Heart Failure: How to Incorporate the Latest Guidelines ... · Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management

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LESLIE L DAVIS, PHD, RN, ANP-BC, FAANP, FAHA

ADULT NURSE PRACTITIONER

ASSOCIATE PROFESSOR OF NURSING

Heart Failure: How to Incorporate the Latest Guidelines Into Your Practice

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Disclosures I have no disclosures relevant to this presentation.

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Topics to Cover▪Discuss implications of recent clinical practice guidelines of pharmacologic treatment of heart failure (HF) with reduced ejection fraction.

▪Determine how to titrate optimal therapy using the most appropriate pharmacologic agents for treating adults with reduced ejection fraction.

▪Review what circumstances would trigger a referral to a HF specialist.

▪Share new tools available for clinicians who treat patients with HF

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Definition: Heart failure with Reduced Ejection Fraction

▪Clinical diagnosis of heart failure and a left ventricular ejection fraction of 40% or less

▪Abbreviated as HFrEF

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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of

HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert

Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.

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Established Therapies for Chronic HF•Angiotensin Converting Enzyme inhibitors (ACE-Is)

•Angiotensin receptor blockers (ARBs)

•Beta-blockers (only the ones approved)

•Loop diuretics

•Aldosterone antagonists

•Hydralazine/isosorbide dinitrate (HYD/ISDN)

•All (except loop diuretics) have been shown to improve symptoms, reduce hospitalization, and/or help patients live longer.

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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF

treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus

Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.


New treatment Guidelines for Heart Failure with Reduced Ejection Fraction

•Updated recommendations on biomarkers*

•Two new medications for patients with HFrEF*• Angiotensin receptor neprilysin inhibitor (ARNI) (sacubitril/valsartan)

• Sinoatrial node modulator (ivabradine)

•Info on heart failure with preserved ejection fraction (HFpEF)

•Info on comorbidities including sleep apnea, anemia and hypertension

•Insights regarding HF prevention *We will focus on these for this presentation (about HF with reduced EF)

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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the

management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:

10.1161/CIR.0000000000000509.

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Updated recommendations on biomarkers: PREVENTION

•For patients at risk of developing HF, natriuretic peptide biomarker–based screening followed by team-based care (including a cardiovascular specialist optimizing GDMT) can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new onset HF.

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10.1161/CIR.0000000000000509.

Includes B-type natriuretic peptide (BNP) or

N-terminal pro-B-type natriuretic peptide (NT-proBNP)


Updated recommendations on biomarkers: DIAGNOSIS

In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF .

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10.1161/CIR.0000000000000509.

Includes B-type natriuretic peptide (BNP) or

N-terminal pro-B-type natriuretic peptide (NT-proBNP)

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Updated recommendations on biomarkers: Prognosis

•Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (unchanged from 2013)•Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (modified)•During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a post-discharge prognosis (new)

•In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (modified)

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10.1161/CIR.0000000000000509.

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 10




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2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment

Writing CommitteeClyde W. Yancy, MD, MSC, MACC, Chair

James L. Januzzi, JR, MD, FACC, Vice Chair

Larry A. Allen, MD, MHS, FACC

Javed Butler, MD, MBA, MPH, FACC

Leslie L. Davis, PHD, RN, ANP-BC

Gregg C. Fonarow, MD, FACC

Nasrien E. Ibrahim, MD, FACC

Mariell Jessup, MD, FACC

JoAnn Lindenfeld, MD, FACC

Thomas M. Maddox, MD, MSC, FACC

Frederick A. Masoudi, MD, MSPH, FACC

Shweta R. Motiwala, MD

J. Herbert Patterson, PHARMD

Mary Norine Walsh, MD, FACC

Alan Wasserman, MD, FACC

Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, &

et al 2017 ACC expert consensus decision pathway for

optimization of HF treatment: answers to 10 pivotal

issues about HF with reduced EF: a report of the ACC

Task Force on Clinical Expert Consensus Decision

Pathways. J Am Coll Cardiol 2018;71(2): 201-230.

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Treatment Algorithm for Guideline-Directed Medical Therapy Including Novel Therapies

Excerpted from:

Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure with Reduced Ejection Fraction

December 2017

DOI: 10.1016/j.jacc.2017.11.025


Beta Blockers

Drug Starting Dose

Bisoprolol 1.25 mg q day

Carvedilol 3.125 mg bid

Metoprolol succinate 12.5-25 mg q day

Target Dose

10 mg q day

25 mg bid (if wt < 85 kg); otherwise 50 mg bid

200 mg daily

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http://www.onlinejacc.org/content/early/recent

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ACE-I (some examples)

Drug Starting Dose

Captopril 6.25 mg tid

Enalapril 2.5 mg bid

Lisinopril 2.5-5 mg daily

Ramipril 1.25 mg q day

Target Dose

50 mg tid

10- 20 mg bid

20 - 40 mg daily

10 mg daily

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ARBs (some examples)

Drug Starting Dose

Candesartan 4 – 8 mg q day

Losartan 25 – 50 mg q day

Valsartan 40 mg bid

Target Dose

32 mg daily

150 mg daily

160 mg twice daily

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Aldosterone Antagonists

Drug Starting Dose

Eplerenone 25 mg q day

Spironolactone 12.5 - 25 mg q day

Target Dose

50 mg q day

25 – 50 mg q day

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• New recommendation: Aldosterone antagonists may reduce hospitalizations in some patients with HFpEF.

• Important: Monitor kidney function and potassium within 2-3 days, again at 7 days





VasodilatorsDrug Starting Dose Target Dose

Hydralazine 25 mg tid 75 mg tid

Isosorbide DN 20 mg tid 40 mg tid_______

Fixed dose combo 20 mg/3.75 mg(one tab) tid 2 tabs tid

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Sacubitril/Valsartan (ARNI)

Indications• HFrEF (EF < 40%)

• NYHA Class II or IV

Contraindications

Cautions

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1. Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC

expert consensus decision pathway for optimization of HF treatment:

answers to 10 pivotal issues about HF with reduced EF: a report of the

ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am

Coll Cardiol 2018;71(2): 201-230.

2. ENTRESTO [prescribing information]. East Hanover, NJ: Novartis

Pharmaceuticals Corp; November 2018.


Sacubitril/Valsartain (ARNI)

Starting dose: 24/26 mg – 49/51 mg twice daily• When to start with lower dose

• When to start with higher dose

Target dose: 97/103 mg twice daily

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Conversion of ACE-I to ARNI (*Sacubitril/valsartan)

•Need 36-hour washout period of ACE-I to avoid angioedema• Would not need to do this if on an ARB

•Ensure the patient has an adequate BP (contraindicated if symptomatic hypotension or decompensated)

•eGFR <30 mL/min/1.73 m2

•Starting dose• If taking < 10 mg enalapril (or equivalent) start with 24/26 mg twice daily• If taking > 10 mg enalapril (or equivalent) start with 49/51 mg twice daily

•Reassess in 2-4 weeks

•If tolerates, up-titrate to 97/103 mg twice daily

•Ongoing monitoring (BP, electrolytes/kidney function after initiation and each up titration)

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Ivabradine

Indications: • HFrEF (EF < 35%)• On maximum tolerated doses of

beta-blocker• Sinus rhythm with resting HR of > 70 bpm• NYHA Class II or III HF

ContraindicationsCautions

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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC

expert consensus decision pathway for optimization of HF treatment:

answers to 10 pivotal issues about HF with reduced EF: a report of the

ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am

Coll Cardiol 2018;71(2): 201-230.

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IvabradineStarting dose: 2.5 – 5 mg twice daily• Lower dose if hx of conduction defects or Age > 75

Target dose: titrate to heart rate 50-60 beats/per/minute.

Maximum dose: 7.5 mg twice daily

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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal

issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.


Pearls for Starting TherapyFor new patients:• Starting ACE-I or ARBS = often better tolerated if

started when a little “wet”

• Starting beta-blockers = often better tolerated if started when a little “dry” (as long as heart rate is adequate)

• Could start both (low doses)

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What’s the Role of Digoxin?

•No survival benefit

•When to start digoxin

•Dosing is tricky, esp in patients with kidney disease

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HF with Preserved Ejection Fraction In appropriately selected patients with HFpEF (with EF ‡45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine clearance < 2.5 mg/dL, potassium < 5.0mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalization.

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10.1161/CIR.0000000000000509.

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Excerpted from:

Optimization of Heart FailureTreatment: Answers to 10 PivotalIssues About HeartFailure with ReducedEjection Fraction

December 2017DOI: 10.1016/j.jacc.2017.11.025

Evaluation of the patient with heart failure

Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal

issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.


Triggers for HF Patient Referral to HF Program (or Specialist)•New onset HF

•Chronic HF with high risk features

•To assist with managing guideline directed medical therapy (GDMT)

•Persistently reduced LVEF (< 35%) despite GDMT for > 3 months

•Need 2nd opinion

•Annual review for established HF patients with advanced disease

•Participation in a clinical trial

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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et

al 2017 ACC expert consensus decision pathway for

optimization of HF treatment: answers to 10 pivotal issues

about HF with reduced EF: a report of the ACC Task Force

on Clinical Expert Consensus Decision Pathways. J Am

Coll Cardiol 2018;71(2): 201-230.

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http://www.onlinejacc.org/content/early/recent

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Case study

55-year-old male with HFrEF who has been seen in your HF clinic for past 6 months.

PMH: Hx of 2 vessel coronary heart disease

Last LVEF: 30% (after being on a stable dose of meds for ~4 months)

Functional heart class: NYHA Class III

Weight: 75 kg (euvolemic)

Blood pressure 110/70 (lying & standing)

HR 66 beats per min

Labs: K+ 4.0, BUN 10, Creat 1.4

Current meds:• Ramipril 10 mg daily• Carvedilol 25 mg bid• Furosemide 40 mg bid• Spironolactone 25 mg bid

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Case study continuedIs he on guideline directed medical therapy (GMDT)?

Are each of the meds at target dose?

What other treatment could be added (since he remains symptomatic)?• Switch ACE-I to ARNI?

• Add Ivabradine?

• Add Hydralazine/Isosorbide dinitrate?

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New ACC Expert Consensus Decision PathwayPublished 9/13/19 online ahead of print

Hollenberg SM, Stevenson LW, Ahmad T, et al. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of PatientsHospitalized With Heart Failure. J Am Coll Cardiol. Published online September 13, 2019. DOI: 10.1016/j.jacc.2019.08.001.

Focus on course of HF admission

•1st ED visit, hosp admission, trajectory check, transition to oral therapies, discharge, & 1st

discharge contact followed by 1st

discharge visit

Several algorithms, tables, worksheets

Stresses communication:

•Among team members, esp surrounding hospital discharge


Example of a Shared Decision-making Tool for ICDs (page 3 of 8)

https://www.cardiosmart.org/SDM/Decision-Aids/Find-Decision-Aids/ICD

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https://www.cardiosmart.org/SDM/Decision-Aids/Find-Decision-Aids/ICD

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New Resources Avail: https://www.cardiosmart.org/MyHFActionPlan

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 34

Other Tools to Use: https://www.acc.org/tools-and-practice-support/quality-programs/succeed-in-managing-heart-failure-initiative

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https://www.cardiosmart.org/MyHFActionPlan

https://www.acc.org/tools-and-practice-support/quality-programs/succeed-in-managing-heart-failure-initiative

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Questions?

Leslie Davis

[email protected]

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mailto:[email protected]

Documents

Heart Failure: How to Incorporate the Latest Guidelines ... · Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management