HEART FAILURE.docx

HEART FAILURE - Diuretics: are first-line drugs w/signs of volume overload or hx of volume overload. Excessive diuresis must be avoided: if blood volume drops too low, CO and bp may fall further compromising tissue perfusion - Limited to symptom reduction - Loop diuretic...

HEART FAILURE - Diuretics: are first-line drugs w/signs of volume overload or hx of volume overload. Excessive diuresis must be avoided: if blood volume drops too low, CO and bp may fall further compromising tissue perfusion - Limited to symptom reduction - Loop diuretics produce profound diuresis, these can promote fluid loss even when GFR is low so these are preferred - ACEs: block production of angiotensin II decrease release of aldosterone, and suppress the degradation of kinins - Influence of remodeling is largely due to elevation of kinins - Lisinopril has convenient dosing of once a day - Typical dose is 10-20mg, lowest dose 2.5 and highest 40mg - ARBs: help improve LV EF, reduce HF symptoms. - Because arbs do not increase bradykinin they do not have the effect on remodeling that ACEs do should only be used if not tolerable to ACEs - Sacubitril/valsartan (Entresto) - Increases natriuretic peptides while suppressing neg effects of the RAAS - Approved for pts w/stages II-IV HF to be used in place of an ACE or ARB - Because Entresto contains an ARB angioedema, high K, and hypotension - Because of angioedema risk: when switching from Ace to Entresto, pt needs about 3 days off of the ACE before starting - Aldosterone antagonist: spironolactone/eplerenone - Add only in pts w/ persistent symptoms despite adequate tx w/ACE and a BB. - AE: hyperkalemia - ARNi - Should not be admin w/ACE or within 36 hrs of last dose of ACE - ACE and ARNi should not be given to pts w/hx of angioedema - BB - Carvedilol, bisoprolol, and sustained release metoprolol can improve LV EF, slow progression of HF, reduce contractility - Recommended first line for most pts - Carvedilol 25mg twice daily, benefit is seen w/ dosages of 6.25 twice daily - Metoprolol XL target dose 200mg daily, benefits seen w/ 100mg XL daily - Vericiguat - New guanylate cyclase stimulator approved to reduce risk of cv death and HF hospitalization following a hospitalization for HF or need for outpt IV diuretics in adults w/ symptomatic HF and EF \