Optimizing Meds
Optimizing meds in patients with HFrEF and CKD
Few patients with chronic kidney disease (CKD) are on optimized meds for heart failure with reduced ejection fraction (HFrEF) . It’s a delicate balance... Hyperkalemia can occur with an ACEI or ARB, Entresto (sacubitril/valsartan), or an aldosterone antagonist. Plus, these meds or SGLT2 inhibitors ( Forxiga, etc ) can cause an initial bump in serum creatinine…
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Pts W/ DM and HF
Carvedilol is better than Metoprolol for HF and DM patients
As a clinical pharmacy specialist, cardiologists will ask you for your recommendations on which beta-blockers are better, carvedilol or metoprolol in patients with heart failure and diabetes . There is tantalizing evidence that carvedilol MIGHT be better. But the truth is not so clear. The first head-to-head comparison sugges…
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Loop Diuretics
Strategies to manage DIURETIC resistance
As a critical care pharmacist, you will hear debate about the best approach for managing "diuretic resistance" in acute decompensated heart failure . Continue to start IV furosemide at 1 to 2.5 times the TOTAL DAILY oral home dose. For example, if the home oral furosemide dose is 40 mg daily, multiply this by 1 to 2.5 for an …
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SGLT-2 Inhibitors
Add SGLT2 inhibitors to your HF patients
As a clinical pharmacist, you will need to ensure appropriate use of SGLT2 inhibitors (empagliflozin, etc), as more hospitals add these medications to formulary. It’s partly because guidelines for heart failure with reduced ejection fraction (HFrEF) now recommend “quad therapy” adding an SGLT2 inhibitor (SGLT2i) to triple therapy , regardless of diabetes. …
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Pts W/ DM and HF
Best DIET in heart failure
As a nutrition support pharmacist, you should advise on the best diet for your patients with heart failure. Previously, the focus on preventing and treating heart failure was to restrict excess sodium intake in order to prevent excess fluid load. While sodium control is still important, macronutrient nutrition may be more important in prevention than previously thou…
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HFrEF Treatment
How to DOSE medications for systolic heart failure
As a cardiovascular pharmacist, you will be asked more how to dose medications for systolic heart failure. Many cardiac conditions rely on a key "number" to determine drug efficacy. For example, blood pressure guides hypertension treatment and LDL levels guide dyslipidemia therapy . But there's no key number to measure efficacy for heart failure . I…
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Myocardial Infarction
Aspirin for PRIMARY prevention is different story
As a cardiovascular pharmacist, you will be asked whether "an aspirin a day" is still good for the heart, based on new U.S. Preventive Services Task Force recommendations. Help patients sort out the facts. This is a case of guidance catching up with the evidence... Recommend aspirin 81 mg/day for SECONDARY prevention , such as…
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HFrEF Treatment
Starting ENTRESTO for heart failure
As a cardiovascular pharmacist, you will hear lots of buzz about Entresto , a new drug for systolic heart failure. It's the first "angiotensin receptor neprilysin inhibitor" (ARNI) and combines valsartan with sacubitril. Sacubitril works by inhibiting the enzyme neprilysin. This increases sodium loss and vasodilation and enhances ARB efficacy (see figur…
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HFrEF Treatment
Keep NEW heart failure guidelines in mind
As a clinical pharmacist, you should put NEW heart failure guidelines in perspective . Big changes in guidelines will lead to debate about managing heart failure with reduced ejection fraction (HFrEF). We’re used to “triple therapy” for HFrEF; an ACEI or ARB , evidence-based beta-blocker (carvedilol, etc), and aldosterone antagonist (spironolac…
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Milrinone
Use Inotropes for select cases of acute or end-stage heart failure
Do the IV inotropes dobutamine ( Dobutrex, Dobuject ) AND MILRINONE ( Primacor, Milicor ) still have a role in treating heart failure with reduced ejection fraction (HFrEF) ? Yes, but only in a small subset of patients. Both medications increase arrhythmias. And widespread use fell out of favor years ago, due to concerns about increased mortality, especially in pat…
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Omega-3 Fatty Acids
Consider discontinuing fish oil in CV patients
What are omega-3 fatty acids? ─ Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are omega-3 fatty acids. They are found in fish and sometimes called "fish oil". Alpha-linolenic acid (ALA) is also an omega-3 fatty acid. It is found in soy, canola oil, flaxseed, and walnuts. Foods that have omega-3 fatty acids, mainly fish, MIGHT prevent hea…
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SGLT-2 Inhibitors
Know the role of empagliflozin (JARDIANCE) in heart failure with preserved ejection fraction
As a pharmacist, you will hear buzz about the role of Jardiance (empagliflozin) in managing heart failure with PRESERVED ejection fraction (HFpEF) . This is in addition to the growing evidence showing benefit of SGLT2 inhibitors in heart failure with REDUCED ejection fraction (HFrEF) . But over half of HF patients have HFpEF, and to date, treatment options for HFpE…
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Nutrition
Be skilled in controlling POTASSIUM levels for patients with heart failure
Getting POTASSIUM levels right for patients with heart failure can be a balancing act due to changes in medications, diet and kidney function. Hypokalemia and hyperkalemia are common electrolyte disorders caused by changes in potassium intake, altered excretion, or transcellular shifts. Diuretic use and gastrointestinal losses are common causes of hypokalemia, while…
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