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What is the general approach for initiating drugs in HFrEF
Initiate as many mortality reducing drugs as the patient can tolerate and then titrate up to target doses
Which decreases mortality in HF patients the most: adding a new class of medication or increasing the dose of the medications they are on?
Adding a new class of medications
What gives the most mortality reduction in HF patients?
Target doses of all GDMTs!!
If a patient is newly diagnosed with HFrEF when should they achieve maximally tolerated or target doses of GDMT medications?
3 months
If a patient is discharged from the hospital for HFrEF when should they achieve maximally tolerated or target doses of GDMT medications?
6 weeks
Which medication classes should be given to a heart failure patient first?
ARNI (or ACEi/ARB), Beta-blocker, MRA, and SGLT inhibitors
When should a HFrEF patient be put on a diuretic (loop diuretic)?
if they are experiencing persistent volume overload (any signs of congestion/hypervolemia) even after taking max doses of GDMT meds
When should a HFrEF patient be put on hydralazine/isosorbide dinitrate?
If they are an African American that is persistently symptomatic and on other GDMT meds
When should a HFrEF patient be put on ivabradine?
Patients with a resting HR >= 70 bpm on maximally tolerated beta-blocker and in sinus rhythm (may or may not have symptoms)
When should a HFrEF patient be put on vericiguat?
patients on GDMT meds with worsening HF evidenced by HF hospitalization or requirement for IV diuretics
After starting Entresto what should be assessed in 1-2 weeks?
tolerability, BP, electrolytes, and renal function
When do you increase the dose of Entresto?
every 1-2 weeks increase the dose stepwise to a target of 97/103 mg twice a day
Which patients start on the lower dose of Entresto?
patients already on a daily equivalent of <= 10 mg enalapril or <= 160 mg valsartan, ACEi/ARB naive, eGFR < 30 mL/min/1.73m2, >= 75 years old
Which patients start on the higher dose of Entresto?
On equivalent of > 10 mg of enalapril or > 160 mg valsartan
When should a HF patient get an ACEi/ARB instead of an ARNI?
if the patient is not able to get/take Entresto for various reasons.
what should be assessed in 1-2 weeks after starting an ACEi/ARB
tolerability. BP, electrolytes, renal function
When do you increase the dose of an ACEi/ARB in patients with HFrEF
every 1-2 weeks and increase the dose stepwise to target doses
What are the starting dose options for sacubitril/valsartan
24/26 mg or 49/51 mg twice a day
What are the starting dose options for lisinopril
2.5-5 mg once a day
What are the starting dose options for valsartan
40 mg twice daily
What is the target dose for sacubitril/valsartan
97/103 mg twice daily
What is the target dose for lisinopril
20-40 mg daily
What is the target dose for valsartan
160 mg twice daily
How many days do you wait to assess tolerability, BP, electrolytes, and renal function in patients starting an MRA?
in 7 days
When do you increase the dose for MRAs
increase the dose stepwise at least every 2 weeks to target dosing and monitoring appropriately
Contraindications for MRAs in HFrEF
eGFR < 30 mL/min/1.73m2 or creatinine > 2.5 mg/dL in men and creatinine > 2 mg/dL in women
Special monitoring for MRAs in HFrEF
electrolytes and renal function 7 days after initiation/titration - after a stable dose check these monthly for 3 months and then every 3 months out to a year
Starting dose for spironolactone
12.5-25 mg once daily
Target dose for spironolactone
25-50 mg once daily
How do the doses of MRAs differ for heart failure compared to patients with HTN?
The doses are lower than what is generally used for HTN
Which SGLT inhibitors do you have to check that the patients eGFR is >= 25 g/mL/1.73m2?
dapagliflozin and sotagliflozin
when do you increase the dose of sotagliflozin
increase the dose stepwise to the target dosing in 2 weeks
Contraindications for SGLT inhibitors
Patients with type I diabetes
Starting dose for dapagliflozin
10 mg once daily
Starting dose for empagliflozin
10 mg daily
Target dose for dapagliflozin
10 mg daily <3
Target dose for empagliflozin
10 mg once a day
Can empagliflozin and dapagliflozin be titrated up from 10 mg?
Yes, if concomitant diabetes for glucose control
starting dose of sotagliflozin
200 mg daily
target dose of sotagliflozin
400 mg daily
What needs to be monitored when using beta-blockers in HFrEF
monitor HR and BP after initiation and during titration
When do you increase the dose of beta-blockers in HF
increase the dose every 2 weeks stepwise to target dosing
starting dose of bisoprolol
2.5 mg daily
target dose of bisoprolol
10 mg daily
starting dose of metoprolol succinate
12.5-25 mg once a day
target dose of metoprolol succinate
200mg daily
Starting dose of carvedilol
3.125-6.25 mg twice daily
target dose of carvedilol
25 mg twice daily
if > 85 kg give patient 50 mg twice daily
What to monitor after giving loop diuretics?
bp, electrolytes, and renal function after initiation and during titration!
When do you titrate the dose of loop diuretics?
titrate to relief of congestion which may be over days or weeks - increase as needed to maintain euvolemia and to
What is the usual start dose of furosemide?
~20-40 mg orally
Why are frequent clinic visits needed for loop diuretics
Need frequent clinic visits until patient is titrated to optimal effect, and may need to prescribe PO potassium in conjunction
If patients have increased distal sodium reabsorption from chronic loop diuretic use what med can be added on?
A thiazide
If a patient has poor delivery of the loop diuretic to the site of effect due to reduced GFR, HF, or gut edema, what can be done?
Increase the dose of loop diuretic
Furosemide 20 mg IV is equivalent to what dose orally?
40 mg
Furosemide 20 mg IV is equivalent to what dose of IV torsemide?
20 mg
Furosemide 20 mg IV is equivalent to what dose of IV bumetanide
1 mg
Furosemide 20 mg IV is equivalent to what dose of IV ethacrynic acid
50 mg
Furosemide 40 mg orally is equivalent to what dose of oral torsemide
20 mg
Furosemide 40 mg orally is equivalent to what dose of oral bumetanide
1 mg
Furosemide 40 mg orally is equivalent to what dose of oral ethacrynic acid
50 mg
Torsemide 20 mg IV is equivalent to what dose orally?
20 mg
Bumetanide 1 mg IV is equivalent to what dose orally?
1 mg
ethacrynic acid 50 mg IV is equivalent to what dose orally?
50 mg
What needs to be monitored when starting hydralazine/isosorbide dinitrate/combo pill
Bp after initiation and during titration
When do you need to increase the dose of hydralazine/isosorbide dinitrate/combo pill
increase the dose every 2 weeks stepwise until at target dosing
hydralazine target dose
75 mg TID
Isosorbide dinitrate target dose
40 mg TID
BiDil target dose
2 tablets TID
What needs to be confirmed before starting ivabradine
confirm beta-blocker is at maximally tolerated/targeted dose and that patient is in sinus rhythm
When to reassess HR in patients and increase stepwise to target dosing using ivabradine
in 2-4 weeks
How to titrate ivabradine in patients with a HR < 50 bpm or symptoms of bradycardia
Reduce dose by 2.5 mg twice daily or discontinue if already at 2.5 mg twice daily
How to titrate ivabradine in patients with a HR 50-60 bpm
maintain current dose and monitor HR
How to titrate ivabradine in patients with a HR > 60 bpm
increase by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily
Pearl for ivabradine
Take with food!!!!
Starting dose of ivabradine
2.5 mg twice daily with food
target dose of ivabradine
7.5 mg twice daily with food!!
What needs to be confirmed before starting a patient on vericiguat
Confirm EF < 45% on maximally tolerated GDMT and has worsening symptoms (recent hospitalization or need for IV diuretics) along with a negative pregnancy test
What needs to be monitored in patients using vericiguat
BP and CBC (anemia) during initiation and titrate
Pearl for vericiguat
Take with food !!
starting dose of vericiguat
2.5 mg daily with food
target dose of vericiguat
10 mg daily with food
Other (rare) therapy options for patients with symptomatic HFrEF and possibly arrhythmias?
digoxin (2b recommendation)
What is an additional therapy that can be used for patients with HF NYHA II-IV?
polyunsaturated fatty acids (PUFA) (2b recommendation)
What is an additional therapy that can be used for patients with HF and hyperkalemia when taking RAASi
potassium binders (2b recommendation)
When may digoxin be added to a medication regimen?
If patient is already on other GDMT and patient is still symptomatic
What are the risks associated with digoxin
cardiac arrhythmias, GI symptoms (anorexia, N/V), neurological symptoms (visual disturbances, disorientation, confusion)
Target plasma concentration for digoxin used in HF
0.5-0.9 ng/mL
Can you develop digoxin toxicity if your plasma concentration is at target (0.5-0.9 ng/mL)?
Yes 😟
Why should you avoid Non-DHP CCBs in HFrEF?
Can worsen EF/CO
Why should you avoid class IC antiarrhythmic drugs and dronedarone in HFrEF?
Increased mortality
Why should you avoid thiazolidinediones in HFrEF?
worsens HF symptoms and hospitalizations
Why should you avoid DPP-4s (saxagliptin and alogliptin) in HFrEF?
increases HF hospitalizations
Why should you avoid NSAIDs in HFrEF?
Worsens HF symptoms (fluid overload)
Note 
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