1/4/18. Heart Failure Guideline Review and Update. Disclosure. Pharmacist Objectives. Pharmacy Technician Objectives. What is Heart Failure?

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1 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, PharmD PGY1 Pharmacy Resident Avera McKennan Hospital Pharmacist Objectives Pharmacy Technician Objectives 1. Identify the symptoms associated with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) 2. Given a patient with HFrEF or HFpEF, explain the current guideline-based treatment options for mortality benefit and symptom relief 1. Select medications approved for use in patients with heart failure and identify their recommended dosages 2. Identify non-pharmacologic treatment options for patients with heart failure What is Heart Failure? Cardinal Symptoms of Heart Failure Chronic, progressive disease of the heart Any structural or functional impairment of ventricular filling or ejection of blood Approximately 6.5 million American adults currently live with heart failure Dyspnea Fatigue, leading to exercise intolerance Fluid retention Pulmonary and/or Splanchnic congestion and/or Peripheral edema 1

2 Heart Failure Classifications Functional Classification of Heart Failure Preserved Ejection Fraction (HFpEF) EF 50% Diastolic Heart Failure Symptoms: Pulmonary Edema Reduced Ejection Fraction (HFrEF) EF 40% Systolic Heart Failure Symptoms: Peripheral Edema ACCF/AHA Stages Development and progression of disease Stages A through D A. At risk, no structural disease or symptoms B. Structural disease without signs or symptoms C. Structural disease with prior or current symptoms D. Refractory disease requiring specialized interventions NYHA Exercise capacity and symptomatic status of disease Classes I-IV I. No limitation of physical activity II. Slight limitation of physical activity III. Marked limitation of physical activity IV. Unable to carry out any physical activity without symptoms, symptoms at rest Non-pharmacological Treatment Options Treatment Recommendations AHA Heart Failure Guidelines 2013 Sodium restriction <2 gram/day Fluid restriction L/day Especially in Stage D Activity 150 minutes of moderate activity/week Smoking Cessation Vaccinations Influenza Pneumococccal Stage A Stage B Heart healthy lifestyle Prevent vascular, coronary disease and left ventricular structural abnormalities Control co-morbid disease states: Hypertension Lipid disorders Obesity Diabetes Mellitus Avoid tobacco and cardiotoxic agents Drug therapy Vascular disease, diabetes mellitus, hypertension ACEI or ARB Statins Prevent heart failure symptoms Prevent further cardiac remodeling Drug Therapy All patients with HFrEF: Initiate ACEI or ARB Initiate beta blocker Cardiac history (MI or ACS) Initiate statin If the patient has structural cardiac abnormalities: Control blood pressure Avoid: Non-dihydropyridine calcium channel blockers 2

3 Stage C Goals of Therapy Stage C Drug Therapy Recommendations HFpEF Control symptoms Improve quality of life Prevent hospitalization Prevent mortality Strategies: Identification of comorbidities HFrEF Control symptoms Patient education Prevent hospitalization Prevent mortality HFpEF Diuresis for symptom relief Follow guideline driven indications for comorbidities Hypertension Atrial Fibrillation Coronary Artery Disease Diabetes Mellitus HFrEF Drugs for routine use: Diuretics ACEI or ARB Beta-blocker Aldosterone Antagonists Drugs for use in selected patients: Hydralazine/isosorbide dinitrate ACEI and ARB Digoxin Loop Diuretics ACE Inhibitors/Angiotensin Receptor Blockers Agents: Furosemide (Lasix) Bumetanide (Bumex) Torsemide (Demadex) Ethacrynic acid (Edecrin) Use in heart failure: Decrease fluid volume Used only for symptom control No morbidity or mortality benefit Use lowest effective dose Adverse effects: Decreased potassium, magnesium, calcium, chloride Increased uric acid levels Photosensitivity Monitoring Renal function Electrolytes Fluid status Blood pressure ACE Inhibitors Agents: Lisinopril mg once daily Enalapril mg BID Ramipril 5 mg BID or 10 mg daily Captopril mg TID (max 450 mg/day) ARBs Agents: Valsartan 160 mg BID Losartan 150 mg daily Candesartan 32 mg once daily ACE Inhibitors/Angiotensin Receptor Blockers Beta-Blockers Reduction in morbidity and mortality Decrease in preload and afterload due to their effects on the renin-angiotensin aldosterone system Angioedema Cough (ACEI only) Hyperkalemia Hypotension Blood pressure Potassium Renal function Agents Metoprolol Succinate (Toprol XL) Goal dose: 200 mg daily Bisoprolol (Zebeta) Goal dose: 10 mg daily Carvedilol (Coreg) Goal dose: 25 mg BID Proven reduction in morbidity and mortality Help improve cardiac function Bradycardia Hypotension Fatigue Dizziness Heart Rate Blood Pressure 3

4 Aldosterone Antagonists Hydralazine/Isosorbide Dinitrate Agents: Spironolactone 25 mg once or twice daily Eplerenone 50 mg daily Morbidity and mortality reduction Increase serum and water excretion Hyperkalemia Elevated SCr Dizziness Gynecomastia Spironolactone only Potassium SCr, BUN, fluid status Guideline recommendations: Alternative for patients who cannot tolerate and ACEI or ARB In addition to an ACEI or ARB in African-American patients with HFrEF NYHA class III-IV HFrEF Morbidity and mortality reduction Dosing: Fixed combination dose: Isosorbide dinitrate 40 mg/hydralazine 75 mg TID Separate dosing: Isosorbide dinitrate 40 mg TID with hydralazine 100 mg TID Digoxin Stage D Used for symptom management No morbidity or mortality benefit Loading dose not required in heart failure Goal level: ng/ml Side effects: Bradycardia, dizziness, nausea, vomiting, diarrhea, vision changes Heart rate, blood pressure, electrolytes, renal function Control symptoms Improve quality of life Reduce hospital readmissions Establish patient s end-of-life goals Options: Water restriction L/day Advanced care measures Heart transplant Chronic inotropes Experimental surgery or drugs Losartan/sacubatril (Entresto) Guideline Updates 2017 ACC/AHA/HFSA Focused Update Mechanism: ARNI (Angiotensin Receptor Neprilysin Inhibitor) Angiotensin receptor blockade antagonizes vasoconstriction and aldosterone release Neprilysin inhibition prevents the breakdown of BNP, thus increasing natriuretic peptides Dosing: Dosage form: Oral tablet (Sacubatril-valsartan): 24 mg-26 mg; 49 mg-51 mg; 97 mg-103 mg Dosing is based on previous ACEI/ARB dose Ensure 36 hour washout period if previously on an ACEI or ARB Titrate to maintenance dose of 97 mg-103 mg twice daily Hypotension, hyperkalemia, dizziness, angioedema BBW: Fetal injury or death; discontinue in pregnancy 4

5 Losartan/sacubatril (Entresto) Ivabradine (Corlanor) Clinical evidence: PARADIGM-HF Entresto vs. moderate dose enalapril Results: Losartan/sacubatril significantly decreased mortality and symptoms/hospitalizations Place in therapy: The clinical strategy of the renin-angiotensin system with ACE inhibitors OR ARBs OR ARNI in conjunction with evidence-based beta blockers and aldosterone antagonists in selected patients is recommended for patients with chronic HFrEF to reduce morbidity and mortality. In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate and ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality Mechanism: Selective inhibition of the I f current in the SA node leading to reduced heart rate Dosing: Initial: 5 mg po BID Dose adjust based on heart rate with goal heart rate between bpm Maximum dose of 7.5 mg po BID Atrial fibrillation, bradyarrhythmias, luminous phenomena Ivabradine (Corlanor) Pharmacist Post-Test Questions Place in therapy: Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF who are receiving guideline-directed management and therapy, 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. 1. Which of the following is/are symptom(s) of HFrEF? a. Peripheral Edema b. Weakness and fatigue c. Dyspnea d. All of the above Pharmacist Post-Test Questions Pharmacy Technician Post-Test Questions 2. Which of the following drugs has been shown to reduce mortality in patients with HFrEF? a. Furosemide b. Ivabradine c. Metoprolol succinate d. Digoxin 1. What is the brand name of the combination product losartan/sacubatril that has been approved for use in heart failure? a. Vasotec b. Hyzaar c. Entresto d. Cozaar 5

6 Pharmacy Technician Post-Test Questions 2. Which of the following non-pharmacologic, lifestyle modifications can a patient make per guideline recommendations? Questions? a. Smoking cessation b. Sodium restriction c. Fluid restriction d. All of the above References Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Colvin MM, et al 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 gask force on clinical practice guidelines and the heart failure society of america. Circulation 2017; CIR Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al ACCF/AHA guideline for the management of heart failure: executive summary, a report of the american college of cardiology foundations/american heart association task force on practice guidelines. JACC 2013; 62 (16):