Chronic Heart Failure Flashcards
(34 cards)
Diagnosis
Sx: fluid overload (SOB, edema)
Echocardiography (echo)
-Measures LVEF (how much blood is pumped out of the LV)
-LVEF < 40 indicates SYSTOLIC dysfunction or HFrEF
Ejection Fraction Categories
55-70%: normal
> = 50%: HFpEF (diastolic dysfunction)
41-49%: HF with mildly reduced EF (HFmrEF, mixed systolic/diastolic)
<= 40%: HFrEF (systolic dysfunction)
<= 40% at baseline but improves to > 40%: HFimpEF
ACC/AHA Classification System
A = at risk for HF (no sx/signs)
-Pts with HTN, ASCVD, diabetes
B = pre-HF (no sx/signs, but elevated biomarkers, SHD, or abnormal cardiac function)
-Patients with LVH, low EF, valvular diseae
C = structural or functional cardiac abnormalities WITH current SX
-Patients with SHD/LVH + SOB, fatigue, reduced exercise intolerance
D = advanced/refractory HF with severe sx or recurrent hospitalizations despite max treatment
HYHA Classification System
1 = no limitations to physical activity, ordinary PA does not cause HF sx
2 = slight limitation to PA, comfortable at rest, but ordinary PA (going up stairs) results in HF sx
3 = marked limitation to PA, comfortable at rest, but minimal exertion (bathing, dressing) results in HF sx
4 = unable to carry on any PA without HF sx or HF sx at rest (SOB while sitting)
Labs/Biomarkers
-Elevated BNP (normal < 100)
-Elevated NT-proBNP (normal < 300)
Left (SNOB H)
-Orthopnea (SOB when flat)
-Nocturnal dyspnea
-Bibasilar rales (crackling lung sounds)
-S3 gallop
-Hypoperfusion
Right (JAEHH)
-Edema
-Ascites
-JVD
-Hepatojugular reflux (neck vein distention)
-Hepatomegaly (enlarged liver due to congestion)
Cardiac Output and Index
CO = HR x SV
CI = CO / BSA
Lifestyle Management
Monitor weight daily (in AM after voiding and before eating)
-Notify if weight goes up by 2-4 lbs in 1 day or 5+ in 1 week
Avoid excessive sodium
-Limit to < 1500 mg/day (in HTN)
Restrict fluid to 1.5-2 L/day in Stage D
BMI < 30 (decrease heart’s workload)
Natural Products for HF
Omega 3 fatty acids (fish oil)
-decrease mortality
Hawthorn and CoQ10
-may improve HF sx
Drugs that Cause/Worsen HF
-DPP4i (alo, saxa gliptins)
-TNFs
-Non-DHP CCBs
-Anti-arrhytmics Class 1 and dronedarone
-Pioglitazone
-Itraconazole
-Anthracyclines (rubicins)
-NSAIDs
STAND A PAIN
GDMT
4 classes that reduce morbidity/mortality
-SGLT2i (must meet GFR criteria)
-ARNI/ACEI/ARB (ARNI preferred)
-BB
-Aldosterone (must meet Scr/GFR/K criteria)
Can be started at same time at low doses or sequentially (wo reaching target doses before next med)
-Goal is for all meds to be titrated to target doses
Other Types of HF: Tx
HFmrEF or HFpEF: SGLT2i
-others can be considered
HFimpEF: should continue tx to prevent relapse even if asx
Sacubitril/Valsartan (Entresto): Dosing
Start 24/26 BID
Target 97/103 BID
If previously taking a moderate-high dose ACEi or ARB:
start 49/51 BID
Sacubitril/Valsartan (Entresto): CI/AE
BBW: fetal injury/death (DC in pregnancy)
CI: within 36 hr of ACEi, hx angioedema, with aliskiren
AE: cough, high K, renal impairment, hypotension, angioedema
Don’t use WITH ACEi or ARB together
PAWK CAR
Target Doses of ACEIs
Ramipril 10 mg
Enalapril 10-20 mg BID
Quinapril 20 mg BID
Lisinopril 20-40 mg
Target Doses for ARBs
Losartan 50-150 mg
Valsartan 160 mg BID
Beta-Blockers: CI/BBW/AE
Same as prior chapters
ABCS DRB
-no abrupt, brady, CNS, sinus, caution in diabetes/raynaud’s/bronchospastic
CI: bradycardia, 2-3 AV block, sick sinus, cardiac failure/shock
Metoprolol Succinate Target Dose
200 mg
-IV to PO: 1 to 2.5
Bisoprolol: Target Dose
10 mg
Carvedilol: Target Dose
Immediate release:
≤ 85 kg: 25 mg BID
> 85 kg: 50 mg BID
Controlled release: 80 mg daily
*Coreg CR capsules can be opened and sprinkled
*Coreg 3.125 BID = 10 CR
*Must take with food
Aldosterone Antagonists: CI/AE
CI
-hyperkalemia, severe renal impairment
-spironolactone: Addison’s
-eplerenone: 3A4 inhibitors
DO NOT START IF K > 5, GFR < 30, SCr > 2 in females or > 2.5 in males
Spiro AE: gynecomastia, impotence, breast tenderness, irregular menses (I BIG)
Ep AE: increase TG (TEE)
SGLT2i: Target Doses
Dapagliflozin (Farxiga): 10 mg
Empagliflozing (Jardiance): 10 mg
NOT TO BE STARTED IF GFR < 20-25
Sotagliflozin (Inpefa) Indication
A dual SLTI/2 inhibitor is approved to CV death, hospitalization and urgent visits for HF
200-400 mg
Loop Diuretics: CI/AE
CI: anuria, hepatic coma (bumex/torsemide, BATH)
Warning: SOA
-sulfa allergy
*except ethacrynic acid
-ototoxicity (more with EA or rapid IV)
-AKI
AE: INC HUB CT DEC KMNCC
-Decrease K, Mg, Na, Cl, Ca
-Increase HCO3, UA, BG, TG, TC
TAKE EARLY IN DAY (not past 4pm)
Loop Diuretic Conversions
= Furosemide 40 mg =
= Torsemide 20 mg =
= Bumetanide 1 mg =
= Ethacrynic acid 50 mg
Furosemide IV:PO ratio 1:2 (20 IV = 40 PO)
