Notes in HF meds

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Published	09/08/2024	{{c1::New York Heart Association (NYHA) Classification}}: these may change with treatmentClass I: no limitations of physical activityClass II: symptom…
Published	09/08/2024	{{c1::American College of Cardiology (ACC) & American Heart Association (AHA) Staging}}: these classifications are more fixedStage A: high ri…
Published	09/08/2024	All pharmacologic agents for HF work to blunt the pathophysiological mechanisms stimulated by heart failure: BANDAIDS♥ {{c1::ACEi / ARBs♥ Beta bl…
Published	09/08/2024	General pharmacotherapy clinical pearlsStart {{c1::low}} and go{{c2::slow}}Titrate as {{c3::tolerates}} OR to adverse effects (titrate and m…
Published	09/08/2024	Meds to avoid in HF: Negative inotropes: {{c1::NDHP CCB (diltiazem, verapamil)}}Oral hypoglycemics: {{c2::thiazolidinediones}} (rosigli…
Published	09/08/2024	Non pharmacologic considerations in HF: sodium and fluid restrictions {{c1::implantable cardioverter defibrillator}} (ICD) - not therap…
Published	09/08/2024	Heart Failure with {{c2::Reduced Ejection Fraction (HFrEF)}} / {{c1::Systolic}} Heart Failure: associated with {{c3::Cardiomegaly}}, enlarged {{c…
Published	09/08/2024	Heart Failure with {{c2::Preserved Ejection Fraction (HFpEF)}}/ {{c1::Diastolic}} Heart Failure associated with: Size is similar to a {{c3::norma…
Published	09/08/2024	HF{{c1::rEF}} typically affects all ages while {{c1::HFpEF}} typically affects the elderly
Published	09/08/2024	HF{{c1::rEF}} typically affects male > females
Published	09/08/2024	HF{{c1::pEF}} typically affects female > males
Published	09/08/2024	HFref has an LVEF of {{c1::<40%}}
Published	09/08/2024	HFpEF has a LFEF of {{c1::>50%}}
Published	09/08/2024	goals of therapy for {{c1::HFrEF}} is to:Reduce mortality and morbidityDecrease hospitalizationsNormalize EFManage comorbidities (ie: AF, DM, HLD, HTN…
Published	09/08/2024	goals of HF{{c3::pEF}} therapy are: Lack of promising data for decreasing mortalityControl} systolic/diastolic BP (keep BP/afterload down)Go…
Published	09/08/2024	HFrEF:Goal BP: {{c1::< 130/80}} (stage A)Goal BP: {{c2::<130 systolic}} (stage C)
Published	09/08/2024	a fib is typically {{c1::persistent}} in HFrEF
Published	09/08/2024	a fib is typically {{c1::paroxysmal}} in HFpEF
Published	09/08/2024	HTN, DM, previous MI, obesity, sleep apnea, and afib are all comorbidites in HFrEF and HFpEF except HFpEF also has {{c1::chronic lung}} disease and {{…
Published	09/08/2024	ACEi recommended for{{c1:: ALL}} patients with symptomatic HFrEF (ie: stage {{c2::C}}) unless contraindicated
Published	09/08/2024	Consider {{c1::short}} acting ACEi ({{c2::Captopril}}, {{c2::Enalapril}}) in patients with {{c3::soft}} BPs
Published	09/08/2024	Monitoring of ACEIs:{{c1::BMP}}: assess within 1-2 weeks of initiation. Repeat in 1 month, then at least 1-2x annually{{c2::Blood Pressure}}: assess w…
Published	09/08/2024	Drug interactions of {{c1::ACEIS}}: Aldosterone antagonists (hyperkalemia)AliskirenTacrolimus/CyclosporineSulfamethoxazole-TrimethoprimNSAID…
Published	09/08/2024	avoid {{c1::ACEIs}} use in:{{c2::Hypotension}}{{c3::AKI}}{{c4::Bilateral renal artery stenosis}}{{c5::Hyperkalemia}} (>5.0 mEq/L){{c…
Published	09/08/2024	Side Effects of ACEIs:hyper{{c1::kalemia}}, {{c2::angio}}edema, {{c3::AKI}}, increased {{c4::SCr}}, induced {{c5::cough}}
Published	09/08/2024	Avoid use of combination {{c1::ACEi}} + {{c2::ARB}} + {{c3::aldosterone antagonist}} (hyper{{c4::kalemia}})
Published	09/08/2024	{{c1::Rami}}pril (PO) (Altace){{c2::Lisino}}pril (PO) (Prinivil){{c3::Quina}}pril (PO) (Accupril)are commonly used ACEIs in HF
Published	09/08/2024	{{c2::Lo}}sartan (PO) (Cozaar) and {{c1::Val}}sartan (PO) (Diovan) are commonly used ARBs in HF
Published	09/08/2024	ARBs side effects: Hyper{{c1::kalemia}}? {{c2::Angioedema}} - possibly {{c3::Acute Kidney}} Injury (↑ {{c4::SCr}})Hypo{{…
Published	09/08/2024	ARBS: Competitive inhibition by binding/blocking angiotensin-II receptors on vasculature resulting in {{c1::vasodilation}} and less&nbs…
Published	09/08/2024	ARBs decrease {{c1::afterload}}
Published	09/08/2024	ARBs recommended in patients who are intolerant of {{c1::ACEi}} (prefer to use {{c1::ACEi}} first)
Published	09/08/2024	ARBs may be used as an alternative to ACEi as first-line therapy in HF{{c1::rEF}} (but ACEi typically preferred)
Published	09/08/2024	{{c1::ARBs}} may be considered in persistently symptomatic patients already taking an ACEi or beta blocker (can add it but usually not used in pr…
Published	09/08/2024	ARBs: Monitoring:{{c1::BMP}}: assess within 1-2 weeks of initiation. Repeat in 1 month, then at least 1-2x annually{{c2::Blood Pressure}}: assess…
Published	09/08/2024	{{c1::BBs}} are recommended to reduce morbidity and mortality in ALL patients with current or priort symptoms of HFrEF (ie: stage C) unless contr…
Published	09/08/2024	*Only use one of the 3 beta blockers indicated for HF ({{c1::carvedilol, metoprolol succinate, bisoprolol}})
Published	09/08/2024	Initiate BBs at {{c1::low}} doses prior to discharge and titrate {{c2::slowly}} until symptomatic {{c4::hypotension}} an…
Published	09/08/2024	Wait until {{c1::euvolemi}}c before initiating {{c2::BB}} (otherwise dieresis prior, do not want to cause {{c3::fluid}} overl…
Published	09/08/2024	Avoid abrupt {{c1::withdrawal}} of BB
Published	09/08/2024	Continue existing BB during acute {{c1::decompensation}} unless cardiogenic {{c2::shock}} or {{c3::hypotensive}}
Published	09/08/2024	DO NOT start or increase BB in patients who are acutely {{c1::decompensated}}
Published	09/08/2024	SEs of {{c1::BB}}:BradycardiaHeart BlockHypotension (less hypotension with metoprolol vs carvedilol because of its selectivity)DizzinessFatigueSe…
Published	09/08/2024	♥ Mineralocorticoid Receptor Antagonists (MRAs) are {{c1::Aldosterone}} Antagonists
Published	09/08/2024	Monitor {{c1::BMP and BP}} when administering MRAs
Published	09/08/2024	MRAs are for:NYHA class {{c1::II-IV}} with EF {{c2::≤ 35%}}Reduce morbidity and mortality!
Published	09/08/2024	Avoid use of MRAs if:SCr {{c1::> 2.5}} (men)SCr {{c2::> 2.0}} OR CrCl {{c3::< 30}} (women)Hyper{{c4::kalemia}}&…
Published	09/08/2024	MRA SEs:Hyper{{c1::kalemia}}↑ {{c2::SCr}}{{c3::Dizziness, hypotension}}(less than ACEi/ARB)Spironolactone:GynecomastiaBreast TendernessHirsutismM…
Published	09/08/2024	Hydralazine:Direct {{c1::arterial}} vasodilation (minimal effect on veins)↓ {{c2::afterload}} / systemic {{c3::vascular …
Published	09/08/2024	hydralazine and nitrates :♥ reduced morbidity / mortality in {{c1::african American}} patients with NYHA class {{c2::III-IV}} HFrE…
Published	09/08/2024	Patients given {{c1::hydralazine and nitrates}} should be receiving optimal therapy with ACE inhibitors and beta blockers unless contraindic…
Published	09/08/2024	{{c2::hydralazine and nitrates}} (ISDN or ISMN) may be used in patients with symptomatic HFrEF who cannot take or tolerate {{c1::ACEi or ARB}}
Published	09/08/2024	hydralazine and nitrates have risk of medication {{c1::noncompliance}} (pill burden)
Published	09/08/2024	{{c1::hydralazine}} + {{c1::nitrate}} available in combo pill: balanced decrease of preload and afterload
Published	09/08/2024	Avoid use of nitrates with {{c1::phosphodiesterase (PDE) 5}} inhibitors
Published	09/08/2024	An ARNI is a combo of an {{c1::ARB}} + {{c1::neprilysin}} ({{c2::Sacubitril}} + {{c2::Valsartan}})
Published	09/08/2024	{{c1::Sacubitril}}: {{c2::neprilysin}} inhibitor, prevents breakdown of endogenous {{c3::BNP}} → resulting in vaso{{c4::dilation}}…
Published	09/08/2024	Monitor {{c1::BP}} and {{c2::BMP}} and {{c3::NT-ptoBNP}} ( will be elevated due to the drug effect) with ARNIs
Published	09/08/2024	•All patients with HFrEF should be stated on –{{c1::ACE/ARB/ARNI with preference for ARNI –BB (carvedilol, metoprolol or bisoprolol) –MRA –SGLT2i}}
Published	09/08/2024	•{{c1::Diuretics}} used as needed and titrated to symptoms
Published	09/08/2024	•{{c1::Hydralazine/isosorbide dinitrate}} can be used in patients who cannot tolerate ACE/ARB/ARNI
Published	09/08/2024	{{c1::Ivabradine (Corlanor®)}}: Mechanism of Action:¡Selectively inhibits HCN channels of SA node §Slows depolarization §Decreases HR § ¡No impact o…
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Published	09/08/2024	{{c1::Vericiguat (Verquvo®)}}: Mechanism of Action¡Soluble guanylate cyclase stimulator (sGC stimulator) ¡ ¡Directly stimulates sGC, independently of …
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Published	09/08/2024	ARNI: *Should be initiated after patient has proven tolerability to {{c1::ACEi or ARB}} (entresto causes more hypotension)
Published	09/08/2024	ARNI: Recommended for patients with chronic symptomatic HFrEF NYHA class {{c1::II}} or {{c1::III}} to reduce morbidity and mo…
Published	09/08/2024	ARNI: Avoid use if history of {{c1::angioedema}}, concomitant {{c5::ACEi}} or {{c4::aliskiren}} use, severe {{c3::h…
Published	09/08/2024	ARNI: Do not administer concomitantly or within 36 hours of an {{c1::ACE inhibitor}}, requires {{c2::wash out}} period (increased …
Published	09/08/2024	ARNI SEs:{{c1::Hypotension}}* (more {{c1::BP lowering}} than ACEi/ARB)Hyper{{c2::kalemia}}↑{{c3::SCr}}{{c3::Angioedema}}
Published	09/08/2024	Only use ethacrynic acid (loop) for SEVERE {{c1::sulfa}} allergies
Published	09/08/2024	{{c1::loops}} are first diuretic choice for volume reduction in HF
Published	09/08/2024	for a pt with {{c1::Gut edema}} prefer torsemide or bumetanide as a diuretic
Published	09/08/2024	{{c1::Diuretics}}:Recommended for symptomatc benefit in patients with HFrEF and evidence of fluid retention (↑ sodium excretion = ↓ free water)Improve…
Published	09/08/2024	MEDS THAT NO LONGER HAVE ANY MORTALITY BENEFIT FOR HF:{{c1::loop duireticsthiazide diuretics  digoxinivabradinedobutaminemilrinone}}
Published	09/08/2024	HF meds with mortality benefits:{{c1:: SGLTARNIMRABBARBSACEIs}}
Published	09/08/2024	{{c2::loop}} diuretics generally {{c1::bolus}} dosing, may prefer continuous infusion if hypotensive, extreme volume overload, and/or poor response to…
Published	09/08/2024	Only add {{c1::thiazide diuretics}} for refractory cases (max out loop first)
Published	09/08/2024	{{c1::Metolazone}} most common thiazide choice for HF
Published	09/08/2024	Adminster thiazide {{c1::30 min}} before loop diuretic
Published	09/08/2024	thiazides have more potent {{c1::electrolyte wasting}} compared to loop diuretic (monitor K+ and Mg+), use with caution
Published	09/08/2024	thiazides are generally not administered {{c1::daily}} for HF pts (long half life, PRN or scheduled 2-3x weekly)
Published	09/08/2024	{{c1::Digoxin}} is a cardiac glycoside
Published	09/08/2024	digoxin Inhibits {{c1::Na+/K+ ATPase}} pump↑ intracellular {{c2::Na+}}↑ intracellular{{c2::Ca++}}Increases cardiac myocyte {{c3::c…
Published	09/08/2024	Monitor {{c1::SCr}} & {{c2::electrolytes}} with digoxin
Published	09/08/2024	{{c1::digoxin}} is *Dosed based on lean/ideal body weigh
Published	09/08/2024	{{c2::digoxin}} may have benefit in patients with HFrEF in reducing {{c1::hospitalzions}} for HF (neutral effect on mortality, just sym…
Published	09/08/2024	digoxin is a blood pressure {{c1::neutral}} (good if patients can’t tolerate BP meds)
Published	09/08/2024	SEs of {{c1::digoxin}} are: Nausea, vomiting, diarrhea, abdominal painBradycardia, arrhythmiasVisual disturbances (orange haloes)HeadacheDiz…
Published	09/08/2024	Reduced dose in elderly & renal dysfunction with {{c1::digoxin}}
Published	09/08/2024	{{c1::digoxin}} has a Narrow therapeutic index
Published	09/08/2024	Drug interactions of {{c1::digoxin}}: amiodarone, AV nodal blocking agents, QTc prolonging agents, electrolyte-depleting medications
Published	09/08/2024	Avoid use of {{c1::digoxin}} in patients with significant conduction blocks, unless permanent pacemaker placed
Published	09/08/2024	Risk for worsening HF upon therapy discontinuation  of {{c1::digoxin}}(consider risk vs benefit of continuing)
Published	09/08/2024	{{c3::Ivabradine}}: Selectively inhibits {{c1::HCN}} channels of {{c2::SA}} node → slows {{c4::depolarization}} and…
Published	09/08/2024	{{c1::ivabradine}}: No impact on cardiac contractility, repolarization, or BP
Published	09/08/2024	ivabradine is Associated with decreased HF {{c1::hospitalizations}}
Published	09/08/2024	Initiate {{c1::ivabradine}} ONLY after maximizing beta blocker therapy and if HR > 70
Published	09/08/2024	Titrate ivabradine by resting {{c1::HR}}
Published	09/08/2024	{{c1::Beta blocker}} should be maximized before initiating ivabradine!
Published	09/08/2024	Must be in {{c1::sinus rhythm}} for ivabradine
Published	09/08/2024	Avoid use in of {{c1::ivabradine}}:Acute decompensated HFHypotensive and/or bradycardic (HR < 60)SSS, SA block, 3rd degree AV block, pacemaker depe…
Published	09/08/2024	SEs of {{c1::ivabradine}}:*Bradycardia Atrial FibrillationVisual brightness (phosphenes)
Published	09/08/2024	Intravenous Inotropes are {{c1::dobutamine}} and {{c1::milrinone}}
Published	09/08/2024	Intravenous Inotropes↑ cardiac {{c1::contractility}} to improve {{c2::CO}} (↑ HR, ↑ stroke volume, ↓ preload, ↑ pulmonary capillar…
Published	09/08/2024	{{c1::Dobutamine}} MOA: Β₁ agonist↔ BP (± vasodilation)
Published	09/08/2024	{{c1::dobutamine}}:Onset: 1 -10 minHalf-life: 2 minRenal elimination as inactive metabolites (prefered for patients with renal impairment)
Published	09/08/2024	Consider dobutamine in severe {{c1::renal dysfunction}}
Published	09/08/2024	Consider milrinone to continue {{c1::B blocker}} therapy
Published	09/08/2024	{{c1::IV Inotropes}}Adverse Effects:ArrhythmiasHypotension (more in milrinone)TachycardiaMyocardial IschemiaHeadacheTremor
Published	09/08/2024	{{c1::Milrinone}}:Phosphodiesterase (PDE) 3 inhibitor ↓ breakdown cAMPCardiac: ↑ {{c2::contractility}}Periphery: ↑ {{c2::vasodilation}}…
Published	09/08/2024	{{c1::milrinone}} Takes longer than dobutamine, especially in renal impaired patient
Published	09/08/2024	{{c1::milrinone}} Renal elimination as unchanged drug (avoid in kidney dysfunction)
Published	09/08/2024	Empagliflozin ({{c1::morbidity}} benefit in HFpEF)
Published	09/08/2024	SGLT2 inhibitors: inhibits SGLT-2 → blocks renal reabsorption of filtered {{c1::glucose}} → increases {{c1::glucose}} elimination
Published	09/08/2024	Recent studies demonstrating benefit of:{{c1::Dapaglizosin}} in HFrEF&{{c2::Empagliflozin}} in HFrEF and HFpEF
Published	09/08/2024	SGLT2 inhibitors have {{c1::renal }}protective propoerties
Published	09/08/2024	May need multidisciplinary approach to monitor blood sugar levels with {{c1::SGLT2I}}
Published	09/08/2024	Stage {{c1::A}}: high risk of HF, but without structural heart disease or s/sx of HF
Published	09/08/2024	Stage {{c1::B}}: structural heart disease without s/sx of HF (no past or present symptoms)
Published	09/08/2024	Stage {{c1::D}}: objective evidence of severe, structural disease, marked symptoms at rest despite optimal therapy
Published	09/08/2024	Stage {{c1::C}}: structural heart disease and previous or current HF symptoms
Published	09/08/2024	Class {{c1::IV}}: symptoms at rest
Published	09/08/2024	Class {{c1::III}}: symptoms with less-than-ordinary physical activity (winded after cleaning)
Published	09/08/2024	Class {{c1::II}}: symptoms with physical activity (winded after exercise)
Published	09/08/2024	Class {{c1::I}}: no limitations of physical activity
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