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Management of Heart Failure
Topic Discussion
Heart failure: heart can’t pump enough blood to meet the metabolic needs of the body
 Systolic: decreased left ventricular ejection fraction (LVEF)
 Diastolic: disturbed relaxation
Pathophysiology
1. Injury
a. Reduction in muslce mass (MI), dilated cardiomyopathies, ventricular hypertrophy (hypertension)
2. Decreased cardiac output
a. Cardiac output = stroke volume (SV)* heart rate (HR)
3. Compensatory mechanisms
a. Tachycardia and increased contractility
b. Increase preload (Sodium (Na) and water (H2O) retention)
i. Preload: the degree of stretch at the end of diastole; approximated by LVEF
c. Vasoconstriction (increases afterload)
i. Afterload: the force the heart must overcome to eject blood
4. Ventricular hypertorophy and remodeling
a. Changes the shape, size, structure and function of the ventricle making it harder for the heart to work
 Neurohormonal model
o Renin-angiotension-aldosterone system (RAAS) activation leads to vasoconstriction, catecholamine
release, Na and H2O retention, remodeling
o Catecholamines: increased heart rate, vasoconstriction, toxic to the myocardium
o Endothelin: vasoconstriction
o Inflammatory cytokines
Presentation
 Symptoms and signs
o Fatigue
o Pulmonary congestion results in dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, pulmonary
edema, pleural effusion, rales, S3
o Systemic congestion results in JVD, peripheral edema, weight gain, cool extremities, nausea/vomiting,
hepatogulular reflux, splenomegaly, hepatomegaly
 Staging (New York Heart Association Classification)
o Stage 1: no limitations of activity
o Stage 2: slight, mild limitation of activity
o Stage 3: marked limitation of activity
o Stage 4: severe limitation of activity; symptoms at rest
 Staging (ACC/AHA)1
o Stage A: patients at high risk of developing heart failure
o Stage B: patients with structural heart disease but no signs and symptoms of heart failure
o Stage C: patients with structural heart disase and symptoms
o Stage D: refractory heart failure
Treatment
 Goals
o Short-term: relieve symptoms and improve quality of life
o Long-term: slow progression of the disease and prolong survival
o Pharmacotherapeutic: disrupt neurohormonal mechanisms, decrease preload, decrease afterload
 Non-drug
o Treat the underlying cause
o Restrict Na to <2g/day
Management of Heart Failure
Topic Discussion
o Avoid overexertion
o Avoid alcohol
o Keep immunizations up to date
o Avoid drugs that worsen heart failure
 Pharmacotherapy
o Drugs that improve survival: ACE-I, beta blockers, aldosterone antagonists
o Drugs that improve symptoms: diuretics, digoxin
o Alternatives: Angiotension receptor blockers (ARBs), Isosorbide dinitrate ( ISDN)/hydralazine
 General approach to treatment (See Figure 1)
 Stage D treatment
o Patients may need additional diuretics
o Patients may be more sensitive to adverse events of Angiotension convertine enzyme inhibitor (ACE-I)
and beta blockers
o Consider surgical measures
Heart Failure with Normal LVEF (diastolic dysfunction)
 Control underlying disease states (ie, bloodp pressure (BP), rate control with a. fib)
 Symptom control: diuretics for congestion, beta blockers, ACE-I, ARB, calcium channel blockers might provide
some symptom relief
Drugs that worsen heart failure
 Negative inotropes: calcium channel blockers, beta blockers, antiarrhythmics (disopyramide, flecanide,
propafenone, sotalol)
 Exogenous Na: sodium polystyrene sulfonate, antibiotics, antacids, cough syrups
 Na-retaining: Nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, androgens/estrogens
 Cardiotoxics: ethanol, doxorubicin, trastuzumab, infliximab
 Others: glitazones
Drugs that are safe in heart failure
 Calcium channel blockers: amlodipine, felodipine
 Antiarrhythmics: amiodarone, dofetolide
References
1. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for
the Diagnosis and Management of Heart Failure in Adults: A report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the
International Society for Heart and Lung Transplantation. Circulation 2009;119:e391–479
Management of Heart Failure
Topic Discussion
Case
 50 yom presents with a new diagnosis of heart failure
 He takes hydrochlorothiazide 25mg daily for hypertension and uses ibuprofen ~3x/week for headaches.
 His LVEF is 50%
 He is currently experiencing peripheral edema and significant shortness of breath
Questions
 What stage of heart failure does the patient have?

What should we do with this patient’s medications today?

What dose should we start at?

What should we monitor?

What is the goal weight loss for this patient?

What else do we want to tell the patient?
The patient returns in a few months and is stable on lisinopril 30mg daily and furosemide 20mg daily.
 What do you want to do now? Drugs and doses?

What do you want to tell the patient about his symptoms?

What might you consider if the patient’s LVEF was low?

What might you consider if the patient is having frequent hospitalizations?
Management of Heart Failure
Topic Discussion
Drug Class
Appropriate Use
Benefit
Mechanism of
Action
Adverse Events
Monitoring
Patients in stage A with
comorbid conditions
requiring use.
Patients in stages B, C, D
Patients intolerant to
ACE-I
Symptom improvement,
decreased
hospitalization,
decreased risk of death
Symptom improvement
and decreased mortality
Prevent conversion of
angiotensin I to
angiogensin II
Hypotension (don’t use if SBP
<80mmHG), angioedema, acute
renal failure, cough,
hyperkalemia, dysgeusia, rash
Hypotension (don’t use if SBP
<80mmHG), angioedema, acute
renal failure, hyperkalemia,
K+ and SCr at 1-2weeks, BP
K+ and SCr at 1-2weeks, BP
Use caution if angioedema with ACE,
renal failure and hyperkalemia are as
likely to occur with ARB as ACE-I
Patients in stages B, C, D
Symptom improvement,
decreased
hospitalization,
decreased risk of death
Inhibits the sympathetic
nervous system effects
and protects against
damage to myocardium
Fluid retention (adjust diuretic),
hypotension, bradycardia,
fatigue, depression, erectile
dysfunction
BP, HR, weight daily
Iniate when patient is stable, may
cause worsening of symptoms initially
Disease state considerations: airway
disase, diabetes, PVD
Don’t stop abruptly
Severe HF with low LVEF
Early after MI
(Weigh risks)
SCr <2.5mg/dl male or
<2.0mg/dl female and k+
<5meq/l
Patients with symptoms
of fluid retention
Symtpom improvement,
decreased
hospitalization,
decreased risk of death
Competes with
aldosterone for binding
to receptor
Hyperkalemia (d/c or decrease
dose when k+ >5.5),
gynocomastia (change to
eplerenone)
BP, SCr
K+ at 3 days, 1 week and
monthly x 3 months (restart
monitoring when dose change,
or ACE-I or ARB started)
Renally adjusted
Rapid symptomatic
improvement
Inhibit reabsorption of
Na in distal tubule
Decreased electrolytes (k+, mg2+,
ca2+), dehydration, hypotension,
azotemia, rash, ototoxicity
Weight (goal weight loss is 0.51kg/day), signs and symptoms
of fluid overload, BP,
electrolytes, SCr, BUN
Digoxin
Patients in stage C with
frequent hospitalizations,
rate control for a.fib
Reduces symptoms,
prevents hospitalization
Inhibits Na/K ATPase
resulting in increased
contractility
Arrhythmias, GI upset,
neurological complaints, vision
changes
ISDN/Hydrala
zine
Alternative for ACEI/ARB, has better efficacy
in African American
patients
Reduce mortality but not
hospitilizations
Arterial and venous
dilation
Headache, GI upset, dizziness,
weakness
HR and rhthm, levels (goal 0.51) at 5-7days and 6-12 hours
after dose, electrolytes and
renal function (renally
eliminated)
BP, HR, ANA titer
Use higher doses in renal
insufficiency, equivalents:
1mgB=20mgT=40mgF
Ethacrynic acid does not have sulfa
component
Predisposing factors for toxicity:
hypothyroid, hypomagnesemia,
hypokalemia, hypercalcemia, most
notable drug interactions: verapamil,
quinidine, amiodarone
Need nitrate free interval, hard to
tolerate and high pill burden
ACE-I
ARB
(candesartan,
valsartan)
Beta Blockers
(carvedilol,
bisoprolol,
metoprolol
succinate)
Aldosterone
antagonists
Loop diuretics
Blocks angiotensin
receptor
Notes
Management of Heart Failure
Topic Discussion
Figure 11
Dosing1