Applying the Latest Advances and Evidence of Clinical Outcomes to Individualize Heart Failure Treatment
|
|
- Buck Lloyd
- 5 years ago
- Views:
Transcription
1 8/18/16 Emerging Challenges in Primary Care: 2016 Applying the Latest Advances and Evidence of Clinical Outcomes to Individualize Heart Failure Treatment Faculty Ola Akinboboye, MD, MPH, MBA, FACP, FACC, FASNC Associate Professor of Clinical Medicine, Cornell University Past President, Association of Black Cardiologists Medical Director, Queens Heart Institute, Rosedale, NY Jan Basile, MD Professor of Medicine, Seinsheimer Cardiovascular Health Program Division of General Internal Medicine, Medical University of South Carolina Ralph H Johnson VA Medical Center, Charleston, SC Phillip B. Duncan, MD Heart Care for You, PC, Chester, VA Brent M. Egan, MD Professor of Medicine, University of South Carolina School of Medicine Greenville Chief Science Officer, Care Coordination Institute President, International Society on Hypertension in Blacks, Greenville, SC Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH Professor of Medicine, Tulane University School of Medicine Tulane Heart and Vascular Institute, New Orleans, LA 2 Faculty Icilma V. Fergus, MD, FACC Past President, Association of Black Cardiologists Director, Cardiovascular Disparities and Associate Professor of Medicine Mount Sinai School of Medicine, New York, NY Robert L. Gillespie, MD, FACC, FASE, FASNC Immediate Past Chairman of the Board, Association of Black Cardiologists Director of Nuclear Imaging, Sharp Rees-Stealy Medical Group, San Diego, CA Barbara Hutchinson, MD, PhD, FACC President, Association of Black Cardiologists President, Chesapeake Cardiac Care, Annapolis, MD Elizabeth Ofili, MD, MPH, FACC Professor of Medicine (Cardiology), Senior Associate Dean, Clinical Research Director, Clinical Research Center, Morehouse School of Medicine Founder and Chairman of the Board, AccuHealth Technologies, Inc., Atlanta, GA 3 1
2 Faculty Anekwe Onwuanyi, MD Professor of Medicine, Chief of Cardiology, Morehouse School of Medicine Medical Director, Heart Failure Program, Grady Health System Atlanta, GA Priscilla E. Pemu, MD, MSCR, FACP Professor of Medicine, Morehouse School of Medicine Atlanta, GA David N. Smith, MD Clinical Assistant Professor of Medicine, Yale University Associate Professor of Medicine, Wingate University Adjunct Professor at UNC Chapel Hill Externship Preceptor and Advisory Board Member for ECPI Charlotte, NC 4 Faculty Kevin L. Thomas, MD Associate Professor of Medicine, Duke University Medical Center Division of Clinical Cardiac Electrophysiology, Duke Clinical Research Institute, Durham, NC Mark A. Thompson, MD Invasive Non-Interventional Cardiologist, Cardiac & Vascular Interventional Group Dallas, TX Laurence O. Watkins, MD, MPH, FACC Former Director, Healthy Heart Center Port St. Lucie, FL Karol E. Watson, MD, PhD Professor of Medicine/Cardiology, Co-director, UCLA Program in Preventive Cardiology Director, UCLA Barbra Streisand Women s Heart Health Program Los Angeles, CA 5 Disclosures Ola Akinboboye, MD, MPH, MBA - As per the American Board of Internal Medicine, Dr. Akinboboye will not present content that will have any direct link with the Cardiovascular Board Exam. Jan Basile, MD serves on the grant/research support team for The National Heart, Lung, and Blood Institute (Sprint). Dr. Basile also serves as a consultant and the grant/research support for the National Heart, Lung, and Blood Institute (Sprint) and Eli-Lilly (Rewind). He is also on the speaker s bureau for Arbor, Amgen and Janssen. Phillip B. Duncan, MD serves on the advisory board for Arbor. Dr. Duncan is also on the speakers bureau for Novartis. Brent M. Egan, MD serves on the advisory committee for AstraZeneca and Valencia as well as a speaker for Medtronic. Dr. Egan serves on the Clinical Evaluation and Treatment team for Up-To-Date. Keith C. Ferdinand, MD, FACC serves as a consultant for Boehringer Ingelheim, Sanofi, Amgen and Eli Lilly. 5 2
3 Disclosures Icilma V. Fergus, MD, FACC has no relationships to disclose. Robert L. Gillespie, MD, FACC, FASE, FASNC serves as an investor for Relypsa. Barbara Hutchinson, MD, PhD, FACC has no relationships to disclose. Elizabeth Ofili, MD, MPH, FACC serves on the grant/research support team for the National Institute of Health. Dr. Ofili also serves as a consultant/advisory board member for Bristol-Myers Squibb, Novartis, Arbor, Merck & Co., Janssen Research and Development. Anekwe Onwuanyi, MD serves as a speaker for Novartis. 6 Disclosures Priscilla E. Pemu, MD, MSCR, FACP serves as an Employee for Morehouse School of Medicine, Piedmont Medical Care Corporation. David N. Smith, MD serves as a speaker for Arbor and CardioDx. Kevin L. Thomas, MD serves as a Consultant for BMS and Pfizer. Mark A. Thompson, MD serves as a speaker/training member for Novartis. Laurence O. Watkins, MD, MPH, FACC is involved in the patient care at Healthy Heart Center, Inc. Karol E. Watson, MD, PhD serves as a consultant for Amgen, GSK, Merck and Quest. 6 Educational Objectives Know the risk factors for heart failure and the role of biomarkers in diagnosis and treatment Recognize the importance of heart rate in cardiovascular risk of heart failure Utilize the most recent clinical evidence to inform decisions for the management of heart failure Identify approaches to facilitate early recognition and optimization of heart failure management 9 3
4 PRE-TEST QUESTIONS 8 Pre-test ARS Question 1 Which of the following was the most prevalent modifiable risk factor for heart failure among predominantly African American patients admitted with a primary diagnosis of heart failure? 1. Hypertension 2. Hyperglycemia 3. Current smoking 4. Hypercholesterolemia 11 Pre-test ARS Question 2 In the SHIFT trial, the use of ivabradine was associated with reductions in cardiovascular mortality or heart failure hospitalization compared to placebo in all patients, EXCEPT those treated with maximum tolerated dose beta blockers. 1. True 2. False 12 4
5 Pre-test ARS Question 3 A 69-year-old white woman presents with a history of NYHA class III/ stage C heart failure with left ventricular ejection fraction 30%, CAD, hypertension, and dyslipidemia. She reports shortness of breath when climbing stairs, but no other symptoms. BP 109/71 mmhg, HR 64 bpm, potassium 4.5 meq/l, and egfr 33 ml/min/1.73m 2. Meds: furosemide 40 mg bid, metoprolol succinate 200 mg qd, lisinopril 20 mg qd, eplerenone 50 mg qd, and atorvastatin 80 mg qd. Which of the following might be appropriate at this time? 1. Patient is stable; maintain current regimen 2. Discontinue metoprolol and initiate ivabradine 3. Discontinue eplerenone based on serum potassium levels 4. Discontinue lisinopril and initiate sacubitril/valsartan after 36 hours 13 Pre-test ARS Question 4 How often do you consider changes to medical therapy for patients with heart failure and a heart rate 70 bpm? 1. Never 2. Rarely 3. Sometimes 4. Often 5. Always 14 Pre-test ARS Question 5 A 61-year-old African American man, NYHA class II/stage C heart failure and left ventricular ejection fraction 30%, obesity (BMI 32.4 kg/m 2 ), hypertension, and dyslipidemia presents for a checkup. He reports shortness of breath when he walks more than 100 feet, but no other symptoms. BP today is 120/78 mmhg, HR 66 bpm, egfr 41 ml/min/ 1.73m 2, and potassium 4.7 meq/l. Meds: metoprolol SR 100 mg qd, furosemide 40 mg bid, valsartan 160 mg bid, atorvastatin 80 mg qd, eplerenone 50 mg qd, aspirin 81 mg qd After reviewing the brief scenario above, please rate each of the statements as consistent with or not consistent with best clinical practice for management of heart failure: Initiate isosorbide dinitrate/hydralazine. 1. Yes, it is consistent 2. No, it is not consistent 15 5
6 Pre-test ARS Question 6 61 y/o AA male, NYHA Class II/stage C, SOB walking 100 feet EF 30% VS: 120/78, HR 66 Labs: egfr 41, K 4.7 meq/l Meds: metoprolol SR 100 mg qd, furosemide 40 mg bid, valsartan 160 mg bid, atorvastatin 80 mg qd, eplerenone 50 mg qd, ASA 81 mg qd. After reviewing the brief scenario above, please rate each of the statements as consistent with or not consistent with best clinical practice for management of heart failure: Consider switching from valsartan to lisinopril/ hydrochlorothiazide. 1. Yes, it is consistent 2. No, it is not consistent 16 Pre-test ARS Question 7 61 y/o AA male, NYHA Class II/stage C, SOB walking 100 feet EF 30% VS: 120/78, HR 66 Labs: egfr 41, K 4.7 meq/l Meds: metoprolol SR 100 mg qd, furosemide 40 mg bid, valsartan 160 mg bid, atorvastatin 80 mg qd, eplerenone 50 mg qd, ASA 81 mg qd. After reviewing the brief scenario above, please rate each of the statements as consistent with or not consistent with best clinical practice for management of heart failure: Discontinue eplerenone based on serum potassium levels. 1. Yes, it is consistent 2. No, it is not consistent 17 Pre-test ARS Question 8 61 y/o AA male, NYHA Class II/stage C, SOB walking 100 feet EF 30% VS: 120/78, HR 66 Labs: egfr 41, K 4.7 meq/l Meds: metoprolol SR 100 mg qd, furosemide 40 mg bid, valsartan 160 mg bid, atorvastatin 80 mg qd, eplerenone 50 mg qd, ASA 81 mg qd. After reviewing the brief scenario above, please rate each of the statements as consistent with or not consistent with best clinical practice for management of heart failure: Initiate ivabradine. 1. Yes, it is consistent 2. No, it is not consistent 18 6
7 Pre-test ARS Question 9 61 y/o AA male, NYHA Class II/stage C, SOB walking 100 feet EF 30% VS: 120/78, HR 66 Labs: egfr 41, K 4.7 meq/l Meds: metoprolol SR 100 mg qd, furosemide 40 mg bid, valsartan 160 mg bid, atorvastatin 80 mg qd, eplerenone 50 mg qd, ASA 81 mg qd. After reviewing the brief scenario above, please rate each of the statements as consistent with or not consistent with best clinical practice for management of heart failure: Switch patient from valsartan to sacubitril/valsartan. 1. Yes, it is consistent 2. No, it is not consistent 19 Pre-test ARS Question 10 Please rate your confidence in your ability to manage patients with heart failure in accordance with current guidelines and evidence: 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 20 Definition of Heart Failure Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood The cardinal manifestations of HF are dyspnea and fatigue, which may limit exercise tolerance and fluid retention, which may lead to pulmonary congestion and peripheral edema HF pathology may affect heart size, wall thickness and ejection fraction Normal heart Hypertrophied heart: HF with preserved EF (HFpEF) Dilated heart: Heart failure, reduced EF (HFrEF) 1. Hunt SA et al. Circulation. 2005;112:e154-e Jessup M et al. N Engl J Med. 2003;348:
8 Heart Failure: Causal Mechanisms Smoking Dyslipidemia Diabetes Obesity OSA MI Systolic Dysfunction Hypertension HF LVH Diastolic Dysfunction Normal LV Structure and Function LV Remodeling Subclinical LV Dysfunction Overt Heart Failure ACC/AHA Stage A Stage B Stage C Modified from: Vasan RS and Levy D. Arch Int Med.1996;153: Heart Failure: Autopsy and Echocardiogram HFpEF Normal LV HFpEF LVH Diastolic Dysfunction HFrEF Dilated LV Aurigemma GP et al. Circulation. 2006;113: Aurigemma GP et al. Circulation. 2006;113: Heart Failure is Associated with Neurohormonal Excess and Nitric Oxide Insufficiency Neurohormones (RAAS/SNS) Endothelial Nitric Oxide Neurohormonal Antagonists Beta Blockers (Class I-IV) Renin-Angiotensin Antagonists -ACE Inhibitors (Class I-IV) -ARBs (Class I-IV) Mineralocorticoid Receptor Antag (Class II-IV) Nitric Oxide Enhancment (NOE) Fixed-dose combination ISDN/HYD Omapatrilat ( Dual ACE and NEP inh) Angiotensin-Neprilysin Antagonist 24 8
9 Risk factors for Heart Failure Diseases that damage the heart increase the risk for heart failure and include: -Coronary heart disease and MI -Hypertension -Diabetes Unhealthy behaviors can also increase the risk for heart failure and include: -Smoking tobacco -Eating foods high in fat, cholesterol, and sodium(salt) -Not getting enough physical activity(inactive or sedentary). -Being obese 25 ACC/AHA 2013 Heart Failure Guideline Recognition and Treatment of Elevated Blood Pressure Hypertension may be the single most important modifiable risk factor for heart failure in the US Hypertensive men and women have substantially greater risk for developing heart failure than normotensive men and women 26 Yancy CW et al. J Am Coll Cardiol. 2013;62:e147-e239. Cardiovascular Risk Factors & Co-morbidities in Heart Failure Patients HTN 98% LVH 61% Uncontrolled HTN CAD 52% 59% Age ± 64 yrs N= % AAs DM 42% ETOH Abuse Ofili EO et al. Am J Cardiol. 1999;83: % Uncontrolled hypertension and LVH associated with increased hospitalization 27 9
10 Natriuretic Peptides: Diagnosis 13 AHA/ACC Heart Failure Stage Stage A: High risk of developing HF but w/o sxs or structural changes Hypertension, Diabetes, Alcohol Abuse, Family history of cardiomyopathy Stage B: Evidence of structural changes in the heart, but w/o signs or sxs Stage C: Prior or Current symptoms of HF Stage D: Refractory Symptoms despite medical care 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2013;128:e240-e319 Yancy CW et al., J Am Coll Cardiol 2013 Oct 15; 62:e New York Heart Association Classification- Functional Status Class I No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations. Class II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations. Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations. Class IV Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased
11 Treatment Options for Heart Failure Drug Class Mechanism of Action Common Adverse Effects Angiotensin converting enzyme inhibitors (ACEIs) Block excess activation of the renin-angiotensin system Cough, lightheadedness Angiotensin receptor blockers (ARBs) Aldosterone antagonists Block excess activation of the renin-angiotensin system Block excess aldosterone; potassium-sparing diuretic Lightheadedness Increased urination, hyperkalemia,gynecomastia Adrenergic blockers; beta blockers (BBs) Diuretics Isosorbide Dinitrate and Hydralazine (FDC I/H) Block effect of excess norepinephrine release Reverse excessive water retention Produces vasodilation by increasing nitric oxide Fatigue, lightheadedness Hypovolemia, hypokalemia Headache, lightheadedness Digoxin Increases cardiac contractility Dysrhythmia 31 New Treatment Options for Heart Failure Drug Class Mechanism of Action Common Adverse Effects Angiotensin receptor blocker, neprilysin inhibitor (ARNI) Ivabridine Block AT1 receptor activation, breakdown of bradykinin, BNP, Ang II Block cardiac lf (funny channel) Hypotension, renal insufficiency, angioedema Reduced heart rate via effects on SA node 32 Heart Failure: Key Issues in 2016 How and when to incorporate new agents into the management of HF How to optimize HF therapy in racial/ethnic minority groups to improve outcomes and reduce disparities 33 11
12 ARS Question Which of the following is the best option for a patient with heart failure Stage IIIC on guideline-directed medical therapy who may be intolerant of optimal beta blocker doses, has CAD and a resting heart rate 80 bpm? 1. Digoxin 2. Ivabradine 3. Sacubitril/valsartan 4. Calcium channel blocker 34 Elevated Resting Heart Rate is a Risk Factor in Heart Failure Böhm M, et al; SHIFT Investigators. Lancet. 2010;376(9744): Targeting Heart Rate in HF Beta blockers Block beta 1 receptors in sino-atrial node and myocardium to reduce heart rate and contractility New agent: Ivabradine Inhibit I f or funny channel of the sinus node pacemaker to reduce heart rate, without affecting BP or other ionic currents. Pure heart rate-reducing agent 36 12
13 SHIFT: Systolic Heart failure treatment with the If inhibitor ivabradine Trial Europe Germany Portugal Greece Spain Belgium Denmark Ireland Sweden Finland Italy Turkey France The Netherlands UK Participating Countries Bulgaria Czech Republic Estonia Hungary Latvia Lithuania Norway Poland Romania Russia Slovakia Slovenia Ukraine North America Canada South America Argentina Brazil Chili Asia China Hong Kong India South Korea Malaysia Australia 6505 patients, 37 countries, 677 centers 37 Primary objective To evaluate whether the I f inhibitor ivabradine improves cardiovascular outcomes in patients with: 1. Moderate to severe chronic heart failure 2. Left ventricular ejection fraction 35% 3. Heart rate 70 bpm and 4. On Guideline-Directed Medical Therapy 38 Inclusion Criteria 18 years Class II to IV NYHA heart failure Ischemic/non-ischemic etiology LV systolic dysfunction (EF 35%) Heart rate 70 bpm Sinus rhythm Documented hospital admission for worsening heart failure 12 months Swedberg K, et al. Eur J Heart Fail. 2010;12: Swedberg K, et al. Lancet. 2010;376(9744):
14 Primary composite endpoint (CV Mortality or HF Hospitalization) Ivabradine n=793 (14.5%PY) Placebo n=937 (17.7%PY) HR = 0.82 [95% CI ] p< Cumulative frequency (%) Ivabradine Placebo - 18% Months Swedberg K, et al. Lancet. 2010;376(9744): Hospitalization for heart failure Cumulative frequency (%) 30 Ivabradine Placebo Ivabradine n=514 (9.4%PY) Placebo n=672 (12.7%PY) HR = 0.74 [95% CI ] p< % Months Swedberg K, et al. Lancet. 2010;376(9744): Mean heart rate reduction Heart rate (bpm) 90 Mean ivabradine dose: 6.4 mg bid at 1 month Ivabradine Placebo 6.5 mg bid at 1 year weeks Months Swedberg K, et al. Lancet. 2010;376(9744):
15 Effect of Ivabradine on Outcomes According to Magnitude of Heart Rate Reduction Patients with primary composite end point (%) bpm -10 to <0 bpm > -10 bpm Day Time (months) 43 Böhm M, Borer J, Ford I, et al. Clin Res Cardiol. 2013;102(1):11-22 SHIFT Conclusions Heart failure with systolic dysfunction and elevated heart rate is associated with poor outcomes (primary composite endpoint in the placebo group is 18%/year) Ivabradine reduced primary endpoint (CV mortality or heart failure hospitalization) by 18% (p<0.0001). The absolute risk reduction was 4.2% This beneficial effect was mainly driven by a favorable effect on hospitalization for heart failure (RRR 26%) Overall, treatment with ivabradine was safe and well tolerated Swedberg K, et al. Lancet. 2010;376(9744): Ivabradine Approved for Systolic Heart Failure FDA approved in 2015 for patients with: stable chronic HF and EF < 35% normal sinus rhythm resting HR 70 bpm, and taking beta blockers at guideline-recommended or highest tolerable dose AHA/ACC Guidelines: Recommend ivabradine in patients with: HFrEF (EF 35%) in sinus rhythm HR 70 bpm, and beta-blocker intolerance, or elevated heart rate on maximally tolerated beta-blocker doses Level IIA/B-R recommendation 45 15
16 8/18/16 ARS Question According to guidelines, which of the following agents should be considered for African American patients with stage III/C CHF and reduced ejection fraction who are symptomatic? 1. Digoxin 2. Sacubitril/valsartan 3. Aldosterone antagonist 4. Isosorbide dinitrate/hydralazine 46 Any degree of uncertainty a physician may have relative to the condition of a patient can contribute to disparities in treatment. Smedley B. et al, IOM March 2002 McMurray J. et al NEJM 2014;371(11): Adapted From: Atlas of Heart Failure: Cardiac Function and Dysfunction edited by Wilson Colucci, Eugene Braunwald; 3rd Ed ISBN Ch 6: Neurohormonal, Renal and Vascular Adjustments in Heart Failure (p 116: Natriuretic Peptides) 48 16
17 Schematic Showing the Mechanism of Action of LCZ696 (Sacubitril/Valsartan) 49 Vardeny et al. Neprilysin Inhibition in Heart Failure; J A C C : H E A R T F A I L U R E V O L. 2, N O. 6, : Pathophysiology of HF: Rationale for ARNI 50 PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint) Kaplan-Meier Estimate of Cumulative Rates (%) Enalapril (n=4212) LCZ696 (n=4187) HR = 0.80 ( ) P = Patients at Risk LCZ696 Enalapril Packer M., et al. For PARADIGM Investigators Days After Randomization
18 PARADIGM-HF: Adverse Events LCZ696 (n=4187) Enalapril (n=4212) P Value Prospectively identified adverse events Symptomatic hypotension < Serum potassium > 6.0 mmol/l Serum creatinine 2.5 mg/dl Cough < Discontinuation for adverse event Discontinuation for hypotension NS Discontinuation for hyperkalemia NS Discontinuation for renal impairment Angioedema (adjudicated) Medications, no hospitalization 16 9 NS Hospitalized; no airway compromise 3 1 NS Airway compromise Packer M., et al. For PARADIGM Investigators 52 PARADIGM-HF: Patient Demographics In the PARADIGM-HF trial, the incidence of angioedema was 0.1% in both the enalapril and sacubitril/valsartan run-in periods. In the double-blind period, the incidence of angioedema was higher in patients treated with sacubitril/ valsartan than enalapril (0.5% and 0.2%, respectively). The incidence of angioedema in Black patients was 2.4% with sacubitril/ valsartan and 0.5% with enalapril 53 PARADIGM-HF: Adverse Events The most common side effects were hypotension, hyperkalemia, and renal impairment. Angioedema was also reported with black patients and patients with a prior history of angioedema having a higher risk
19 Sacubitril/valsartan Approved and Recommended FDA Approved to reduce the risk of cardiovascular death and hospitalization in chronic heart failure patients (NYHA Class II- IV) and reduced EF 2016 ACC/AHA Guidelines: Recommend sacubitril/valsartan for patients with: NYHA class II or III HF and reduced EF who tolerate an ACE inhibitor or ARB Replacement of ACE/ARB with ARNI recommended to further reduce morbidity/mortality Close surveillance of serum potassium and creatinine (LOE I-BR) Yancy, CW, et al Heart Failure Focused Update on Pharmacologic Therapy 55 Case # 1 58-year-old AA woman History of non-ischemic cardiomyopathy and hypertension frequent shortness of breath during normal daily activities 1 pillow orthopnea hospitalized 6 months ago for HF Dilated LV; EF 38%; mild mitral regurgitation; no history CAD Medications: valsartan 160 mg qd; carvedilol 25 mg bid; furosemide 40 mg bid. Allergic to enalapril. BP 125/80 mmhg, pulse 68 bpm, weight 255 Ibs No JVD; lungs clear; cardiac regular rate and rhythm; grade 2/6 systolic murmur; abdomen soft non tender; extremities 1+ bilateral edema 56 ARS Question What would you add to this patient s medication regimen to reduce risk for CV events and improve survival? 1. Digoxin 2. Ivabradine 3. Sacubitril/valsartan 4. Isosorbide dinitrate/hydralazine 57 19
20 Case #1 (cont d) Clinical Pearl #1 Patient has NYHA Class III HF, moderately symptomatic Patient was recently hospitalized due to HF During this follow up visit: evaluate for ongoing/new symptoms optimize evidence-based therapy to improve symptoms, reduce hospitalization and increase survival ACC/AHA Guideline: HYD and ISDN I IIa IIb III I IIa IIb III The combination of HYD and ISDN is recommended for African Americans with NYHA class III IV HFrEF on GDMT IA A combination of HYD and ISDN can be useful with HFrEF who cannot be given ACE-Is or ARBs IIa B GDMT-Guideline Directed Management Therapy Yancy CW et al. J Am Coll Cardiol. 2013:62:e147-e Oxidative Stress Nitroso-Redox Imbalance in Heart Failure Isosorbide dinitrate Stimulation Nitric oxide synthase Citrulline Oxidase Hydralazine Inhibition L-Arginine Physiologic pathway NO O 2 O 2 Pathologic pathway O 2 Formation of cyclic guanosine monophosphate Peroxynitrite (ONOO ) DNA damage S-nitrosylation: post-translational modification of effector molecules Inhibition Cell damage Oxidized proteins 60 Hare JM. N Engl J Med. 2004;351:
21 Trial Heart Failure Trials: Rx Total Non- African Americans (%) African Americans African Americans (%) V-HeFT I + II1 ISDN/HYD, Enalapril SOLVD 2 Enalapril US Carvedilol 3 Carvedilol COPERNICUS 4 Carvedilol BEST 5 Bucindolol MERIT-HF 6 Metoprolol EPHESUS 7 Eplerenone Val-HeFT 8 Valsartan VALIANT9 Valsartan, Valsartan/Captopril CHARM 10 Candesartan A-HeFT 11 ISDN/HYD TOTAL 44,488 40,525 3, Carson P et al. J Card Fail. 1999;5: ; 2. Hall WD. Ethn Dis. 1999;9: ; 3. Yancy CW et al. N Engl J Med. 2001;344: ; 4. Packer M et al. N Engl J Med. 2001;344: ; 5. BEST Investigators. N Engl J Med. 2001;344: ; 6. MERIT-HF study group. Lancet. 1999;353: ; 7. Pitt B et al. N Engl J Med. 2003;348: ; 8. Cohn JN. N Engl J Med. 2001;345: ; 9. Pfeffer MA et al. N Engl J 61 Med. 2003;349: ; 10. Yusuf S et al. Lancet. 2003;362: Taylor AL et al. AHEFT- N Engl J Med. 2004;351: African American Heart Failure Trial (A-HeFT) Objective Demonstrate the safety and efficacy of ISDN/HYD compared with placebo in African American patients with moderate to severe HF concurrently receiving standard HF treatment Inclusion Criteria Patients self-identified as African American NYHA class III or IV HF (> 3 months) LVEF < 35% (or < 45% with dilated LV by echo) Standard therapy for HF, including ACEI/ARB + BB (> 3 months) 63 21
22 A-HeFT Characteristics (Inclusion Criteria) Standard Therapy Medications (All Patients) Diuretics: 94% ACE inhibitors: 78% ARBs: 28% Beta-blockers: 87% Digoxin: 62% Spironolactone: 39% Taylor AL et al. N Engl J Med. 2004;351: A-HeFT: All-Cause Mortality Primary Efficacy Endpoint Composite score: All-Cause Mortality; First HF Hospitalization; Change in QoL at 6 months relative to baseline Fixed Dose Isosorbide/Hydralazine Survival (%) Placebo N=1050 Hazard ratio= % Decrease P= Days Since Baseline Visit Date Fixed-dose I/H Placebo Taylor AL et al. N Engl J Med. 2004;351: Case #1 (cont d) Clinical Pearl #2 Patient has persistent symptoms despite optimal neurohormonal blockade with valsartan and carvedilol FDC I/H (Fixed Dose Combination Isosorbide Dinitrate and Hydralazine should be added to treatment regimen FDC I/H is the evidence-based guideline treatment that is recommended at this time for this patient with NYHA Class III HFrEF It is important to consider how the addition of FDC I/H to current treatment (valsartan and carvedilol) will affect the blood pressure in this patient 66 22
23 AHEFT: FDC I/H Did Not Significantly Reduce SBP when Baseline SBP was less than 112 mmhg Anand I S et al. Journal of the American College of Cardiology, Volume 49, Issue 1, 2007, Conclusions Identifying and treating risk factors for heart failure is a continuous and ongoing process across the stages of HF (from stage A-C) Monitor at risk patients with diagnostic studies where appropriate, in order to detect cardiac remodeling and progression from stage A to B and C. Use biomarkers like BNP to support the diagnosis of decompensated HF 68 Conclusions (cont d) Heart failure with reduced ejection fraction (HFrEF) and elevated heart rate >70 bpm despite maximally tolerated beta blocker therapy, is associated with poor outcomes. These patients may benefit from the If inhibitor, Ivabradine. Sacubitril/valsartan may be appropriate for patients with HF and reduced ejection fraction; small sample size of African Americans in PARADIGM may limit use in this population. Recognize the impact of health disparities, and apply the best clinical trial evidence to support the treatment of HF in African Americans and other ethnic minorities
Emerging Challenges in Primary Care: Applying the Latest Advances and Evidence of Clinical Outcomes to Individualize Heart Failure Treatment
Emerging Challenges in Primary Care: 2016 Applying the Latest Advances and Evidence of Clinical Outcomes to Individualize Heart Failure Treatment Faculty Ola Akinboboye, MD, MPH, MBA, FACP, FACC, FASNC
More informationTreating Heart Failure in Biodiverse Patient Populations: Best Practices and Unveiling Disparities in Blacks
Treating Heart Failure in Biodiverse Patient Populations: Best Practices and Unveiling Disparities in Blacks 12th Annual Leadership Summit on Health Disparities & Congressional Black Caucus Spring Health
More informationImpact of the African American Heart Failure Trial (A-HeFT): Guideline-based Therapy in Blacks with Heart Failure 2016
Impact of the African American Heart Failure Trial (A-HeFT): Guideline-based Therapy in Blacks with Heart Failure 2016 National Minority Quality forum APRIL 11, 2016 Washington,D.C. Keith C. Ferdinand,
More informationSaudi Arabia February Pr Michel KOMAJDA. Université Pierre et Marie Curie Hospital Pitié Salpétrière
Prevention of Cardiovascular events with Ivabradine: The SHIFT Study Saudi Arabia February 2011 Pr Michel KOMAJDA Université Pierre et Marie Curie Hospital Pitié Salpétrière Paris FRANCE Declaration Of
More informationHEART FAILURE: PHARMACOTHERAPY UPDATE
HEART FAILURE: PHARMACOTHERAPY UPDATE 3 HEART FAILURE REVIEW 1 5.1 million x1.25 = 6.375 million 40 years old = MICHAEL F. AKERS, PHARM.D. CLINICAL PHARMACIST CENTRACARE HEALTH, ST. CLOUD HOSPITAL HF Diagnosis
More informationChecklist for Treating Heart Failure. Alan M. Kaneshige MD, FACC, FASE Oklahoma Heart Institute
Checklist for Treating Heart Failure Alan M. Kaneshige MD, FACC, FASE Oklahoma Heart Institute Novartis Disclosure Heart Failure (HF) a complex clinical syndrome that arises secondary to abnormalities
More informationDisclosures. Overview. Goal statement. Advances in Chronic Heart Failure Management 5/22/17
Disclosures Advances in Chronic Heart Failure Management I have nothing to disclose Van N Selby, MD UCSF Advanced Heart Failure Program May 22, 2017 Goal statement To review recently-approved therapies
More informationDisclosures. Advances in Chronic Heart Failure Management 6/12/2017. Van N Selby, MD UCSF Advanced Heart Failure Program June 19, 2017
Advances in Chronic Heart Failure Management Van N Selby, MD UCSF Advanced Heart Failure Program June 19, 2017 I have nothing to disclose Disclosures 1 Goal statement To review recently-approved therapies
More informationIntroduction: Clinical Trials: Assessing Safety and Efficacy for a Diverse Population
Introduction: Clinical Trials: Assessing Safety and Efficacy for a Diverse Population FDA and JHU-CERSI White Oak, Maryland Wednesday, December 2, 2015 Keith C. Ferdinand, MD, FACC,FAHA,FNLA,FASH Professor
More informationDisclosures. This speaker has indicated there are no relevant financial relationships to be disclosed.
Disclosures This speaker has indicated there are no relevant financial relationships to be disclosed. And the Beat Goes On: New Medications for Heart Failure Alison M. Walton, PharmD, BCPS The Case of
More informationBeyond ACE-inhibitors for Heart Failure. Jacob Townsend, MD NCVH Birmingham 2015
Beyond ACE-inhibitors for Heart Failure Jacob Townsend, MD NCVH Birmingham 2015 % Decrease in Mortality Current Therapy HFrEF 0% Angiotensin receptor blocker ACE inhibitor Beta blocker Mineralocorticoid
More informationTreating HF Patients with ARNI s Why, When and How?
Treating HF Patients with ARNI s Why, When and How? 19 th Annual San Diego Heart Failure Symposium for Primary Care Physicians January 11-12, 2019 La Jolla, CA Barry Greenberg M.D. Distinguished Professor
More information2017 CCS HF Guidelines Medical Therapy for HFrEF When What Order and How Much?
2017 CCS HF Guidelines Medical Therapy for HFrEF When What Order and How Much? Dr. Shelley Zieroth University of Manitoba @ShelleyZieroth @CanHFSociety Disclosures Consulting/Advisory Board: Amgen, Astra
More information1/4/18. Heart Failure Guideline Review and Update. Disclosure. Pharmacist Objectives. Pharmacy Technician Objectives. What is Heart Failure?
Disclosure Heart Failure Guideline Review and Update I have had no financial relationship over the past 12 months with any commercial sponsor with a vested interest in this presentation. Natalie Beiter,
More informationESC Guidelines for diagnosis and management of HF 2012: What s new? John Parissis, MD Athens, GR
ESC Guidelines for diagnosis and management of HF 2012: What s new? John Parissis, MD Athens, GR Disclosures ALARM INVESTIGATOR RESEARCH GRANTS BY ABBOTT USA AND ORION PHARMA The principal changes from
More information2017 Summer MAOFP Update
2017 Summer MAOFP Update. Cardiology Update 2017 Landmark Trials Change Practice Guidelines David J. Strobl, DO, FNLA Heart Failure: Epidemiology More than 4 million patients affected 400,000 new cases
More informationSystolic Dysfunction Clinical /Hemodynamic Guide for Management From Neprilysin Inhibitors to Ivabradine
Systolic Dysfunction Clinical /Hemodynamic Guide for Management From Neprilysin Inhibitors to Ivabradine Donna Mancini MD Choudhrie Professor of Cardiology Columbia University Speaker Disclosure Amgen
More informationNew Paradigms in Rx of Symptomati Heart Failure:Role of Ivabradine & Angiotensin Neprilysin Inhibition
New Paradigms in Rx of Symptomati Heart Failure:Role of Ivabradine & Angiotensin Neprilysin Inhibition Prakash Deedwania, MD, FACC, FACP, FCCP, FAHA Professor of Medicine, UCSF School of Medicine, Director,
More informationA patient with decompensated HF
A patient with decompensated HF Professor Michel KOMAJDA University Pierre & Marie Curie Pitie Salpetriere Hospital Department of Cardiology Paris (France) Declaration Of Interest 2010 Speaker : Servier,
More informationUpdates in Congestive Heart Failure
Updates in Congestive Heart Failure GREGORY YOST, DO JOHNSTOWN CARDIOVASCULAR ASSOCIATES 1/28/2018 Disclosures Edwards speaker on Sapien3 valves (TAVR) Stages A-D and NYHA Classes I-IV Stage A: High risk
More informationCongestive Heart Failure: Outpatient Management
The Chattanooga Heart Institute Cardiovascular Symposium Congestive Heart Failure: Outpatient Management E. Philip Lehman MD, MPP Disclosure No financial disclosures. Objectives Evidence-based therapy
More informationDrugs acting on the reninangiotensin-aldosterone
Drugs acting on the reninangiotensin-aldosterone system John McMurray Eugene Braunwald Scholar in Cardiovascular Diseases, Brigham and Women s Hospital, Boston & Visiting Professor, Harvard Medical School
More informationWhat s New in Heart Failure? Marie-France Gauthier, BSc, PharmD, ACPR Clinical Pharmacist at Montfort Hospital
What s New in Heart Failure? Marie-France Gauthier, BSc, PharmD, ACPR Clinical Pharmacist at Montfort Hospital Disclosures I have no current or past relationships with commercial entities Learning objectives
More informationLong-Term Care Updates
Long-Term Care Updates July 2015 By Amy Friedman Wilson, PharmD Heart failure (HF) is a clinical condition in which ventricular filling or ejection of blood is structurally or functionally impaired. 1
More informationSacubitril/valsartan: A New Management Strategy for the Treatment of Heart Failure. Elizabeth Pogge, PharmD, MPH, BCPS, FASCP
Sacubitril/valsartan: A New Management Strategy for the Treatment of Heart Failure Elizabeth Pogge, PharmD, MPH, BCPS, FASCP Disclosure Elizabeth Pogge reports no actual or potential conflicts of interest
More informationUpdates in Heart Failure (HF) 2016: ACC / AHA and ESC
Updates in Heart Failure (HF) 2016: ACC / AHA and ESC Patrick McBride, MD, MPH Professor of Medicine & Family Medicine, UW School of Medicine and Public Health Special thanks to: Clyde W. Yancy, MD, MSc
More informationSatish K Surabhi, MD.FACC,FSCAI,RPVI Medical Director, Cardiac Cath Labs AnMed Health Heart & Vascular Care
Satish K Surabhi, MD.FACC,FSCAI,RPVI Medical Director, Cardiac Cath Labs AnMed Health Heart & Vascular Care None Fig. 1. Progression of Heart Failure.With each hospitalization for acute heart failure,
More informationHeart Failure Background, recognition, diagnosis and management
Heart Failure Background, recognition, diagnosis and management Speaker bureau: Novartis At the conclusion of this activity, participants will be able to: Recognize signs and symptoms of heart failure
More informationHeart Failure A Team Approach Background, recognition, diagnosis and management
Heart Failure A Team Approach Background, recognition, diagnosis and management Speaker bureau: Novartis At the conclusion of this activity, participants will be able to: Recognize signs and symptoms of
More informationIntroduction to Heart Failure. Mauricio Velez, M.D. Transplant Cardiologist APACVS 2018 April 5-7 Miami, FL
Introduction to Heart Failure Mauricio Velez, M.D. Transplant Cardiologist APACVS 2018 April 5-7 Miami, FL Disclosures No relevant financial relationships to disclose Objectives and Outline Define heart
More informationHeart Failure: Current Management Strategies
Heart Failure: Current Management Strategies CSHP Fall Education Session- September 30th, 2017 Carolyn MacKinnon & Tamara Matchett BscPharm, ACPR Candidates Objectives 1. Describe the pathophysiology &
More informationDisclosures for Presenter
A Comparison of Angiotensin Receptor- Neprilysin Inhibition (ARNI) With ACE Inhibition in the Long-Term Treatment of Chronic Heart Failure With a Reduced Ejection Fraction Milton Packer, John J.V. McMurray,
More informationTherapeutic Targets and Interventions
Therapeutic Targets and Interventions Ali Valika, MD, FACC Advanced Heart Failure and Pulmonary Hypertension Advocate Medical Group Midwest Heart Foundation Disclosures: 1. Novartis: Speaker Honorarium
More informationRationale and Practical Aspects of Sacubitril- Valsartan and Ivabradine Use in Heart Failure Patients
Rationale and Practical Aspects of Sacubitril- Valsartan and Ivabradine Use in Heart Failure Patients Javed Butler, MD, MPH, MBA Patrick H. Lehan Professor of Medicine Professor of Physiology Chairman,
More informationNeprilysin Inhibitor (Entresto ) Prior Authorization and Quantity Limit Program Summary
Neprilysin Inhibitor (Entresto ) Prior Authorization and Quantity Limit Program Summary FDA APPROVED INDICATIONS DOSAGE 1 Indication Entresto Reduce the risk of cardiovascular (sacubitril/valsartan) death
More informationUpdate in Congestive Hear Failure DRAGOS VESBIANU MD
Update in Congestive Hear Failure DRAGOS VESBIANU MD Case 58 yo AAM c/o shortness of breath for 3 weeks. Used to walk one mile per day and now he has noticed that he gets short of breath after 2 blocks.
More informationFrom PARADIGM-HF to Clinical Practice. Waleed AlHabeeb, MD, MHA Associate Professor of Medicine President of the Saudi Heart Failure Group
From PARADIGM-HF to Clinical Practice Waleed AlHabeeb, MD, MHA Associate Professor of Medicine President of the Saudi Heart Failure Group PARADIGM-HF: Inclusion Criteria Chronic HF NYHA FC II IV with LVEF
More informationUPDATES IN MANAGEMENT OF HF
UPDATES IN MANAGEMENT OF HF Jennifer R Brown MD, MS Heart Failure Specialist Medstar Cardiology Associates DC ACP Meeting Fall 2017 Disclosures: speaker bureau for novartis speaker bureau for actelion
More informationKnown Actions of Digoxin
Known Actions of Digoxin Hemodynamic effects in heart failure Increases cardiac output, no effect on blood pressure Decreases PCWP Increases LVEF (
More informationHeart Failure New Drugs- Updated Guidelines
Heart Failure New Drugs- Updated Guidelines Eileen Handberg, PhD, ANP-BC, FAHA, FACC Professor of Medicine Division of Cardiovascular Medicine University of Florida Disclosures 1. 3 2. 6 3. 8 4. 11 Dunlay
More informationOutline. Classification by LVEF Conventional Therapy New Therapies. Ivabradine Sacubitril/valsartan
New Pharmacological Therapies for Heart Failure Mark Drazner, MD, MSc Clinical Chief of Cardiology Medical Director, CHF/VAD/Transplant James M. Wooten Chair in Cardiology UT Southwestern Medical Center
More informationDISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.
DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this
More informationHFpEF, Mito or Realidad?
HFpEF, Mito or Realidad? Ileana L. Piña, MD, MPH Professor of Medicine and Epidemiology/Population Health Associate Chief for Academic Affairs -- Cardiology Montefiore-Einstein Medical Center Bronx, NY
More informationSystolic Dysfunction Clinical/Hemodynamic Guide for Management; New Medical and Interventional Therapeutic Challenges
Systolic Dysfunction Clinical/Hemodynamic Guide for Management; New Medical and Interventional Therapeutic Challenges Clyde W. Yancy, MD, MSc, FACC, FAHA, MACP Magerstadt Professor of Medicine Professor,
More informationNew Winners in the World of Heart Failure. Laura Steffens PharmD Candidate 2016 CICU Presentation August 12, 2015
New Winners in the World of Heart Failure Laura Steffens PharmD Candidate 2016 CICU Presentation August 12, 2015 Jessup 2014 Shaking Things Up 2003: FDA approved eplerenone for the treatment of heart failure
More informationHeart Failure Management. Waleed AlHabeeb, MD, MHA Assistant Professor of Medicine Consultant Heart Failure Cardiologist
Heart Failure Management Waleed AlHabeeb, MD, MHA Assistant Professor of Medicine Consultant Heart Failure Cardiologist Heart failure prevalence is expected to continue to increase¹ 21 MILLION ADULTS WORLDWIDE
More informationUnderstanding and Development of New Therapies for Heart Failure - Lessons from Recent Clinical Trials -
Understanding and Development of New Therapies for Heart Failure - Lessons from Recent Clinical Trials - Clinical trials Evidence-based medicine, clinical practice Impact upon Understanding pathophysiology
More informationLCZ696 A First-in-Class Angiotensin Receptor Neprilysin Inhibitor
The Angiotensin Receptor Neprilysin Inhibitor LCZ696 in Heart Failure with Preserved Ejection Fraction The Prospective comparison of ARNI with ARB on Management Of heart failure with preserved ejection
More informationAldosterone Antagonism in Heart Failure: Now for all Patients?
Aldosterone Antagonism in Heart Failure: Now for all Patients? Inder Anand, MD, FRCP, D Phil (Oxon.) Professor of Medicine, University of Minnesota, Director Heart Failure Program, VA Medical Center 111C
More informationManagement Strategies for Advanced Heart Failure
Management Strategies for Advanced Heart Failure Mary Norine Walsh, MD, FACC Medical Director, HF and Cardiac Transplantation St Vincent Heart Indianapolis, IN USA President American College of Cardiology
More informationState-of-the-Art Management of Chronic Systolic Heart Failure
State-of-the-Art Management of Chronic Systolic Heart Failure Michael McCulloch, MD 17 th Annual Cardiovascular Update Intermountain Medical Center December 16, 2017 Disclosures: I have no financial disclosures
More informationHeart Failure Clinician Guide JANUARY 2018
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Heart Failure Clinician Guide JANUARY 2018 Introduction This evidence-based guideline summary is based on the 2018 National Heart Failure Guideline.
More informationContemporary Management of Heart Failure. Keerthy K Narisetty, MD Comprehensive Heart Failure Management Program BHHI Primary Care Symposium
Contemporary Management of Heart Failure Keerthy K Narisetty, MD Comprehensive Heart Failure Management Program BHHI Primary Care Symposium Disclosures I have no relevant relationships with commercial
More informationHeart Failure Clinician Guide JANUARY 2016
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Heart Failure Clinician Guide JANUARY 2016 Introduction This evidence-based guideline summary is based on the 2016 National Heart Failure Guideline.
More informationThe ACC Heart Failure Guidelines
The ACC Heart Failure Guidelines Fakhr Alayoubi, Msc,R Ph President of SCCP Cardiology Clinical Pharmacist Assistant Professor At King Saud University King Khalid University Hospital Riyadh-KSA 2017 ACC/AHA/HFSA
More informationWomen s Heart Health: Holistic Approaches Throughout the Lifetime - Key Differences in Heart Failure in Women
Women s Heart Health: Holistic Approaches Throughout the Lifetime - Key Differences in Heart Failure in Women C. Noel Bairey Merz MD Medical Director and Barbra Streisand Women s Heart Center Preventive
More informationLITERATURE REVIEW: HEART FAILURE. Chief Residents
LITERATURE REVIEW: HEART FAILURE Chief Residents Heart Failure EF 40% HFrEF Problem with contractility EF 40-50% HFmrEF EF > 50% HFpEF Problem with filling/relaxation RISK FACTORS Post MI HTN DM Obesity
More informationSacubitril/Valsartan in HFrEF for All Protagonist View George Honos MD FRCPC FCCS FACC
Sacubitril/Valsartan in HFrEF for All Protagonist View George Honos MD FRCPC FCCS FACC Head of Cardiology Medical Manager / CV Program CHUM Disclosure Statement Within the past two years: I have had an
More informationOptimizing CHF Therapy: The Role of Digoxin, Diuretics, and Aldosterone Antagonists
Optimizing CHF Therapy: The Role of Digoxin, Diuretics, and Aldosterone Antagonists Old Drugs for an Old Problem Jay Geoghagan, MD, FACC BHHI Primary Care Symposium February 28, 2014 None. Financial disclosures
More informationClinical Pearls Heart Failure Cardiology/New Drugs
Clinical Pearls Heart Failure Cardiology/New Drugs Friday, September 9 th, 2016 Heidi Burres, PharmD, BCACP MTM Pharmacist Fairview Pharmacy Services Thank You to XYZ Event Sponsor(s): Wi-fi Information:
More informationHeart Failure Update. Bibiana Cujec MD May 2015
Heart Failure Update Bibiana Cujec MD May 2015 Disclosures Participation in clinical trial GUIDE IT (BNP in management of HF) Plan Review of new trials/ccs guidelines Management of heart failure: cases
More informationHow Do You Mend a Broken Heart: The New Agents to Treat HF Paradigm Shift or Just the Same Old Drugs?
How Do You Mend a Broken Heart: The New Agents to Treat HF Paradigm Shift or Just the Same Old Drugs? Gregg C. Fonarow, MD FACC, FAHA, FHFSA Co-Chief UCLA Division of Cardiology Director, Ahmanson-UCLA
More informationDisclosure of Relationships
Disclosure of Relationships Over the past 12 months Dr Ruilope has served as Consultant and Speakers Bureau member of Astra-Zeneca, Bayer, Daiichi-Sankyo, Menarini, Novartis, Otsuka, Pfizer, Relypsa, Servier
More informationThe NEW Heart Failure Guidelines
The NEW Heart Failure Guidelines Daily Practice HF scenario of the Case Presentations HF as a complex and heterogeneous syndrome Several proposed pathophysiological mechanisms involving the heart and the
More informationCongestive Heart Failure 2015
Definition Congestive Heart Failure 215 JP Mehegan/ Mercy Cardiology n Cardiac failure; Congestive heart failure; Chronic heart failure (synonyms) n When the heart is unable to pump sufficiently and at
More informationVitals HR 90 BP 125/58 Tmax 98.7F O2 Sat 97% on NC 2L/min BMP SCr 1.78 K 3.9 Gluc 194 A1c 7.5 Cardiac LVEF 55% NTproBNP 9,200 Troponin 0.
ALDOSTERONE ANTAGONIST IN HEART FAILURE WITH PRESERVED EJECTION FRACTION ABBREVIATIONS BMP: basic metabolic panel HPI: history of present illness CAD: coronary artery disease HR: heart rate PINHUI (JUDY)
More informationI know the trials in heart failure but how do I manage my patient? Dosing of neurohormones antagonists
I know the trials in heart failure but how do I manage my patient? Dosing of neurohormones antagonists Alessandro Fucili (Ferrara, IT) Massimo F Piepoli (Piacenza, IT) Clinical Case: 82 year old woman
More informationESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure
Patients t with acute heart failure frequently develop chronic heart failure Patients with chronic heart failure frequently decompensate acutely ESC Guidelines for the Diagnosis and A clinical response
More information9/10/ , American Heart Association 2
Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP Vice Dean, Diversity & Inclusion Magerstadt Professor of Medicine Professor of Medical Social Sciences Chief, Division of Cardiology Northwestern University, Feinberg
More informationSummary/Key Points Introduction
Summary/Key Points Introduction Scope of Heart Failure (HF) o 6.5 million Americans 20 years of age have HF o 960,000 new cases of HF diagnosed annually o 5-year survival rate for HF is ~50% Classification
More informationCase 1. Case 2. What do you think about reducing or discontinuing some of the above now that his LVEF has normalized?
Case 1 A primary care colleague inquires what to do with a patient (HFrEF in NSR) who has a digoxin level of 2.8ng/ml. Level was obtained at 10am, patient takes all medications at one time upon arising
More informationPharmacological Treatment for Chronic Heart Failure. Dr Elaine Chau HK Sanatorium & Hospital, Hong Kong 3 August 2014
Pharmacological Treatment for Chronic Heart Failure Dr Elaine Chau HK Sanatorium & Hospital, Hong Kong 3 August 2014 1 ACC/AHA 2005 guideline update for Diagnosis & management of CHF in the Adult -SA Hunt
More information2/15/2017. Disclosures. Heart Failure = Big Problem. Heart Failure Update Reducing Hospitalizations and Improving Patient Outcomes 02/18/2017
Heart Failure Update Reducing Hospitalizations and Improving Patient Outcomes 02/18/2017 Julio A. Barcena, M.D. South Miami Heart Specialists Disclosures I have no relevant commercial relationships to
More informationOptimal blockade of the Renin- Angiotensin-Aldosterone. in chronic heart failure
Optimal blockade of the Renin- Angiotensin-Aldosterone Aldosterone- (RAA)-System in chronic heart failure Jan Östergren Department of Medicine Karolinska University Hospital Stockholm, Sweden Key Issues
More informationManagement of chronic heart failure: update J. Parissis Attikon University Hospital
Management of chronic heart failure: update 2015 J. Parissis Attikon University Hospital Disclosures: received honoraria for lectures from Servier, Pfizer, Novartis Discharges in Thousands Heart Failure
More informationHeart Failure (HF): Scope of the Problem. Temporal Trends in Age-Adjusted Survival After HF Diagnosis. More malignant than most cancers
Patients in US (millions) Heart Failure (HF): Scope of the Problem 1 4 2 3.5 4. 1. 1991 21 237 US prevalence*: 5. million US annual incidence: 7, Annual mortality: 22,754 5-1% depending on severity Cost:
More informationHeart Failure Medical and Surgical Treatment
Heart Failure Medical and Surgical Treatment Daniel S. Yip, M.D. Medical Director, Heart Failure and Transplantation Mayo Clinic Second Annual Lakeland Regional Health Cardiovascular Symposium February
More informationPractical considerations for the use of ARNI in CHF: clinical cases. J. Parissis, Heart Failure Clinic, University of Athens, Athens, Greece
Practical considerations for the use of ARNI in CHF: clinical cases J. Parissis, Heart Failure Clinic, University of Athens, Athens, Greece Disclosures: Research grants and honoraria for lectures from
More informationContemporary Advanced Heart Failure Therapy
Contemporary Advanced Heart Failure Therapy Andrew Boyle, MD Professor of Medicine Medical Director of Advanced Heart Failure Thomas Jefferson University Philadelphia, PA Audience Response Question 40
More informationHighlight Session Heart failure and cardiomyopathies Michel KOMAJDA Paris France
Highlight Session 2014 Heart failure and cardiomyopathies Michel KOMAJDA Paris France # esccongress www.escardio.org/esc2014 HEART FAILURE AND CARDIOMYOPATHIES TOPIC 1 Drug Therapy TOPIC 2 Device Therapy
More informationHeart Failure Therapies State of the Art 2017
Heart Failure Therapies State of the Art 2017 Andrew J. Sauer, MD Assistant Professor Director, Center for Heart Failure Medical Director, Heart Transplantation UNOS Primary Transplant Physician asauer@kumc.edu
More informationDisclosure Statement. Heart Failure: Refreshers and Updates. Objectives. CHF: Chronic Heart Failure. Definitions. Definitions 2/19/2018
Disclosure Statement Heart Failure: Refreshers and Updates Tracy K. Pettinger, PharmD Clinical Associate Professor College of Pharmacy The planners and presenter of this presentation have disclosed no
More informationPre-Activity Assessment/ Evaluation Form
Pre-Activity Assessment/ Evaluation Form Pre-Activity Assessment Please take a moment to complete the pre-activity assessment prior to the start of the activity. Evaluation Form Please take a moment at
More informationHeart Failure. Disclosures. Objectives: 8/28/2017. This is not a virus. It doesn t go away. none
Heart Failure This is not a virus. It doesn t go away Shelley Wojtaszczyk, FNP-C, CHFN Heart Failure Program Coordinator Mercy Hospital of Buffalo none Disclosures Objectives: Defining and identifying
More informationHeart Failure Pharmacotherapy An Update
Heart Failure Pharmacotherapy An Update Kenneth Mishler, PharmD, MBA Objectives Review the epidemiology of heart failure (HF) Review evidence based guidelines for the use of mediations used to treat HF
More informationGuideline-Directed Medical Therapy
Guideline-Directed Medical Therapy Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation OPTIMAL THERAPY (As defined in
More informationHeart Failure: Guideline-Directed Management and Therapy
Heart Failure: Guideline-Directed Management and Therapy Guideline-Directed Management and Therapy (GDMT) was developed by the American College of Cardiology and American Heart Association to define the
More informationDISCLOSURES ACHIEVING SUCCESS THROUGH FAILURE: UPDATE ON HEART FAILURE WITH PRESERVED EJECTION FRACTION NONE
ACHIEVING SUCCESS THROUGH FAILURE: UPDATE ON HEART FAILURE WITH PRESERVED EJECTION FRACTION Lori M. Tam, MD Providence Heart Institute DISCLOSURES NONE 1 OUTLINE Systolic vs. Diastolic Heart Failure New
More informationCardiovascular Clinical Practice Guideline Pilot Implementation
Cardiovascular Clinical Practice Guideline Pilot Implementation Pharmacologic Management of Chronic Heart Failure Sept 15, 2004 Angela Allerman, PharmD, BCPS DoD Pharmacoeconomic Center Promoting high
More informationEpidemiology of Symptomatic Heart Failure in the U.S.
William T. Abraham, MD, FACP, FACC, FAHA, FESC Professor of Medicine, Physiology, and Cell Biology Director, Division of Cardiovascular Medicine Deputy Director Davis Heart and Lung Research Institute
More informationTreatment with Hydralazine and Nitrates Uri Elkayam, MD
Treatment with Hydralazine and Nitrates Uri Elkayam, MD Professor of Medicine University of Southern California School of Medicine Los Angeles, California elkayam@usc.edu Hydralazine and Isosorbide Dinitrate
More information2016 Update to Heart Failure Clinical Practice Guidelines
2016 Update to Heart Failure Clinical Practice Guidelines Mitchell T. Saltzberg, MD, FACC, FAHA, FHFSA Medical Director of Advanced Heart Failure Froedtert & Medical College of Wisconsin Stages, Phenotypes
More informationAkash Ghai MD, FACC February 27, No Disclosures
Akash Ghai MD, FACC February 27, 2015 No Disclosures Epidemiology Lifetime risk is > 20% for American s older than 40 years old. > 650,000 new cases diagnosed each year. Incidence increases with age: 2%
More informationANGIOTENSIN RECEPTOR-NEPRILYSIN INHIBITORS IN HEART FAILURE FROM CHD
ANGIOTENSIN RECEPTOR-NEPRILYSIN INHIBITORS IN HEART FAILURE FROM CHD Karen Stout, MD FACC Professor, Medicine/Pediatrics University of Washington Seattle, WA USA No disclosures Case 35 year old man with
More informationHeart Failure Guidelines For your Daily Practice
Heart Failure Guidelines For your Daily Practice Juan M. Aranda, Jr., MD, FACC, FHFSA Professor of Medicine Director of Heart Failure and Cardiac Transplantation University of Florida College of Medicine
More informationHeart Failure. Subjective SOB (shortness of breath) Peripheral edema. Orthopnea (2-3 pillows) PND (paroxysmal nocturnal dyspnea)
Pharmacology I. Definitions A. Heart Failure (HF) Heart Failure Ezra Levy, Pharm.D. HF Results when one or both ventricles are unable to pump sufficient blood to meet the body s needs There are 2 types
More informationTreatment with Hydralazine and Nitrates Uri Elkayam, MD
Treatment with Hydralazine and Nitrates Uri Elkayam, MD Professor of Medicine University of Southern California School of Medicine Los Angeles, California elkayam@usc.edu Hydralazine and Isosorbide Dinitrate
More informationBiomarkers in the Age of Sacubitril/Valsa rten: Has the PARADIGM Changed
Biomarkers in the Age of Sacubitril/Valsa rten: Has the PARADIGM Changed Alan S. Maisel MD FACC Professor of Medicine, University of California, San Diego, Director, CCU and Heart Failure Program San Diego
More informationImproving outcomes in heart failure with reduced EF
Improving outcomes in heart failure with reduced EF Justin A. Ezekowitz, MBBCh MSc FRCPC FACC FESC FAHA Associate Professor, University of Alberta Co-Director, Canadian VIGOUR Centre Cardiologist, Mazankowski
More information