Topic Discussion 2 - Heart Failure Medications

At what EF have medications been shown to have benefit in HF? <40%, >EF tx sxs
o What medications are commonly used in Heart Failure Medications?
o What medications have been shown to decrease hospitalizations?
o What medications have been shown to decrease risk of death?

ACE Inhibitors
o MOA
o ACE pathway
o Any above others?
o Benefit for HF
Recommended in all patient w/ or w/o hx MI/ACS with rEF if not CI
Improve acute sxs and reduce mortality
o Contraindications
Angioedema, pregnant
Caution
Baseline SBP <80, baseline sCr >3, bilateral renal artery stenosis,
K>5
o Education pts
Postural hypotension
 Angioedema
Higher risk in A.A.
Cough (up to 20%)
o Monitoring
SCr, K
o Goal dosing
Start low and slow up to maximally tolerated doses
Abrubt d/c can worsen sxs
ARBs
o ACE vs ARB?
Improve acute sxs and reduce mortality and reduce hospitalizations
ARBs secondary to ACE if intolerant of ACE
o Contraindications
o ARB trial after ACE inhibitor failure
Angioedema
Cough
o Monitoring
BP (hypotension)
K, sCr
Renin Inhibitor
o Aliserken (Tekturna)
No shown benefit in HF
Entresto (Valsartan/Sacubitril) ARNI
o VS. ACE inhibitor
Further reduces mortality than ACE
o Mortality/Hospitilaztion Benefit
o Dosing
New Start vs Previous ACE/ARB
Goal HF dose
36 hour wash out period
o Monitoring
BNP vs pro-BNP
o Not recommended in pt. With hx of angioedema
BB
o Recommended in all HF patients with hx of MI/ACS and rEF to decrease
mortality and morbidity, decrease sxs, decrease hospitilizations
o MOA
o Which are approved for HF
Bisoprolol, carvedilol, and metoprolol succinate
o Selective vs non-selective
B1 selective - bisoprolol and metoprolol
B1, B2, A1 - carvedilol
o Contraindications?
OK to use CAUTIOUSLY in reactive airway disease and asymptomatic
bradycardia
o Goal BB dosing
Low and slow
o Adverse Effects
Initiation of tx
Fluid rtn and worsening HF
 Fatigue
bradycardia/heart block
o Expected unless symptomatic
hypotension
Diuretics
o Used in patients with current or history of fluid retention
Few HF patients can maintain target weight without diuretics
o Increase urinary Na excretion and decrease signs of fluid rtn.
Improves sxs of fluid rtn, and exercise intolerance
No morbidity/mortality benefit (except aldosterone antagonists)

Loop
o Furosemide, torsemide, bumetanide
o In fluid overloaded patient to reduce sxs
o PO to IV lasix conversion
2:1
o DOA
Dosing multiple times per day?
o Diuretic sliding scale?
o Pts may become unresponsive to therapy
Increase dietary Na, NSAIDs, impaired renal perfusion
 Overcome with IV therapy or addition of thiazide
o Adverse effects
K/Mg depletion (potential cardiac arrhythmia), hypotension, azotemia
Thiazide
o Chlorthiazie, HCTZ, Indapamide, Metolazone
o Patients with HTN, mild fluid rtn
o Add on therapy in patients with Loop Resistence

o Aldosterone Receptor Antagonists

Eplernone and Spironolactone
Patient selection
NYHA class II-IV patients, LVEF <35%, GFR>30 mL/min, and K+
<5
Reduce Mortality, Morbidity, hospitalizations (RALES trial)
Monitoring
K, sCr
o Increased Hyperkalemia
ACE/ARB, renal dysfxn
Potentially harmful if K not monitored
Goal Dosing

o K effects
Decrease - Loops
Increase - Aldosterone antagonists
o Loop of Henley (MOA)
 Corlanor (Ibavridine)
o Used only in patients maximized on BB, in NSR, and resting HR >70
o Decrease hospitalizations
Digoxin
o Decrease Hospitalizations
No morbidity/mortality benefit
o Avoid in pts with AV block unless they have a pacemaker
o Caution in patients on amio and beta-blocker
o Monitoring
Digoxin levels
Tx range - 0.5-0.9ng/ml
Sxs of toxicity (Dig level >2) (increased risk in elderly, renal dysfxn, and
low body wt)
GI toxicity (nausea/vomiting)
Visual disturbances (Van Gough starry night)
Cardiac arrhythmia
Vasodilators
o Isosorbide/Hydralazine (Bidil)
Recommended in persistently symptomatic AA
Use in patients who cannot take ACE/ARB due to intolerance
Hypotension, renal dysfxn
Reduce morbidity and mortality
But not as good as ACE
Does not reduce hospitalizations
Adherence is a barrier
TID dosing
SE
o HA, dizziness, GI distress
Statins
o Decrease inflammation, oxidative stress, and vascular performance
o No HF benefit themselves, but benefit CVD in general
 Nutritional Supplements
o Omeg-3s
Reduce mortality and hospitalizations
o IV Iron
Patients with lron deficiency/anemia
Can improve functional status and QOL
EPO not recommended
o No benefit in HF
Nutritional supplements
CoQ10, carnitine, taureine

Drugs known to worsen HF

o Hormonal therapies
Growth hormone, thyroid hormone, testosterone
No benefit
Nitrates and PDE5 inhibitors
Should not routinely be used to increase exercise intolerance
o Antirythmics
Most increase HF mortality
Many are negative inotropes
Class I and III
o Sotalal and dronedarone should be avoided
Amiodarone and dofetalide have neutral effects
o CCBs
Nondihydropyridine calcium channel blockers
negative inotropic effects may be harmful
DHP
Worsen fluid rtn
Except amlodipine
o NSAIDs
Inhibit renal prostaglandins which mediate renal vasodilation and inhibit
Na resorptions i
Worsen Na+/fluid rtn
Blunt diuretic effects
Increase morbidity/mortality (both selective and non-selective)
o TZDs
Increased HF events
Worsens Na resorption in collecting duct
(perixisome proliferator-activated receptor gama located in
kidneys)