HF pt2 Flashcards
What drug classes are neurohormonal blockers?
- RAS inhibitors
- BBs
- SGLT2i
- MRA
- Hydralazine/ISDN
What are the suggested benefits of ACEi?
- Reduce sxs, improve NYHA, improve clinical status, decrease hospitalizations (30% RRR), improve exercise tolerance and QOL
- Reduce mortality, slow progression of HF
What are the mechanisms of ACEi benefit in HF?
Inhibition of angiotension 2 formation and enhancement of bradykinin:
- Decreased NE, improved endothelial fx, inhibition of cardiac hypertrophy
- Improved cardiac hemodynamics, reduced aldosterone, decreased endothelin-1
- Decreased arginine vasopressin, reduced vasoconstriction, reduced Na and water rentention
Why are ACEi underdosed and underused?
- CKD: lower doses
- Hypotension: symptomatic vs low BP
What is the dosing of ACEi?
Titrate slowly to target dose used:
- Start low and double dose q1-4 wks
What are the cautions in ACEi dosing?
- Caution if: volume depleted, SBP <80, K >5, SCr >3
- Lower doses and more monitoring required required w SCr >3 and/or ClCr <30 ml/min
What are the absolute CIs w ACEi?
- Pregnancy or intent to become pregnant
- Hx of angioedema or hypersensitivity
- Bilateral renal artery stenosis
- Hx of WELL DOCUMENTED intolerance due to sx hypotension, decline in renal fx, hyperkalemia, or cough
What are the specifics to ACEi mx of renal function and K?
- Prior to therapy, 1-2 wks after each increase in dose and at 3-6 months intervals
- When other txs are added that may decrease renal function
- In pts w hx of renal dysfunction
- SCr may rise after initiation (<= 30% acceptable)
What are AEs of ACEi?
- Hypotension
- Functional renal insufficiency
- Hyperkalemia
- Skin rash and dysgeusia
- Cough
- Angioedema
When are ARBs an alternative to ACEi?
- Unable to take ACEi due to cough
- ACEi-induced angioedema
What are the monitoring parameters of ACEi?
- Volume status (normalize prior to initiation)
- Regular mx of renal fx and K
- BP: avoid sx hypotension
What are the effects of sacubitril/valsartan?
- Sacubitril: metabolite inhibits neprilysin (neprilysin increases natriuretic peptides)
- Valsartan: ARB effects
What is the indication of entresto?
Reduce risk of CV death/hospitalization for HFrEF pts w NYHA class 2-4
What are the AEs and CI of entresto?
AEs:
- Hypotension (> risk than enalapril)
- Elevations in SCr, K (< than enalapril)
- Angioedema
CI:
- Pregnancy
What is the initial dose of entresto for high dose ACEi and ARB pop?
S 49/V 51 mg BID
What is the max dose of entresto for high ACEi and ARB pop?
S 97/V 103 mg BID
What is dose of ACEi in high dose ACEi pop?
> 10 mg total daily enalapril or therapeutically equivalent
What is dose of ARB in high dose ARB pop?
> 160 mg total daily valsartan or equivalent
What is the initial dose of entresto in low to medium dose ACEi or ARB, ACEi/ARB naive, eGFR <30, moderate hepatic impariment, and/or age >75?
S 24/V 26 mg BID
What are the high dose ACEi equivalents?
Enalapril 20 mg/day = captopril 150 mg/day = lisinopril 20 mg/day
What is the ARNI/ACEi/ARB recommendation for stage B?
ACEi: class 1 OR ARBs: if intolerant to ACEi
What is the ARNI/ACEi/ARB recommendation for stage C?
- ARNI: pts w current or previous sxs
- ACEi: pts w current or previous sxs when use of ARNI is not feasible
- ARBs: if tolerant to ACEi when ARNI is not feasible
- ARNI: pts w current or previous sxs who tolerate ACEi/ARB, replacement w ARNI further reduces mortality
What is an important guideline between ARNI and ACEi?
ARNI should not be administered concomitantly w ACEi or within 36 h of last dose
What is a proposed mechanism of BB that allow its use in HF?
Reverse remodeling
