ccs heart failure guidelines: 2014 update on new therapies, biomarkers, anemia management, and...

CCS Heart Failure Guidelines: 2014 Update On New Therapies, Biomarkers,

Anemia Management, And Complex Cases

October 2014

Heart Failure Guidelineswww.ccs.ca

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trademarks on any slides or anywhere in your presentation or publications.• Do not modify the slide content.• If repeating recommendations from the published guideline, do not modify the recommendation wording.


Moe GW, Ezekowitz JA et al., Can J Cardiol

Anemia in HF



How prevalent is anemia in heart failure?

• Rare?• Occasional?• Frequent?

It Depends:-on the patient you are seeing (view next slide for range of anemia in patients)-on oms criteria (hemoglobin levels-note difference between male vs female)-characteristic of population; age, sex, race and degree of renal failure -on NYHA class



Anemia in patients with heart failure

Hb = hemoglobinHct = hematocritHF = heart failure

The prevalence of anemia in heart failure patients is approximately:

– 30% for Inpatients

– 20% for Outpatients



The prevalence of anemia and the severity of heart failure

Source: STAMINA Registry – 45 General Cardiologist sites, n=673, 12 Academic sites (incl. HF Specialists), n=337

2% 2% 4%6% 8%

29% 30%

40%

60%

12%

44%

11%

52%

19%14%13%

29%

21%20%

56%

0%

10%

20%

30%

40%

50%

60%

70%

I (n=158) II (n=467) III (n=340) IV (n=25)

Pat

ien

ts

Hb<10g/dL (n=32) Hb<=11g/dL (n=97) Hb<=11.5g/dL (n=165) Hb<=12.0g/dL (n=244) Hb<=12.5g/dL (n=337)

NYHA Class



What are the causes of anemia in HF patients?

1. Blood tests (too many)

2. Blood lost (anywhere in GI system)

3. Medications

4. CKD

5. Don’t know



↓ Cardiac output

↓ Renal perfusion

Pro inflammatory CytokinesActivation RAAS

ACEi / ARBVolume overload

Hemodilution

CKD

↓ EPO secretion

↓ Bone marrow (response)

↓ Production

Anemia

Figure 1 - Mechanism of the development of anemia in heart failure



How important is anemia in your initial work up of a patient with heart failure?

• Limited• Moderate• Important• What?

Anemia is important because it has been linked to the prognosis of patients with HF: refer to following slides



Anemia is associated with increased risk for hospitalization in heart failure

patients Study Design N Anemia Risk Assessment Limitations

Alexander1

Retrospective cohort study of a population based HF database

90,316Anemia was an independent risk factor of 1-year rehospitalization (RR 1.162; 95% CI: 1.134 to 1.191)

no confirmation of the HF diagnosis; undercounts of minorities and biased results.

Polanczyk2

Prospective, single center, observational study

205Anemia was an independent predictor of 3-month rehospitalization (p=0.002)

Too small of a population to resolve a small difference in readmission rates; role of confounding variables due to lack of control

OPTIME-CHF3 Retrospective chart review

906

Anemia was an independent predictor of 60-day death or rehospitalization (odds ratio of 0.89 per 1 g/dL increase in hemoglobin; 95% CI: 0.82 to 0.97)

Anemia may have been caused by hemodilution in hospitalized patients

Kosiborod4Retrospective chartreview 2,281

Patients had 2% higher risk of 1-year rehospitalization for every 1% lower hematocrit (95% CI: 1.01 to 1.03; p=0.0002)

Lack of data on transfusions or other treatments for anemia; study generalizability to non-study population

COPERNICUS5

Randomized,double blind,placebo controlledtrial

2,286Anemia was an independent risk factor for 1-year morbidity (HF hospitalization) and mortality outcomes

-

1Alexander M, et al. Am Heart J. 1999;137:919-9272Polanczyk CA, et al. J Card Failure. 2001;7:289-298

3Felker GM, et al. Am J Cardiol. 2003;92:625-6284Kosiborod M, et al. Am J Med. 2003;114:112-119

5Anker SD, et al. J Am Coll Cardiol. 2004;43(suppl A):Abstract 842-2



Hemoglobin and mortality in heart failure patients



0

5

10

15

20

25

30

35

I II III IV V

Haemoglobin quintiles

%

All cause mortality

Hemoglobin and mortality

Hgb 11.3

Hgb 12.8

Hgb 13.6

Hgb 14.4

Hgb 15.7

O’Meara et al. CHARM Investigators. Circulation 2006



What is the rationale for anemia correction?

Potential Benefits• Improved oxygen delivery• Improved exercise tolerance• Attenuate adverse

remodeling• Improved Quality of Life • Antiapoptotic?• Decrease in hosp./death?

Potential Risks • Increased thrombosis • Platelet activation • Hypertension• Endothelial activation

Adapted from Felker and O’Connor J Am Coll Cardiol. 2004;44:959-966.

Potential benefits and risks of treating anemia in HF:



Randomized controlled trials play a critical role in advancing patient care through guidelines

Drug Discovery

PatientOutcomes

Clinical Trials

Guidelines

QualityIndicators

CaregiverPerformance

Califf, R et al JACC 2002;40(11):1895-1901



1.Yes

2.No

3.Refer to a) GP

b) GI

c) IM

d) Next cardiologist

Should I treat anemia in a patient with heart failure?

The decision to treat, not to treat, or to refer the patient is discussed in the 2014 Heart

Failure Guidelines.



Table 1 Randomized, controlled studies with intravenous iron in patients with heart failure

van Veldhuisen, D. J. et al. (2011) Anemia and iron deficiency in heart failure:mechanisms and therapeutic approaches

Nat. Rev. Cardiol. doi:10.1038/nrcardio.2011.77

Evidence to support treatment of anemia



MethodStudy design: The FAIR-HF trial was a randomized, double-blind, multicenter study.

Study population: A total of 495 patients were enrolled in this study. Ambulatory patients who had chronic heart failure of NYHA class II or III, a LVEF of 40–45% or less, a hemoglobin level between 95 and 135 g/L and iron deficiency. Uncontrolled hypertension, other significant heart diseases and inflammation were some of the excluding factors.

Treatment regimen: Ferric carboxymaltose or saline was administered to the patients randomly as an intravenous bolus injection of 4 ml. Dosing was done every week till repletion of iron was achieved and after that every 4 weeks as maintenance therapy after 8th or 12th week of initiation of therapy.

End point: The primary end point was a self-reported Patient Global Assessment (PGA) form and NYHA functional class in the 24th week. Safety end points were serious and non-serious adverse effects, hospitalization and death up to the 26th week of study.

The FAIR-HF trial



Noticed an improvement in intravenous iron, compared to placebo (note: scale is between 30-35 metres). The 6-minute-walk test aims to improve exercise tolerance and perception of symptomology.



The administration of ferric carboxymaltose in patients with chronic heart failure and iron deficiency with or without anemia was beneficial (seeing an improvement in symptomology).



Figure 4 Effect of intravenous iron (ferric carboxymaltose) in patients with heart failure and iron deficiency in various subgroups (including those with and without anemia). Seem to be responding to improvement in iron storage.

van Veldhuisen, D. J. et al. (2011) Anemia and iron deficiency in heart failure:mechanisms and therapeutic approaches

Nat. Rev. Cardiol. doi:10.1038/nrcardio.2011.77

Permission obtained from Massachusetts Medical Society © Anker, S. D. et al. Ferric carboxymaltose in patients with heart failure and iron deficiency. N. Engl. J. Med. 361, 2436–2448 (2009)

The effect of intravenous iron



Practical Tip: Symptomatic patients with low transferrin and/or ferritin levels should be considered for supplementary iron therapy principally with a goal of improving symptoms

Anemia recommendations

We suggest that for patients with documented iron deficiency, oral or intravenous iron supplement be initiated to improve functional capacity (Weak Recommendation, Low-Quality Evidence).

Values and Preferences:The iron supplement recommendation was derived mostly from the experience of clinicians, small clinical trials, and 2 large randomized controlled trials (RCTs).

Recommendation



Advantages of EPO Therapy

1. Increase hemoglobin level2. Increases peak O2 consumption3. Improve functional class4. Decreases ventricular remodeling5. Improve cardiac and renal functions6. Reduce diuretic dose7. Reduce hospitalizations8. Reduce mortality rate (small study)

1. Increase hypertension2. Increase thrombosis3. Increase endothelin activation4. Expensive

Disadvantages of EPO Therapy

EPO therapy



RED-HF trial (Reduction of Events by Darbepoetin Alfa in Heart Failure)

Available online at NEJM.org



I was hoping I’d be in the

active therapy group.

Well, I was hoping I’d be

in the placebo group.



Darbepoetin alfa group (target hemoglobin 13.0 to 14.5 g/dL)N = 1200

Placebo groupN = 1200

Study Population

•Hemoglobin 9 to 12 g/dL

•LVEF ≤ 35%

•NYHA Class II to IV

Approximately 620 global sites

1:1 randomization

Timelines

Event driven: ~1150 eventsStudy End September 1 2012

Began enrolling June 2006

Site Evaluation & Selection

Follow-up

RED-HF trial



KCCQ primary analysis: Change from baseline to month 6

KCCQ Symptom Frequency Score Mean Change From Baseline to Month 6

0

1

2

3

4

5

6

7

8

9

10

6.20

3.91

2.4695% CI: (0.90, 4.02)

P = 0.011

Ch

ang

e fr

om

Bas

elin

e in

KC

CQ

S

ymp

tom

Fre

qu

ency

Sco

re

Darbepoetin alfa (n = 925)

Placebo(n = 927)

Data on file, Amgen.

Mixed effects model estimating treatment effect adjusted for region, type of device, and baseline KCCQ score; scale scores range from 0 to 100, with higher scores indicating better functioning.

KCCQ Overall Summary Score Mean Change From Baseline to Month 6

0

1

2

3

4

5

6

7

8

9

10

6.68

4.48

2.2095% CI: (0.65, 3.75)

P = 0.005

Ch

ang

e fr

om

Bas

elin

e in

KC

CQ

O

vera

ll S

um

mar

y S

core

Placebo(n = 929)

Darbepoetin alfa (n = 928)



Primary outcome: All cause death or first hospitalization for worsening heart failure

Years of Randomization

Pro

p. o

f S

ub

ject

Wit

h E

ven

t (%

)

Subjects at risk:

11361142

975956

855818

712695

581591

473497

385395

281290

212211

161154

10192

Stratified Log-rank, p = 0.87

PlaceboDarbepoetin alfa

100

80

60

40

20

0

0 1 2 3 4 5



Selected adverse events of interest

n (%)Darbepoetin alfa

(N = 1133)Placebo

(N = 1140)Risk difference

(95% CI) p-value

Ischaemic cerebrovascular conditions 51 (4.5) 32 (2.8) 1.7 (0.2, 3.2) 0.031

Embolic and thrombotic events 153 (13.5) 114 (10.0) 3.5 (0.9, 6.1) 0.009

Hypertension 81 (7.1) 69 (6.1) 1.1 (-0.9, 3.1) 0.292

Malignancies 69 (6.1) 68 (6.0) 0.1 (-1.8, 2.1) 0.900

Hypersensitivity reactions 99 (8.7) 96 (8.4) 0.3 (-2.0, 2.6) 0.787



EPO recommendation

Practical Tip: Patients with severe chronic kidney disease and anemia should be referred to a nephrologist to seek the optimal therapy for anemia.

Values and Preferences:The recommendations against the use of erythropoiesis-stimulating agents (ESAs) were derived from robust data from RCTs.

Recommendation

We recommend erythropoiesis stimulating agents not be routinely used to treat anemia in HF (Strong Recommendation, High-Quality Evidence).



Conclusion

1. Identify anemia and potential causes; anemia is a marker of the severity of the disease (HF)

2. Evaluate

3. Consider treatment options



Biomarkers



• Establishing diagnosis and selecting optimal therapy for any given patient are current challenges, as costs associated with HF diagnostic and therapeutic strategies continue to rise

• Biomarkers may help stratify risk and individualize therapy

• This update will review the role of circulating biomarkers for the management of patients with HF with a focus on its role in the monitoring for disease progression

Optimal use of biomarkers



B-type natriuretic peptides

Increased myocardial wall stress due to volume or pressure overload activates the B-type natriuretic peptide (BNP) gene in cardiac myocytes, producing the intracellular precursor propeptide (proBNP).

Cleavage releases the biologically active BNP and biologically inert amino-terminal fragment (NT-proBNP).

BNP stimulates natriuresis and vasodilation with consequent afterload reduction, inhibits renin-angiotensin-aldosterone release and sympathetic nervous activity, and reduces fibrosis.



Diagnosis of heart failure

• A 74 y.o. lady presents to ER with increased shortness of breath on exertion for 2 months, no chest pain

• Known for hypertension and diabetes but has never had angina or a notion of coronary artery disease. No family history of CAD and stopped smoking 15 years ago but smoked 30 cigarettes a day for 40 years

• Medications: Perindopril 4mg qd, Metformin 500mg bid, Calcium and Vitamin D

• P/E: Pulse 82 bpm, BP 150/85mmHg, T 37.1, RR 16, JVP and carotids normal, S4 but otherwise cardiac auscultation is normal, mild bibasal crackles, unremarkable abdominal exam and no peripheral oedema




• Chest X-Ray: COPD, no clear signs of HF• CBC normal• E+, BUN, creatinine: normal• High sensitivity troponin T: 21 µg/L (gives normal in your lab)

Do you believe BNP or NT-proBNP could help you make the proper diagnosis?A) I really do not see how

B) I know for sure what her diagnosis is

C) I would rather check procalcitonin, as this must be infectious

D) Yes, they could help me clarify whether or not this is HF

E) It’s really too expensive and does not really help




• Her NT-proBNP levels: 1600 pg/mL

Recommendation

We recommend that B-type NP (BNP)/amino-terminal fragment of propeptide BNP (NT-proBNP) levels be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (Strong Recommendation, High-Quality Evidence).

Values and Preferences:These recommendations remain unchanged from previous CCS HF guidelines.



Natriuretic peptides for HF diagnosis

Table 2. Natriuretic peptides cut points for the diagnosis of heart failure Age (years) HF is unlikely HF is possible but

other diagnoses need to be considered

HF is very likely

BNP All < 100 pg/ml 100-500 pg/ml > 500 pg/ml

NT-proBNP < 50 < 300 pg/ml 300-450 pg/ml > 450 pg/ml

50 - 75 < 300 pg/ml 450-900 pg/ml > 900 pg/ml

> 75 < 300 pg/ml 900 - 1800 pg/ml > 1800 pg/ml

HF, heart failure



The troubling case of Mr. B

• Mr. B. is 70 y.o. and comes in your office in May 2012 for his follow-up (q 4 months). He lives 7 hours from your hospital and is followed by his GP and you, his cardiologist, for HF due to ischemic cardiomyopathy. The last echo (4 months) showed and EF of 25%, severe functional MR, Mild RV dysfunction, moderate to severe TR, PAPs 55mmHg

• He still smokes 10 cigarettes/day, has COPD, respects his water and salt intake limits and takes his medications

• He has had prior myocardial infarctions and coronary bypasses in 2001, has no ischemia but a large scar on his nuclear scan done 4 months ago. His ICD was implanted in primary prevention in 2005, he had a narrow QRS. He never had ICD therapies.



The troubling case of Mr. B

• Current medications: ASA 80mg qd, Bisoprolol 10mg qd, Candesartan 16mg bid, Spironolactone 25mg qd, Furosemide 80mg bid

• Mr. B’s NYHA class often varies between 2 and 3. Today he reports being more short of breath (definitely NYHA 3) for about 6 weeks but he is stressed with financial and family issues. He seems depressed and worried

• He did not cough more than usual and did not have fever

• On physical examination: well perfused, very thin, pulse 60 (NSR), BP 95/55mmHg (usual), JVP 12 (V wave nadir), S3+, holosystolic apical murmur 3/6, clear lungs, mild peripheral oedema. ECG: SR, right ventricular pacing

• His last labs were done with his GP 3 weeks ago and showed stable Hb 125g/L and creatinine 120umol/L, K 4.0



What would you do?

A) Increase furosemide to 120mg bid and send him back to his GP until next time (4 months)

B) Ask for NP levels today at your hospital and then decide what to do

C) Add digitalis to his therapy

D) Refer him for Mitra-Clip evaluation

E) All of the above

Note: There is no HF clinic closer to where he lives and his GP seems him every 3-4 weeks



What we did:

His NT-proBNP level was 7500 (prior was 3700) and his creatinine up to 142umoL/L. We did increase his diuretics but also reevaluated all potential means of improving his outcome (was referred for Mitra-Clip evaluation).



Recommendations

We recommend measurement of BNP/NT-proBNP levels be considered in patients with an established diagnosis of HF for prognostic stratification (Strong Recommendation, High-Quality Evidence).

We suggest, in ambulatory patients with HF due to systolic dysfunction, measurement of BNP or NT-proBNP to guide management should be considered to decrease HF-related hospitalizations and potentially reduce mortality. The benefit is uncertain in individuals older than 75 years of age (Weak Recommendation, Moderate-Quality Evidence).

Values and Preferences:These recommendations are based on multiple small RCTs, most of which demonstrated benefit, and 3 meta-analyses, which universally demonstrated benefit. It is realized that there is still a large RCT ongoing that might modify the conclusions.

Recommendation



Evidence for NP-guided therapy

• In the available trials, 3 systematic reviews and meta-analyses (Figures) synthesizing the RCT results, NP-guided therapy has been shown to improve survival and reduce hospitalizations

• In these studies, NP-guided therapy had no benefits in 2 subgroups: age >75 years and those with HFpEF

• Consequently, a larger multicenter trial of a single-target NP level (NT-proBNP 1000 pg/ml) and the use of guideline-approved therapies in both treatment arms is now underway, the Guiding Evidence Based Therapy Using Biomarker Intensified Treatment (GUIDE-IT, NCT01685840)

• The ongoing single-centre EX-IMPROVE-CHF, NCT00601679) will also help clarify the role of NP-guided therapy in HF management



Effect of NP-guided management on mortality: hazard ratios from meta-analysis



Effect of NP-guided management on HF hospitalizations: HRs from meta-analysis



What’s a significant change in NP level?

• A change of 30% in NP level likely exceeds the day to day variation and is in general considered relevant.

• For ambulatory patients with HF evaluated in the clinic, a NP level that increases more than 30% should therefore call for more intensive follow up and/or intensified medical treatments, even if they are not congested clinically.

• The latter can include diuretic therapy or intensification of ACE inhibitors, β-blockers and mineralocorticoid receptor antagonists if their doses are not yet at the targets defined by clinical trials.



Pre-discharge NP levels

• Besides predicting prognosis of patients in general, BNP level obtained pre-discharge has been associated with mortality and rehospitalization.

• Indeed, predischarge NP in conjunction with change in NP has now been incorporated into a risk score for death and readmission of HF in patients admitted with HF.

Salah K, Kok WE, Eurlings LW et al. ELAN-HF Score. Heart 2014;100(2):115-125.



Pre-discharge NP levels

Values and Preferences:This recommendation is based on multiple small RCTs, all of which demonstrated an association with clinical outcomes. Although the risk of readmission is decreased with lower NP levels, clinicians should also consider the limitations of delaying discharge from the hospital for this purpose.

Recommendation

We suggest that measurement of BNP or NT-proBNP in patients hospitalized for HF should be considered before discharge, because of the prognostic value of these biomarkers in predicting rehospitalization and mortality (Strong Recommendation, Moderate-Quality Evidence).



Preventing heart failure

• The preliminary results of STOP-HF and PONTIAC trials suggest that a NP guided strategy for at-risk individuals may provide benefit in both preventing and treating HF, leading to reductions in cardiac mortality and hospitalizations.

• Asymptomatic individuals at high risk for the development of HF but without established heart disease: Subjects with hypertension, hypercholesterolemia, obesity, known vascular disease, diabetes, arrhythmia requiring treatment, valvular abnormalities.



Preventing heart failure

Practical Tip: We suggest that individuals with risk factors for the development of HF, NP levels be used to implement strategies to prevent HF. An increased level of NP of BNP > 100 pg/mL and NT-proBNP > 300 pg/mL, higher values than those used in the 2 trials discussed below to avoid over screening, along with the presence of risk factors for HF, should at least trigger more intensive follow up (See Prevention of HF in CJC Published Article).



Algorithm of the use of natriuretic peptides

Risk factors for HF

Stable ambulatory HF

Hospitalized for HF and before

discharge

Patient Population Natriuretic Peptide Level Actions

> 30% from admission value

More frequent follow up, consideration of

intensification of existing therapy

More frequent follow up ± intensification of

HF therapy

Discharge if relatively free from congestion

NT-proBNP > 300 g/mL

BNP > 100 g/mL

> 30% from clinic baseline value



Other biomarkers ready for clinic?Biomarkers Pathophysiological

pathways / comorbid conditions with prognostic implications

HF populations targeted

Advantages Potential benefits Challenges before implementation

NGAL Renal Function Acute HF Early detection of renal function deterioration

Adjusting therapy to improve prognosis by avoiding acute renal failure progression

Unclear if using NGAL in acute HF to modify therapies improves clinical outcomes

Cystatin C Renal Function Acute and chronic HF More sensitive detection of changes in renal function

Same as above Unclear if using Cystatin C, over using eGFR, to modify clinical management provides further clinical benefit

Cardiac hs-troponins

Myocyte death Acute and Chronic HF Very sensitive marker predicting higher risk of CV events regardless of etiology

Optimization of therapy in patients with elevated hs-cTn should be more aggressive

Prognostication improves only for mortality and use to modify therapy has not been tested

ST2 Fibrosis / inflammation / immunity

Acute and chronic HFrEF, HFpEF and previously low EF recovered

Additional prognostic value beyond NPs suspectedLow week-to-week variations

Could provide additional value for short and long term prognostication, regardless of LVEF

Unclear if using ST2 in acute HF to modify therapies improves clinical outcomes;

Galectin-3 Cardiac and vascular fibrosis Incident HF, HFrEEF and HFpEF

Early detection of risk and long term prognostication in HF

Preventive measures and therapy optimization based on levels could improve outcomes

Recent study showed ST2 superior to Galectin-3 in a multivariable prediction model



Clinical trials that might influence practice



HF – Preserved ejection fraction

• No therapy specifically recommended for HF-PEF with “strong”

• Complicated phenotype(s) and trial design(s)

• Different patient demographics

• Many pharmacologic and non-pharmacologic interventions have been tried:

• ACE, ARB, BB, exercise, etc

• Recently: mineralocorticoid antagonists (TOPCAT)


Moe GW, Ezekowitz JA et al., Can J CardiolDesai, Rationale and design, Am Heart J 2011

Pfeffer, TOPCAT NEJM 2013Desai, Rationale and design, Am Heart J 2011

Pfeffer, TOPCAT NEJM 2013

TOPCAT

• International, multi-center, double-blind, placebo-controlled RCT• NIH Sponsored

• Significant CAN involvement: Sites, Exec, Country Leaders• Randomization, 1:1

– Spironolactone, 15, 30, 45 mg daily

– matching placebo

• Primary outcome: CV death, HF hosp, or aborted cardiac arrest• Assumed: 3-year placebo rate of 17.4%



• Inclusion: – Symptomatic Heart Failure– Age ≥ 50– LVEF ≥ 45%– stratified according to:

• HF Hospitalization within the past year, or

• Elevated natriuretic peptides– BNP ≥100 pg/mL– NT-proBNP ≥360 pg/mL

• Major Exclusion: – eGFR<30 mL/min/1.7m2

– potassium ≥5 mmol/L– uncontrolled hypertension,

AF with rate > 90/min, recent ACS, restrictive, infiltrative, or hypertrophic cardiomyopathy

TOPCAT: Eligibility criteria

Desai, Rationale and design, Am Heart J 2011Pfeffer, TOPCAT NEJM 2013

Desai, Rationale and design, Am Heart J 2011Pfeffer, TOPCAT NEJM 2013



N=3445 pts

Age, median (IQR), years 67 (61-76)

Female, % 52

Ejection Fraction, median, % 56

Diabetes, % 33

Atrial Fibrillation, % 35

eGFR, median, IQR 65 (54, 79)

< 60 (ml/min/1.73m2) 39%Eligibility Stratum, %

Hosp. for HF 72Natriuretic Peptide 29

Medications, %ACE-I or ARB 84Beta-blocker 78

Diuretic 81

TOPCAT: Baseline characteristics

S. Shah Circ HF 2012S. Shah Circ HF 2012



Placebo Spironolactone

HR = 0.89 (0.77 – 1.04)

p=0.138

351/1723 (20.4%)351/1723 (20.4%)

320/1722 (18.6%)320/1722 (18.6%)

(CV Death, HF Hosp, or Resuscitated Cardiac Arrest)

TOPCAT: Primary outcome

Pfeffer, TOPCAT NEJM 2013Pfeffer, TOPCAT NEJM 2013

Placebo



• BNP/NT-proBNP: 28.5%• Prior HF hosp: 71.5%

Enrolled by:Spiro

event ratePlacebo

event rateHazard Ratio

(95% CI)P-value

Natriuretic peptide

15.9% 23.6% 0.65 (0.49-0.87) 0.003

Heart Failure Hosp

19.6% 19.1% 1.01 (0.84-1.21) 0.923

*P=0.013 for interaction

TOPCAT: Enrollment strata




US, Canada, Argentina, Brazil

Russia, Rep Georgia

12.6 per 100 pt-yr12.6 per 100 pt-yr

2.3 per 100 pt-yr2.3 per 100 pt-yr

Placebo:280/881 (31.8%)Placebo:280/881 (31.8%)

Placebo:71/842 (8.4%)Placebo:71/842 (8.4%)

TOPCAT: Placebo event rates




HR=0.82 (0.69-0.98)

HR=1.10 (0.79-1.51)

Interaction p=0.122

US, Canada, Argentina, Brazil

Russia, Rep Georgia

Placebo:280/881 (31.8%)Placebo:280/881 (31.8%)

Placebo:71/842 (8.4%)Placebo:71/842 (8.4%)

TOPCAT: Regional strata




TOPCAT: Regional strata


• Fully adjusted model for primary endpoint including region and other variables:– HR 0.85, 95%CI 0.73 to 0.99, p=0.043

– “15% relative risk reduction for the primary endpoint in favor of spironolactone”



TOPCAT: Safety

• Doubling in the rate of hyperkalemia:• 9.1% in the placebo group• 18.7% in the spironolactone group

– no deaths due to hyperkalemia

• Fewer events of hypokalemia• No renal failure leading to dialysis



HF-PEF Recommendation

Values and Preferences:This recommendation is based on a prespecified subgroup analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, which includes analysis of the predefined outcomes according to admission NT-proBNP level, and the corroborating portion of the trial conducted within North and South America.

Recommendation

We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/L, and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation, Low-Quality Evidence).



HF – Reduced ejection fraction

• Current GDMT (ACE or ARB, BB and MRA) reduces the risk of mortality, hospitalization and improves quality of life

• Multiple, adequately powered RCT• Residual risk despite GDMT




Fonarow G C et al. J Am Heart Assoc 2012;1:16-26Fonarow G C et al. J Am Heart Assoc 2012;1:16-26

• Cumulative reduction in the odds of death over 2 years compared with no treatment



PARADIGM-HF

McMurray NEJM 2014McMurray NEJM 2014

• International, multi-center, double-blind, placebo-controlled RCT• Randomization, 1:1

– LCZ696 200 mg BID

– Enalapril 10 mg BID

• Primary: composite of CV death and/or hospitalization for HF


Moe GW, Ezekowitz JA et al., Can J Cardiol Vardeny CPT 2013Vardeny CPT 2013



Inclusion: •NYHA II-IV HF•LVEF ≤40 % [≤35% amend]•Elevated NPs

– BNP ≥150 pg/mL

– NT-proBNP ≥600 pg/mL

•Guideline-recommended use of beta-blockers and mineralocorticoid receptor antagonists

Inclusion (con’t)

Any ACEi or ARB, but able to tolerate stable dose equivalent to at least enalapril 10 mg daily for at least 4 weeks

Major Exclusion: •SBP < 95 mmHg•eGFR < 30 ml/min/1.73 m2

•K > 5.4 mEq/L

PARADIGM-HF: Eligibility criteria




2 weeks 1-2 weeks 2-4 weeks

Single-blind run-in period Double-blind period

Enalapril

10 mg BID

100 mgBID

100 mgBID

200 mgBID

Enalapril 10 mg BID

LCZ696 200 mg BID

Rand’n

N=8399 patientsN=977N=1102

PARADIGM-HF: Design




LCZ696(n=4187)

Enalapril(n=4212)

Age (years) 63.8 ± 11.5 63.8 ± 11.3Women (%) 21.0% 22.6%Ischemic cardiomyopathy (%) 59.9% 60.1%LV ejection fraction (%) 29.6 ± 6.1 29.4 ± 6.3NYHA functional class II / III (%) 71.6% / 23.1% 69.4% / 24.9%Systolic blood pressure (mm Hg) 122 ± 15 121 ± 15Heart rate (beats/min) 72 ± 12 73 ± 12N-terminal pro-BNP (pg/ml) 1631 (885-3154) 1594 (886-3305)B-type natriuretic peptide (pg/ml) 255 (155-474) 251 (153-465)History of diabetes 35% 35%Beta-adrenergic blockers 93.1% 92.9%Mineralocorticoid antagonists 54.2% 57.0%ICD and/or CRT 16.5% 16.3%

PARADIGM-HF: Baseline chars.




0

16

32

40

24

8

Enalapril(n=4212)

360 720 10800 180 540 900 1260Days After Randomization

41874212

39223883

36633579

30182922

22572123

15441488

896853

249236

LCZ696Enalapril

Patients at Risk

1117

Kap

lan

-Mei

er E

stim

ate

of

Cu

mu

lati

ve R

ates

(%

)

914

LCZ696(n=4187)

HR = 0.80 (0.73-0.87)P = 0.0000002

Number needed to treat = 21

PARADIGM-HF: Primary endpoint

McMurray NEJM 2014 McMurray NEJM 2014



Enalapril(n=4212)

LCZ696(n=4187)

HR = 0.80 (0.71-0.89)P = 0.00004

Number need to treat = 32

Kap

lan

-Mei

er E

stim

ate

of

Cu

mu

lati

ve R

ates

(%

)

Days After Randomization

41874212

40564051

38913860

32823231

24782410

17161726

1005994

280279

LCZ696Enalapril

Patients at Risk

360 720 10800 180 540 900 12600

16

32

24

8

693

558

PARADIGM-HF: CV death




41874212

40564051

38913860

32823231

24782410

17161726

1005994

280279

LCZ696Enalapril

Enalapril(n=4212)

LCZ696(n=4187)

HR = 0.84 (0.76-0.93)P<0.0001

Kap

lan

-Mei

er E

stim

ate

of

Cu

mu

lati

ve R

ates

(%

)

Days After RandomizationPatients at Risk

360 720 10800 180 540 900 12600

16

32

24

8

835

711

PARADIGM-HF: All cause mortality




LCZ696(n=4187)

Enalapril(n=4212)

Hazard Ratio

(95% CI)

PValue

Primary endpoint

914(21.8%)

1117(26.5%)

0.80(0.73-0.87)

0.0000002

Cardiovascular death

558(13.3%)

693(16.5%)

0.80(0.71-0.89)

0.00004

Hospitalization for heart failure

537(12.8%)

658(15.6%)

0.79(0.71- 0.89)

0.00004

PARADIGM-HF: endpoints




LCZ696(n=4187)

Enalapril(n=4212)

PValue

Prospectively identified adverse events

Symptomatic hypotension 588 388 < 0.001

Serum potassium > 6.0 mmol/l 181 236 0.007

Serum creatinine ≥ 2.5 mg/dl 139 188 0.007

Cough 474 601 < 0.001

Discontinuation for adverse event 449 516 0.02

Discontinuation for hypotension 36 29 NS

Discontinuation for hyperkalemia 11 15 NS

Discontinuation for renal impairment 29 59 0.001

Angioedema (adjudicated)

Medications, no hospitalization 16 9 NS

Hospitalized; no airway compromise 3 1 NS

Airway compromise 0 0 ----

PARADIGM-HF: Safety endpoints




Is 1 trial enough?

Slide courtesy of J McMurraySlide courtesy of J McMurray

Do we need to do another trial to obtain regulatory approval/change clinical practice?

Number of trials with P < 0.05

showing efficacy

P value required in a single trial to provide same strength of evidence

PARADIGM-HF: Effect on primary

endpoint

PARADIGM-HF: Effect on

cardiovascular death

1 0.05

2 0.00125

3 0.00003125

4 0.00000078

5 0.0000000195 0.00000040.0000004

0.000080.00008

Based on formula (0.025)n x2 (personal communication Stuart Pocock)




Values and Preferences:This recommendation places high value on medications proven in large trials to reduce mortality, HF rehospitalization, and symptoms. It also considers the health economic implications of new medications. The recommendation is conditional because the drug is not yet approved for clinical use in Canada and the price is still not known.

Recommendation

We recommend that in patients with mild to moderate HF, an EF ≤ 40%, an elevated NP level or hospitalization for HF in the past 12 months, a serum potassium < 5.2 mmol/L and an eGFR ≥ 30 mL/min and treated with appropriate doses of guideline-directed medical therapy should be treated with LCZ696 in place of an ACE inhibitor or an angiotensin receptor blocker, with close surveillance of serum potassium and creatinine (Conditional Recommendation, High-Quality Evidence).



Appendix: Useful CCS Heart Failure Guideline Algorithms



Algorithm for Prevention and Treatment of Clinically Stable Heart Failure



Referral Pathway for Device Therapy in Patients with Chronic Heart Failure



Acute Heart Failure – Diagnosis



Acute Heart Failure – Acute Management



Approach to Assessment for CAD in Patients with HF



Decision Regarding Coronary Revascularization in HF



Algorithm for Management of Different Stages of HF using

Natriuretic Peptides



Appendix: CCS Heart Failure Guideline

Resources



To access this tool, and to view all of our guideline resources, please visit www.ccs.ca.

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