HF- Ochs

Causes of HFrEF:

• CAD

• Dilated cardiomyopathies (drug-induced, viral infections)

• pressure overload (HTN, semilunar stenosis)

• volume overload

Causes of HFpEF

• AV (mitral/ tricuspid) stenosis

• increase ventricular stenosis (HTN, hypertrophic cardiomyopathy)

• pericardial disease

Most common cause of HFrEF is ______.

CAD

What is a similar cause in HFrEF and HFpEF?

HTN

LVEF ≤40% is…

HFrEF

LVEF between 41-49% is…

HFmrEF

A LVEF ≥50% is…

HFpEF

Previous LVEF ≤40% and a follow up measurement of LVEF is >40% is…

HFimpEF

What mechanism describes the fact that the harder the myocardium is stretched, the harder it contracts?

Frank-Starling mechanism

How does an increase in afterload effect SV?

increase AL= decrease SV

If I increase SVR, what do I do to SV?

decrease

If HFpEF, what process of the heart is impaired/incomplete?

relaxing and filling

Symptoms of HFpEF:

• pulmonary edema

• dyspnea

• reduced exercise tolerance

In HFrEF, what process of the heart is impaired?

contraction

HFrEF results in decreased _____ and that activates compensatory mechanisms.

CO

Angiotensin II, causes vaso_____________, and sodium ______________.

vasoconstriction and sodium retention

Angiotensin II causes increases in what hormones?

• NE

• aldosterone

• ADH

NE can lead to what effect on the ventricles?

ventricular hypertrophy

BNP is released in response to what?

pressure or volume overload

What is the normal function of the SGLT2 transporter?

• reabsorbs glucose in the proximal tubule

Inhibition of the SGLT2 results in…

diuresis and naturesis

3 primary symptoms of HF:

1. dyspnea

2. fatigue

3. fluid overload

Do the severity of HF symptoms correspond with the EF?

NO

Other common symptoms of HF:

• 4 -pnea’s

  • dyspnea

  • othropnea

  • paroxysmal nocturnal dyspnea

  • bendopnea

• swollen ankles

• exercise intolerance

What are some signs specific for HF?

• JVD

• Cardiomegaly

• Hepatojugular reflex

• S3 Gallop

• Cheyne-Stokes respiration

What lab test can be an indicator of HF?

BNP

What are some cardiac events that are precipitating Factors of HF?

• MI

• a fib

• uncontrolled HTN

What are some exacerbating medications for HF?

• Non-DHPs

• Doxorubicin, Daunorubicin

• Cocaine, Amphetamines

• NSAIDs, COX-2 Inhibitors

• Glucocorticoids

• DPP-4 Inhibitors

How do glucocorticoids exacerbate HF?

A side effect of glucocorticoids is fluid retention, which can exacerbate symptoms of HF

Which NYHA Class does this describe?

• pts w/ cardiac diseases but no limitations of physical activity

• ordinary physical activity does not cause any symptoms

Class I

Which NYHA Class does this describe?

• pts w/ cardiac disease that results in inability to carry on physical activity without discomfort

• SYMPTOMS OF CONGESTIVE HF ARE PRESENT even at rest. with any physical activity, increased discomfort is present.

Class IV

Which NYHA Class does this describe?

• pts w/ cardiac disease that results in slight limitations of physical activity

• ordinary physical activity results in fatigue, palpitation, SOB, or angina

Class II

Which NYHA Class does this describe?

• pts w/ cardiac disease that results in marked limitation of physical activity, daily life activities

• although pts are comfortable at rest, less than ordinary activity will lead to symptoms

Class III

PRACTICE: Which of the following is not a common cause of HFrEF?

a. CAD

b. dilated cardiomyopathy

c. pericardial disease

d. pressure overload

c

If a pt. with heart failure is placed is stage C, is there any way that patient can be moved to B?

no! once in a class cannot move back

What describes stage A of HF? (symptoms, no symptoms, structure heart disease, etc.?)

• high risk for HF but…

• no structural heart disease

• no symptoms of HF

What describes stage B of HF? (symptoms, no symptoms, structure heart disease, etc.?)

• structural heart disease

• NO signs or symptoms of HF

What describes stage C of HF? (symptoms, no symptoms, structure heart disease, etc.?)

• structural heart disease

• HAS prior or current symptoms of HF

What describes stage D of HF? (symptoms, no symptoms, structural heart disease, etc.?)

• Refractory HF requiring specialized interventions

We generally treat HF according to what ___________ of HF it is.

stage

How do you treat a pt in stage A of HF?

• control comorbidities per their guidelines

  • Ex: treat HTN according to HTN guidelines

Is a statin indicated for treatment of heart failure?

• If they are, what role do they play in HF?

• If not, what are they indicated for?

NO! Statins are indicated due to hisory of MI or ACS NOT INDICATED FOR HF!!!!

What is the general approach to a pt. in stage B of HF?

If LVEF ≤40%

• ACEI

• BB

If LVEF ≤40% and history of MI/ACS

• ARB if intolerant of ACEI

• Statin therapy

• BB

Continue strategies from Stage A

What is the GDMT therapy for pts. in stage C of HF?

ARNI + BB + MRA + SGLT2i + Diuretics

In addition to our GDMT therapy, for select pts. what are some medications that we could also use for special situations in Stage C?

• hydralazine + isosorbide dinitrate

• loop diuretics

• digoxin

• ivabradine

In which of the following drugs do you NOT see a mortality and morbidity benefit?

a. Entresto

b. Spironolactone

c. Bisoprolol

d. Digoxin

d. Digoxin only has a morbidity benefit-NO MORTALITY

Can non-diabetics take an SGLT2i?

yes

In order to take a MRA / Aldosterone antagonist, you must have a GFR >____ml/min AND a K <___ mEq/L.

• GFR >30 ml/min

• K <5.0 mEq/L

In what situation would Hydralazine+ isosorbide dinitrate reduce morbidity and mortality?

in black patients

When a pt reaches stage D of HF, what are some advanced therapies that can be used?

• heart transplant

• palliative care

• palliative inotropes

• experimental drugs

In HFimpEF, what is the recommended tx?

• continue GDMT

In pts w/ HFpEF, what is the best recommended tx?

• diuretics as needs

• consider GDMT meds to decrease HF hospitalizations and CV mortality

What is an important electrolyte that must be monitored with RAAS inhibitors?

• potassium

• RAAS causes Hyperkalemia

If switching from an ACE to ARNI, how long is the washout period?

36 hr

If switching from an ARB to ARNI, how long is the washout period?

no washout period required

No not take any RAAS inhibitor if you have a history of _______________.

angioedema

What are the ADRs of BB?

• BRADYCARDIA

• heart block

• BRONCHOSPASM- in carvedilol

• hypotension

• worsening HF

What class of medications used in HF has the strongest evidence of dose related benefits of mortality?

BBs

Only initiate beta-blockers if the pt has no evidence of…

volume overload

What 2 SGLT2 inhibitors are used in HF? Give brand and generic name

• Dapagliflozin- Farxiga

• Empagliflozin- Jardiance

What diuretic is preferred in HF?

loop diuretic

WHAT is the dose conversion for Loop diuretics?

Ethacrynic acid ___mg = Furosemide ___mg = Torsemide ___mg = Bumetanide ___mg

Ethacrynic acid 50mg = Furosemide 40mg = Torsemide 20mg = Bumetanide 1mg

• 50=40=20=1

For Furosemide what is the PO:IV ratio?

2:1

(PO:IV ratio)

If I had 40 mg of Furosemide PO, what would that be in IV mg?

20 mg

If I had 30 mg of Torsemide PO, what would that be in IV mg?

30 mg

Digoxin is usually used in HFrEF to decrease ________________ for HF.

hospitalizations

What is the target serum drug conc of Digoxin?

0.5-0.9 ng/ml

ADRs of Digoxin:

• vision effects (halos, issues w/ colors)

• GI

• arrythmias (brady and tachy_

When is hydralazine+ isosorbide dinitrate used for HF?

1. If on all GDMT meds, and they aren’t working

2. black pts.

3. If can’t take RAAS meds

Hydralazine + Isosorbide dinitrate ADRs:

• lupus like syndrome

• HA
  hypotension

• rash

• tachycardia

What would a DHP CCB be used in HF?

• for symptomatic tx in HFpEF

What is the benefit of using Ivabradine?

• special place in therapy!!

• Reduces hospitalizations and CV death in pts who are NYHA Class II-III w/ LVEF <35% who are receiving GDMT w/ a resting sinus rhythm HR >70 BPM

  • basically high HR even on max BB

Non-pharm tx of HF:

• vaccinate against respiratory illnesses

• sodium restriction

• fluid restriction