Chronic Heart Failure Terms & Definitions Study Set

Clinical dx of HF

ACC/AHA Staging

A: at risk for developing HF

B: Pre-HF structure/functional cardiac abnormality no sx

C: structure/functional cardiac abnormality + prior/current sx

D: Advanced HF

NYHA Functional Classes

- I = no limitations physical activity

- II = physical activity --> sx HF

- III = limitation in physical activity

- IV = sx at rest

What is considered HFrEF?

LVEF < 40%

S/Sx HF

Meds that Cause/Worsen HF

"Drug Information NATION"

Dipeptidyl peptidase 4 inhibitors

Immunosuppressants

Non-DHP CCBs

Antiarrhythmics

Thiazolidinediones

Itraconazole

Oncology drugs

NSAIDs

HF pathophysiology

structural or function cardiac disorder that impaired the ventricle to fill or eject blood

HFrEF is a low cardiac output state

main pathways that are activated in HF are the renin- angiotensin-aldosterone system (RAAS), the sympathetic nervous system (SNS) and vasopressin

Lifestyle management of HF

- Daily weights (notify doctor of weight gains 3-5lbs in wk)

- Sodium restriction (< 1,500 mg/day)

- Restrict fluid (1.5-2 L/day) in Stage D HF

- pneumococcal & yearly influenza

- Smoking cessation. Limit EtOH. No illicit drugs

- Reduce weight to BMI

Drug Targets related to HF pathophysiology

CHF Treatment Overview

1)

- ARNI, ACE inhibitors or ARBs

- BB

- Loop diuretics

2)

- ARAs

- SGLT2i

- Hydralazine & Nitrates

- Ivabradine

3)

- Digoxin

- sGC stimulator (vericiguat)

What is Entresto?

sacubitril/valsartan

neprilysin inhibitor + ARB

NYHA Class II-IV reduce HF hospitalizations and cardiovascular death

preferred first-line treatment in all patients with HFrEF, and would be used in place of an ACE inhibitor or other ARB

Entresto CIs

Do not use with or within 36 hours of ACE inhibitors

Do not use with history of angioedema

Entresto BBW

Can cause injury and death to the developing fetus when used in the 2nd and 3rd trimesters; discontinue as soon as pregnancy is detected

Entresto: Warnings, SEs, Monitoring

Warnings: Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)

SEs: cough, hyperkalemia, elevated SCr, hypotension

Monitoring: BP, K, renal function, s/sx of HF

What is the target dose of Vasotec?

10-20 mg PO BID

What is Vasotec?

enalapril

ACEi

decreases mortality in HFrEF

What is the target dose for lisinopril?

20-40 mg daily

What is Prinivil?

lisinopril

ACEi

decreases mortality in HFrEF

What is Zestril?

lisinopril

ACEi

decreases mortality in HFrEF

What is the target dose for Accupril?

20 mg BID

What is Accupril?

Quinapril

ACEi

decreases mortality in HFrEF

What is Altace?

ramipril

ACEi

decreases mortality in HFrEF

What is the target dose of Alsace?Altace

10 mg daily

What is Cozaar?

Losartan

ARB

decreases mortality in HFrEF

What is Diovan?

valsartan

ARB

decreases mortality in HFrEF

What is Toprol XL?

metoprolol succinate

BB - beta 1 selective

Provide benefit in controlling heart rate and reducing arrhythmia risk; decreases mortality in HFrEF

What is Coreg/Coreg CR?

Carvedilol

BB - beta and alpha 1 blocker

Provide benefit in controlling heart rate and reducing arrhythmia risk; decreases mortality in HFrEF

take with food

What is the Toprol XL target dose?

200 mg daily

What is the Coreg target dose?

85 kg or less: 25 mg BID

> 85 kg: 50 mg BID

What is the Coreg CR target dose?

80 mg daily

What is Lasix?

furosemide

loop diuretic

Reduce blood volume --> decreases edema and congestion (most HF patients need a loop diuretic for symptom relief)

What is Bumex?

bumetanide

loop diuretic

Reduce blood volume --> decreases edema and congestion (most HF patients need a loop diuretic for symptom relief)

Rapid IV admin can --> ototoxicity

What are the loop diuretics?

furosemide, bumetanide, torsemide

Loop diuretic PO dose Conversions

furosemide 40 mg

=

torsemide 20 mg

=

bumetanide 1 mg

=

ethacrynic acid 50 mg

Furosemide IV:PO

1:2

(other loops 1:1)

What is Aldactone?

spironolactone

aldosterone antagonist/K sparing diuretic

- decreases morbidity and mortality in NYHA Class II-IV

- provides added diuresis --> improve symptoms and EF

- Do not use if K > 5

- Do not use if CrCl < 30 or Cr > 2

What is Farxiga?

dapagliflozin

SGLT2i

- Initially approved for type 2 diabetes

- found to decrease morbidity and mortality in NYHA Class II-IV HFrEF with or without diabetes

- do not use if eGFR < 25

What is Jardiance?

empagliflozin

SGBT2i

- Initially approved for type 2 diabetes

- found to decrease morbidity and mortality in NYHA Class II-IV HFrEF with or without diabetes

- do not use if eGFR < 30

What is BiDil?

hydralazine + isosorbide dinitrate

- decreases morbidity and mortality in black patients with NYHA Class when added to an ACE iARB + BB, or in other patients who cannot tolerate an ACE i or ARB

- recommended in persistently symptomatic black patients with NYHA Class III-IV, despite treatment with ARNI, BB, ARA, SGLT2 inhibitor

BiDil: CIs

Do not use with PDE-5 Inhibitors (b/c nitrate component)

BiDill: Warnings and SEs

Warnings: Drug-induced lupus erythematosus (DILE) due to hydralazine component

Hydralazine SEs: Peripheral edema/headache/flushing/palpitations/reflex tachycardia

Nitrate SEs: Hypotension, headache, dizziness, lightheadedness, flushing, tachyphylaxis (need 10-12 hour nitrate-free interval), syncope

What is ivabradine?

hyperpolarization-activated cyclic nucleotide-gated channel blocker

- decreases HR: must have HR 70+ bpm to start

- reduces risk hospitalization for HF but does not effect mortality

Ivabradine: Warnings and SEs

Warnings: bradycardia which can increase risk of QT prolongation and ventricular arrhythmias

SEs: Bradycardia, hypertension, atrial fibrillation,

What is the target resting HR when on ivabradine?

50-60 BPM

What is Digitek?

Digoxin

Provides a small increase in cardiac output, improves symptoms and decreases cardiac hospitalizations (does not decrease mortality)

What is Digox?

Digoxin

Provides a small increase in cardiac output, improves symptoms and decreases cardiac hospitalizations (does not decrease mortality)

What is Lanoxin?

Digoxin

Provides a small increase in cardiac output, improves symptoms and decreases cardiac hospitalizations (does not decrease mortality)

Digoxin MOA

inhibits the Na-K-ATPase pump, causing a positive inotropic effect (increases CO), and exerts a parasympathetic effect, which causes negative chronotropy (decreases HR)

Digoxin dosing

0.125-0.25 mg PO daily

if CrCl

What is the therapeutic range of digoxin?

0.5-0.9 ng/mL

Digoxin Monitoring

Electrolytes, renal function, HR

Digoxin Toxicity s/sx

Initial: N/V, loss of appetite and bradycardia

Severe: blurred/double vision, greenish-yellow halos

What is the antidote for Digoxin?

DigiFab (digoxin immune Fab)

Digoxin: Drug Interactions

- caution w/ other meds that decrease HR: BBs, clonidine, Non-DHP CCBs, amiodarone

(reduce dose by 50% when starting amiodarone)

What abnormal lab values can increase the risk of digoxin toxicity?

hypokalemia, hypomagnesemia, hypercalcemia

What is vericiguat?

soluble guanylate cyclase (sGC) stimulator : increases cyclic GMP and leads to smooth muscle relaxation and vasodilation

SEs: hypotension

Vericiguat: CIs

Do not use with riociguat

What is the mEq concentration of KCl 10% sln?

20 mEq/15 mL

KCl formulations

What can happen if IV loop diuretics are administered too quickly?

can lead to ototoxicity

Toprol XL Counseling

- no crushing/chewing but can be cut along score line

-take w/ meal

- titrate dose up