Arjun Khadilkar, MD

Arjun Khadilkar, MD



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* -thread ?- #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

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

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

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

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

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

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

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!!

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

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

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

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

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

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! ?

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