heart failure care: managing modern era of gdmt failure care gdmt อ_ภู...2013 accf/aha...
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Heart Failure Care: Managing Modern Era of GDMT
Assist Prof. Poukwan Arunmanakul MSc (Clinical Pharmacy), PharmD, BCPS
Pharmaceutical Care Department
Chiang Mai University
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Goal of Medical Treatment in HF care
97 YO HF patient. Old anterior wall MI with apical aneurysm, Severe LV systolic dysfunction
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Definitions
• HFrEF: Clinical diagnosis of HF and LVEF ≤40%.
• GDMT: Guideline-directed medical therapy
• Optimal therapy: Treatment provided at either the target or the highest-tolerated dose for a given patient
• Target dose: Doses targeted in clinical trials
European Heart Journal, Volume 37, Issue 27, 14 July 2016
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Evidence-based doses of disease-modifying drugs in heart failure with reduced ejection fraction
European Heart Journal, Volume 37, Issue 27, 14 July 2016
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The Progress and Complexity of Heart failure Treatment
RAAS blockades and Beta-blocker in all patients, mineralocorticoid antagonist
Hydralazine-Isosorbide mononitrate, Ivabradine, digoxin
NYHA class I NYHA Class II-III (Previously or current) NYHA Class IV
Yancy et al. JACC 71 (2) 201-230; 2017
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Pivotal issue in HFrEF
• 1.How to initiate, add, or switch therapy to new evidence-based guideline-directed treatments for HFrEF
• 2. How to achieve optimal therapy given multiple drugs for HF (including augmented clinical assessment that may trigger additional changes in guideline-directed therapy)
Yancy et al. JACC 71 (2) 201-230; 2017
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57 YO M with Ischemic DCM
• Multiple readmission in 2015 with NSTEMI, ADHF
• CAG 3/7/2015: TVD • Dyslipidemia, Type II
DM, CKD • NYHA class II
Left main: normal LAD: proximal stenosis 70%, long lesion, mid stenosis LCX: Mid stenosis 50% RCA: dominant, proximal occluded, collateralized from LAD
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Initial Phase 57 YO M with Ischemic DCM
3/7/2015 BP 92/60 (symptomatic)
HR 81
EF 16%
Scr 2.03
K 4.0
Beta-blockers ?
ACEI ?
MRA ?
Diuretic Furosemide 40 mg 2-2-0
Other medication
ASA, Clopidogrel, Nitrate, Atorvastatin
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Medical Therapy for Stage C HFrEF
2013 ACCF/AHA Guideline for the Management of Heart Failure
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Yancy et al. JACC 71 (2) 201-230; 2017
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Yancy et al. JACC 71 (2) 201-230; 2017
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Initial Phase 57 YO M with Ischemic DCM
3/7/2015 BP 92/60 (symptomatic)
HR 81
EF 16%
Scr 2.03
K 4.0
Beta-blockers Carvedilol 6.25 mg ¼ x 2
ACEI wait
MRA Spironolactone 25 mg 1x1
Diuretic Furosemide 40 mg 1-1-0
Other medication
ASA, Clopidogrel, Nitrate, Atorvastatin
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Starting and Target Doses of Select Guideline-Directed Medical Therapy for HF
• HF is a complex syndrome typically associated with multiple comorbidities; most patients are on multiple medications.
• To assess tolerability of medications and best assess the trajectory of HF, it is often necessary for patients to have more frequent follow-up, especially after initiation or titration of therapy.
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Titration Phase 57 YO M with Ischemic DCM
3/7/2015 18/7/2015 BP 92/60 (symptomatic) 95/67
HR 81 78
EF 16% -
Scr 2.03 1.75
K 4.0 4.2
Beta-blockers Carvedilol 6.25 mg ¼ x 2 ?
ACEI wait ?
MRA Spironolactone 25 mg 1x1 ?
Diuretic Furosemide 40 mg 1-1-0
?
Other medication ASA, Clopidogrel, Atorvastatin
ASA, Clopidogrel, Atorvastatin
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Titration Phase 57 YO Male with Ischemic DCM
3/7/2015 18/7/2015 BP 92/60 (symptomatic) 95/67
HR 81 78
EF 16% -
Scr 2.03 1.75
K 4.0 4.2
Beta-blockers Carvedilol 6.25 mg ¼ x 2 Carvedilol 6.25 mg ¼ x 2
ACEI wait Enalapril 5 mg ½ x 2
MRA Spironolactone 25 mg 1x1 Spironolactone 25 mg 1x1
Diuretic Furosemide 40 mg 1-1-0
Furosemide 40 mg 1-0-0 + flexible diuretic
regimen
Other medication ASA, Clopidogrel, Atorvastatin
ASA, Clopidogrel, Atorvastatin
Digoxin was added to help control heart rate
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The most important tool in HF management
Self daily weight monitoring :
If weight increases > 1 kg within 1 or 2 days
double the dose of diuretics , until returns to ideal BW
• Weigh every morning
• After going to toilet
• Before getting dressed
• Before breakfast
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Property Furosemide Bumetanide Torsemide
Bioavailabilty (%) 10-90 (average 50)
80-100 80-100
Affect by food Yes ( AUC 30-40%)
Yes No
Metabolism 50% renal conjugation
50% hepatic 80% hepatic
Half life (hr) Normal Renal dysfunction Hepatic dysfunction Heart failure
1.5-2 2.8 2.5 2.7
1
1.6 2.3 1.3
3-4 4.5 8 6
Onset (min) Oral iv
30-60
5
30-60
2-3
30-60
unavailable
Duration 7 4-6 12-16
Start dose (iv) mg 40-80 1-2 10-20
Dose equivalent 40 20 1
Pharmacokinetic of loop diuretic
Ann Pharmacolher 2009;43:1836-47., https://www.radcliffecardiology.com/articles/diuretic-therapy-heart-failure-current-approaches
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Change in Diuretic regimen (2 weeks later)
57 YO M with Ischemic DCM 3/7/2015 18/7/2015
BP 92/60 (symptomatic) 95/67
HR 81 78
EF 16% -
Scr 2.03 1.75
K 4.0 4.2
Beta-blockers Carvedilol 6.25 mg ¼ x 2 Carvedilol 6.25 mg ¼ x 2
ACEI wait Enalapril 5 mg ½ x 2
MRA Spironolactone 25 mg 1x1 Spironolactone 25 mg 1x1
Diuretic Furosemide 40 mg 1-1-0
Furosemide 40 mg 0-0-1 at 8pm + flexible
diuretic regimen (another 1 tab at 11 pm)
Other medication ASA, Clopidogrel, Atorvastatin
ASA, Clopidogrel, Atorvastatin, Digoxin
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Optimized Phase (Current Regimen) 59 YO M with Ischemic DCM
6/3/2018 BP 97/65
HR 65
EF 35.5% , no readmission since 2016
Scr 1.60
K 4.1
Beta-blockers Carvedilol 6.25 mg 1 ½ x 2
ACEI Enalapril 5 mg ½ -0- 1
MRA Spironolactone 25 mg 1x1
Diuretic Furosemide 40 mg 0-0-1 at 8pm + flexible diuretic regimen
(another 1 tab at 11 pm)
Other medication Digoxin 0.25 mg ½ EOD ASA, Clopidogrel, Atorvastatin,
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Yancy et al. JACC 71 (2) 201-230; 2017
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Yancy et al. JACC 71 (2) 201-230; 2017
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Expectation vs. Reality
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Other Medications that can Exacerbated HF symptoms
European Heart Journal, Volume 37, Issue 27, 14 July 2016
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GDMT Intensification Phase 2-4 months, 1-4 week cycles
• Serial evaluation and titration of medication • Clinical visit with clinical symptoms evaluation,
vital sign, exam, lab • If volume status required treatment, adjust
diuretic • If euvolumic and stable, start
increase/adjusted/switch GDMT, follow up every 2 weeks
• Repeat clinic visit with electrolytes and metabolic panel as indicated
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GDMT Stabilized phase (Follow up approximately 3 months)
• Repeat lab test and metabolic panel
• Ongoing clinical symptoms assessment
• Empower patients and care givers to ensure adherences, medication reconciliation
• Evaluation of Echocardiogram anually and EKG as needed
• Consult EP for device therapy as needed
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Thank you for your attention