Heart failure management

What is considered HFrEF?
What is considered HFpEF?

HFrEF EF<40%
HFpEF EF>50% but still has symptom

What can be an objective sign that patient has heart failure?

Sudden large increase in body weight 2-3kg indicating fluid retention

what is Euvolemia?

Dry weight
Diuresed

When should patient check in when there is a body weight change?

if there is 1-2kg increase in a 24h period or >2.3kg in a week

What are some red flags patient should watch out for?

Orthopnea
Dyspnea
f there is 1-2kg increase in a 24h period or >2.3kg in a week
frequent dry, hacking cough

What is a sign of dehydration in patient?

If urea rises faster than Cr

What do you do if you want to change from ACEi to ARNi?

switch from ACEi to ARni (sacubitril varsartan) requires 36h wash-out period

What are the standard non-pharm counselling points you need to tell patients about their drugs?

1. It is to improve symptoms and exercise capacity
2. prevention of worsening HF leading to hospitalisation
3. increase survival
4. Weigh themselves daily!!!

What are the drugs that can cause hyperkalemia?

ACEi
ARB
ARNi
Spiralactone

What are the fantastic 4 in Heart failure management?

ACEi/ARNi
Beta blocker
MRA (mineralocorticoid receptor antagonist)
SGLT2

Loop diuretics (not in the 4 but use when patient need to diurese)
Ivabradine (used adjuct to BB if heart rate still not under control)

What are the beta blockers tested for use in heart failure patient?

Bisoprolol
Carvedilol
Metoprolol XL
Nebivolol

What is the heart rate target for Heart failure?

50-70bpm

When do you withhold BB?

Hypotension
Heart rate slower than 50
Pleural effusion

What is pleural effusion?

Fluid overload
cannot start medication, need to diurese first

what are some contraindications for ACEi?

angioedma
bilateral renal artery stenosis
pregnancy

What to monitoring when giving ACEi?

K level
Renal panel SCr
urea
BP
1-2 weeks after starting
1-2 weeks after adjusting

When to start ACEi?

when the patient is euvolaemia
36h after ARNi washout

When to stop ACEi?

Expected to increase K and Cr
K<5.5 is OK
increase in 50% Cr is OK

STOP
K>5.5
Cr>300 increase more than 100%

What are some ADR of ACEi?

Dry cough

What to add to beta blocker if patient has cocomm AFib?

Add digoxin

When reduce BB?

When patient HR< 50bpm
Half the dose

When to give patients K+ supplement?

When patient's K drops below the lowest level
Potassium cholride
Stop K supplement if K>4.6

What are some contraindication of ARNi?

angioedema
Bilateral renal artery stenosis
Renal impairment
Hypotension

Why must you wash out ACEi if you want to switch to ARNi?

to reduce the risk of angioedema

What to monitor when you are giving ARNi?

K+ and renal panel Cr Urea BP
1-2 weeks after starting
1-2 weeks afrer adjusting

When to stop ARNi?

Increase of K<5.5 is Ok
Increase K>5.5 must STOP

But, when K is increasing a lot, try to remove other drugs first, NSAIDs, diuretics (if patient not congested), SGLT2
The idea is to keep ARNi and the fantastic 4 as much as possible

What are some ADR with ARNi?

Possible cough in HF patients

What do you need to monitor when giving SGLT2?

monitor SCr (renal function)
K level
1 week after starting
4 weeks after adjusting

When to stop MRA?

K>5.5 / SCr>221 (half the dose)
K>6.0 / SCr>310 (STOP immediately)

What are some ADR with MRA?

Spironolactone --> Gynaecomastia (male patients)
consider eplerenone

What do you monitor if you are giving SGLT2i?

Renal Panel SCr
BP
blood sugar
fluid balance

What are some ADR of SGLT2i?

Genito-urinary infections
Hypoglycemia
Dehydration

What do you monitor if you are giving diuretics?

Renal panel SCr
K level
Urea
BP
1-2 weeks after starting and adjusting

When do you use diuretics?

Use it wen patients have congestive symptoms. Patients can use it PRN
This is used to maintain euvolaemia

What are some possible DDI of ACEi?

K supplements
MRAs
NSAIDs

What are some possible DDI of BB?

watch out for bradycardia or AV blocks
Should not use with Verapamil!!!!!
Digoxin
Amiodarone

What are some possible DDI of MRA?

K supplements
ACEi
NSAIDs
Strong CYP3A4 inhibitors Itraconazole, claritromycin

What are some possible DDI of ARNi?

K supplements
ACEi
MRA
NSAIDs

What are some possible DDI of SGLT2i?

antidiabetic drugs, insulin

What are some possible DDI of diuretics?

watch out for hypotension when using with ACEi or ARb

How is the severity of HF classified?

based on patient's symptoms