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CHF
Chronic Heart Failure
| Generic | Brand | Drug Class | Dosing | MOA | BBW/CI | ADEs | Monitoring | DDI |
|---|---|---|---|---|---|---|---|---|
| Sacubitril/ valsartan | Entresto | Angiotensin receptor-neprilysin inhibitor (ARNI) | Start: 24/26mg BID If previously taking a mod-high dose of ACEi or ARB: start 49/51mg BID Target dose: 97/103mg BID | |||||
| Angiotensin receptor-neprilysin inhibitor (ARNI) | Sacubitril inhibits neprilysin, increasing beneficial vasodilatory peptides (natriuretic peptides, substance P, and bradykinin), promoting vasodilation and diuresis. Valsartan blocks AT₁ receptors, reducing vasoconstriction and sodium/ water retention | BBW: can cause injury and death to the developing fetus when used in the 2nd and 3rd trimester; discontinue as soon as pregnancy is detected CI: -hx angioedema -do NOT use within 36 hours of ACEi -do not use with aliskiren in diabetes | angioedema, hyperkalemia, renal impairment (↑ risk with bilateral renal artery stenosis), hypotension/dizziness (↑ risk if volume depleted), can cause cough (due to bradykinin) | BP, K, renal function (SCr), s/sx of HF, angioedema | HyperK⁺: caution with other K⁺-↑ drugs; avoid K⁺- salt substitutes ACEi → ARNI: 36-hr washout. RAASi: Avoid combination due to ↑ renal impairment, hyperK⁺, and hypotension. NSAIDs: ↑ risk of renal impairment. ↓ Li⁺ clearance → ↑ risk of Li⁺ toxicity | |||
| Captopril | not listed | Angiotensin-converting enzyme (ACE) inhibitor | Start 6.25mg TID, 1 hour before meals Target dose: 50 TID (no bold or underlined) | |||||
| Enalapril | Vasotec (tablet) Epaned (Oral solution) | Angiotensin-converting enzyme (ACE) inhibitor | Start: 2.5mg PO BID Target Dose: 10-20 mg PO BID (know target) | |||||
| Lisinopril | Zestril (tablet) Qbrelis (oral solution) | Angiotensin-converting enzyme (ACE) inhibitor | Start 2.5-5mg daily Target: 20-40mg QD (know target) | |||||
| Perindopril | not listed | Angiotensin-converting enzyme (ACE) inhibitor | Start: 2mg daily Target: 8-16mg daily (no bold or underlined) | |||||
| Quinapril | Accupril | Angiotensin-converting enzyme (ACE) inhibitor | Start: 5mg BID Target: 20mg BID (know target) | |||||
| Ramipril | Altace | Angiotensin-converting enzyme (ACE) inhibitor | Start: 1.25-2.5mg daily Target: 10mg daily (know target) | |||||
| Trandolapril | not listed | Angiotensin-converting enzyme (ACE) inhibitor | Start 1mg daily Target: 4mg daily (no bold or underlined) | |||||
| Fosinopril | not listed | Angiotensin-converting enzyme (ACE) inhibitor | Start: 5-10mg daily Target: 40mg daily (no bold or underlined) | |||||
| Angiotensin-converting enzyme (ACE) inhibitor | -block the conversion of angiotensin I to angiotensin II -results in ↓ VC and ↓ aldosterone secretion -block the degradation of bradykinin-> contributes to cough and angioedema | BBW: can cause injury and death to the developing fetus when used in the 2nd and 3rd trimester; discontinue as soon as pregnancy is detected CI: -hx angioedema -do NOT use within 36 hours of ACEi -do not use with aliskiren in diabetes | angioedema, hyperkalemia, renal impairment (↑ risk with bilateral renal artery stenosis), hypotension/dizziness (↑ risk if volume depleted), can cause cough (due to bradykinin), headache | BP, K, renal function (SCr), s/sx of HF, angioedema | HyperK⁺: caution with other K⁺-↑ drugs; avoid K⁺- salt substitutes ACEi → ARNI: 36-hr washout. RAASi: Avoid combination due to ↑ renal impairment, hyperK⁺, and hypotension. NSAIDs: ↑ risk of renal impairment. ↓ Li⁺ clearance → ↑ risk of Li⁺ toxicity | |||
| Candesartan | Atacand | Angiotensin II receptor blockers (ARB) | Start: 4-8mg daily Target dose: 32mg daily (no bold or underlined) | |||||
| Losartan | Cozaar | Angiotensin II receptor blockers (ARB) | Start: 25-50mg daily Target: 50-150mg daily (know target) | |||||
| Valsartan | Diovan | Angiotensin II receptor blockers (ARB) | Start :40mg BID Target: 160mg BID | |||||
| Angiotensin II receptor blockers (ARB) | blocks angiotensin II from binding to the angiotensin II type-1 (AT1) receptor results in ↓ VC and ↓ aldosterone secretion | BBW: can cause injury and death to the developing fetus when used in the 2nd and 3rd trimester; discontinue as soon as pregnancy is detected CI: -hx angioedema -do NOT use within 36 hours of ACEi -do not use with aliskiren in diabetes | angioedema (not as common), hyperkalemia, renal impairment (↑ risk with bilateral renal artery stenosis), hypotension/dizziness (↑ risk if volume depleted) | BP, K, renal function (SCr), s/sx of HF, angioedema (less) | HyperK⁺: caution with other K⁺-↑ drugs; avoid K⁺- salt substitutes ARB → ARNI: NO washout. RAASi: Avoid combination due to ↑ renal impairment, hyperK⁺, and hypotension. NSAIDs: ↑ risk of renal impairment. ↓ Li⁺ clearance → ↑ risk of Li⁺ toxicity | |||
| Metoprolol succinate (ER) | Toprol XL (tablet) Kapspargo Sprinkle (capsure) | Beta-1 Selective Blocker | Start 12.5-25mg daily Target: 200mg daily (know target) | -IV ≠ PO: IV-to-PO ratio is 1:2.5 -IR tabs: May be split; do not crush or chew. Take with or immediately after meals. -ER capsules: May be opened and sprinkled on 1 tsp soft food (e.g., applesauce, yogurt, pudding); do not crush/chew. | ||||
| Bisoprolol | not listed | Beta-1 Selective Blocker | Start: 1.25mg daily Target: 10mg daily | |||||
| Carvedilol | Coreg (tablet) Coreg CR (ER capsule) | Non-selective Beta-Blocker and Alpha-1 Blocker | Immediate release: Start: 3.125mg BID Target: < or = 85kg (187lbs): 25mg BID >85kg: 50mg BID Controlled release: Start: 10mg daily Target: 80mg daily (know all targets) | -Take with food: ↓ absorption rate and risk of orthostatic hypotension. -Carvedilol CR: Swallow whole; may open capsule and sprinkle on applesauce. -CR vs IR: CR has lower BA; doses are not 1:1. Conversion: IR 3.125 mg BID → CR 10 mg once daily. | ||||
| Beta-1 Selective Blocker | lower heart rate and blood pressure by competing with adrenaline and noradrenaline for beta-1 adrenergic receptors primarily located in the heart | BBW: don't d/c abruptly (especially in CHD/IHD); taper over 1-2 weeks to avoid acute tachycardia, HTN, and ischemia CI: severe bradycardia, 2nd/3rd degree AV block, or sick sinus syndrome (unless pt has permanent pacemaker), cardiac failure or shock | -Diabetes: May worsen/mask hypoglycemia. Asthma/COPD: May cause bronchospasm. Raynaud’s/PVD: May worsen symptoms/cold extremities. Hyperthyroidism: May mask tachycardia. SEs: Bradycardia, hypotension, fatigue, dizziness, depression, impotence. | HR, BP, s/sx of HF | Insulin/SUs: ↑ hypoglycemia; may mask tremor, palpitations, anxiety. ↓ HR drugs: Caution with digoxin, verapamil, diltiazem, amiodarone. CYP2D6: metoprolol affected by CYP2D6 inhibitors/inducers. | |||
| Non-selective Beta-Blocker and Alpha-1 Blocker | β₁ receptors in heart & kidneys: ↓ HR, contractility, and renin release → ↓ cardiac workload and BP. β₂ in bronchi & blood vessels: Blocking causes bronchoconstriction and ↓ VD. α₁ in vascular smooth muscle: Blocking causes VD → ↓ SVR and afterload. | BBW: don't d/c abruptly (especially in CHD/IHD); taper over 1-2 weeks, HTN, and ischemia CI: severe bradycardia, 2nd/3rd degree AV block, or SSS (unless permanent pacemaker), cardiac failure or shock +++ severe hepatic impairment & asthma | Caution in diabetes, Asthma/ COPD, Raynaud’s/ PVD, Hyperthyroidism SEs: Bradycardia, hypotension, fatigue, dizziness, impotence. ++Warning: Intraoperative floppy iris syndrome has occurred in cataract surgery (due to α₁ ) | HR, BP, s/sx of HF | Insulin/SUs: ↑ hypoglycemia; may mask symptoms. ↓ HR drugs: Caution with digoxin, verapamil, diltiazem, amiodarone. CYP2D6: affected by inhibitors/ inducers. P-gp inhibition: ↑ levels of digoxin, cyclosporine, dabigatran, ranolazine. | |||
| Dapagliflozin | Farxiga | Sodium-glucose cotransporter 2 (SGLT2) | 10mg PO daily | |||||
| Empagliflozin | Jardiance | Sodium-glucose cotransporter 2 (SGLT2) | 10mg PO daily | |||||
| Sodium-glucose cotransporter 2 (SGLT2) | block the sodium-glucose cotransporter 2 protein in the early proximal tubule of the kidneys, preventing the reabsorption of filtered glucose and sodium into the bloodstream | Don't initiate for HF if eGRF <20-25 | see diabetes chater | see diabetes chater | see diabetes chater | |||
| Spironolactone | Aldactone (tablet) CaroSpir (oral suspension) | non-selective aldosterone receptor antagonist | Start: 12.5-25mg daily Target: 25-50mg daily CaroSpir: start 10-20mg daily; may increase to 37.5mg daily (know target) | Oral suspension ≠ tablets: For doses >100 mg, use tablets to avoid supratherapeutic levels. | ||||
| Eplerenone | Inspra (tablet) | Selective aldosterone receptor antagonist | Start: 25mg daily Target: 50mg daily | |||||
| aldosterone receptor antagonist (ARA) | Compete with aldosterone at receptors in the DCT and CD → ↓ Na⁺/water retention and cardiac remodeling Spironolactone: Nonselective → also blocks androgen receptors → endocrine effects. Eplerenone: Selective aldosterone antagonist | CI: hyperkalemia, sever renal impairment, Addisons disease (spiro), taking strong CYP3A4 inibitors (epler) | Do not initiate for HF if: K⁺ >5, CrCl <30, SCr >2 (female) or >2.5 (male). SEs: HyperK+ (↑ risk with renal impairment), dizziness, hyperchloremic metabolic acidosis (rare) Spiro: Gynecomastia, breast tenderness, impotence, amenorrhea. Epler: ↑ TG. | BP, K, renal function, fluid status, s/sx HF | -HyperK: Use caution with other K⁺-↑ drugs. -RAAS: Avoid triple therapy due to ↑ hyperK and renal insufficiency. -Epler is a major CYP3A4 substrate. Avoid with Strong 3A4 inhibitors: clarithromycin, cobicistat, ritonavir, ketoconazole, itraconazole. | |||
| Furosemide | Lasix (tabs, solution, injection) Furoscix (inj) Lasix ONYU (inj) | Loop diuretics | Oral: 20-40mg daily or BID Max: 600mg/day | -Injection: Store at room temp; refrigeration causes crystals. Use only if clear/colorless. -Furoscix/Ony: Given subQ via on-body infusor. -Light-sensitive: Store injection in amber bottle; IV admixtures don’t require protection. | ||||
| Bumetanide | Bumex (tabs, inj) Enbumyst (nasal spray) | Loop diuretics | Oral: 0.5-1mg daily or BID Max 10mg/day | -Light-sensitive: Store injection in amber bottle; IV admixtures don’t require protection. | ||||
| Torsemide | Soaanz (tablet) | Loop diuretics | Oral: 10-20mg daily Max 200mg/day | |||||
| Ethacrynic Acid | Edecrin (tab, inj) | Loop diuretics | Oral: 50-200 daily Max 400mg/daily | |||||
| Loop diuretics | Inhibits the Na⁺-K⁺-2Cl⁻ cotransporter in the thick ascending limb of the loop of Henle. ↑ Excretion: Na⁺, K⁺, Cl⁻, Mg²⁺, Ca²⁺, and water. ↓ Fluid volume: ↓ preload and congestion → easier cardiac pumping. Goal: Restore euvolemia/ dry weight. | BBW: profound diuresis resulting in fluid and electrolyte depletion CI: anuria, hepatic coma (bumetanide and torsemide only) | -Sulfa allergy: Low cross-reactivity; give ETA. -Ototoxicity: Hearing loss, tinnitus, vertigo; ↑ risk w/ ETA or rapid IV admin. -↓ Na, K, Cl, Mg, Ca -↑ HCO₃, UA, BG, TG, TC -AKI, Orthostatic hypotension, sunburn, myalgias. -QAM to avoid nocturia | -renal function, fluid status (input/ output, weight) BP, electrolytes, s/sx of HF -Oral equivalents: Furosemide 40 mg = Torsemide 20 mg = Bumetanide 1 mg = Ethacrynic acid 50 mg. -IV:PO: Furosemide 1:2; bumetanide & ethacrynic acid 1:1. | -NSAIDs: ↑ in Na and water retention can ↓ the effect of loop diuretics. It may also cause renal impairment. -Ototoxic drugs -Thiazides: ↑ diuresis and electrolyte abnormalities. -Lithium: May alter levels → toxicity or inadequate treatment. | |||
| Hydralazine/ isosorbide dinitrate | BiDil (tablet) | vasodilator and nitrate combination | Start: 20/37.5mg TID (1 tab TID) Target: 40/75mg TID (2 tabs TID) | |||||
| Hydralazine | not listed | Direct arterial vasodilator | Start 25-50mg TID-QID Target: 300mg/day in divided doses | |||||
| Isosorbide dinitrate | Isordil Titradose | vasodilators and antianginal | ||||||
| Direct arterial vasodilator | relaxes the smooth muscle in small arteries to widen blood vessels and lower blood pressure | CI: mitral valve rheumatic heart disease, CAD | -Drug induced lupus erythematosus (DILE- dose and duration related) -peripheral edema, HA, flushing, palpitations, reflex tachycardia, N/V, peripheral neuritis, blood dyscrasias, hypotension | HR, BP, ANA titer, s/sx of HF | none listed | |||
| Nitrate vasodilators and antianginal | nitric oxide donors that stimulate soluble guanylyl cyclase, increasing cyclic GMP (cGMP) to relax vascular smooth muscle and reduce both cardiac preload and afterload | CI: do not use with PDE-5 inhibitors or riociguat | hypotension, HA, dizziness, tachyphylaxis (need 10-12 hour nitrate-free interval), syncope | HR, BP, s/sx of HF | Do not use with PDE5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil) or riociguat. The combination can cause severe hypotension. | |||
| Ivabradine | Corlanor | I f current inhibitors or "funny channel" blockers | Start: 5mg PO BID; after 2 weeks, adjust dose based on HR Maintenance: 2.5-7.5mg PO BID Target resting HR between 50-60 bpm | Criteria for use includes normal sinus rhythm and a resting HR > or = 70 bpm | ||||
| I f current inhibitors or "funny channel" blockers | Blocks the funny current (If) in the SA node → ↓ firing rate → ↓ heart rate. | CI:ADHF, SSS or SA block or 3rd-degree AV block (unless permanent pacemaker in place), clinically significant hypotension or bradycardia, HR maintained exclusively by pacemaker, severe hepatic impairment, use with a strong CYP3A4 inhibitor. | -Bradycardia: May ↑ QT prolongation and ventricular arrhythmia risk; not recommended in 2nd-degree AV block. -Atrial fibrillation: ↑ risk. -Fetal toxicity: Use contraception. -SEs: Bradycardia, HTN, luminous phenomena (phosphenes- flashes of light). | HR, ECG, BP | -Do not use with moderate or strong CYP3A4 inhibitor or strong CYP3A4 inducer. -Caution with other drugs that decrease heart rates like digoxin, beta blockers, clonidine, non-DHP CCBs, amiodarone, and dexmedetomidine. | |||
| Digoxin | Lanoxin (tab, solution, inj) | cardiac glycosides | -Typical dose: 0.125 to 0.25mg PO daily. -LD not used in HF -CrCl < 60 mL/min: ↓ dose or freq; hold in acute renal failure. -↓ dose by 20 to 25% when switching from PO to IV. -Therapeutic range for HF: 0.5 to 0.9 ng/mL. (Higher range for AFib.) | Antidote- Digifab | ||||
| cardiac glycosides | -Inhibits Na⁺/K⁺-ATPase pump in myocardial cells → ↑ intracellular Ca²⁺ → positive inotropy → ↑ CO -↑ Parasympathetic activity → slows AV nodal conduction → negative chronotropy → ↓ HR | CI: ventricular fibrillation | Warn: 2nd/ 3rd degree <3 block, vesicant (avoid extravasation) SE: dizziness, HA, NV Dig Toxicity: -abdominal pain, blurred vision, green-yellow halos, confusion, bradycardia, arrhythmias -↑ risk w/ hypoK, hypoMg, hyperCa -hypothyroidism ↑ dig levels | electrolytes, renal function, ECG, BO, digoxin level (draw 12-24 hours after dose) | -Pgp & CYP3A4 (minor) substrate -Pgp inhibitors ↑ dig levels Amiodarone/ dronedarone: ↓ dig dose by 50% -Pgp inhibitors: caution w/ verapamil, cyclosporine, itraconazole, erythromycin, clarithromycin, propafenone, quinidine. -Caution w/ drugs that↓ HR | |||
| Vericiguat | Verquvo | soluble guanylate cyclase stimulator | Inital: 2.5mg PO daily with food; after 2 weeks titrate dose as tolerated Target: 10mg daily with food | |||||
| soluble guanylate cyclase stimulator | Increases cyclic GMP and leads to smooth muscle relaxation and vasodilation. | BBW: do not use if pregant; contraception required during use and for one month after stopping treatment CI: do not use with riociguat (another soluble guanylate cyclase stimulator) | hypotension, anemia, dyspepsia | not listed | -May enhance the hypotensive effects of PDE5 inhibitors. This combination should be avoided. -Patients taking long-acting nitrates like isosorbide mononitrate and dinitrate were excluded from studies because of the potential for increased hypotension | |||
| Potassium Chloride | ER capsules ER Tabs: K-Tab, Klor-Con, Klor-Con 10, Klor-Con M10/M15/M20 Oral packet: Klor-Con Oral Solution: 10% (20mEq/15mL), 20% (40mEq/15mL) | potassium supplement | Hypokalemia prevention: 20-40mEq/day in 1-2 divided doses Mild hypokalemia: 40-100 mEq/day in 2-4 divided doses; adjusted based on lab values -No more than 40mEq should be given as a single dose to avoid GI discomfort | CI: hyperkalemia, delayed or obstructed passage through the GI tract | hyperkalemia (caution in renal impairment and Addisons disease) and meds that increase K -abdominal pain/ cramping, diarrhea, N, flatulence -Take with meals and a full glass of water to decrease GI irritation | K, Mg, Cl, pH, urine output |
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