1. Beta blockers
1.1. MOA: reverses SNS and neurohormonal (RAAS) activation
1.2. bisoprolol, metroprolol, carvedilol
1.2.1. lessens sxs, improves status, reduce risk of death/hospitalization
1.3. AE: worsened HF, fluid retention (pt might feel worse initially->must be titrated to target); fatigue; depression; bradycardia; hypotension
2. Aldosterone antagonists
2.1. spironolactone, eplerenone
2.1.1. class iV HF who are taking ACE and other meds
2.1.2. stage II-IV HF w/reduced EF and sxs despite tx
2.1.3. AE: hyperkalemia, K+ must be less than 5; gynecomastia; hyperkalemia (if given w/ ACE//ARB
3. add on therapies
3.1. digitalis
3.1.1. positive inotrope; inhibits Na/K atpase ->increased intracellular Ca; reduced combined risk of hospital/death; add on therapy for HFrEF class III and IV w/sxs; used after 1st and 2nd line tx
3.1.2. AE: cardiac arrhythmias; GI, anorexia, nv, diarrhea; visual: yellow halos, blurred vision, photophobia; neuro: confusion, disorientation; numerous drug interactions; low TI
3.1.3. digibind blocks digoxin toxicity
3.2. hydralazine/isosorbide dinitrate
3.2.1. combo drug; added therapy for pts intolerant of ACE/ARB; complimentary vasodilating effects
3.2.2. AE: may NOT be tolerated well; cardiac: chest pain; CNS: HA, dizzy; neuro: weakness; drug induced lupus syndrome
4. physio
4.1. compensatory mechanisms (SNS, RAAS, vent hypertrophy) to maintain CO
5. standard trifecta therapy:
5.1. ACE, ARB, angtiotensin receptor neprilysin inhibitor (ARNI) + beta blocker + loop, aldosterone antagonist diuretics
6. ACE inhibitors
6.1. MOA:inhibits Ang II to reduce preload and afterload
6.2. drugs: rampipril, enalapril, lisinopril, fosinopril, quinapril
6.2.1. improve symptoms, slow dz progression, decrease mortality
6.2.2. AE: COUGH, angioedema, hypotension, K+ rentention, worsening renal fxn, doses must be titrated to therapeutic doses
6.2.3. CI: pregnancy; b/l renal stenosis; angioedema
7. ARBSs
7.1. MOA: sacubitril (neprilysin inhibitor): increases natriuretic peptides ->
7.1.1. degrade neprilysin
7.2. drugs: entresto = sacubitril + valsartan
7.2.1. reduce risk of cardiovascular death and hospitalization
7.2.2. used when ace inhibitor not tolerated
7.2.3. AE: hypotension; hyperkalemia; cough; dizziness; renal failure angioedema
7.2.4. CI: pregnancy
8. loopdiuretics
8.1. furosemide, bumetanide, torsemide
8.1.1. decreases fluid retention sx of HF w/ current of hx of fluid retention
8.1.2. AE: hyoptention, electrolye imbalances, azotemia,
8.1.3. monitor: electrolytes, renal fxn, vol. status (weigh pt daily)