Does My Patient Always Require Diuretics???

Transcription

1 Does My Patient Always Require Diuretics??? Shelley Zieroth, MD Associate Professor, Section of Cardiology Director, SBH Heart Failure and Transplant Clinics Head, Medical Heart Failure Program WRHA Cardiac Sciences Program Vice President, Canadian Heart

2 Disclosures Consulting/Advisory Board: Amgen, Astra Zeneca, Boehringer Ingelheim, Medtronic, Novartis, Servier Speaker: Boehringer Ingelheim, Medtronic, Novartis, Servier, St. Jude Medical (Abbot) Clinical Trials: Amgen, Bayer, Boehringer Ingelheim, Medtronic, Merck, Novartis, Servier, Tenax Research Grants: Novartis Educational Grants: Servier

3 I have received no commercial support for this talk Mitigating bias: Based on CCS HF and Diabetes Canada guidelines content I am talking about stopping drugs for this talk

4 Co-presented by CHFS & Ted Rogers Centre for Heart Research May Metro Toronto Convention Centre Largest HF meeting in Canada To register visit: Who should attend: Healthcare and research professionals involved in heart failure care: Primary Care Cardiologists and Internal Medicine specialists (community & academic) Nurses, nurse practitioners and allied health Residents & fellows Investigators, research staff & trainees

5 Mr. Drinks After Work Guy ID: 55 yr male with a diagnosis of alcohol related cardiomyoypathy EF 20% on diagnosis June 2017, Angiogram normal NYHA 3 symptoms have improved to NYHA 1 Meds: Enalapril 5 mg BID Metoprolol 25 mg po BID Lasix 80 mg po OD Spironolactone 25 mg po OD BP 100/70, no edema, JVP normal, no murmurs, lungs good Abstained since diagnosis On Triple therapy 6 months you order a MUGA

6 YES PRIMARY CARE PHYSICIANS CAN ORDER MUGA S

7 His LVEF has normalized!!!! He desparately wants off his diuretics and all his meds Do you dare?? Mr. Drinks After Work Guy

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9 Inpatient Diuretics

10 Outpatient Diuretics

11 Therapeutic Approach to Patients With HFrEF STEP 3: Consider Newer Therapies

12 Other Considerations ARNI s: sacubitril/valsartan has some diuretic effect..if on low dose diuretics eg mg you may be able to stop or reduce the dose

13 ARNI s: The Cardiovascular And Renal Effects Of The NP System Oppose Those Of The RAAS LCZ696 Sacubitril (pro-drug) ANP BNP CNP ANP BNP CNP NEP inhibitor (active metabolite [LBQ657]) Valsartan NPR-A NPR-B NPR-C Neprilysin AT 1 receptor GTP GTP Endocytosis Receptor recycling Signalling cascades cgmp Inactivation of NPs Vasodilation Cardiac fibrosis/hypertrophy Natriuresis/diuresis Vasoconstriction Cardiac fibrosis/hypertrophy Sodium/water retention ANP=atrial natriuretic peptide; Ang=angiotensin; AT1 = angiotensin II type 1; BNP=B-type natriuretic peptide; cgmp=cyclic guanosine monophosphate; CNP=Ctype natriuretic peptide; GTP=guanosine triphosphate; NEP=neprilysin; NP=natriuretic peptide; NPR=natriuretic peptide receptor; RAAS=renin-angiotensinaldosterone system / Levin et al. N Engl J Med 1998;339;321 8; Gardner et al. Hypertension 2007;49: Molkentin. J Clin Invest 2003;111: ; Nishikimi et al. Cardiovasc Res 2006;69: Guo et al. Cell Res 2001;11:165 80; Von Lueder et al. Circ Heart Fail 2013;6: Yin et al. Int J Biochem Cell 2003;35:780 3; Mehta and Griendling. Am J Physiol Cell Physiol 2007;292:C82 97; Langenickel & Dole. Drug Discovery Today: Ther Strateg 2012;9:e131 9

14 Other Considerations SGLT2i s have an diuretic effect and the same considerations of diuretic reduction should occur

15 SGLT2i s and Diuretics Carefully review patient volume status and blood pressure (BP) before initiation Volume status Assess and treat accordingly BP Assess and treat accordingly Usual systolic BP lowering is 5 mmhg?effects on potassium (K + ) SGLT2 inhibition does not reduce potassium levels Proposed management of concomitant diuretics when initiating a SGLT2i in high-risk patients with type 2 diabetes Hypervolemia Continue diuretic and monitor BP/lytes/Cr/ weight, assuming not hypotensive Caution with multiple diuretics Hypertensive Continue diuretic therapy and monitor BP/lytes/Cr/ weight 1) What is the volume status? Euvolemia 2) What is the blood pressure? Normotensive Thiazides Continue therapy and monitor BP Loop diuretics Consider reducing dose by 50% and monitor BP/weight - If stable, continue therapy - If increasing, reinstitute diuresis - If decreasing, stop diuretic Volume Contraction Stop diuretic and monitor Initiate SGLT2i when euvolemic Hypotensive Caution, hold or reduce diuretic and re-institute if required Data from: Cherney DZ, Udell JA. Circulation. 2016;134:

16 When should I measure LVEF? Clinical Scenario Timing of measurement Modality of Measurement New Onset Heart Failure Immediately or within 2 ECHO (preferred when weeks for baseline available); or MUGA or assessment CMRI Following titration of triple therapy for HFrEF, or consideration of ICD/CRT implantation 3 months after completion of titration Stable Heart Failure Approximately every 2-3 years, especially if EF is above 40% Following significant clinical event (i.e. hospitalization for HF) Within 30 days, during hospitalization if possible. ECHO or MUGA or CMR (preferably the same modality and lab as initial test) ECHO or MUGA or CMRI ECHO or MUGA or CMRI, cardiac catheterization in context of ACS Comments 70% request ECHO and 30% MUGA, report should include numeric EF or small range of EF as well as diastolic function evaluation LVEF following optimal medical therapy may obviate device therapy. Rationale is to screen for those who may cross from HFrEF to HFpEF and vice versa, which may change therapeutic goals Frequently helpful information such as EF, degree of valvular dysfunction and RVSP.

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18 Patient Support Tools 4 lb in 2 days means need more diuretic Restrictions: 2g Sodium 2 Liters all fluids Heart and Stroke Canada

19 Mr. Drinks After Work Guy You reduce his diuretic in half for one month then discontinue it completely He monitors his wts and symptoms and all good You wean him off his Bblocker and MRA You continue his enalapril to treat residual hypertension

20 Conclusions Diuretics can be withdrawn in: Patients demonstrating clinical and echocardiographic improvements With appropriate patient support tools Occasionally when starting on sacubitril/valsartan or an SGLT2i