Heart Failure

Kaitlyn Kastberg, PharmD

PGY-1 Pharmacy Resident
Objectives

Discuss Describe Apply

Appropriate The evidence for The information

guideline directed including SGLTis in from this heart
medical therapy for the updated heart failure overview to a
heart failure failure guidelines patient case
treatment
 HFrEF (HF w/ reduced EF)
Heart • LVEF ≤ 40%

Failure HFimpEF (HF w/ improved EF)

Acronyms • Previous LVEF ≤ 40% + a follow-up > 40%

and Left HFmrEF (HF w/ mildly reduced EF)

Ventricle
• LVEF 41-49%

Function
HFpEF (HF w/ preserved EF)
1
• LVEF ≥ 50%
 Renin-Angiotensin System
Inhibition

Beta-Blockers
GDMT for
HFrEF 1 Mineralocorticoid Receptor
Antagonists

Sodium-Glucose Cotransporter 2
Inhibitors
 Ivabradine

• MOA: Inhibits f-channels within the SA node

• On maximally tolerated BB + HR ≥ 70

Vericiguat

Additional • MOA: Soluble Guanylate Cyclase (sGC) Stimulator

• Recent HF hospitalization or IV diuretics

Therapies to Digoxin

• Symptomatic HFrEF despite GDMT

Consider 1,2,3
Omega-3 Polyunsaturated Fatty Acids

• HF NYHA 2-4

Potassium Binders

• Hyperkalemia while on RAASi therapy

HFmrEF, HFimpEF, & HFpEF management1
Symptomatic
HFimpEF HFpEF
HFmrEF
• SGLT2is have • Continue GDMT • Blood pressure
demonstrated to prevent control
the most benefit relapse • SGLT2is can be
• Can consider beneficial
RAASi, MRAs, or • Can consider
BBs ARB/ARNi or
MRA
DAPA-HF4

Inclusion Criteria Exclusion Criteria

• 4744 patients randomized 1:1 to placebo vs. EF < 40% Type 1 Diabetes
dapagliflozin at 410 centers in 20 countries
NYHA 2-4 Recent treatment with
• Primary Outcome: Composite of worsening or unacceptable side
heart failure or death from cardiovascular effects from SGLT2i
causes
Pro-BNP of at least 600 Symptoms of
• Outcome occurred in 386 patients (16.3%) in hypotension or SBP < 95
dapagliflozin group vs. 502 patients (21.2%) in
placebo group
Standard drug therapy eGFR < 30
• HR, 0.74; 95% CI [0.65 to 0.85]; P<0.001
EMPEROR-
Preserved5

• 5988 patients were randomized 1:1 to Inclusion Criteria Exclusion Criteria

empagliflozin or placebo at 622 centers in 23
countries NYHA 2-4 w/ EF > “Disorder that can
• Primary Outcome: Composite of adjudicated 40% change clinical
cardiovascular death or hospitalization for heart
failure, analyzed as the time to the first event course”
• Outcome occurred in 415 patients (13.8%) in the
empagliflozin group vs. 511 patients (17.1%) in Pro-BNP of at least
the placebo group. 300
• HR 0.79; 95% CI [0.6 – 0.9]; p < 0.001
 Acute Coronary Syndrome

Uncontrolled Hypertension

Arrhythmias
Precipitating Acute infections
Factors Leading Nonadherence
to Anemia
Hospitalization 1
Thyroid dysfunction

Negative inotropes

Increased Na retention
Acute Decompensated HF
Presentation 1,6

WARM AND DRY COLD AND DRY

WARM AND WET COLD AND WET

 Fluid Overload
Treatment1 • IV loop diuretics
• May have to add a thiazide diuretic
• Discharge plan should address
home diuretics
Loop Diuretic Equivalent Doses • Adjuncts for dyspnea relief
• IV nitroglycerin or nitroprusside
Furosemide PO 40 mg
Furosemide IV 20 mg
Torsemide IV/PO 20 mg
Bumetanide IV/PO 1 mg
 Decreased CI, Increased SVR, Increased PCWP

Clinical Criteria:

• SBP < 90 mmHg for 30 minutes

Cardiogenic
• Hypoperfusion
• Decreased mentation
• Cold extremities
Shock1,6 • UOP < 30 mL/hr
• Lactate > 2

Hemodynamic Criteria:

• Cardiac Index < 2.2 L/min/m^2

• PCWP > 15 mmHg
Cardiogenic Shock Management1,6

Dobutamine Milrinone
2-10 mcg/kg/min 0.125-0.75 mcg/kg/min
β1 and β2 agonism + α1 agonism PDE3 inhibitor
Risk of ventricular arrhythmias, BP effects, Risk of ventricular arrhythmias, hypotension,
nausea/fever accumulation in renal impairment
↑ CO, ↑ HR, ↔ SVR ↑ CO, ↑ HR, ↓ SVR
 • JL is a 63-year-old male who presents to
the ED with complaints of “trouble
breathing.” The patient also reports an 8-
pound weight gain in one week.
• Vitals: BP 141/84, HR 76, Temp 98F

Patient Case • CrCl 55 mL/min, K 4.3

• On exam, pulmonary rales heard and 2+
pitting edema.
• PMHx is significant for HF, Afib, and HTN.
• Home medications include Entresto,
Toprol XL, Eliquis, and Aleve.
References

1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A
Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice
Guidelines. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063
2. Lexi-Drugs/Ivabradine. Lexicomp Online. Waltham, MA: Wolters Kluwer Health, Inc. July 27, 2022.
http://online.lexi.com. Accessed August 10, 2022.
3. Lexi-Drugs/Vericguat. Lexicomp Online. Waltham, MA: Wolters Kluwer Health, Inc. August 9, 2022.
http://online.lexi.com. Accessed August 10, 2022.
4. McMurry JV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection
Fraction. N Engl J Med. 2019; 381:1995-2008. doi:10.1056/NEJMoa1911303
5. Anker SD, Butler J, Filippatos G, et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. N Engl J
Med. 2021;385:1451-1461. doi:10.1056/NEJMoa2107038
6. Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement
From the American Heart Association. Circulation. 2017;136(16):e232-e268. doi:10.1161/CIR.0000000000000525