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Chronic Heart Failure with Reduced Ef Guide to Outpatient Success

This guide provides an overview of chronic heart failure with reduced EF, including biomarkers, neurohormonal blockade, treatment guidelines, and outpatient management options. Learn how to improve patient outcomes and reduce readmissions.

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Chronic Heart Failure with Reduced Ef Guide to Outpatient Success

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  1. Chronic Heart Failure with Reduced Ef Guide to Outpatient Success Kelly Axsom, MD Assistant Professor of Medicine Division of Heart Failure, Transplantation and Mechanical Circulatory Support March 1, 2018

  2. Disclosures • None Footer text is edited under "view/header and footer" menu

  3. Outline • Heart Failure Background • Biomarkers • Background for Neurohormonal Blockade • Treatment Guideline/Pathway • - Drug Class Review • - Outpatient Visit Review • Non-LVAD Technologies for Outpatient Management

  4. Heart Failure is a Syndrome • Symptoms • Dyspnea • Edema • Supported by imaging, hemodynamics, labs • “Preserved” LV Function • “Reduced” LV Function • Ischemic • Non-ischemic • Inherited • Myocarditis • Infection • Inflammatory • Valvular heart disease • Post cardiotomy • Idiopathic • Infiltrative

  5. Heart Failure Global Healthcare Impact • Estimated 26 million worldwide • US 5.7 million • 670,000 new cases/year • Leading cause for hospitalization in US and Europe • 1 million admissions/year • >25% monthly readmission rate • 50% mortality within 5 years of diagnosis • $32 billion annual cost • With aging population it is estimated that HF will cost $70 billion in 2030  80% due to hospitalizations Fonarow et al JACC 2007;50:768-77.

  6. NYHA Functional Class

  7. AHA/ACC Stages h Yancy CW, et al. Circulation. 2013;128: e240-e327 .

  8. Biomarkers

  9. Troponin • Only found in cardiac myocytes • Commonly elevated in heart failure • Acute • Chronic

  10. BNP • HF diagnosis • High Age, arrhythmia, pulmonary disease, stroke, high output ARNI (entresto) increases BNP (not NT-proBNP) • Low Obesity, Tamponade, flash pulmonary edema, PRE-LV reasons for HF • Trending NT-proBNP is NOT associated with improved 6mo all cause mortality or HF readmission Stienen et al Circ.2017 epub. De Vecchis et al J Clin Med 2016:5:99.ACC/AHA 2017 Heart Failure Guidelines

  11. Future Biomarkers • Soluble ST2 • Cardioprotective signaling in the myocardium • Interleukin (IL)‐1 receptor‐like family of proteins, is released in response to myocyte stretch; neutralizes IL-33 • Galectin-3 • -galactoside binding lectin and a mediator of tissue fibrosis and inflammation • Persistently elevated galectin-3 predicts new-onset HF • Useful in chronic HFpEF to predict worsening • Hopeful for predictive of worsening in chronic HF • Future: test to screening for heart failure Circ HF. 2013;6:117-1179 de Boer RA, et al. Annals of Med 2011; 43(1): 60-8

  12. Myocardial injury to the heart (CAD, HTN, CMP, valvular disease) Initial fall in LV performance,  wall stress Activation of RAS and SNS Fibrosis, apoptosis,hypertrophy, cellular/molecular alterations,myotoxicity Peripheral vasoconstriction Sodium retention Hemodynamic alterations Remodeling and progressive worsening of LV function Morbidity and mortality Arrhythmias Pump failure Heart failure symptoms FatigueActivity altered Chest congestionEdemaShortness of breath Neurohormonal Activation in Heart Failure RAS, renin-angiotensin system; SNS, sympathetic nervous system.

  13. Landmark Neurohormonal Trials V HeFT1 – Hydralazine/Nitrates CONSENSUS – Enalapril SOLVD – Enalapril VEHFTII – Enalapril vs Hydral/Nitrates SOLVD – Enalapril asymptomatic US Carvedilol – Carvedilol RALES – spironolactone CIBUS – Bisoprolol MERIT HF – Metoprolol XL Copernicus – Carvedilol VAL-HEFT – Valsartan A-HeFT – Hydral/Nitrates AA EMPHASIS – Eplerenone Paradigm-HF - Entresto V-HeFT II CIBIS-II VAL-HeFT SOLVD MERIT-HF US Carvedilol HFS PARADIGM-HF COPERNICUS CONSENSUS EMPHASIS V-HeFT1 A-HeFT SOLVD RALES

  14. Drugs that Reduce Mortality in HFrEF Angiotensin receptor blocker Mineralocorticoid receptor antagonist ACE inhibitor Beta blocker • 0% • 10% • % Decrease in Mortality • 20% • Drugs that inhibit the renin-angiotensin system have modest effects on survival • 30% • 40% • Based on results of SOLVD-Treatment, CHARM-Alternative, • COPERNICUS, MERIT-HF, CIBIS II, RALES and EMPHASIS-HF

  15. HFrEF – Mortality Reduction Fonarow et al. JAMA Cardiology. 2016;1(6):714-717,

  16. Treatment Pathway

  17. Diuretics

  18. ACEI/ARB • Suppression of angiotensin II production • Increases kinin-mediated prostaglandin production • Arterial vasodilation • Decrease LV afterload • Favorable cardiac remodeling • ACC/AHA Class I Recommendation • First Drug Class

  19. ACEI/ARB

  20. Angiotensin Receptor-Neprilysin InhibitorEntresto (Valsartan Sacubitril)

  21. PARADIGM-HF: CV Death or HF Hospitalization 40 Enalapril (n=4212) 1117 32 914 24 LCZ696 (n=4187) Kaplan-Meier Estimate of Cumulative Rates (%) 16 8 0 0 180 360 540 720 900 1080 1260 Days After Randomization Patients at Risk LCZ696 Enalapril 4187 4212 3922 3883 3663 3579 3018 2922 2257 2123 1544 1488 896 853 249 236

  22. Starting Entresto • Because of risk of angioedema • NO ACEI for 36h prior to dosing • Never concomitant ACEI/ARB and Entresto • Dosing: 24/26; 49/51; 97/103 – twice daily • When starting: • Decrease diuretic by half (unless overloaded) • Big impact on BP

  23. Sympathetic Nervous System ActivationBeta-Blockers • Mediated through actions on α1, β1 and β2 receptors • Increases ventricular volumes • Peripheral vasoconstriction • Impairs sodium excretion by kidneys • Induces cardiac hypertrophy • Provokes arrhythmias • Increases heart rate • AHA/ACC Class I Recommendation • Start with ACEI or as 2nd drug

  24. Beta-Blockers

  25. Japanese Registry OPTIMIZE-HF Registry Discharge on Beta-Blocker Reduces Mortality Tsuchihashi-Makaya et al Circ J 2010:74:1364-1371 Fonarow et al Am Heart J 2007:153:82ew-82e11.

  26. Beta-blockers and HF • Without BB at discharge • Mortality rate 8.6% in 60-90days • Rehospitalization rate 29.6% within 60-90 days • No difference in outcomes with β-blocker with and those without COPD • β-blocker use in patients with COPD and HF • Decrease risk mortality • Decrease risk of COPD exacerbation O’Connor et al Am Heart J 2008:156:662-73.; Mentz et al Am J Cardiol. 2013:111:582-7.; Du et al PLoS One. 2014:9:e113048.

  27. Aldosterone Antagonist

  28. Afterload Reduction Imdur not studied in HF

  29. Funny Channel (If) Inhibitor • Reduce HF hospitalizations • NNT 26 over 12mo to prevent combined HF admit or death • No impact on Mortality • Must be in sinus • On maximally tolerated BB

  30. Ivabradine Class IIa HFrEF on maximally tolerated NH titrate to HR <70bpm

  31. Medication Titration • Every visit increase neurohormonal blockade to target doses • Lisinopril 20 mg/Losartan 150 mg daily/Entresto 49/51 mg or higher • Coreg 25 mg BID/Metoprolol XL 200 mg • Spironolactone 25-50 mg • Hydralazine 75mg/Isosorbide 40mg TID • Increase doses in between visits • Diuretics to maintain euvolemia • *Entresto often need less diuretic

  32. Education • What is Heart Failure • Understanding/Reviewing symptoms • Medication Reconciliation • Help live longer and better • Cost and barriers to getting or taking meds • Give new medication list • Low sodium diet/fluid restriction • Daily weight checks • What to do who to call if weights change • 2 lbs in a day or 5 lbs in a week  Call or if inc then double diuretic

  33. Heart Failure Decompensation Chronic heart failure5 million in the US10 million in Europe Normal heart Death Initial myocardial injury First ADHF episode:Pulmonary edemaER admission Heart Viability Later ADHF episodes:Rescue therapyICU admission Last year Initial phase Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.

  34. Consider Advanced Heart Failure • High Risk Features • 2 or more ED visits/Hospitalizations for Heart Failure in 6 months • Intolerance to HF Medications • Recent need for IV inotropes • Persistent symptoms • Exercise limitation, profound fatigue, dyspnea at rest or w/ ADLs • Hypotension (BP <100/60) • Renal Insufficiency (Cr >1.7, BUN >45) • Challenging arrhythmias or ICD shocks • Age <50 • Complex congenital or valve disease

  35. Newer Non-LVAD HF Devices

  36. CardioMEMS – Abbott • NYHA Class III (HFrEf or HFpEf) • At least 3 HFRH in 12months • ComorbiditiesCOPD, CKD, Obesity • Engaged patients • CUMC Experience • - 9 patients on monitoring • - 12m prior to implant 38 HFRH • - 55 monitored months  1 HFRH

  37. RSV Positive 86F ICM Ef 15%, severe COPD, multiple prior cancers, CKD Admitted every year with combo – URI HF ↑Imdur Hydralazine Metolazone Prednisone Double Lasix

  38. ReDS – Sensible Medical • Radar sensors – technology used to see through walls • Vest that measures fluid • Uses • ER • POC • In-patient Units • SAR • Transitions of care • Community health workers

  39. HeartLogicTM – Boston Scientific

  40. NYP Outpatient HF Cards

  41. Treatment Pathway

  42. Thank you Email: kma2161@cumc.columbia.edu New Outpatients: 212-305-9268 Cell: 302-981-1278

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