt d/c of these two (2) drugs may worsening HF symptoms

1. digoxin (Lanoxin®)

2. β-blockers

[Contraindications]:

adjust digoxin dose in this group of patients

renal dysfunction

[MOA]:

ARA (aldosterone receptor antagonists)

1. inhibit the effects of aldosterone

2. ↓ remodeling

3. ↓ Na+/water retention

[in HF]: ↓ preload

[Agent]:

non-selective ARA & its MOA

spironolactone (Aldactone®)

[MOA]:

also blocks androgen & progesterone receptors that's associated with its gynecomastia SE

[Agent]:

selective ARA

eplerenone (Inspra®)

[often reserved for ptn who do not tolerate spironolactone d/t its endocrine SE]

[Benefit of Use in HF]:

ARA (aldosterone receptor antagonists)

↓ preload

↓ mortality

[SEs]:

two (2) SEs of ARA

1. hyperkalemia

2. metabolic acidosis

[SEs]:

important SE of eplerenone (Inspra®)

↑ SCr

[Contraindications]:

three (3) CIs of ARA

1. K+ >5.0 mEq/L (per guideline)

2. SCr >2.5 mg/dL

3. CrCl ≤30 mL/min

[Drug Interactions]:

six (6) drugs that can cause HYPERkalemia if used concomitantly in CHF

1. ACEIs

2. ARBs

3. K+ supplements

4. potassium-sparring diuretics

5. ARAs

6. NSAIDs

[Agents]:

three (3) ARBs agents used in HF

1. candesartan (Atacand®)

2. losartan (Cozaar®)

3. valsartan (Diovan®)

[Med Pearl]:

this agent is considered to be "equivalent" or "superior" to ACEIs in HF treatment

none

[ARBs are "NOT" equivalent or superior to ACEIs in HF]

[MOA]:

hydralazine (Apresoline®)

causes arterial vasodilation

[in HF]: ↓ afterload

[MOA]:

isosorbide dinitrate (Isordil®)

causes venous dilation

[in HF]: ↓ preload

isosorbide dinitrate

(Isordil®)

[Agent]:

these two (2) agents must be used together in HF

1. hydralazine (Apresoline®)

2. isosorbide dinitrate (Isordil®)

[Agent]:

the usage of this agent "monotherapy" in HF can ↑ mortality

hydralazine (Apresoline®)

[Benefit of Use in HF]:

hydralazine/isosorbide dinitrate (BiDil®)

↓ mortality

[SEs]:

three (3) SEs of hydralazine (Apresoline®)

1. reflex tachycardia

2. peripheral edema

3. lupus-like syndrome

[SEs]:

main SE of isosorbide mononitrate/dinitrate

headache

[Agent]:

approved for AA patients with NYHA class III-IV HF

hydralazine/isosorbide dinitrate (BiDil®)

hydralazine/isosorbide dinitrate

BiDil®

isosorbide mononitrate

Imdur®

[Contraindications]:

isosorbide mononitrate/dinitrate

PDE-5 inhibitors

[sildenafil, tadalafil]

[SEs]:

four (4) SEs of hydralazine/isosorbide dinitrate (BiDil®)

1. reflex tachycardia

2. peripheral edema

3. lupus-like syndrome

4. HA

[Agent]:

three (3) IV Vasodilators for ADHF treatment

1. nitroglycerin (NTG®)

2. nitroprusside (Nipride®)

3. nesiritide (Natrecor®)

[Brand & MOA]:

nitroglycerin

NTG®

[IV vasodilator for ADHF]

[low dose]: venous vasodilation = ↓ preload

[high dose]: arterial dilation = ↓ afterload

[SEs]:

four (4) SEs of nitroglycerin (NTG®)

1. hypotension

2. HA

3. lightheadedness

4. tachycardia

[Contraindications]:

three (3) CIs of nitroglycerin (NTG®)

1. SBP

[Agent]:

tolerance can develop from these two (2) agents

1. nitroglycerin (NTG®)

2. dobutamine

[overcome by ↑ infusion rate]

[Med Pearl]:

nitroglycerin (NTG®) is very useful for ADHF treatment in this group of patients

myocardial ischemia

[the imbalance btw oxygen supply & demand = angina]

[Brand & MOA]:

nitroprusside

Nipride®

[IV vasodilator for ADHF]

arterial & venous vasodilation

[↓ preload, ↓ afterload]

[SEs]:

four (4) SEs of nitroprusside (Nipride®)

1. hypotension

2. HA

3. tachycardia

4. cyanide/thiocyanate

[Med Pearl]:

nitroprusside (Nipride®) should be avoid in renal failure patients d/t this SE

cyanide/thiocyanate

[risk ↑ if infusion > 24 hours]

[Agent]:

this vasodilator needs to be protected from light (cover with opaque material or aluminum foil)

nitroprusside (Nipride®)

[Contraindications]:

three (3) CIs of nitroprusside (Nipride®)

1. SBP

[Brand & MOA]:

nesiritide

Natrecor®

[IV vasodilator for ADHF]

arterial & venous vasodilation

[↓ preload, ↓ afterload]

[SEs]:

two (2) SEs of nesiritide (Natrecor®)

1. hypotension

2. ↑ SCr

[Agent]:

three (3) IV Positive Inotropes for ADHF treatment

1. dopamine

2. dobutamine

3. milrinone

[Agent]:

has dose-dependent hemodynamic effects

dopamine

[MOA & Dosage]:

"renal dose" of dopamine

[Dose]:

0.5-3 μg/kg/min

[MOA]:

stimulates D1 receptors,

↑ urine output

[MOA & Dosage]:

"cardiac dose" of dopamine

[Dose]:

3-10 μg/kg/min

[MOA]:

stimulates β1 receptors,

↑ CO

↑ HR

[MOA & Dosage]:

"pressor dose" of dopamine

[Dose]:

>10 μg/kg/min

[MOA]:

stimulates α1 receptors,

↑ BP

[MOA]:

dobutamine

β1 agonist = ↑ CO

β2 agonist = vasodilation

weak α1 agonist