Heart Failure Drugs

Question 1

ARNI
Sacubitril (Neprilysin Inhibitor) +
Valsartan (ARB)

Answer 1

MOA: Sacubitril inhibits neprilysin reducing degradation of natriuretic peptide. It also increases angiotensin 2 conc. which is blocked by valsartan. This combination produces vasodilation, increasing glomerular filtration rate, reducing sympathetic tone and aldosterone release and increases bradykinine level

Indication: HF (NYHA class 2-4) with HFrEF

Side effects: Hyperkalaemia, increased serum creatinine, renal impairment, hypotension

Counsel:
- Get up gradually as you may feel dizzy
- Do not take potassium supplement while your taking this medicine
- If changing from an ACEI or SARTAN ensure patients understand the changes and cease drug to avoid confusion

Dose: initially 24/26 mg bd if tolerated, double dose every 2-4 weeks to 97/103 mg bd
Do not use with an additional sartan

Question 2

Souble cGMP stimulators
(Vericiguat)

Answer 2

MOA: Increase vasodilation through the activation of cGMP. This is by nitric oxide (promotes vasodilation) causing the production of cGMP interfering with the contractile medchanism within smooth muscle.

Indication: symptomatic HF with ef <45%

Side effect: hypotension, fainting, dizziness, anaemia, headache

Counsel
- Take with food
- If you feel dizzy ro light-headed while taking this medicine contact doctor

Question 3

Selective Cardiac Myosin Activator
(Omecamtiv Mecarbil)

Answer 3

MOA: Improves ferritin levels for patient with HF that have iron deficiency (not they may or may not have anaemia). It is taken up by macrophages whereby iron is released and stored as ferritin or interacts with transferrin for transport

Indication: Considered if ferritin <100 or if ferritin 100-299 and transferrin saturation <20%

Question 4

ACE inhibitors

Answer 4

Withhold loop diuretics for 24 hours on initiation of ACE inhibitors
Withhold/reduce dose of thiazide for 24 hours on initiation of ACE inhibitors (cause hypotension)

Start treatment when patient is supine to minimise hypotensive effect

Question 5

Beta blockers

Answer 5

Start low and go slow
Potential deterioration symptoms of HF during initiationa dn titration of BB - dont stop taking this medication

Medications include: Bisoprolol Carvedilol, Metoprolol

Question 6

Aldosterone Antagonist

Answer 6

Eplerenone: initially 25mg daily, increase to 50mg daily within 4wks if potassium conc <5mmol/L Metabolised by CYP3A4 (conc increased, increase SE when given with an Cyp3a4 inhibitor)

Spironolactone: Initially 25mg daily, increase to 50mg daily after 8 weeks if HF progressess and potassium conc <5mmol/L . Not suitable for CrCL<30ml/min

Question 7

SGLT2 Inhibitor

Answer 7

Empagliflozin: 10mg once daily. not recommended if eGFR <20mL/min/1.73m2
Dapagliflozin 10mg once daily. not recommended if eGFR <25mL/min/1.73m2

Question 8

Loop diuretics

Answer 8

Bumetanide: 0.5-4mg once or twice daily
Frusemide: initially 20-40mg once or twice daily

Take in the morning. If you are taking it twice a day take first dose in the morning and second dose at lunchtime
1mg of Bumetanide = 40mg frusemide

Question 9

Digoxin

Answer 9

Used for those HF and AF or poor rate control
Toxicity may result deterioration renal function or dehydration

Question 10

Ivabradine

Answer 10

Added to therapy if continuing symptoms of moderate to severe HF
Aim of resting heart rate of 50-60 beats/minute
CYP3A5 inhibitors may reduce ivabradines clearance and increase ADR

Start 5mg bd, adjust 2-4 weeks according to HR