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IPC CARDIOLOGY 2 JEN > Heart Failure Treatment Slides > Flashcards

Heart Failure Treatment Slides Flashcards

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1
Q

General Approach for drugs via HF treatment

A

Try to initiate AS MANY mortality reducing drugs as the patient can tolerate, then titrate up to the target doses

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2
Q

The addition of a new class of medications decreases…

A

Mortality A LOT

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3
Q

Increasing a dose of a mortality decreasing drug decreases…

A

Mortality A LITTLE

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4
Q

Target doses of all GDMT=

A

Most mortality reduction
A little bit of everything is better than a lot of a few things

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5
Q

Treatment goals: If ‘de novo’ (newly diagnosed) HFrEF, achieve maximally tolerated or target doses within…

A

3 months

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6
Q

Treatment goals: If discharged from the hospital for HFrEF, achieve maximally tolerated or target doses within…

A

6 weeks

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7
Q

HFrEF Treatment GDMT

A

ARNI (or ACEI/ARB) +
Evidence-based
beta-blocker + MRA
+ SGLT inhibitor

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8
Q

HFrEF Treatment GDMT: What to do for patients with persistent volume overload?

A

Add/titrate a diuretic agent (usually a loop diuretic)
(very common)

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9
Q

HFrEF Treatment GDMT: What to do for patients with persistently symptomatic African-American patients on other GDMT?

A

Add hydralazine/isosorbide dinitrate
(decreases mortality but only in a certain population)

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10
Q

HFrEF Treatment GDMT: What to do for patients with a resting HR ≥ 70 bpm on maximally tolerated beta-blocker and in sinus rhythm

A

Add Ivabradine (Corlanor)

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11
Q

HFrEF Treatment GDMT: What to do for patients on on GDMT with worsening HF evidenced by HF hospitalization or requirement for IV diuretics

A

Add Vericiguat (Verquvo)

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12
Q

ARNI wash out

A

If previously on ACEI, allow 36-hour
wash out then select appropriate dose

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13
Q

How many weeks to monitoring for ARNI?

A

1-2 weeks! Assess tolerability, monitor BP, electrolytes, renal function

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14
Q

How many weeks to increase dose for ARNI?

A

Every 1-2 weeks increase dose stepwise to a target of 97/103 mg twice daily

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15
Q

Starting Dose of ARNI

A

24/26 mg twice daily
o On daily equivalent of ≤ 10 mg enalapril or ≤ 160 mg valsartan
o ACEI/ARB naive
o eGFR < 30 mL/min/1.73 m2
o ≥ 75 years old

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16
Q

Other starting dose of ARNI

A

49/51 mg twice daily
o On equivalent of > 10 mg enalapril or > 160 mg valsartan

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17
Q

Every patient that has HF is typically on an…

A

ARNI

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18
Q

When would an ACEI/ARB be used instead of an ARNI?

A

Cost can be an issue for some patients or BID may be tough with the ARNI for some patients

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19
Q

How many weeks to monitoring for ACEI/ARB?

A

1-2 weeks! Assess tolerability, monitor BP, electrolytes, renal function

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20
Q

How many weeks to increase dose for ACEI/ARB?

A

Every 1-2 weeks increase dose stepwise target doses

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21
Q

Sacubitril/Valsartan (Entresto) starting dose?

A

24/26 mg- 49/51 mg BID

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22
Q

Sacubitril/Valsartan (Entresto) target dose?

A

97/103 mg BID

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23
Q

Lisinopril starting dose?

A

2.5-5 mg daily

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24
Q

Lisinopril target dose?

A

20-40 mg daily

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25
Valsartan starting dose?
40 mg BID
26
Valsartan target dose?
160 mg BID
27
What is the monitoring time for a MRA?
7 days! Assess tolerability, monitor BP, electrolytes, renal function
28
What are MRAs at high risk for?
HYPERKALEMIA
29
Contraindications for MRAs?
eGFR <30 mL/min/1.73 m2, or creatinine >2.5 mg/dL in men or creatinine >2 mg/dL in women
30
For MRAs, for stable dose, check...
Monthly for 3 months and then every 3 months out to a year
31
Spironolactone starting dose?
12.5-25 mg daily
32
Spironolactone target dose?
25-50 mg daily
33
To initiate SGLT ensure eGFR...
Ensure eGFR ≥ 25mg/mL/1.73m2 for dapagliflozin and sotagliflozin
34
For Sotagliflozin, increase dose...
stepwise to target dosing in 2 weeks
35
Starting and Target Doses for Dapagliflozin and Empagliflozin?
10 mg daily
36
Starting dose for Sotagliflozin
200 mg daily
37
Target dose for Sotagliflozin
400 mg daily
38
There is no renal cutoff for...
Empagliflozin
39
Contraindications for SGLT Inhibitors?
Patients with Type 1 diabetes
40
What is the monitoring time for a Beta-Blocker?
Monitor HR and BP after initiation and during titration
41
For Beta-Blockers increase dose...
Every 2 weeks stepwise to target dosing
42
Bisoprolol starting dose?
2.5 mg daily
43
Bisoprolol target dose?
10 mg daily
44
Metoprolol Succinate starting dose?
12.5-25 mg daily
45
Metoprolol Succinate target dose?
200 mg daily
46
Carvedilol starting dose?
3.125-6.25 mg BID
47
Carvedilol target dose?
25 mg BID **85 kg: 50 mg BID Be sure to watch for patients weight!
48
What is the monitoring time for a Loop Diuretic?
Monitor BP, electrolytes, and renal function after initiation and during titration
49
For a Loop Diuretic titrate until...
Titrate until the relief of congestion over days-weeks
50
Furosemide IV dose
20 mg
51
Furosemide oral dose?
40 mg
52
Torsemide IV and oral dose?
20 mg
53
Bumetanide IV and oral dose?
1 mg
54
Ethacrynic Acid IV and oral dose?
50 mg
55
Add loop diuretics if patients are experiencing any signs of...
Congestion (hypervolemia)
56
For starting a loop diuretic, usually start at...
20-40 mg Furosemide (or equivalent) -Increase as needed for hypervolemia -Frequent clinic visits until titrated to optimal effect
57
When taking a loop diuretic what is a common side effect/ADR
HYPOKALEMIA (peeing out a lot of potassium)
58
What may need to be prescribed by mouth with a loop diuretic?
Potassium in conjunction
59
Which drugs are the Vaso/venodilators?
Hydralazine Isosorbide Dinitrate
60
For these vaso/venodilators how do you select starting doses?
As separate tablets or fixed combination
61
When do you monitor BP for these vaso/venodilators?
After initation and during titration
62
How often do you increase the dose for hydralazine and isosorbide dinitrate?
Every 2 weeks stepwise to target dosing
63
Target dose of Hydralazine?
75 mg TID
64
Target dose of Isosorbide Dinitrate?
40 mg TID
65
Starting dose of BiDil (20 mg isosorbide dinitrate + 37.5 mg Hydral)?
2 tablets TID
66
When can Ivabradine be started?
After confirming that beta-blocker is at maximally tolerated/target dose, patient is in sinus rhythm
67
When should you be reassessed for Ivabradine?
2-4 weeks...Reasess HR and increse stepwise to target dosing
68
Ivabradine starting dose?
2.5 mg BID with food
69
Ivabradine target dose?
7.5 mg daily with food
70
Titrating for Ivabradine: What to do for HR < 50 bpm or symptoms of bradycardia?
Reduce dose by 2.5 mg BID or d/c if already at 2.5 mg BID
71
Titrating for Ivabradine: HR > 60 bpm
Increase by 2.5 mg BID until maximum dose of 7.5 mg BID
71
Titrating for Ivabradine: HR 50-60 bpm?
Maintain current dose and monitor HR
72
Which drug do you need to see a negative pregnancy test with?
Vericiguat
73
When can Vericiguat be started?
Confirm EF < 45%, on maximally tolerated GDMT and has worsening HF symptoms
74
When do you monitor for Vericiguat?
Monitor BP and CBC (anemia) during initiation and titrate
75
How does increasing the dose work for Vericiguat?
Double the dose every 2 weeks until a target dose is achieved
76
Vericiguat target dose?
10 mg daily with food
77
Additional Therapies: What to take with symptomatic HFrEF?
Consider adding Digoxin
78
Medication Classes to Avoid In HFrEF
Non-DHP CCBs, Class IC Antiarrhythmic Drugs, and Dronedarone, Thiazolidinediones, DPP4s, NSAIDs
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IPC CARDIOLOGY 2 JEN (6 decks)

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