Chronic heart failure

  1. Reduce mortality in patients with systolic HF
    • ACEI/ARB, beta blockers, aldosterone antagonists (ARA)
    • ACEI and ARAs - class effect
  2. BiDil
    • Hydralazine/isosorbide DInitrate
    • Adjunct with ACEI/ARB in self-ID African American with NYHA Class III-IV -- to reduce mortality
    • Patients NYHA II-III who cannot tolerate ACEI/ARB for mortality reduction
    • SE: HA with any nitrate (can pretreat with APAP)
    • CI: PDE-5 inhibitors (sildenafil)
    • SE: Lupus-like syndrome from hydralazine (fever, joint/muscle aches, fatigue)
  3. HF beta blockers
    • Carvedilol (IR and ER) (Coreg): nonselective beta blocker + alpha-1 blocking in arterial walls
    • - Target dose of Coreg <85 kg is 25mg BID
    • Metoprolol succinate (Toprol XL): beta-1 selective, split tab on scored line
    • Bisoprolol (Zebeta)
    • For all HF patients to reduce mortality
    • BBW: do not withdrawn abruptly, TAPER use
    • Warning: Do not use in severe bradycardia (HR <55), mask hypoglycemia (sweating, hunger not masked), HYPERglycemia with non-selective BB
    • Titrate every 2 weeks
    • MOA: binds to beta-adrenergic receptors and blocks Epi and NE
    • For all patients to reduce mortality
    • Sacubitril/valsartan (Entresto): stop ACEI 36 hours before starting Entresto, do not use with other ACEI/ARB
    • BBW: pregnancy
    • CI: bilateral renal artery stenosis, h/o angioedema
    • SE: dry cough (accumulation of bradykinin 2/2 inhibition of ACE)
  5. Drugs that worsen HF
    • Thiazolidinediones (TZD): pioglitazone (Actos)-- BBW in patients with NYHA III-IV, d/t increase risk of edema
    • Class 1 antiarrhythmics: mexiletine, propafenone, procainamide, quinidine
    • - Amiodarone and dofetilide -- less risk of worsening HF
    • Oncology agents: anthracyclines (doxorubicin, daunorubicin have lifetime max dose)
    • Nondihydropyridine CCBs: diltiazem, verapamil (works heart harder, negative inotropic effects)
    • NSAIDs: increases NA and water retention
    • Immunosuppressants: TNF inhibitors, interferons (certolizumab, infliximab, etanercept, rituximab), MTX is okay
    • Itraconazole
    • Prednisone
  6. Loop diuretic drugs
    • Ethacrynic acid (Edecrin)
    • Torsemide (Demadex)
    • Bumetanide (Bumex)
  7. Monitor K+
    • When starting or up-titrating an ACEI, ARB, aldosterone antagonist, diuretic
    • When patient's renal function changes
  8. ACEI/ARB drugs
    • ACEI MOA: blocks conversion of angiotensin I to angiotensin II
    • ARB MOA: blocks AT II directly at a receptor site on the smooth muscle wall of vessel
    • Irbesartan (Avapro)
    • Captopril (Capoten): shortest t1/2, dosed TID
    • Enalapril (Vasotec)
    • Quinapril (Accupril)
    • Ramipril (Altace)
    • Valsartan (Diovan)
  9. Aldosterone receptor antagonists (ARA)
    • MOA: blocks aldosterone (causes Na and water retention, increases BP), cause increase in serum K+
    • Eplerenone (Inspra): selective ARA
    • - CI: strong 3A4 inhibitors (voriconazole), should not exceed 25mg daily with moderate 3A4 inhibitors (diltiazem)
    • Spironolactone (Aldactone): non-selective ARA; also blocks androgen (gynecomastia, breast tenderness, impotence)
    • Do not start if K >5 mEq/L
    • If already on it, stop when K reaches 5.5 mEq/L, hold until K <5
  10. Coreg IR to CR conversion
    • Carvedilol 3.125 mg BID = Coreg CR 10 mg daily
    • Carvedilol 6.25 mg BID = Coreg CR 20 mg daily
    • Carvedilol 12.5 mg BID = Coreg CR 40 mg daily
    • Carvedilol 25 mg BID = Coreg CR 80 mg daily
  11. Loop diuretic conversion
    Furosemide 40 mg= bumetanide 1 mg
  12. Digoxin
    • MOA: inhibits Na/K/ATPase pump, digoxin and K+ compete for binding. When K+ is low, less competition at receptor --> more digoxin toxicity
    • Maintain K+ between 4-5 mEq/L
    • TI: 0.5-0.9 ng/mL (for HF)
    • + inotrope, - chronotrope (increase force of heart's contraction, decrease HR)
    • Reduces HF hospitalizations only
    • Digoxin toxicity: N, confusion, abdominal pain, prolonged PR interval, greenish halo around lights
    • Antidote: DigiFab (Digoxin Immune Fab)
  13. Loop diuretics
    • Only for sx control
    • MOA: inhibit Na reabsorption in thick ascending limb of Loop of Henle
    • Ethacrynic acid: highest risk for ototoxicity, no sulfa moiety
    • Other ototoxic drugs: vancomycin, aminoglycosides
    • Least to most potent: ethacrynic acid, furosemide, torsemide, bumetanide
    • Reduces: Na, K, Mg, Cl, Ca
    • Increases: uric acid, TG, total cholesterol
    • SE: hyperglycemia, photosensitivity, hyperuricemia
  14. Causes of HF
    • Common: MI, long-standing HTN
    • Less common: chronic alcohol, illicit drugs, valvular disease
  15. K+ formulations
    • Klor-Con M: can be cut and/or dissolved in water
    • Micro-K: can be opened and sprinkled on food
  16. Ivabradine
    • Ivabradine (Corlanor)
    • Indication: EF <35%, normal sinus rhythm (NSR), HR >= 70 BPM
    • SE: phosphenes (brightness/flashes of light)
  17. Natural products for HF
    • Fish oils (proven by most studies)
    • Hawthorn, coenzyme Q10 (proven by some studies)
    • Avoid: Ma huang (ephedra)
  18. ARNI (angiotensin receptor blocker neprilysin inhibitor)
    • Entresto
    • MOA: inhibits neprilysin and blocks the AT 1 receptor (hence actions of AG II)
  19. Digoxin amiodarone DDI
    • Due to inhibition of P-glycoprotein and 3A4
    • Digoxin = P-gp substrate
    • Amiodarone =  P-gp inhibitor
    • Reduce digoxin dose by 50% when starting amiodarone  
    • Other drugs that interact with digoxin: dronedarone, verapamil, macrolides, itraconazole
  20. Lifestyle mod- fluid restriction
    Fluid restriction only beneficial in NYHA Class IV
  21. HFrEF- normal EF versus reduced EF
    • Systolic dysfunction
    • Normal EF: 55-70%
    • Reduced EF: <40%
Card Set
Chronic heart failure