ARNI (Angiotensin Receptor blocker / Neprilysin Inhibitors [Sacubutril/Valsartan]) Heart Failure Medication and Symptomatic HF despite ACEI/ARB and B-blocker therapy Bilateral renal artery stenosis Moderate/Severe aortic stenosis : K+ > 5.5 mmol/l Dysfunction: GFR < 30 ml/min : SBP < 90 mmhg or Allergy: angioedema, hives, rash - MRA -NSAIDS/COX2 inhibitors - Stop ACEI x 36hr prior to start - Stop ARB and start following day (reverse) Titrate every 3-6 Goal: Target with x 2-3 Reassess diuretic /vasodilator Reduce/hold of other vasodilators +/- ARNI x 1-2 weeks No improvement, hold/reduce ARNI x 1-2 wks & reassess See Diuretic Reassess 1-2 wks K+ > 5.2 mmol/l MRA - Dysfunction K+ 5.2-5.5 K+ 5.6-6.0 K+ > 6.0 reduce/hold MRA MRA, hold ARNI K+ in 3-5, Reassess ARNI K+ in 2-3, Reassess ARNI >30% in serum creatinine Every Visit C -Addition of nephrotoxic drugs (NSAIDS/COX2) -Co-morbidity interplay ARNI Blood Pressure Creatinine 3) > 30% in Scr Potassium Obtain baseline value prior to any up-titration or change in symptom status If stable: Q 3-6 months x 2-3 Hold ARNI Increase diuretic; reduce/hold of ARNI Other considerations: Angioedema: Stop ARNI, contact physician Do not re-challenge Scr in 5-7 Rechallenge at lower
Angiotensin Converting Enzyme Inhibitors (ACEI) / Angiotensin Receptor Blockers (ARBS)* Heart Failure Medication and Symptomatic HF or Bilateral renal artery stenosis Moderate/Severe aortic stenosis : K+ > 5.5 mmol/l Dysfunction: Creatinine > 220 µmol/l : SBP < 90 mmhg or Allergy: angioedema, hives, rash Intolerance: cough (ACE) -Baseline cough -NSAIDS/COX2 inhibitors Titrate every 1-3 Goal: Target with * x 2-3 Reassess diuretic / other nonessential meds that lower BP Consider staggering s Reduce/hold of other vasodilators +/- ACEI/ARB x 1-2 weeks No improvement, hold/reduce ACEI/ARB x 1-2 wks & reassess See Diuretic Reassess 1-2 wks K+ > 5.2 mmol/l* - Dysfunction K+ 5.2-5.5 K+ 5.6-6.0 K+ > 6.0 reduce/hold MRA (if applicable) MRA. hold ACEI/ARB Treat hyperkalemia MD/NP +/- send to ED K+ in 3-5, Reassess ACEI/ARB K+ in 2-3, Reassess ACEI/ARB C x 2-3 of ACEI/ARB >30% in serum creatinine* Blood Pressure Every Visit -Addition of nephrotoxic drugs: NSAIDS/COX2 -Co-morbidity: DM, dehydration, CKD Creatinine 3) > 30% in Scr Potassium *Obtain baseline value prior to any up-titration or change in symptom status If stable: Q 3-6 months Hold ACEI/ARB Increase diuretic per Diuretic ; reduce/hold of ACEI/ARB Other considerations: Angioedema: Stop ACEI/ARB contact physician Do not rechallenge Caution when substituting ARB for ACEI Cough: Rechallenge at lower at baseline as may be due to worsening HF If intractable cough secondary to ACEI consider: Trial of another ACEI or lower Switch to ARB Reassess in 2 weeks and document *This is intended for single agent (ACEI or ARB)
Beta - Blockers Heart Failure Medication and Bifascicular block PR interval prolongation (>0.24 msec) Bradycardia:HR< 60 bpm or symptomatic 2 nd or 3 rd degree AV block without a pacemaker :SBP< 90 mmhg or Asthma Acute decompensated heart failure Intolerance or allergy COPD with reversible component Other rate controlling drugs: - verapamil, diltiazem -amiodarone, -sotalol -digoxin -ivabradine. Titrate every 2-4 Goal: Target with Other BP lowering drugs: - vasodilators (nitrates, hydralazine, CCB) - ACEI/ARB/ARNI - diuretics x 2-3 Reassess diuretic, other BP lowering drugs. consider staggering s See below (volume overload) No improvement, hold/reduce BB x 1-2 wks reassess Heart Rate Status Bradycardia HR < 55 bpm with Other rate controlling drugs: -diltiazem, verapamil - sotalol - amiodarone -digoxin -Ivabradine Conduction Abnormality -Bifascicular block -PR interval prolongation - 2 nd or 3 rd degree AV block in the absence of PPM Consider decreasing BB. Reassess in 1-2 weeks, Stop BB Consider referral to Cardiologist Volume overload C Other precipitants of fluid retention: NSAIDS/COX2, glitazones - Salt/fluid intake - Non adherence -Co-morbidity Mild Moderate to severe Maintain BB Increase diuretic Sodium/fluid restriction Consider reducing BB Increase diuretic Sodium/fluid restriction see diuretic of BB Blood Pressure Heart Rate Baseline ECG Baseline heart rate assessment (home/pharmacy monitoring) assessment (home/pharmacy monitoring) ECG as clinically indicated: after each up-titration Δ in symptom status *verapamil and diltiazem are contraindicated in systolic heart failure (EF < 40%) **This is a guide to monitoring; increase monitoring may be required given patient s status and co-morbidities assessment Patient should be instructed to perform daily weights Other Extreme limiting fatigue (other causes ruled out): could consider decreasing of BB, review in 1-2 weeks
Diuretics Heart Failure Medication and Heart failure with signs and of fluid overload* Worsening / new SOB Worsening SOBOE Recent weight gain** Peripheral pitting edema Orthopnea/PND Sacral edema / Ascites JVP assessment-jvd Hepatojugular reflex Pulmonary edema: rales, crackles, CXR - restriction -Sodium restriction (<2gm/d) -Underlying renal -History of past diuretic use -Non-adherence -Other precipitants: NSAIDs,COX2 glitazones, increase BB -Sodium load /Co-morbidity Titrate up, down or maintain according to Goal: Minimum to achieve euvolemia; should be reassessed each visit Status Blood Pressure K+ with Hypokalemia K+<3.5 mmol/l* -K+ supplementation -Addition of ACEI/ARB/ARNI - function -GI loss Consider K+ Supplementation. x 2-3 & reassess maintenance 3-7 Reassess diuretic /vasodilator Decrease diuretics/stagger of other medications affecting BP Reduce/hold of other vasodilators +/- ACEI/ARB/ARNI x 1-2 wks. volume deplete x 2-3 &assess maintenance 3-7 Reassess diuretic SCr Indication of Diuretic >30 % in serum creatinine* assessment to titrate diuretics C -Addition of ACEI/ARB/ARNI -Nephrotoxic drugs: NSAIDS, COX2 Creatine * 3)> 30 % in SCr Potassium **Obtain baseline value prior to any up-titration or Δ in symptom status * assessment (home/pharmacy monitoring) *Common signs and include new and worsening shortness of breath, weight gain, HF cough, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, ascites **Weight gain: 2-3 lbs in 1-2 or 5 lbs in 1 week **This is a guide to monitoring; increased monitoring may be required given patient s status and co-morbidities Consider IV Lasix if non responsive to oral Lasix and Metolazone Reduce/hold diuretic x2-3 Reassess diuretic Consider reduce/hold MRA first; then ACEI/ARB/ARNI. Blood Pressure
Mineralocorticoid Receptor Antagonists (MRA) Heart Failure Medication and Symptomatic heart failure (NYHA II-IV) on ACEI/ARB/ARNI + BB and : K+ > 5.2 mmol/l : creatinine > 220 µmol/l or a creatinine clearance < 30 ml/min -K+supplements -K+sparing diuretics -NSAIDS/COX2 inhibitors -ACEI/ ARB/ ARNI See key points Titrate monthly depending Goal: Target (see dosing below) or K+ >5.2 mmol/l* -ACEI/ ARB/ ARNI - K+5.2-5.5 K+ >5.5 dietitian consult. If no major changes in K+ dietary intake, then Hold MRA Reduce/hold ACE/ARB/ARNI physician/np K+ in 3-5 K+ in 2-3 Dysfunction > 30 % in SCr* - addition of nephrotoxic drugs: NSAIDS/COX2 -ACEI/ARB/ARNI assessment Reduce/hold diuretic x 2-3 diuretic Consider rechallenge at lower of MRA Baseline Scr / GFR Creatinine Potassium After initiation: 3, 1 week, 4 weeks, then monthly x 3 Prior to up-titration of MRA 1 week post up-titration of MRA With dehydration, illness, change in symptom status or change in other medications affecting potassium/serum creatinine Goal is to keep patient at target or maximally tolerated of evidence based medications Clinical course of HF is variable frequent reassessment of medication regime required Complete and thorough history and physical assessment essential with each adjustment. Key Points DOSING: The usual is 25 mg daily, however, those with poor renal function and/or a history of hyperkalemia should be initiated on 12.5 mg daily and titrated as tolerated. Some patients may have their increased to 50mg with close monitoring. Populations studied: - Spironolactone*: LVEF < 35 % and NYHA III-IV HF - Eplerenone: high risk NYHA II [aged >55 years and LVEF 35% and QRS duration >130 ms), and recent hospitalization for HF or elevated BNP/NT-proBNP levels] Recent evidence has documented significant issues with hyperkalemia and renal and warrants close clinical monitoring Stop K+ supplementation and other K+ sparing diuretics at initiation of MRA Should be on ACEI/ARB/ARNI + BB prior to initiation Other considerations: Gynecomastia (4-5% of males) with spironolactone. Consider switching to Eplerenone.