HEART FAILURE-UPDATES AND PRACTICAL APPROACHES TO PATIENT CARE

Transcription

1 HEART FAILURE-UPDATES AND PRACTICAL APPROACHES TO PATIENT CARE DR DEAN T. GOROSKI, BCPS, CAPT, USPHS 2018 MPA WINTER CE AND SKI MEETING BIG SKY, MT JANUARY 6, 2018

2 DISCLOSURE Dr. Goroski has no actual, perceived, probable, suggested, potential, imaginary, conceptualized, likely, hopeful, aggravated, insinuated, or otherwise conflict of interest in relation to this program/presentation.

3 OBJECTIVES At the completion of this presentation, participants will be able to : Describe and differentiate the main diagnoses of heart failure Describe the pharmacologic goals of heart failure treatment and identify opportunities to optimize treatment Identify lifestyle changes to promote positive patient outcomes in heart failure management

4 OBJECTIVES Describe and differentiate the main diagnoses of heart failure Describe the pharmacologic goals of heart failure treatment and identify opportunities to optimize treatment Identify lifestyle changes to promote positive patient outcomes in heart failure management

5 CHRONIC HEART FAILURE (CHF) HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling(diastole) or ejection(systole) of blood. The cardinal manifestations of HF are dyspnea and fatiguewhich may limit exercise tolerance, and fluid retention-which may lead to pulmonary and/or splanchnic congestion and/or peripheral edema. Clyde W. Yancy et al. Circulation. 2013;128:e240-e327

6 HF DEFINITION IN BASIC TERMS Previously defined as Congestive Heart Failure Heart is unable to pump blood a sufficient volume of blood (cardiac output) to meet metabolic demands of the body Cardiac Output (CO) = Heart Rate (HR) x Stroke Volume (SV)

7 MORE DEFINITIONS Afterload--tension developed in the LV wall as systole occurs. Mainly determined by arterial blood pressure Preload--combination of pressure and volume in the left ventricle at the end of diastole (completely filled ventricle)

8 AND MORE DEFINITIONS Ejection Fraction (EF) The percentage of left ventricular blood volume ejected during systole(contraction) Normal is generally defined as 60-70% Right-sided and Left-sided HF Anatomical definitions only

9 HFPEF (DIASTOLIC DYSFUNCTION) Associated with an EF >40% Ventricle has diastolic stiffness Reduced compliance Unable to fill adequately Most common cause of HFpEF is hypertension Therapy aimed at heart rate & blood pressure control

10 HFREF (SYSTOLIC DYSFUNCTION) Low EF <40% Unable to eject enough blood to keep up with the metabolic demands of the body Ventricle has difficulty contracting ventricles become dilated congested with retained blood Most common cause of HFrEF MI (CAD)

11 PRESENTATION SIGNS Pulmonary rales Lower leg edema Jugular venous distention Increase BNP SYMPTOMS Dyspnea (on exertion) Orthopnea Paroxysmal nocturnal dyspnea Edema Fatigue Exercise intolerance

12 ASSOCIATED COMPLICATIONS IN HF MANAGEMENT Cardiac-AF, heart block, valvular abnormalities, CAD, anticlotting therapies Organ systems-renal failure, hepatic failure, respiratory disease Endocrine-DM, hypo/hyperthyroidism, endocrine tumors Other-obesity, nutrition, tobacco, toxins, emotional, economic, social, educational, financial, geographic, physical, transplant considerations, gout, etc..

13 CLASSIFICATION SYSTEMS NYHA -- functional status based on symptom severity I -- No symptoms with activity II -- Symptoms with usual activity III -- Symptoms with minimal activity IV -- Symptoms at rest ACC/ AHA -- based on disease evolution & progression A -- High risk for development but without of structural heart disease B Structural heart disease but without signs or symptoms of HF C Structural heart disease but with symptoms now or in past D -- Refractory, end-stage HF

14 GOALS OF HF MANAGEMENT Reduce morbidity/mortality rates Increase health-related quality of life measures and functional status Decrease health care associated costs

15 OBJECTIVES Describe and differentiate the main diagnoses of heart failure Describe the pharmacologic goals of heart failure treatment and identify opportunities to optimize treatment Identify lifestyle changes to promote positive patient outcomes in heart failure management

16 PATHOPHYSIOLOGY Damage heart is unable to meet demands Compensatory Mechanisms The body s response to decreased CO Intended to be short term response, detrimental in long term Maintain circulatory homeostasis after acute reductions in blood pressure or renal perfusion Neurohormonal Model Sympathetic nervous system (SNS) Renin-Angiotensin-Aldosterone System (RAAS)

17 SNS Causes tachycardia Tries to increase CO by increasing HR Causes increase in oxygen demand Eventually decreases filling time actually decreases SV Increases contractility Tries to increase CO by increasing SV Causes increase in oxygen demand

18 Direct remodeling of cardiac tissue RENIN ANGIOTENSIN ALDOSTERONE SYSTEM Increased fibrosis of cardiac tissue Angiotensin II receptors on the heart Increased fibrosis of endothelial & cardiac tissue Increases thirst drive Increases ADH release Increased Preload Increases water reabsorption from collecting duct Direct remodeling of cardiac tissue

19 CURRENT TREATMENTS LIVE LONGER MEDICATIONS Shown to improve mortality Beta-Blockers ACE-I/ARB Aldosterone Antagonists Hydralazine & isosorbide dinitrate *Sacubitril / valsartan FEEL BETTER MEDICATIONS No benefit on mortality Can help with hospitalizations Diuretics Loop Thiazide (Metolazone) Digoxin *Ivabradine

20 BETA BLOCKERS Recommended in stage B HFrEF and beyond, even if asymptomatic Can increase EF, especially if due to ischemic causes if compelling need for HR control (reduction of symptoms) Carvedilol, metoprolol SUCCINATE, bisoprolol only not a class effect for all beta blockers

21 BETA BLOCKERS Initiate therapy at low dose and advance, generally by doubling Q2-4 weeks, to predefined target doses Monitor closely for changes in vitals and symptoms (HF worsening, fatigue, bradycardia, hypotension) PEARL metoprolol succ. for hypotensive pts and/or concomitant respiratory disease PEARL carvedilol for hypertensive and/or DM

22 ACE INHIBITORS/ARBS Recommended in all stages and diagnoses of HF, unless contraindicated (angioedema, bilateral RAS, hyperkalemia) ACEIs generally considered over ARBs, unless development of kinin related cough (approx 10-20%) already on ARB therapy Data suggest class effect for ACEI, possible class effect for ARB

23 ACE INHIBITORS/ARBS Check renal function and electrolytes in 1-2 weeks after initiation, periodically thereafter Initiate therapy at low dose and advance, generally by doubling, to predefined target doses If target doses not tolerated, intermediate dosing acceptable PEARL losartan is the only antihypertensive capable of reducing uric acid levels ( mg/dl), so

24 ALDOSTERONE ANTAGONISTS Recommend in NYHA II-IV or AHA Stage C (stage B?) EF<35% After β blockers, and ACE-I titrated to max dose Of note, class II pts need CV hospitalization or high BNP After acute MI with EF<40% Useful in pts needing additional antihypertensive agents

25 ALDOSTERONE ANTAGONISTS Spironolactone initial dose mg daily, target 25mg daily Eplerenone initial dose 25mg daily, target 50mg daily More selective, better tolerated Do not start if SCr > 2.5 in men, >2.0 in women, or GFR < 30, or if potassium is greater than 5.0 meq/l Recheck potassium and renal function 2-3 days after start, again at 7 days, and again with dose changes (including ACEI or ARB)

26 HYDRALAZINE/ISDN Recommended for pts of African descent with symptomatic HFrEF (NYHA III-IV or AHA Stage C) ADD ON therapy for patients already on optimal ACEI/ARB and B blocker Recommended in pts of any race with current or prior symptomatic HFrEF that cannot be given ACEI or ARB therapy DO NOT substitute hydralazine/isdn for ACEI or ARB

27 SACUBITRIL / VALSARTAN (ENTRESTO) Newest Class of Medications for HF treatment Angiotensin Receptor-Neprilysin Inhibitor (ARNI) combination Approved for treatment of HFrEF, currently being studied in HFpEF *2016 and 2017 Update: In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE-I or ARB, replacement with an ARNI is recommended to further reduce morbidity and mortality. (Used in place of ACEI or ARB) Target Dose is 97mg/103mg BID Initial 24mg/26mg BID in ACEI/ARB naïve 49mg/51mg BID previously on ACEI/ARB

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29 ADDITIONAL INFO Precautions/ Contraindications Angioedema Contraindicated with those with history Hypotension Drugs that increase potassium Adverse Effects Hypotension Hyperkalemia Cough Dizziness Renal failure Angioedema

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31 LOOP DIURETICS Furosemide, bumetanide and torsemide Bumetanide and torsemide better availability and BP effects Reduce symptoms and hospitalizations, but not mortality Recognized as a threshold medication (think of QD vs BID) Risks-hypotension, fluid depletion, azotemia, hypokalemia, hypomagnesemia, arrhythmia

32 LOOP DIURETICS Hypotensive effects predominant during threshold phase, less afterwards Can be used even with GFR < 15ml/min Can potentiate gout through serum concentration effects Long-term use can potentiate diuretic resistance with need to increase dose or add thiazide

33 THIAZIDE-LIKE DIURETIC Metolazone acts distal tubule in addition to mild effects in proximal tubule VERY potent diuresis in combination with loop Retains benefits even with GFR < 30ml/min CAUTION C-SO2-NH2 PEARL delayed onset, delayed persistence

34 THIAZIDE DIURETICS Hydrochlorothiazide and Chlorthalidone Effects in the distal tubule (after loop) Greater blood pressure effects and longer persistence than loop diuretics Remove more sodium from system than loops Beneficial in hypertensive patients with mild fluid retention Can potentiate gout by blocking uric acid excretion

35 DIURETIC SUMMARY Factors to consider for diuretic therapy Blood pressure Volume status-degree of challenge, fluid overload vs fluid depletion Electrolyte balance-chem panel 3-5 days after starting or changing therapy Response and compliance to therapy Gout, allergies, lifestyle, adherence, morbidity/mortality

36 DIGITALIS May be added to HFrEF patients with persistent symptoms despite optimized GDMT Digoxin + B blocker = better control of ventricular response, esp during exercise Goal serum levels of ng/ml Multiple drug interaction and toxicity concerns

37 IVABRADINE (CORLANOR) If (Funny) Channel Inhibitor in SA node Consider in those who have a high HR despite optimal treatment Reduce the risk of hospitalization in chronic HF with the following characteristics: Stable, symptomatic heart failure LVEF <35% Sinus rhythm with resting HR >70 bpm On maximum tolerated doses of BB or contraindication to BB therapy Initial dosing 5mg BID, target dose 10mg BID

38 Swedberg K etal. Lancet 2010;376: 880 NNT for all-cause hospital admission is 25 over 2 years Reduction in deaths due to HR over 2 years: NNT 50 BEAUTIFUL Trial

39 ADDITIONAL INFO Adverse Effects Bradycardia Atrial fibrillation (d/c in this instance) Phosphenes (visual brightness) Monitoring BP, HR and rhythm Dizziness/fatigue Cost approx. $375/month

40 OBJECTIVES Describe and differentiate the main diagnoses of heart failure Describe the pharmacologic goals of heart failure treatment and identify opportunities to optimize treatment Identify lifestyle changes to promote positive patient outcomes in heart failure management

41 MEDICATIONS TO AVOID Antiarrythmics (except amiodarone and dofetilide) Calcium channel blockers (except amlodipine) NSAIDS Thiazolidinediones Nutritional supplements (except Omega 3s) and hormonal supplements unless to replace true deficiency

42 LIFESTYLE MODIFICATIONS Dietary sodium considerations Self-assessment and management Obesity management Exercise End of life considerations

43 DIETARY SODIUM RECOMMENDATIONS Stage A and B HF take salt shaker off the table, avoid adding extra to cooking Stage C and D HF excessively low and high sodium intake associated with worse outcomes, restrict <3gm sodium daily Sodium intake generally > 4gm/day in general population Salt substitutes may contain potassium!!

44 DAILY SELF-ASSESSMENT AND SELF- MANAGEMENT Monitoring of blood pressure at home direct comparison of personal and clinic readings Daily weight assessment and planning morning weight and charting finding dry or goal weight pre-determined strategies for out-of-range

45 OBESITY MANAGEMENT?? Obesity considered BMI > 30 HF-lowest mortality and hospitalization rates seen in BMI Highest mortality cardiac cachexia > morbidly obese > normal > overweight > obese lowest Consider appropriate weight loss if indicated

46 EXERCISE Exercise training (or regular physical activity) is recommended as safe and effective for HF patients able to participate Regular walking is considered gold standard Cardiac rehabilitation can increase HRQOL, functional capacity, exercise duration and morbidity

47 END OF LIFE PLANNING My take medical treatments and guidelines focus on battling mortality to the end, but fail to address acceptance of mortality and finding peace in dying with dignity. Have the talk with patients and family Plan for advanced directives, DNR/DNI, final resting place, estate planning, etc. Five Wishes Document (excellent resource!!)

48 QUESTION 1 HF with Reduced Ejection Fraction (HFrEF)is now used to describe what type of HF? A. Systolic Heart Failure B. Diastolic Heart Failure C. Right-sided Heart Failure D. Broken-heart syndrome (Tatsukobu s) E. No idea

49 QUESTION 1 HF with Reduced Ejection Fraction (HFrEF)is now used to describe what type of HF? A. Systolic Heart Failure B. Diastolic Heart Failure C. Right-sided Heart Failure D. Broken-heart syndrome (Tatsukobu s) E. No idea

50 QUESTION 2 Which of the following medications has NOT been shown to decrease mortality in HFrEF? A. Carvedilol B. Spironolactone C. Furosemide D. Lisinopril

51 QUESTION 2 Which of the following medications has NOT been shown to decrease mortality in HFrEF? A. Carvedilol B. Spironolactone C. Furosemide D. Lisinopril

52 QUESTION 3 What home-monitoring technique is best to determine the efficacy of a diuretic regimen? A. Skin pinch technique B. Seeing how your pants fit C. Asking a friend if you look puffy D. Daily home weights

53 QUESTION 3 What home-monitoring technique is best to determine the efficacy of a diuretic regimen? A. Skin pinch technique B. Seeing how your pants fit C. Asking a friend if you look puffy D. Daily home weights

54 RECOGNITION OF PEERS Dr. Tracy K. Pettinger, Clinical Associate Professor, Idaho State University Thank you for allowing me to use content from your 2017 presentation at Northwest Pharmacy Conference!! Dr Timothy Murray, CAPT USPHS, BCPS-AQ Cardiology Thank you for years of mentorship and collaboration on our patients in the Indian Health Service!!

55 REFERENCES 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Available at: ACC/AHA/HFSA Focused Update on Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA 2013 Guidelines for the Management of Heart Failure. Available at full.pdf ACC/AHA Guidelines for the evaluation and management of heart failure. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Am J Cardiol May 19. Available at:

56 REFERENCES CONTINUED McMurray JJ, et al. Angiotension-neprilysin inhibitor versus enalapril in heart failure. N Engl J Med 2014; 371: Swedberg K, et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010; 376: Fox, K et al. Ivabradine for patients with stable coronary artery diesase and left-ventricular systolic dysfunction (BEAUTIFUL): a randomised, double-blind, placebo-controlled trial. Lancet 2008; 372: Klein L, O Connor CM, Gattis WA, et al. Pharmacologic therapy for patients with chronic heart failure and reduced systolic function: Review of trials and practical considerations. Am J Cardiol 2003; 91:18F- 40F.

57 QUESTIONS?? CAPT Dean T. Goroski Pharmacy Supervisor Crow/N. Cheyenne Hospital Crow Agency, MT