CONTINUING EDUCATION tion causes harm.6,9 • Exercise and regular physical activity are recommended for those able to participate; cardiac rehabilitation is also useful to help stable patients improve functional status and mortality.6
T E S T YO U R K N O W L E D G E QUESTION #2:
What are the nonpharmacological interventions that should be initiated in all HF patients?
Patients with ACC/AHA Stage A/No NYHA Functional Classification deemed at high risk for HF (but without structural heart disease or HF symptoms), the recommendation is to treat risk factors and control hypertension and lipid disorders according to guidelines and control or avoid other risk factors such as obesity, DM, tobacco use, and known cardiotoxic agents.6 Patients with ACC/AHA Stage B / NYHA Functional Classification I with structural heart disease, but without signs or symptoms of HF and no limitation of physical activity (in whom ordinary physical activity does not cause HF symptoms), the recommendation for patients with recent or remote myocardial infarction (MI) or acute coronary syndrome (ACS) with HFrEF is to treat with an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for those intolerant to ACE inhibitor due to cough or angioedema (see Appendix B). Taking an ACE or ARB will prevent symptomatic HF and reduce mortality.6 In addition beta blockers have been shown to reduce mortality, and statins prevent symptomatic HF and cardiovascular events.6 If the patient has structural cardiac abnormalities without MI or ACS, blood pressure control is also recommended to prevent symptomatic HF. All patients with HFrEF should receive an ACE inhibitor and a beta blocker.6 Use of an implantable cardioverter defibrillator (ICD) in patients with asymptomatic cardiomyopathy who are >40 days post MI with left ventricular ejection fraction (LVEF) < 30 percent is also recommended.6 Nondihydropyridine calcium channel blockers with negative inotropic effects (e.g., Verapamil or Diltiazem) may be harmful to those that are asymptomatic with low LVEF and no symptoms of HF or MI and should be avoided.6 Patients with ACC/AHA Stage C / NYHA Functional Classification I – IV should follow all recommendations for Stages A and B when appropriate (see Appendix A). Diuretics will improve symptoms (SOB/orthopnea) and quality of life for those patients with evidence of fluid retention, although 22 |
Insight
the effects on mortality are unknown.6,9 The loop diuretics are most commonly used, typically at high doses.6,9 Thiazides may be introduced or added to reach an euvolemic state. ACE inhibitors are indicated for all at this stage, or an ARB may be used if ACE inhibitor intolerant.6,9 Angiotensin receptor neprilysin inhibitors (ARNI) may be used in place of an ACE inhibitor or ARB in those with chronic symptomatic HFrEF NYHA class II or II to further reduce morbidity and mortality.8,9 ARNI therapy should not be used in those with a history of angioedema with previous ACE or ARB therapy and is contraindicated with concomitant ACE or ARB. A 36-hour washout period is required from the last dose of an ACE inhibitor before starting an ARNI.8,9 Beta blockers are recommended in all to reduce mortality but only bisoprolol, carvedilol, and metoprolol succinate sustained release have been studied.6,8,9
T E S T YO U R K N O W L E D G E Q U E ST I O N # 3 :
Which beta blockers are indicated for use in HF patients? Aldosterone receptor antagonists may be needed for those with NYHA II-IV HF and a LVEF of 35 percent or less to reduce mortality and morbidity in patients receiving optimal therapy with an ACE inhibitor and a beta blocker.6,8,9 Aldosterone receptor antagonists may also be added following an MI in those with LVEF ≤ 40 percent with symptoms of HF or DM.6,8,9 If used inappropriately, aldosterone receptor antagonists may be harmful due to hyperkalemia or renal insufficiency.6,9 When used in those with renal insufficiency, they increase the potential for hyperkalemia, thus monitoring of potassium levels, renal function, and diuretic dose is essential. Use is not recommended in those with baseline serum potassium > 5.0mEq/L. Start at a low dose and increase slowly if indicated.8,9 When used with ACE inhibitors, the risk of hyperkalemia increases, and if potassium supplements are used, they should be discontinued or reduced.6
T E S T YO U R K N O W L E D G E Q U E ST I O N # 4:
What is the recommended washout period in patients on an ACE inhibitor who are prescribed the fixed combination sacubitril and valsartan?