Heart Failure

Front 1

Classification

Back 1

NHYA System

Class I - IV

Front 2

Class I

Back 2

Symptoms with more than ordinary activity

Front 3

Class II

Back 3

Symptoms with ordinary activity

Front 4

Class III

Back 4

Symptoms with minimal activity

Class IIIa. No Dyspnea at rest

Class IIIb. Recent Dyspnea at rest

Front 5

Class IV

Back 5

Symptoms at rest

Front 6

HF Precipitants

Back 6

Anemia

Ischemia

Arrhythmia

Infection

Medication non-adherence

Drugs

Front 7

HF Precipitants (Drugs)

Back 7

NSAID (including ASA)

Diabetes: glitazones, gliptins → avoid in LV dysfunction otherwise just counsel

verapamil/diltiazem

VW Class I antiarrhythmics

BB

Front 8

ACEi - Efficacy for 3 years of Treatment

(Mortality)

Back 8

RRR: ~20%

NNT x3y: ~18

Front 9

ACEi - Efficacy for 3 years of Treatment

(HF admission)

Back 9

RRR: ~25%

NNT x 3y: ~28

Front 10

ACEi- Efficacy for 3 years of Treatment

(Reinfarction)

Back 10

RRR: ~20%

NNT x3y: ~42

Front 11

ACEi

(Benefits)

Back 11

Mortality, Class I-IV

Morbidity (hospitalization)

Front 12

ACEi

(Dosing Strategy)

Back 12

Start low, titrate to target doses over several weeks

Front 13

ACEi

(Risks/Monitoring)

Back 13

Hypotension, Hyperkalemia, renal dysfunction, cough, angiodema

Front 14

ACEi

(Do not give to...)

Back 14

Allergy/intolerance

HypovolemiaHypotension

Renal dysfunction (SrCr > 200)

- Instead of DC and ACEi you would decr. dose of ACEi or diuretic or tell patient to increase salt consumption

Hyperkalemia

Bilateral renal artery stenosis or RAS in patient with solitary kidney

Aortic stenosis

Front 15

ACEi

(Captopril)

Back 15

Start Dose: 6.25mg to 12.5mg tid

Target Dose: 25mg to 50mg tid

Front 16

ACEi

(Enalapril)

Back 16

Start Dose: 1.25mg to 2.5mg bid

Target dose: 10mg bid

Front 17

ACEi

(Ramipril*- Favourite ACEi)

Back 17

Start Dose: 1.25mg to 2.5mg

Target Dose: 5mg bid

Front 18

ACEi

(Lisinopril)

Back 18

Start Dose: 2.5mg to 5mg od

Target Dose: 20mg to 35mg od

Front 19

ACEi

(Trandolapril)

Back 19

Start Dose: 1mg od

Target Dose: 4mg od

Front 20

Beta Blockers- Efficacy for 1 year treatment

(Mortality)

Back 20

RRR: ~30%

NNT x 1y: ~26

Front 21

Beta Blockers- Efficacy for 1 year treatment

(HF admission)

Back 21

RRR: ~30%

NNT x1y: ~25

Front 22

Beta Blockers

(Benefits)

Back 22

Mortality, Class I-IV

Morbidity (hospitalization)

Front 23

Beta Blockers

(Dosing Strategy)

Back 23

Start low, work toward target doses from trials over several weeks

Front 24

Beta Blockers

(Risks/monitoring)

Back 24

(See Checklist)

Abrupt withdrawal, worsening HF symptoms during first 1-12 weeks

Front 25

Which Beta Blocker?

Back 25

All are equally effective

Start low, go slow (titrate up every 1-2w)

Front 26

Carvedilol

(Dosage)

Back 26

Start dose: 3.125mg bid

Target dose: 25mg bid

Front 27

Bisoprolol

(Dosage)

Back 27

Start Dose: 1.25mg od

Target Dose: 10mg od

Front 28

Metoprolol CR/XL

Back 28

Start Dose: 12.5mg to 25mg od

Target Dose: 200mg od

Front 29

Beta Blockers

(Do not give to...)

Back 29

Allergy/intolerance

Bradycardia

Hypotension

Heart block > primary

Asthma/ severe COPD

Severe PVD

Hypoglycemia risk

Front 30

Diuretics

(Benefits)

Back 30

Morbidity, if fluid overload, Class II-IV

Front 31

Diuretics

(Dosing strategy)

Back 31

Furosemide 10-160mg daily

HCTZ may be added for synergy (not as useful as it doesn't make you pee as much)

Add metolazone if really resistant to furosemide

Front 32

Diuretics

(Risks/Monitoring)

Back 32

Hypovolemia, Hypokalemia, Hypmagnesemia, Hyperglycemia, Hyperuricemia (HCTZ), Hypocalcemia (furosemide)

Front 33

MRA

(Benefits)

Back 33

Mortality, Class I-IV

Morbidity

Front 34

MRA

(Dosing Strategy)

Back 34

Add 25mg once daily to stable Class III/IV

patent already on ACEI + B-Blockers

Front 35

MRA

(Risks/Monitoring)

Back 35

HYPERKALEMIA, breast tenderness, gynecomastia, hypotension

Front 36

MRA

(Which to choose...)

Back 36

RALES trial showed adding spironolactone to patients already on ACEi and BB with Class3/4 HF reduced mortality

Eplerinone is spironolactone without gynecomastia; good evidence but more expensive

Eplerinone recommended in class II

Front 37

MRA

(Do not give to the following patients spironolactone)

Back 37

Allergy/intolerance

Hypotension

Class ¾ HF

Hyperkalemia

Front 38

ARBs

(Benefits)

Back 38

Morbidity (vs placebo, and when added to standard therapy), Class I-IV.

Mortality (Candesartan, whether or not on ACEi)

Front 39

ARBs

(Dosing strategy)

Back 39

Start low go slow when adding to the ACEi Therapy. When switching from ACEi to ARB, may switch directly to a comparable dose.

Front 40

ARBs

(Risks/Monitoring)

Back 40

Renal dysfunction

Hypotension

Hypokalemia

Front 41

ARB

(Which to pick...)

Back 41

Choose CANDESARTAN

Dose doesn't matter based on mortality - does for morbidity

(Could add ARB to ACEi and BB but this further increases risk of hypotension and hyperkalemia)

Front 42

Candesartan

(Dosage)

Back 42

Start Dose: 4mg od

Target Dose: 32mg od

Front 43

Valsartan

(Dosage)

Back 43

Start Dose: 40mg bid

Target Dose: 160mg bid

Front 44

Digoxin

(Benefits)

Back 44

Morbidity, Clss II-III

Front 45

Digoxin

(Dosing Strategy)

Back 45

0.0625-0.375 mg QD depending on renal function, age, tolerability.

Front 46

Digoxin

(Risks/Monitoring)

Back 46

CNS ADRs (confusion, hallucinations), diarrhea, inc. toxicity during hypokalemia, monitor RENAL FUNCTION

Front 47

Which drugs reduce mortality?

Back 47

-ACEi

-BB

-K-sparing

-ARB