Conflict of Interest Statement. Pharmacy Technician Objectives. Pharmacist Objectives

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1 Updates to Heart Failure Guidelines: Are you ready to SHIFT into a new PARADIGM? Conflict of Interest Statement I have no actual or potential conflict of interest in relation to this activity Denise M Kolanczyk, PharmD, BCPS AQ Cardiology Assistant Professor, Pharmacy Practice Midwestern University Chicago College of Pharmacy Clinical Pharmacist, Internal Medicine Loyola University Medical Center Pharmacist Objectives Describe the role of sacubitril/valsartan and ivabradine with other heart failure (HF) guideline directed medical therapies (GDMT) Discuss the role of the pharmacist when optimizing HF therapies Pharmacy Technician Objectives Identify new guideline directed medications for HF Discuss the role of the pharmacy technician when involved with HF patients 2017 Focused HF Guidelines Overview Biomarkers New therapies for Stage C heart failure with reduced ejection fraction (HFrEF) Updates on heart failure with preserved ejection fraction (HFpEF) management New data for co morbidities HF prevention Medical Management of HFrEF: 2013 Guidelines Stage A No structural heart disease No s/sx of HF Control risk factors Smoking cessation Exercise Avoid EtOH Stage B Structural heart disease No s/sx of HF ACE I* (or ARB*) and BB* titrated to target/ maximum doses * denotes evidence to support reductions in mortality ACEI= ACE inhibitor; ARB= angiotensin receptor blocker BB= beta blocker; EtOH= alcohol; ISDN= isosorbide dinitrate Stage C Structural heart disease (+) s/sx of HF Diuretics, ACE I* (or ARB*), BB* titrated to target/ maximum doses Stage D Refractory symptoms requiring intervention Heart transplant Mechanical circulatory support Consider hydralazine/ ISDN*, aldosterone antagonists*, digoxin Yancy et al J Am Coll Cardiol 2013;62(16) 1

2 Sacubitril/valsartan Sacubitril/valsartan Brand Name Entresto FDA Approval July 2015 Indicated to reduce the risk of cardiovascular (CV) death and hospitalization for HF in patients with chronic HFrEF (NYHA Class I IV) Mechanism of Action Angiotensin receptor neprilysin inhibitor Dose and Titration Recommendations Preparations Recommended starting dose: 49/51 mg mg twice daily May consider 24/26 mg twice daily in select patients Titration recommendations: Double the dose after 2 4 weeks Target dose: 97/103 mg twice daily, as tolerated by the patient Film coated tablet: 24/26mg, 49/51mg, 93/103mg Contraindications Adverse effects Monitoring parameters STOP Angioedema related to previous ACE I or ARB use Concomitant use with ACE I and ARB Concomitant use with aliskiren Pregnancy Hyperkalemia Increased serum creatinine (SCr) Hypotension Dizziness Cough Potassium, BUN/SCr, blood pressure ARNI should not be administered concomitantly with ACE inhibitors or another ARB A 36 hour washout period needs to occur when stopping an ACE I and starting sacubitril/valsartan Entresto [package insert] 2015 Entresto [package insert] 2015 PARADIGM HF Trial Inclusion Criteria Baseline Characteristics randomized, doubleblind, parallel group, active controlled Single blind run in period x 6 weeks Double blind period, randomized 1:1 to LCZ mg BID or enalapril 10 mg BID Median follow up: 27 months Age 18+ NYHA II IV symptoms, LVEF of 40% or less (was changed to 35% or less in December 2010 by amendment to protocol) Also required to have elevated BNP level of at least 150 pg/ml Mean age 64 years ~22% women Caucasian: 66% Black: 5% LVEF: ~30% NYHA II: ~72% NYHA III: ~24% Ischemic cardiomyopathy 60% Hypertension 70% Endpoints Primary Composite: Death from CV causes or first hospitalization for HF Secondary Endpoints: Time to death from any cause Change from baseline to 8 months in clinical summary score on KCCQ Time to onset of new atrial fibrillation (AF) Time to first occurrence of decline in renal function BNP= Brain natriuretic peptide; KCCQ= Kansas City Cardiomyopathy Questionnaire; LVEF= left ventricular ejection fraction; NYHA= New York Heart Association McMurray et al N Engl J Med 2014; 371(11) PARADIGM HF Results Mean LCZ696 dose: 375±71 mg LCZ696 (n=4187) Mean enalapril dose: 189±34 mg Enalapril (n=4212) HR or Difference pvalue PRIMARY COMPOSITE OUTCOME, n (%) Death from CV causes or first hospitalization for 914 (218) 1117 (265) 080 ( ) < 0001 Death from CV causes 558 (133) 693 (165) 080 ( ) < 0001 First hospitalization for 537 (128) 658 (156) 079 ( ) < 0001 SECONDARY OUTCOMES, n (%) Death from any cause 711 (17) 835 (198) 084 ( ) < 0001 Change in KCCQ 436± ±036 summary score at 8 mo 164 ( ) 0001 New onset AF 84 (31) 83 (31) 097 ( ) 083 Decline in renal function 94 (22) 108 (26) 086 ( ) 028 McMurray et al N Engl J Med 2014; 371(11) PARAGON HF Trial Inclusion Criteria Endpoints randomized, double blind, parallel group, active controlled Active run in period (3 8 weeks) Double blind period (up to 57 months), randomized 1:1 to LCZ696 or valsartan CURRENTLY ONGOING Enrollment: 4822 pts Estimated Completion Date: March 2019 Age 50+ LVEF 45% or greater Symptoms of HF and requiring diuretics for at least 30 days Current symptoms of HF Structural heart disease documented by echocardiogram Elevated NT probnp Primary Endpoint: Cumulative number of primary composite events of CV death and total (first and recurrent) HF hospitalizations Secondary Endpoints: Change in the clinical summary score from baseline to Month 8 by KCCQ Change from baseline to month 8 in NYHA functional class Time to first occurrence of a composite renal endpoint Time to all cause mortality Recommendations for RAS Inhibition RECOMMENDATION COR LOE Clinical strategy of inhibition of RAS with ACE Is or ARBs or ARNI in conjunction with evidenced based beta blockers and aldosterone antagonists in selected patients is recommended for patients with chronic HFrEF to reduce morbidity and mortality The use of ACE Is is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality 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 Is because of cough or angioedema In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate and ACE I or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality I I I I ACE I: A ARB: A ARNI: B R ACE I: A ARB: A ARNI: B R 2

3 Ivabradine Brand Name Corlanor FDA Approval April 2015 Mechanism of Action Hyperpolarization activated cyclic nucleotide gated channel blocker Dose and Titration Recommendations Preparations Recommended starting dose: 5 mg twice daily Consider 25 mg twice daily in patients with conduction defections or bradycardia Titration recommendations: After 2 weeks, adjust dose based on heart rate HEART RATE DOSE ADJUSTMENT > 60 bpm Increase dose by 25 mg twice daily (maximum dose 75 mg twice daily) bpm Maintain current dose < 50 bpm Decrease dose by 25 mg twice daily If current dose is 25 mg twice daily, STOP THERAPY Tablets: 5 mg, 75 mg Corlanor [package insert] 2015 Contraindications Adverse effects Monitoring parameters Ivabradine Acute decompensated heart failure Blood pressure < 90/50 mmhg Sick sinus syndrome, sinoatrial block, or 3 rd degree AV block Resting heart rate < 60 bpm prior to treatment Severe hepatic impairment Pacemaker dependence Concomitant use with strong CYP3A4 inhibitors Bradycardia Hypertension Atrial fibrillation Luminous phenomena (phospenes see flashes of light) Heart rate Blood pressure ECG (increase risk of QTc prolongation and ventricular arrhythmias in patients who develop low HRs and bradycardia) Corlanor [package insert] 2015 SHIFT Trial Inclusion Criteria Baseline Characteristics Endpoints randomized, double blind, placebo controlled, parallel group Run in period of 14 days without treatment Randomized to ivabradine or placebo Median follow up: 23 months Age 18+ Stable chronic HF x 4 weeks or longer Previous hospital admission for in past 12 months LVEF of 35% or less Mean age 604 years Primary Composite: CV death or hospital ~24% women admission for worsening HF Caucasian: 89% Secondary Endpoints: LVEF: 29% All cause mortality Any CV death Mean HR 799 bpm Death from HF Hospital admission for NYHA II: 49% NYHA III: 50% All cause admission to hospital Ischemic cardiomyopathy 68% Any CV admission Composite of CV death, Background therapies: hospital admission for RAAS blockade: 91% and Beta blocker: 89% hospital admission for Antialdosterone: ~60% non fatal myocardial Digoxin: 22% infarction (MI) Diuretics: ~84% Swedberg K et al Lancet 2010;376 SHIFT Results Ivabradine (n=3241) Placebo (n=3264) HR or Difference p Value PRIMARY COMPOSITE OUTCOME, n (%) CV death or hospital admission for 793 (24) 937 (29) 082 ( ) <00001 SECONDARY OUTCOMES, n (%) All cause mortality 503 (16) 552 (17) 090 ( ) 0092 Any CV death 449 (14) 491 (15) 091 ( ) 0128 Death from HF 113 (3) 151 (5) 074 ( ) 0014 All cause admission to hospital 1231 (38) 1356 (42) 089 ( ) 0003 Any CV hospital admission 977 (30) 1122 (34) 085 ( ) Hospital admission for 514 (16) 672 (21) 074 ( ) <00001 Composite of CV death, hospital admission for and hospital admission for non fatal MI Mean ivabradine dose at 28 days: 64 ± 16 mg BID Mean ivabradine dose at 1 year: 65 ± 16 mg BID 825 (25) 979 (30) 082 ( ) <00001 Swedberg K et al Lancet 2010;376 Recommendations for Ivabradine Summary of GDMT in Stage C HFrEF RECOMMENDATION COR LOE 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 (or GDMT), 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 IIa B R FDA Approved Indication: To reduce the risk of hospitalization for in patients with stable, symptomatic chronic HF with LVEF 35%, who are in normal sinus rhythm with resting HR 70 bpm and either on maximally tolerated doses of betablockers or have a contraindication to beta blocker use HFrEF Stage C NYHA I IV ACEI or ARB AND GDMT beta blocker NYHA II IV egfr 30 ml/min/172m 2 K+ < 50 meq/dl NYHA II III Stable on ACEI or ARB NYHA III IV Persistently symptomatic AA NYHA II III Maximally tolerated BB dose Normal sinus rhythm Resting HR 70 ADD Aldosterone Antagonist SWITCH to ARNI ADD Hydralazine/ISDN ADD Ivabradine AA= African American; ACEI= ACE inhibitor; ARB= angiotensin receptor blocker; ARNI= angiotensin receptor neprilysin inhibitor; BB= beta blocker; egfr= estimated glomerular filtration rate; HR= heart rate; ISDN= isosorbide dinitrate; K= potassium; NYHA= New York Heart Association 3

4 Think, Pair, Share Question #1 Which of the following medications used in HFrEF has morbidity and mortality reducing benefits? A Aliskiren B Digoxin C Ivabradine D Sacubitril/valsartan Medical Management of HFpEF: 2013 Recommendations Supported in 2017 Focused Update TREAT PRECIPITATING CONDITIONS 1 Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines 2 Coronary revascularization in patients with coronary artery disease who demonstrate angina or myocardial ischemia despite GDMT 3 Manage AF according to published clinical practice guidelines to improvement symptomatic HF MAINTAIN EUVOLEMIA 1 Diuretics should be used for relief of symptoms due to volume overload AVOID THERAPIES THAT ARE NOT SUPPORTED BY EVIDENCE 1 Avoid treating patients based on recommendations for HFrEF 2 Routine use of nitrates or phosphodiesterase 5 inhibitors to increase activity or quality of life in patients with HFpEF is ineffective Yancy et al J Am Coll Cardiol 2013;62 Spironolactone in HFpEF Lack of evidence from clinical outcome trials involving patients with HFpEF Much of management pertains to coexisting conditions Small studies showed promise with improvement in diastolic function measures with mineralocorticoid receptor antagonists TOPCAT was designed to test whether spironolactone improved clinical outcomes in patients with HFpEF Pitt B et al N Engl J Med 2014;370 TOPCAT Trial Inclusion Criteria Baseline Characteristics Endpoints international, randomized, doubleblind, placebo controlled Run in period of 14 days without treatment Randomized 1:1 to spironolactone or placebo Initial dose: 15mg daily; titrated to 45mg daily during first 4 months Mean follow up: 33 years Age 50+ At least one sign and one symptom of HF LVEF of 45% or more Controlled SBP Serum K + < 5 mmol/l In addition, eligible patients had the following within 60 days of randomization: Previous hospitalization within past 12 months (715%) Elevated BNP or NTproBNP (285%) Mean age 687 years ~515% women Caucasian: ~89% LVEF: 56% NYHA II: ~635% NYHA III: ~335% Blood pressure SBP: 130 mmhg DBP: 80 mmhg Serum K + 43 mmol/l Primary Endpoint: Composite of death from CV causes, aborted cardiac arrest, or hospitalization for HF Secondary Endpoints: Death from any cause Hospitalization for any reason Myocardial infarction Stroke Safety Endpoints Hyperkalemia Hypokalemia Elevated SCr level SBP= systolic blood pressure Pitt B et al N Engl J Med 2014;370 TOPCAT Results Mean spironolactone dose at 8 months: 25mg per day Spironolactone (n=1722) Placebo (n=1723) HR or Difference p Value PRIMARY OUTCOME, n (%) Composite of death from CV causes, aborted cardiac arrest, or hospitalization for HF 320 (186) 351 (204) 089 ( ) 014 COMPONENTS OF THE PRIMARY OUTCOME, n (%) Death from CV causes 160 (93) 176 (102) 090 ( ) 035 Aborted cardiac arrest 3 (02) 5 (03) 060 ( ) 048 Hospitalization for HF 206 (120) 245 (142) 083 ( ) 004 SECONDARY ENDPOINTS, n (%) Death from any cause 252 (146) 274 (159) 091 ( ) 029 Hospitalization for any cause 766 (445) 792 (460) 094 ( ) 025 Myocardial infarction 65 (38) 64 (37) 100 ( ) 098 Stroke 57 (33) 60 (35) 094 ( ) 073 Pitt B et al N Engl J Med 2014;370 TOPCAT: post hoc analysis Indicated marked regional differences in event rates There was ~4 fold difference identified in the composite event rate between patients randomized from Russia and Georgia compared to patients enrolled from the Americas Demographic characteristics and response to spironolactone was further explored Pitt B et al N Engl J Med 2014;370 Pfeffer MA et al Circulation 2015;131 4

5 SPIRONO OUTCOME LACTONE (n=886) Primary outcome 242 (273) [104] Death from CV causes 96 (108) [36] Hospitaliza tion for HF 184 (208) [79] Recurrent HF Summary of Trial Outcomes by Treatment Arms and Region AMERICAS (n=1767) No (%) with Event [Incident Rate per 100 patient y) 361 events [137] PLACEBO (n=881) 280 (318) [126] 127 (144) [49] 216 (245) [97] 438 events [170] HR P Value 082 ( ) ( ) ( ) 0042 IRR=075 ( ) 0024 SPIRONO LACTONE (n=836) 78 (93) [25] 64 (77) [20] 22 (26) [072] 33 events [11] RUSSIA/GEORGIA (n=1678) No (%) with Event [Incident Rate per 100 patient y) PLACEBO (n=842) 71 (84) [23] 49 (58) [16] 29 (34) [095] 37 events [12] HR P Value 110 ( ) ( ) ( ) 0327 IRR=083 ( ) 058 Pfeffer MA et al Circulation 2015;131 Summary of Trial Outcomes by Treatment Arms and Region SPIRONO OUTCOME LACTONE (n=886) All cause mortality 178 (201) [65] All cause hospitalization 526 (594) [329] Myocardial infarction 48 (54) [19] Stroke AMERICAS (n=1767) No (%) with Event [Incident Rate per 100 patient y) 38 (43) [15] PLACEBO (n=881) 207 (235) [77] 535 (607) [358] 46 (52) [18] 39 (44) [16] HR P Value 083 ( ) ( ) ( ) ( ) 078 RUSSIA/GEORGIA (n=1678) No (%) with Event [Incident Rate per 100 patient y) SPIRONO LACTONE (n=836) 74 (89) [23] 240 (287) [97] 17 (20) [05] 19 (23) [06] PLACEBO (n=842) 67 (80) [20] 257 (305) [104] 18 (21) [06] 21 (25) [07] HR P Value 112 ( ) ( ) ( ) ( ) 076 Pfeffer MA et al Circulation 2015;131 Recommendations for Spironolactone RECOMMENDATION COR LOE In appropriately selected patients with EF 45%, aldosterone receptor antagonists might be considered to decrease hospitalizations IIb B R elevated BNP levels or HF admission within 1 year estimated GFR > 30 ml/min creatinine <25 mg/dl potassium <50 meq/l Co Morbidities in Heart Failure Hypertension Anemia Sleep Disorders Hypertension Goals in HF 2017 ACC/AHA/HFSA Focused Update Stage A: < 130/80 mmhg Stage C (HFrEF and HFpEF): SBP <130 mmhg 2017 Hypertension Guideline HFrEF: < 130/80 mmhg HFpEF: SBP < 130 mmhg Preferred Agents to Manage Hypertension in Heart Failure Patients Heart Failure with Reduced Ejection Fraction ACEIs or ARBs ARNIs Beta blockers Mineralocorticoid receptor antagonists Diuretics Heart Failure with Preserved Ejection Fraction Diuretics ACEIs or ARBs Beta blockers Whelton PK et al Hypertension 2017 Nov 13 Whelton PK et al Hypertension 2017 Nov 13 5

6 Iron Repletion in HF: A Brief Review Trial Population and Intervention Endpoints and Results FAIR HF Anker SD, et al randomized, double blind, placebocontrolled NYHA Class II and LVEF 40% OR NYHA Class III and LVEF 45% NYHA Class II (~18%) NYHA Class III (~82%) LVEF ~32% Ferritin <100 mcg/ml OR Ferritin between mcg/ml with transferrin saturation <20% Randomized 2:1 x 24 weeks: Ferric carboxymaltose IV 200 mg (n=304) Placebo (n=155) Primary Endpts at Wk 24 Self reported Patient Global Assessment 50% IV iron pts reported much or moderate improvement compared to 28% placebo (p<00001) NYHA Functional Class Improvement 47% IV iron pts having NYHA class I or II, compared to 30% in placebo (p<00001) Secondary Endpts: Wks 4 and 12 Self reported Patient Global Assessment Wks 4 and 12: p<00001 NYHA Class Wks 4 and 12: p<00001 KCCQ Scores: Improvement at weeks 4, 12, and 24 (p<00001) Anker SD et al N Engl J Med 2009;361 Iron Repletion in HF: A Brief Review Trial Population and Intervention Endpoints and Results CONFIRM HF Ponikowski P, et al randomized, double blind, placebo controlled NYHA Class II or III NYHA Class II (~56%) NYHA Class III (~44%) LVEF 45% (~37%) BNP >100 pg/ml (~771 pg/ml) OR NT probnp >400 pg/ml (~2500 pg/ml) Ferritin <100 mcg/ml OR Ferritin between mcg/ml with transferrin saturation <20% Randomized 2:1 x 36 weeks: Ferric carboxymaltose IV mg (mean/median dose 1500 mg, range ) (n=150) Placebo (n=151) Primary Outcomes 6 minute walking test (baseline to week 24) Baseline values were similar Significant improvements were noted at week 24 in the IV iron group (p=00002) Secondary Outcomes Changes in NYHA functional class Significant improvements at wks 24, 36, and 52 (p values: SS) Patient Global Assessment Significant improvements seen at wks 12, 24, and 36 (p values: SS) Quality of life Outcome related end points (see next slide) Ponikowski P et al Eur Heart J 2015;36 CONFIRM HF: Hospitalizations and Deaths Endpoint or Event IV iron (n=150) No Events Incidence/100 ptsyrs Deaths (89) CV Death (81) Death due to 4 4 (30) Hospitalization (263) CV related hospitalization Hospitalization due to (76) (166) Placebo (n=151) No Events Incidence/100 pt yrs (194) (99) (85) 3 3 (21) (370) (263) Time to First Event HR 95%CI P value 089 ( ) ( ) ( ) ( ) ( ) ( ) 0009 Ponikowski P et al Eur Heart J 2015;36 Recommendations for Anemia RECOMMENDATION COR LOE In patients with NYHA Class II and III HF and iron deficiency (ferritin < 100 ng/ml or 100 to 300 ng/ml if transferrin satursation < 20%), intravenous iron replacement might be reasonable to improve functional status and quality of life IIb B R In patients with HF and anemia, erythropoietin stimulating agents should not be used to improve morbidity and mortality III B R Role of the Pharmacist Ensure successful implementation of GDMT Orchestrate dose titrate for optimization of GDMT Incorporate medications for co morbid conditions Resolve barriers to medication access Patient education Liaison between patients and health care providers Role of the Pharmacy Technician Resolving barriers to medication access Communicating with prescribers and pharmacists Completing medication histories Adams KF et al Pharmacotherapy 2017;37(6) 6

7 Think, Pair, Share Question #2 Which of the following does a pharmacist and pharmacy technician share when caring for a heart failure patient? A Communicate with providers B Complete a medication history C Incorporate medications for co morbidities D A and B E A, B and C Summary Pharmacists and pharmacy technicians have crucial roles in patients with heart failure Important to recognize new medications for HF and understand roles in therapy Assess coexisting co morbidities for optimization that may impact quality of life and improvement in functional status References References Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America J Am Coll Cardiol 2017;70: Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2013;62: Entresto [package insert] East Hanover, NJ: Novartis; 2015 McMurray JJV, Packer M, Desai AS, et al Angiotensin neprilysin inhibition versus enalapril in heart failure N Engl J Med 2014;371(11): Corlanor [package insert] Thousand Oaks, CA: Amgen; 2015 Swedberg K, Komajda M, Bohm M, et al Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo controlled Lancet 2010;376: Pitt B, Pfeffer MA, Assmann SF, et al Spironolactone for heart failure with preserved ejection fraction N Engl J Med 2014;370(15): Pfeffer MA, Claggett B, Assmann SF, et al Regional variation in patients and outcomes in the treatment of preserved cardiac function heart failure with an aldosterone antagonist (TOPCAT) trial Circulation 2015;131:34 42 Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Hypertension 2017 Nov 13 Anker SD, Colet JC, Filippatos G, et al Ferric carboxymaltose in patients with heart failure and iron deficiency N Engl J Med 2009;361: Ponikowski P, van Veldhuisen DJ, Comin Colet J, et al Beneficial effects of long term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency Eur Heart J 2015;36: Adams KF, Giblin EM, Pearce N, et al Pharmacotherapy 2017;37(6):

8 ICHP Champion Webinar, March 2018 Updates to Heart Failure Guidelines: Are You Ready to SHIFT into a New PARADIGM? Post Test Questions PHARMACIST QUESTIONS 1 SJ is a 56 year old Caucasian female with heart failure (ejection fraction 30%), hypertension, and coronary artery disease (s/p PCI in 2013) She was discharged from the hospital one week ago after being treated for a heart failure exacerbation Her doctor mentioned a new medication that may help her heart failure She is currently taking enalapril 10 mg PO BID, metoprolol succinate 100 mg PO daily, furosemide 40 mg PO BID, aspirin 81 mg PO daily, and atorvastatin 20 mg PO daily All labs and vital signs are at goal/within normal limits She is not reporting any side effects from medications Which of the following would you consider to optimize SJ s HF management? A Switch metoprolol succinate to ivabradine B Switch enalapril to sacubitril valsartan C Change to a high intensity statin D A and C E B and C 1 Which of the following treatment strategies would you consider in a HFpEF patient? A Recommend sacubitril valsartan as an alternative to an ACEI or ARB B Recommend spironolactone to decrease risk of hospitalizations C Treat hypertension with a systolic blood pressure goal of <120 mmhg D Treat iron deficiency anemia with IV iron to improve NYHA functional status PHARMACY TECHNICIAN QUESTIONS 1 You are preparing discharge medications for a HF Meds2Beds program The following medications are to be delivered to the patient s bedside: enalapril, carvedilol, sacubitril valsartan, and torsemide Which of the following steps would you take? A Alert the pharmacist about the inclusion of both enalapril and sacubitril valsartan B Educate the patient to stop enalapril 36 hours before starting sacubitril valsartan C Resolve any barriers to medication access D A and B E A and C 2 Based on current guidelines, which of the following is a medication that can be used in both types of heart failure (HFrEF and HFpEF)? A Aliskiren B Hydralazine/isosorbide dinitrate C Ivabradine D Spironolactone Key: Pharmacist 1 E, 2 B; Technician 1 E, 2 B