Classification
LVEF for HFrEF and HFpEF
HFrEF: LVEF <40%
HFimpEF: Previous LVEF <40% and follow-up measurement of LVEF >40%
HFmrEF: LVEF 41-49%
HFpEF: LVEF >50%
What does left ventricular ejection fraction (LVEF) measure?
The amount of blood pumped out of the left ventricle with each contraction
What are the pillars for guideline-directed medial therapy for HFrEF?
ACE/ARB/ARNI*
Aldosterone antagonist
Beta Blocker
Sodium-glucose cotransporter-2 inhibitors (SGLT2i)
*Preferred
Name two side effects associated with ACEi
Cough
Hyperkalemia
Increased Scr
Hypotension
What is the target dose for metoprolol succinate in patients with HFrEF?
What tools can we use to classify our patients with heart failure?
ACC/AHA Stages of Heart Failure
New York Heart Association Classification
LVEF
List 3 general signs or symptoms of heart failure
Dyspnea/SOB
Cough
Fatigue
Weakness
Rales
S3 gallop
What beta blockers are indicated for heart failure?
Carvedilol
Bisoprolol
Metoprolol Succinate
By how much can we expect to see a patient's Scr increase following initiation of an ACEi?
A transient bump of ~0.3 mg/dL
IV:PO for metoprolol
IV:PO=1:2.5
What biomarkers can be use for diagnosis of heart failure?
B-type natriuretic peptide (BNP)
N-terminal prohormone of B-type natriuretic peptide (NT-proBNP)
Name one mechanism by which the body compensates for the decrease in cardiac output?
Increased SNS activation
Increased RAAS system activation
Increase natriuretic peptides
Increased vasopressin production
Name 3 medications that have been shown to decrease mortality in HFrEF
ACEi/ARB/ARNI
Beta Blockers
Aldosterone Receptor Antagonist
SGLT2i
Which medication class is considered teratogenic?
ACEi/ARB/ARNI
What is the generic name of Entresto(R) and what classes do they belong to?
Sacubitril: neprilysin inhibitor
Valsartan: ARB
Name and briefly describe the stages of heart failure
Stage A: At-risk for heart failure
Stage B: Pre-heart failure
Stage C: Symptomatic heart failure
Stage D: Advanced Heart Failure
How would you counsel a patient to monitor for signs of fluid overload at home?
Increased swelling/coughing
Increased SOB with activity
3 pillow orthopnea
Weight gain of: 2-4 pounds/day or 5 lbs/week
Has been shown to decrease morbidity and mortality in African Amirian patients with NYHA Class III-IV heart failure when added to optimized regimens
Describe the mechanistic differences between carvedilol and metoprolol and how that would effect your selection of medication.
Metoprolol: B1 selective, less effect on BP more HR
Carvedilol: Non-selective beta blocker (B1/B2) and alpha-1, more BP effects as well as lung receptors and HR
Name two criteria you would you look for when starting spironolactone on a patient?
K< mEq/L
CrCL> 30 mL/min
SCr < 2.0 mg/dL (females) or SCr < 2.5 mg/dL (males)
Name and briefly describe the NYHA Functional Classes
Class I: No symptoms or limitations in ordinary physical activity
Class II: Mild symptoms and slight limitations during ordinary activity
Class III: Marked limitation in activity even during minimal activity. Comfortable only at rest.
Class IV: Severe limitation. Experiences symptoms even at rest.
A patient presents with a K 3.4, Mg 1.8. How would you attempt to correct these electrolytes.
Correct magnesium:
PO: magnesium oxide 400 mg PO q 4 hours x 2 doses
IV: magnesium sulfate 2 grams IV over two hours x 1
Correct potassium:
PO: potassium chloride ER tablet/packet 40 mEq, followed by potassium chloride 20 mEq 2 hours later
IV: Central line: potassium chloride 20 mEq IV over 60 minutes x 3 ; peripheral line: potassium chloride 10 mEq IV over 60 minutes x 6 doses
Describe how you would transition a patient from lisinopril 40 mg daily to Entresto(R)
36-hour washout period
Taking a high dose ACEi, start Entresto(R) at tier 2 dose (49/51 mg) BID
Titrate to target dose of tier 3 (97/103 mg)
What are the renal cut offs for Farxiga(R) and Jardiance(R) for heart failure?
Farxiga(R): eGFR<25 mL/min initiation is not recommended, however patients previously established may continue
Jardiance(R): eGFR<20 mL/min benefits not well established
A patient presents to the ED with heart failure exacerbation. They are on furosemide 40 mg daily at home. What would you recommend for a dose and what trial would you reference?
Dose trial
2.5x the home dose for heart failure exacerbation