•OUTPATIENT HEART FAILURE MANAGEMENT

• CARDIOVASCULAR SUMMIT

• MARCH 6, 2016

• PREETHAM REDDY, MD, FACC

• COLORADO SPRINGS CARDIOLOGISTS

DISCLOSURES

● SPEAKER BUREAU FOR ZOLL

● I WILL ONLY BE SPEAKING ABOUT GUIDELINE RECOMMENDED THERAPIES WITH EXCEPTION OF TWO NEW DRUG OPTIONS

ROADMAP

● BACKGROUND

● DEFINITIONS

● HEART FAILURE “MADE” EASY

● PALLIATIVE CARE & HOSPICE

BACKGROUND

● HEART FAILURE

– AFFECTS APPROX. 6 MILLION AMERICANS

– >800,000 NEW DIAGNOSES ANNUALLY IN THE US

– MOST COMMON MEDICARE DISCHARGE DIAGNOSIS

● 150% INCREASE IN ADMISSION RATES OVER THE LAST 20Y

● 50% OF HOSPITAL ADMISSIONS FOR HEART FAILURE ARE PATIENTS WITH HFPEF

● MORTALITY: 50% AT 5 YEARS

DEFINITIONS

● HEART FAILURE IS:

“COMPLEX CLINICAL SYNDROME THAT CAN RESULT FROM

ANY STRUCTURAL OR FUNCTIONAL CARDIAC DISORDER

THAT IMPAIRS THE ABILITY OF THE VENTRICLES TO FILL

WITH OR EJECT BLOOD”● CARDINAL SYMPTOMS:

FATIGUE & DYSPNEA● CLINICAL SIGNS:

FLUID RETENTION & EXERCISE INTOLERANCE

Hunt SA et al. “ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult.” Circulation. 2001; 104:2996-3007.

DEFINITIONS

CLASSIFICATION EJECTION FRACTION

DESCRIPTION

I. Heart Failure with Reduced Ejection Fraction (HFrEF)

≤ 40% a.k.a. Systolic HF. RCTs have mainly enrolled HFrEF patients & it is only in these patients that efficacious therapies have been demonstrated to date.

II. Heart Failure with Preserved Ejection Fraction (HFpEF)

≥ 50% a.k.a. Diastolic HF. To date, efficacious therapies have not been identified.

a. HFpEF, Borderline 41-49% Borderline / intermediate group. Characteristics, treatment patterns & outcomes similar to those with HFpEF.

b. HFpEF, Improved > 40% A subset of HFpEF patients who previously had HFrEF.

DEFINITIONS

• STAGES IN THE DEVELOPMENT OF HEART FAILURE

DEFINITIONSACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural heart disease or symptoms of HF.

None  

B Structural heart disease but without signs or symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

C Structural heart disease with prior or current symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.

III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.

IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

D Refractory HF requiring specialized interventions.

HF “MADE” EASY

● MEDICATIONS

● ADVICE

● DEVICES

● EDUCATION

MEDICATIONS● OLD STANDARDS

– BETA-BLOCKERS (BB)

– ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEI) & ANGIOTENSIN RECEPTOR BLOCKERS (ARB)

– MINERALOCORTICOID RECEPTOR ANTAGONISTS (MRA)

– NITRATES / HYDRALAZINE (BIDIL)

– DIGOXIN

● NEW OPTIONS

– NEPRILYSIN INHIBITOR

– IVABRADINE

MEDICATIONS: OLD FAITHFUL

● BETA-BLOCKERS REDUCE MORTALITY IN HFREF

– ONLY THREE DRUGS W INDICATION:

● CARVEDILOL (COPERNICUS)

● METOPROLOL SUCCINATE (MERIT-HF)

● BISOPROLOL (CIBIS-II)

– DOSE DEPENDENT → MORE IS BETTER & REDUCES MORTALITY FURTHER

– CAUTION IN COPD & RIGHT-SIDED HEART FAILURE

– METOPROLOL TARTRATE INFERIOR TO CARVEDILOL (COMET)

MEDICATIONS: OLD FAITHFUL

● ACE INHIBITORS REDUCE MORTALITY IN HFREF

– ALL ACE INHIBITORS HAVE AN INDICATION FOR HFREF

– ARB CAN BE SUBSTITUTED BUT NOT A PRIMARY CHOICE

– BEST EVIDENCE FOR:

● CANDESARTAN (CHARM)

● VALSARTAN (VAL-HEFT)

● LOSARTAN (HEAAL)● ACE INHIBITORS REDUCE MORBIDITY IN HFREF

– TITRATION OF DOSE REDUCES FUTURE HOSPITALIZATIONS (ATLAS)

– TARGET DOSE IS MAX DOSE OF ACEI/ARB

MEDICATIONS: OLD FAITHFUL

● MRAS REDUCE MORTALITY IN HFREF

– SPIRONOLACTONE (NON-SELECTIVE)● MORTALITY REDUCTION: CLASS III-IV CHF (RALES)

– EPLERENONE (SELECTIVE A1)● MORTALITY REDUCTION: CLASS II CHRONIC HF

(EMPHASIS-HF)

● NITRATES/HYDRALAZINE (BIDIL)

– AFRICAN-AMERICANS: MORTALITY REDUCTION (A-HEFT)

MEDICATIONS: OLD FAITHFUL

● DIGOXIN REDUCES MORBIDITY IN HFREF (DIG)

– DIG LEVEL 0.5-1 REDUCED HOSPITALIZATION

– DIG LEVEL >1 INCREASED MORTALITY

● DIURETICS

– JUDICIOUS USE REDUCES HOSPITALIZATION

MEDICATIONS: NKOTB

● LCZ696

– VALSARTAN/SACUBITRIL (ENTRESTO)

– 1:1 MIXTURE OF ARB & NEPRILYSIN INHIBITOR (ARNI)

– FDA APPROVED JULY 7, 2015 BASED ON RESULTS FROM PARADIGM-HF

– TRIAL STOPPED EARLY DUE TO POSITIVE INTERVAL EFFICACY ANALYSIS

– NOT GUIDELINE RECOMMENDED… YET

MEDICATIONS: NKOTB ● IVABRADINE (CORLANOR)

– SPECIFICALLY BINDS THE FUNNY CHANNEL

● PROLONGS DIASTOLIC DURATION → SLOWS HR

– DOES NOT ALTER:

● VENTRICULAR REPOLARIZATION

● MYOCARDIAL CONTRACTILITY

● BLOOD PRESSURE

– STUDIED IN THE SHIFT TRIAL

SHIFT TRIAL

SHIFT TRIAL

MEDICATIONS: NKOTB

● IVABRADINE (CORLANOR)

– APPROVED BY THE FDA IN 2015

– BASED ON THE RESULTS OF THE SHIFT TRIAL FOR HFREF

– NOT GUIDELINE RECOMMENDED… YET

MEDICATIONS

● WHAT IS CONSPICUOUSLY MISSING FROM THE ABOVE LIST?

– EVIDENCE-BASED REDUCTION IN MORTALITY OR MORBIDITY WITH MEDICATION THERAPY IN HFPEF

● DIGOXIN (DIG)

● NEBIVOLOL (ELANDD & SENIORS)

● CANDESARTAN (CHARM-PRESERVED)

● IRBESARTAN (I-PRESERVE)

● PERINDOPRIL (PEP-CHF)

● SILDENAFIL (RELAX)

● SPIRONOLACTONE (TOPCAT)

ADVICE

● DESCRIBING THEIR MEDICAL CONDITION TO THE PATIENT IN A WAY THAT THEY CAN UNDERSTAND

● DESCRIBE THE SYMPTOMS OF CHF

● EMPHASIZE TAKING MEDICATIONS AS PRESCRIBED

● DISCUSS SALT LIMITATIONS

● DAILY WEIGHTS

● CARDIAC REHAB & EXERCISE PROGRAM

DEVICES

● IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS (ICDS)

● WEARABLE CARDIOVERTER-DEFIBRILLATORS (WCDS)

● BIVENTRICULAR PACING

● ADVANCED THERAPIES

– VENTRICULAR ASSIST DEVICES

– CARDIAC TRANSPLANTATION

DEVICES

● IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS (ICD)

– LVEF < 40%

– LIFE EXPECTANCY > 1 YEAR

– NOT IN REFRACTORY CLASS IV CHF

● UNLESS AS BRIDGE TO TRANSPLANT (BTT)

● UNLESS ALSO WIDE QRS & CANDIDATE FOR BIV PACING

– > 40 DAYS POST MI OR REVASCULARIZATION

– > 3 MONTHS AFTER NEWLY DIAGNOSED NICM

DEVICES

● WEARABLE CARDIOVERTER-DEFIBRILLATOR (WCD)

– <40 DAYS POST-MI OR REVASCULARIZATION

– <3 MONTHS FROM NEW DIAGNOSIS OF NICM

– POST-ICD EXTRACTION

DEVICES

● BIVENTRICULAR PACING + ICD (BIV-ICD)● LVEF < 35%● QRS > 120MS

– CLINICAL RESPONSE BETTER IF LBBB OR IVCD

– CLINICAL RESPONSE WORSE IF RBBB● CLASS III OR IV CHF● MAYBE EVEN IN CLASS I & II (MADIT-CRT)

DEVICES● TRANSPLANTATION – GOLD STANDARD

– MEDICAL THERAPY: 75% MORTALITY AT ONE YEAR

– TRANSPLANTATION: 12% MORTALITY AT ONE YEAR

– NUMBER OF TRANSPLANTS (2300-2600/YR) STABLE SINCE 1991

● VENTRICULAR ASSIST DEVICE

– IMPROVE QUANTITY & QUALITY OF LIFE

– BRIDGE TO TRANSPLANTATION (BTT) OR DESTINATION (DT)

– REMATCH TRIAL (2001)

● MEDICAL THERAPY: 75% MORTALITY AT ONE YEAR

● PULSATILE FLOW LVAD: 48% MORTALITY AT ONE YEAR

– CONTINUOUS FLOW LVADS: 32% MORTALITY AT 1Y

MED TX VS LVAD VS TRANSPLANT

EDUCATION● DAILY WEIGHTS

– KEEP LOG

– CLEAR DIRECTIONS BASED ON WEIGHT CHANGES

● SALT RESTRICTION

– 2 GRAM SALT DIET, NO ADDED SALT, NO “SALTY” FOODS

● NOTHING OUT OF A CAN, MINIMIZE EATING OUT, NO PROCESSED MEATS/FOODS

● NUTRITIONIST CONSULTATION

● PHARMACOLOGY CONSULTATION

● CARDIAC REHAB

PALLIATIVE CARE & HOSPICE

● PROGNOSTICATION IN HEART FAILURE IS DIFFICULT

– SEATTLE HEART FAILURE SCORE (SHFS)

– KANSAS CITY CARDIOMYOPATHY QUESTIONNAIRE (KCCQ)

– ACUTE DECOMPENSATED HEART FAILURE NATIONAL REGISTRY (ADHERE)

● PROVIDER COMMUNICATION OF PROGNOSIS

PALLIATIVE CARE & HOSPICE

● ADVANCED CARE PLANNING

– ADVANCE DIRECTIVES

– HEALTHCARE PROXY DECISION MAKER

● GOALS OF CARE

THANK YOU!

● ANY QUESTIONS?

ENTRESTO MECHANISM OF ACTION