Medical Management for Heart Failure with a Reduced Ejection Fraction.
Here is my approach/work-up for this consult (Part 4).
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
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#MedTwitter #MedEd #Cardiotwitter #IMG
Here is my approach/work-up for this consult (Part 4).
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
Remember:
- Acute heart failure remain to be the most common indication for hospital admission in adults > 65 years!
- 90-day and 1-year post-discharge mortality is high; studies reported ~14% and ~37%, respectively.
- Management: symptoms, decongestion, & hemodynamics
- Acute heart failure remain to be the most common indication for hospital admission in adults > 65 years!
- 90-day and 1-year post-discharge mortality is high; studies reported ~14% and ~37%, respectively.
- Management: symptoms, decongestion, & hemodynamics
See if there are precipitating/treatable factors for decompensation!
- Medication non-compliance
- Acute myocardial ischemia
- Arrhythmias
- PE
- Infections (pneumonia, UTI, endocarditis)
- Alcohol/drug use
- Uncontrolled HTN
- BB in decompensated state
- Valvular Pathology
- Medication non-compliance
- Acute myocardial ischemia
- Arrhythmias
- PE
- Infections (pneumonia, UTI, endocarditis)
- Alcohol/drug use
- Uncontrolled HTN
- BB in decompensated state
- Valvular Pathology
Diuretics:
- Reduces intravascular volume & vasodilatory effect
- Can start with IV Lasix 20/40 (if naive)
- Side-effects: hypotension, low K/Ca/Mg
- Can add subsequent thiazide diuretic (HCTZ, Metolazone, or Chlorothiazide) for synergistic effect
- Reduces intravascular volume & vasodilatory effect
- Can start with IV Lasix 20/40 (if naive)
- Side-effects: hypotension, low K/Ca/Mg
- Can add subsequent thiazide diuretic (HCTZ, Metolazone, or Chlorothiazide) for synergistic effect
Inotropic Therapy:
- Consider when signs of decompensated HF despite vasodilators & diuretics
- Dobutamine (B1-agonist)/Milrinone (PDE-III inhibitor) can be used to augment cardiac output
- Associated with increased myocardial O2 deamnd and cardiac arrhythmias
- Consider when signs of decompensated HF despite vasodilators & diuretics
- Dobutamine (B1-agonist)/Milrinone (PDE-III inhibitor) can be used to augment cardiac output
- Associated with increased myocardial O2 deamnd and cardiac arrhythmias
ACE Inhibitors:
- Reduces morbidity/mortality
- Long-term benefits related to attenuation of RAAS
- Relative contraindications: K > 5.5, Cr > 3, SBP < 90
- Should continue even with improvement in EF or completion resolution in symptoms
- Major effects: cough/angioedema
- Reduces morbidity/mortality
- Long-term benefits related to attenuation of RAAS
- Relative contraindications: K > 5.5, Cr > 3, SBP < 90
- Should continue even with improvement in EF or completion resolution in symptoms
- Major effects: cough/angioedema
ARB:
- Antagonist of angiotensin II type I receptors
- Generally reserved for patients that are ACE-intolerant
- Appears to be < 10% cross-reactivity for ACE-inhibitor associated angioedema in patients
- Antagonist of angiotensin II type I receptors
- Generally reserved for patients that are ACE-intolerant
- Appears to be < 10% cross-reactivity for ACE-inhibitor associated angioedema in patients
Hydralazine & Isosorbide Dinitrate:
- Reduction in morbidity and mortality in selected patients
- Combination has a substantial reduction in mortality when added to African-American patients when on optimal GDMT (ACE and BB)
- Can develop reflex tachycardia/drug-induced SLE
- Reduction in morbidity and mortality in selected patients
- Combination has a substantial reduction in mortality when added to African-American patients when on optimal GDMT (ACE and BB)
- Can develop reflex tachycardia/drug-induced SLE
Beta-Blockers:
- First-line therapy for chronic symptomatic patients (NYHA class I-IV)
- Bisoprolol, Carvedilol, Metoprolol Succinate are recommended
- Relative contraindications: bradycardia, hypotension, prolonged PR intervals
- Start when euvolemic and not decompensated!!
- First-line therapy for chronic symptomatic patients (NYHA class I-IV)
- Bisoprolol, Carvedilol, Metoprolol Succinate are recommended
- Relative contraindications: bradycardia, hypotension, prolonged PR intervals
- Start when euvolemic and not decompensated!!
Aldosterone Receptor Antagonists:
- Indicated in patients with HFrEF and NYHA (class II-IV) receiving ACE/ARB/ARNI & BB without significant renal dysfunction
- Most common side-effect: Hyperkalemia with renal dysfunction
- Spironolactone: Gynecomastia/Galactorrhea
- Indicated in patients with HFrEF and NYHA (class II-IV) receiving ACE/ARB/ARNI & BB without significant renal dysfunction
- Most common side-effect: Hyperkalemia with renal dysfunction
- Spironolactone: Gynecomastia/Galactorrhea
Digoxin:
- Can use in patients with persistent HF symptoms despite GDMT and/or patients with AF to control ventricular rate
- Narrow therapeutic window!
- Usual starting dose is 0.125 mg in patients with normal renal function
- Can use in patients with persistent HF symptoms despite GDMT and/or patients with AF to control ventricular rate
- Narrow therapeutic window!
- Usual starting dose is 0.125 mg in patients with normal renal function
Ivabradine:
- Funny channel inhibitor in the sinus node
- Should be considered in patients with HFrEF with NYHA class II-III receiving GDMT, including maximally tolerated BB and have HR > 70 beats/minute
- Funny channel inhibitor in the sinus node
- Should be considered in patients with HFrEF with NYHA class II-III receiving GDMT, including maximally tolerated BB and have HR > 70 beats/minute
ARNI
- Sacubitril-Valsartan is common
- Prevents the breakdown of natriuretic peptides and leads to increased natriuresis, decreased sympathetic tone, aldosterone, and cardiac fibrosis/hypertrophy
- Should have 36-hour washout after stopping ACE to avoid angioedema
- Sacubitril-Valsartan is common
- Prevents the breakdown of natriuretic peptides and leads to increased natriuresis, decreased sympathetic tone, aldosterone, and cardiac fibrosis/hypertrophy
- Should have 36-hour washout after stopping ACE to avoid angioedema
Others:
- Statins: Used as secondary prevention in atherosclerotic cardiovascular disease; no benefit in HF without CAD
- ASA: prevents reinfarction and other vascular events in patients with know CAD
- Statins: Used as secondary prevention in atherosclerotic cardiovascular disease; no benefit in HF without CAD
- ASA: prevents reinfarction and other vascular events in patients with know CAD
There should be close follow-up for these patients with their PCP, cardiologist, and pharmacy team!
Combination therapy with ACE/ARB/ARNI, BB, MRA, SGLT2 and try to initiate during the index hospitalization. Continue to titrate to maximal dose as tolerated.
Comment below! ๐
Combination therapy with ACE/ARB/ARNI, BB, MRA, SGLT2 and try to initiate during the index hospitalization. Continue to titrate to maximal dose as tolerated.
Comment below! ๐
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