sreeni r. gangasani md, facc · heart failure is a growing and expensive public health issue 5.1m...

Residency:William Beaumont Hospital

Medical School:Kurnool Medical College

Fellowship:William Beaumont Hospital

Cardiologist at Cardio-Vascular GroupFellow of American College of CardiologyNo Financial Relationships to disclose

Board Certified in• Internal Medicine• Cardiovascular Diseases

Special interests:• General Cardiology•Echocardiography•Nuclear •Preventative Cardiology

Sreeni R. Gangasani MD, FACC.

A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.

7/12/2018 CardioVascular Group

How many Americans suffer from heart failure

A) A) 2.5 M

B) B) 5 M

C) C) 7.5 M

D) D) 10 M

Heart failure is a growing and expensive public health issue

5.1M AMERICANS SUFFER FROM HEART FAILURE3

> 650KNEW HEART FAILURE DIAGNOSES EACH YEAR1,2

2.8MOFFICE AND ED VISITS EACH YEAR5

1 in 2HEART FAILURE PATIENTS DIE IN 5 YEARS45 YRS

HEART FAILURE IS THE LEADING CAUSE OF HOSPITALIZATIONS AMONG > 65-YEAR-OLD PATIENTS7

EVERY 30 SECONDS, SOMEONE IS HOSPITALIZED FOR HEART FAILURE8

1.0MHEART FAILURE HOSPITALIZATIONS EACH YEAR6

TOTAL COST OF HEART FAILURE IN THE U.S. EXPECTED TO DOUBLE BY 20309

$31B $70B2013 2030

> 1/2 OF COSTS SPENT ON HOSPITALIZATIONS2

25%READMISSION WITHIN 30 DAYS2

50%READMISSION WITHIN 6 MONTHS12

MOST HEART FAILURE PATIENTS SUFFER RE-CONGESTION WITHIN 60 DAYS –EVEN AT THE BEST HOSPITALS11

HIGH READMISSION RATES

AVERAGE HOSPITAL LENGTH OF STAY10

5.1 DAYS

$

1/5THOF ALL MEDICARE ADMISSIONS IN THE U.S. HAVE A DIAGNOSIS OF HEART FAILURE13

HFrEF (Systolic HF) EF( Ejection Fraction) <40%

HFmrEF EF40-49%

HFpEF: ( Diastolic HF) Normal EF over 50%


Class I: No symptoms with ordinary activity

Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina

CardioVascular Group7/12/2018

Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain

Class IV:Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest

CardioVascular Group7/12/2018

Symptom improvement

Functional capacity improvement

Enhancing quality of life

Reducing frequency of hospitalizations

Decreasing associated mortality


Management of contributing factors and associated conditions

Lifestyle modification Pharmacologic therapy Device therapy if indicated Cardiac rehabilitation Preventive care.



HFrEF Stage C

NYHA Class I – IV

Treatment:

For NYHA class II-IV patients.

Provided estimated creatinine

>30 mL/min and K+ <5.0 mEq/dL

For persistently symptomatic

African Americans,

NYHA class III-IV

Class I, LOE A

ACEI or ARB AND

Beta Blocker

Class I, LOE C

Loop Diuretics

Class I, LOE A

Hydral-Nitrates

Class I, LOE A

Aldosterone

Antagonist

AddAdd Add

For all volume overload,

NYHA class II-IV patients

A/1. Losartan B/2. Carvedilol C/3. Lasix D/4. Aldactone


Diuretics Beta blockers ACE inhibitors or ARBs, ARNI Hydralazine plus nitrate Digoxin Aldosterone antagonists. Ivabradine ( Corlanor)


/contents/hydralazine-drug-information?source=see_link


/contents/digoxin-drug-information?source=see_link



Beta blockers( Bisoprolol, Carvedilol, long acting Metoprolol Succinate)

ACE inhibitors, ARB, ARNI

Hydralazine plus nitrates( African americansand Who can’t tolerate ACEI or ARB)

Aldosterone antagonists (MRA)




Sacubitril/Valsartan(entresto) reduces the cardiovascular death by incremental

A) 10% B) 20% C) 30% D) 40%


10%

Angiotensin Neprilysin Inhibition With LCZ696 Doubles Effect on Cardiovascular Death of Current

Inhibitors of the Renin-Angiotensin System

20%

30%

40%

ACEinhibitor

Angiotensinreceptorblocker

0%

% D

ec

rea

se

in

Mo

rta

lity

18%

20%

Effect of ARB vs placebo derived from CHARM-Alternative trial

Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial

Effect of LCZ696 vs ACE inhibitor derived from PARADIGM-HF trial

Angiotensinneprilysininhibition

15%


†Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. ‡See 2013 HF guideline. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor-blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I, contraindication; COR, Class of Recommendation; CrCl, creatinine clearance; CRT-D, cardiac resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; ISDN/H, isosorbide dinitrate hydral-nitrates;


Pharmacological Treatment for Stage C HF With Reduced EF

I

ACE-I: A

The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors (Level of Evidence: A), OR ARBs (Level of Evidence: A), OR ARNI (Level of Evidence: B-R) in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality.

NEW: New clinical trial data prompted clarification and important updates.

ARB: A

ARNI: B-R

COR LOE RecommendationsComment/Rationale




IACE-I:

A

The use of ACE inhibitors is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality.

2013 recommendation repeated for clarity in this section.

I ARB: A

The use of ARBs to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic HFrEF who are intolerant to ACE inhibitors because of cough or angioedema.

2013 recommendation repeated for clarity in this section.




III: Harm

B-R

ARNI should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor.

NEW: Available evidence demonstrates a potential signal of harm for a concomitant use of ACE inhibitors and ARNI.

III: Harm

C-EOARNI should not be administered to patients with a history of angioedema.

NEW: New clinical trial data.




IARNI:

B-R

In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality.

NEW: New clinical trial data necessitated this recommendation.




IIa B-R

Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving GDEM*, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm or greater at rest.

NEW: New clinical trial data.

*In other parts of the document, the term “GDMT” has been used to denote guideline-directed management and

therapy. In this recommendation, however, the term “GDEM” has been used to denote this same concept in order

to reflect the original wording of the recommendation that initially appeared in the “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the

Management of Heart Failure”.


Ivabradine (Corlanor) effects the heart rate working at

A)SA node level B) AV node level C) Left bundle D) All of the above


IIb B-R

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 <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations.

NEW: Current recommendation reflects new RCT data.

Pharmacological Treatment for Stage C HF With Preserved EF


IIb B

The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF.

2013 recommendation remains current.


Patients with HF should receive specific education to facilitate HF self-care.

Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status.

Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.


I IIa IIb III

I IIa IIb III

I IIa IIb III

Continuous positive airway pressure (CPAP) can be beneficial to increase LVEF and improve functional status in patients with HF and sleep apnea.

Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality.


I IIa IIb III

I IIa IIb III

Class I recommendation :Targeting an optimal blood pressure (BP) of <130/80 mm Hg in those with hypertension and at increased risk (stage A HF).

Titration of GDMT to attain systolic BP (SBP) <130 mm Hg in patients with HFrEF and hypertension.

Titration of GDMT to attain SBP <130 mm Hg in patients with HFpEF and persistent hypertension after management of volume overload.


Cumulative risk reduction if all the evidence based therapies are used

A) 20% B) 40% C) 60% D) 80%



Cumulative risk reduction if all evidence-based therapies

are used: 80%Absolute risk reduction: 28.1%

Relative-risk 2 yr Mortality

None 35%ACEI or ARB 23% 27%Beta Blocker 35% 18%Aldosterone Ant 30% 13%CRT-D (EF<35, QRS>120) 36% 8.3%ARNI 16% 6.9%

Betablocker

Mineralocorticoidreceptor

antagonist

Drugs That Reduce Mortality in Heart Failure With Reduced Ejection Fraction

ACEinhibitor

Angiotensinreceptorblocker

Drugs that inhibit the renin-angiotensin system have modest effects on

survival

Based on results of SOLVD-Treatment, CHARM-Alternative,

COPERNICUS, MERIT-HF, CIBIS II, RALES and EMPHASIS-HF

10%

20%

30%

40%

0%

% D

ecre

ase in

Mo

rtality



GDMTRR Reduction

in Mortality

NNT for Mortality

Reduction

(Standardized to 36 mo)

RR Reduction

in HF

Hospitalizations

ACE inhibitor or

ARB17% 26 31%

Beta blocker 34% 9 41%

Aldosterone

antagonist30% 6 35%

Hydralazine/nitrate 43% 7 33%

GDMT: Guideline determined medical therapyNNT: Number needed treat

Class IIa recommendation:

For a formal sleep assessment in patients with NYHA class II– IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness.

Class IIb recommendation

For utilization of continuous positive airway pressure in patients with cardiovascular disease and obstructive sleep apnea, to improve sleep quality and daytime sleepiness.

Class III recommendation: Harm

for use of adaptive servo-ventilation in patients with NYHA class II–IV HFrEF and central sleep apnea, as it causes harm.


Class IIb recommendation: For intravenous iron replacement in patients with New York Heart Association (NYHA) class II and III HF and iron deficiency (ferritin <100 ng/ml or 100-300 ng/ml if transferrin saturation <20%), to improve functional status and QoL.

Class III recommendation :Erythropoietin stimulating agents should not be

used in patients with HF and anemia to improve morbidity and mortality, as there is no benefit.


Substance Potential effects

Thiazolidinediones (glitazones) Worsening of HF

CCB (excluding amlodipine and felodipine) Negative inotropic effect

Worsening of HF

Increase in hospitalizations

NSAID, COX-2 inhibitors Sodium and water retention

Worsening of kidney function

Worsening of HF

Increase in hospitalizations

Adding an ARB to an ACEI and a MRA Possible worsening of kidney function

Increased risk of hyperkalemia

Dronedarone (for control of frequency and rhythm in AF)

Increased risk of cardiovascular events

Increased mortality

Class I antiarrhythmic agents Increased mortality

Combination of ivabradin, ranolazine, and nicorandil

Unclear safety


Overview of contraindicated drugs in HF patients


EMPA-REG OUTCOME TRIAL

Mechanical circulatory support

Cardiac transplantation

Palliative care.


Mechanical Circulatory

Support

Treatment of Stages A to D


Until definitive therapy (e.g., coronary revascularization, MCS, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance.

Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage D refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation.


I IIa IIb III

I IIa IIb III

Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance.

Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.


I IIa IIb III

I IIa IIb III

Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with HF.

Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.


I IIa IIb III

I IIa IIb III

Harm

Harm


Left Ventricular Assist Device(LVAD)

CardioVascular Group

Heartware LVAD

7/12/2018


Heartmate II LVAD

CardioVascular Group

Heartware LVAD

7/12/2018

Cardiac Transplantation

Treatment of Stages A to D



Heart Transplantation

Providing evidence-based medical care to inpatients with heart failure

Engaging heart failure patients and their families as active partners in care

Creating reliable processes that ensure a proper handoff to the caregivers who will provide follow-up care.


Discharge Instructions regarding meds/F/U ACEI/ARB/Entresto use Beta blocker use at discharge Heart failure appropriate care measure Medication counseling Smoking cessation,


Heart failure is a chronic, progressive disease that is generally not curable, but treatable

Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors/ARB, Entresto, Beta blockers, Aldactone, Digoxin and Diuretics

It is estimated 15% of all heart failure patients may be candidates for cardiac resynchronization therapy

Use Aldactone if renal fx and K+ levels are good in both HFrEF and HFpEF.


Avoid use of Metoprolol tartarate in pts with low EF( Use Metoprolol succinate or Coreg)

Use BNP for risk stratification and prognosis assessment in all stages of HF

Treat co morbidities in HF like Sleep apnea, Anemia, HTN and Ischemia.

Consider LVAD/Transplant for stage IV advanced HF for younger patients at early stages

Consider Palliative care for advanced HF pts with more than 3 hospitalizations in 1 year who are not candidates for LVAD/TXP


Thank you


sreeni r. gangasani md, facc · heart failure is a growing and expensive public health issue 5.1m...

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