Montepara Heart Failure

A diagnosis of heart failure means a patient has _____

Cardiomyopathy + symptoms

Etiology/Causes of heart failure

Ischemic cardiomyopathy

• Coronary artery disease

  • Myocardial ischemia and infarction

Non-ischemic cardiomyopathy

• Dilated cardiomyopathy

  • Valvular heart disease, arrhythmias, alcoholism, cardiotoxic drugs, thyroid disease, diabetes, sepsis, myocarditis, pericarditis, peripartum, stress, familial, idiopathic

• Hypertrophic cardiomyopathy

  • Hypertension, familial, idiopathic

• Restrictive cardiomyopathy

  • Amyloidosis, sarcoidosis, chemotherapy, and/or radiation exposure, idiopathic

Other

• Pulmonary

  • Pulmonary embolism, pulmonary hypertension, COPD/asthma, sleep apnea

Medications that can cause/worsen HF

Antiarrhythmics (Class I agents, dronedarone, sotalol)

Chemotherapy (anthracyclines (Ex. doxorubicin), trastuzumab, cyclophosphamide)

Non-DHP calcium channel blockers (diltiazem, verapamil)

Thiazolidinediones (rosiglitazone, pioglitazone)

Dipeptidyl peptidase-4 inhibitors (saxagliptin, sitagliptin)

Cilostazol

Corticosteroids

NSAIDs (aspirin can be used for cardioprotection)

Normal ejection fraction

50-70%

Ejection fraction in HFpEF

≥ 50%

Ejection fraction in HFmrEF

41-49%

Ejection fraction in HFrEF

≤ 40%

Most common cause of HFpEF

Hypertension

Symptoms of right heart failure

Congestion of peripheral tissues

• Dependent edema and ascites

• GI tract congestion

  • Anorexia, GI distress, weight loss

• Liver congestion

  • Signs related to impaired liver function

Symptoms of left heart failure

Decreased cardiac output

• Activity intolerance and signs of decreased tissue perfusion

Pulmonary congestion

• Impaired gas exchange

  • Cyanosis and signs of hypoxia

• Pulmonary edema

  • Cough with frothy sputum

  • Orthopnea

  • Paroxysmal nocturnal dyspnea

NYHA Class I HF

No limitation of physical activity

Ordinary physical activity does not cause HF symptoms

NYHA Class II HF

Slight limitation of physical activity

Comfortable at rest, but ordinary physical activity results in HF symptoms

NYHA Class III HF

Marked limitation of physical activity

Comfortable at rest, but less than ordinary activity causes HF symptoms

NYHA Class IV HF

Unable to carry on any physical activity without HF symptoms, or HF symptoms at rest

What is the main difference between NYHA HF Classes and HF Stages A-D?

Patients can move up or down the NYHA classes, but can only get progressively worse in terms of Stages A-D

Nonpharmacological therapy of HF

Restrict sodium intake to < 1500 mg/day

Restrict fluid intake to 1.5-2 L/day if signs of congestion

Monitor and document body weight daily

Eat a heart-healthy diet

Improve functional status with exercise or cardiac rehabilitation

Quit smoking

Limit alcohol intake

Continuous positive airway pressure in patients with HF and sleep apnea

Four pillars of HFrEF pharmacotherapy with mortality benefit

ARNI

• If pt can’t use → ACEI or ARB

Beta blocker

MRA

SGLT2I

General dosing principle for treating HF

Start low and titrate to target or maximally tolerated dose

• Target dose is what has shown mortality benefits

• Continue to increase to target even if patient feels better + don’t stop meds

Recommendation for ACEIs in HFrEF

Use in patients to reduce morbidity and mortality when the use of an ARNI is not feasible

Recommendation for ARBs in HFrEF

Use in patients to reduce morbidity and mortality when the use of an ARNI is not feasible and patient is intolerant to ACEIs because of cough or angioedema

ARBs recommended in HFrEF

Candesartan

Losartan

Valsartan

Recommendation for ARNIs in HFrEF

Use to reduce morbidity and mortality in place of an ACEI or ARB (unless contraindications, intolerance, or inaccessibility exist)

Adverse Effects of ARNIs

Dry, hacking cough

Angioedema

Hyperkalemia

Hypotension

Renal dysfunction

Dizziness

Contraindications for ARNIs

Use within 36 hours of an ACEI

History of angioedema associated with ACEI or ARB therapy

Use with aliskiren in patients with diabetes

Pregnancy (teratogenic)Mo

Monitoring for ARNUs

Blood pressure

Potassium

Renal function

Drug Interactions with ARNIs

ACEI, ARB, aliskiren

BNP is not an accurate marker of _____ if on Entresto

Fluid status

• Monitor NT-proBNP instead

Recommendation for beta blockers in HFrEF

Use 1 of the 3 with proven mortality benefits in stable, euvolemic patients

• Euvolemic → normal fluid status (decongested)

Beta blockers recommended in HFrEF

Bisoprolol

Carvedilol

Metoprolol succinate

Recommendation for MRAs in HFrEF

Use to reduce morbidity and mortality in patients with serum potassium < 5 mEq/L and eGFR > 30 mL/min/1.73 m²

Recommendation for SGLT2 inhibitors in HFrEF

Use to reduce morbidity and mortality, irrespective of the presence of type 2 diabetes

SGLT2 inhibitors recommended in HFrEF

Dapagliflozin

Empagliflozin

Adverse Effects of SGLT2 Inhibitors

Dehydration

Urinary tract infection

Genital mycotic infection

Renal dysfunction

Hypoglycemia if used in combination with insulin or a sulfonylurea

• Very rare in monotherapy

Contraindications for SGLT2 Inhibitors

Known hypersensitivity to drug

Patients on dialysis

Monitoring for SGLT2 Inhibitors

Blood pressure

Volume status

Renal function

Glucose

Drug Interactions with SGLT2 Inhibitors

Caution with diuretics

• May need to lower diuretic dose or discontinue diuretic

eGFR requirements for SGLT2 inhibitor therapy

eGFR ≥ 25 for dapagliflozin and ≥ 20 for empagliflozin before initiation

• If eGFR is lower, drug will not be able to reach its site of action due to not enough renal perfusion

Recommendation for hydralazine/isosorbide dinitrate in HFrEF

Use to reduce morbidity and mortality in African American patients who are receiving optimal medical therapy

Can be useful in patients who cannot be given an ARNI, ACEI, or ARB because of drug intolerance or kidney dysfunction

Adverse Effects of Hydralazine/Isosorbide Dinitrate

• Headache

• Hypotension

Hydralazine

• Peripheral edema

• Reflex tachycardia

• Palpitations

• Drug-induced lupus

ISDN

• Dizziness

• Syncope

Contraindications for Hydralazine/Isosorbide Dinitrate

Hydralazine

• Mitral valve rheumatic heart disease

• Coronary artery disease

ISDN

• Concurrent use with PDE-5 inhibitors (due to profound hypotension) and riociguat

Monitoring for Hydralazine/Isosorbide Dinitrate

Blood pressure

Heart rate

Antinuclear antibody (ANA) titer (hydralazine)

Drug Interactions with Hydralazine/Isosorbide Dinitrate

Caution with other drugs that reduce blood pressure

Recommendation for diuretics in HFrEF

Use in patients with fluid retention to relieve congestion, improve symptoms, and prevent worsening of HF

• No mortality benefit

Diuretics recommended in HFrEF

Bumetanide

Furosemide

Torsemide

Metolazone

• Used 30 minutes before loop diuretic to enhance effect when patient has loop diuretic resistance

General dosing principle for diuretics in HFrEF

No target dose, increase dose until congestion clears up

Converting doses between loop diuretics

Furosemide → 40 mg (PO), 20 mg (IV), Oral:IV = 2:1

Torsemide → 20 mg, Oral:IV = 1:1

Bumetanide → 1 mg, Oral:IV = 1:1

Recommendation for digoxin in HFrEF

May be considered to decrease hospitalizations for patients with symptoms despite optimized 4 pillars

• No mortality benefit

Unlike atrial fibrillation therapy, when digoxin is used for heart failure, it does NOT require a _____

Loading dose

Adverse Effects of Digoxin

N/V/D

Bradycardia/AV block

Arrhythmias

Headache

Mental disturbances

Dizziness

Contraindication for Digoxin

Ventricular fibrillation

Monitoring for Digoxin

Heart rate

ECG

Electrolytes

Renal function

Serum digoxin level (0.5-0.9 ng/mL)

Recommendation for ivabradine in HFrEF

Can be beneficial to reduce hospitalizations for patients with LVEF ≤ 35%, who are receiving optimal 4 pillars therapy, including a beta blocker at maximum tolerated dose, in normal sinus rhythm, and with a heart rate of 70 bpm or greater at rest

• No mortality benefit

Adverse Effects of Ivabradine

Bradycardia

• Can increase risk of QT prolongation and ventricular arrhythmias

Hypertension

Atrial fibrillation

Phosphenes

• Transient flashes of bright light

Contraindications for Ivabradine

ADHF

Blood pressure < 90/50 mmHg

Sick sinus syndrome, SA block, or 3rd degree AV block (unless pacemaker)

Resting heart rate < 60 bpm prior to treatment

Severe hepatic impairment

Pacemaker dependence

Concurrent use with strong CYP3A4 inhibitors

Monitoring for Ivabradine

Heart rate

Blood pressure

ECG

Recommendation for vericiguat in HFrEF

May be considered to decrease hospitalizations for patients with LVEF < 45% following a hospitalization for HF or need for outpatient IV diuretics

• No mortality benefit

Adverse Effects of Vericiguat

Hypotension

Anemia

Nausea

Dyspepsia

Contraindications for Vericiguat

Concomitant use of other soluble guanylate cyclase stimulators (riociguat)

Pregnancy (teratogenic)

Monitoring for Vericiguat

Blood pressure

Adverse effects

Drug Interactions with Vericiguat

PDE-5 inhibitors

Nitrates

Medications used for HFrEF with mortality benefits

ACEIs

ARBs

ARNIs

Beta blockers

Aldosterone Antagonists/MRAs

SGLT2 inhibitors

Hydralazine/ISDN

Medications used for HFrEF without mortality benefits

Diuretics

Digoxin

Ivabradine

Vericiguat

Treatment recommendations for HFpEF

Mostly focuses on blood pressure control

Diuretics as needed

→ SGLT2 inhibitors (very good)

       → ARNIs, MRAs, ARBs (greater benefit with LVEF closer to 50)

Treatment recommendations for HFmrEF

Some benefit seen from 4 pillars

Diuretics as needed

→ SGLT2 inhibitors

→ ACEIs, ARBs, ARNIs, MRAs, beta blockers (3 evidence based)