RAAS blocker + B Blocker Troubleshooting

Transcription

1 RAAS blocker + B Blocker Troubleshooting Heart Failure ECHO Clinic Virtual Heart Failure Consultation and Education Prof Ken McDonald & Dr. Patricia Campbell 13 th March 2017

2 HF activates 3 neurohormonal systems Sympathetic nervous system Natriuretic peptide system NPRs NPs Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy HF SYMPTOMS & PROGRESSION Epinephrine Norepinephrine Renin-angiotensinaldosterone system Ang II α 1, β 1, β 2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility AT 1 R Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis Levin et al. N Engl J Med 1998;339:321 8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27 42 Kemp & Conte. Cardiovascular Pathology 2012; Schrier & Abraham. N Engl J Med 2009;341:577 85

3 HFrEF Triple Therapy Standard ESC HF Guidelines Eur J Heart Fail Aug;18(8):

4 Evolution of therapy in HF: Sacubitril/Valsartan as a new alternative to an ACEI or ARBs in patients with HFrEF 1 SNS β-blockers NP system Neprilysin inhibitors HF SYMPTOMS & PROGRESSION Epinephrine Norepinephrine α 1, β 1, β 2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility NPRs NPs Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy INACTIVE FRAGMENTS LCZ696 RAAS Ang II AT 1 R Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis RAAS inhibitors (ACEI, ARB, MRA) LCZ696: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression 1. McMurray et al. Eur J Heart Fail 2013;15: Figure references: Levin et al. N Engl J Med 1998;339:321 8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27 42 Kemp & Conte. Cardiovascular Pathology 2012; Schrier & Abraham. N Engl J Med 2009;341:577 85

5 Further RAAS adjustments if ongoing issues ESC HF Guidelines Eur J Heart Fail Aug;18(8):

6 Dose matters Kidney + Heart Rate + BP also matter Ensure ACEi/ARB (ARNI) and B-blocker maximally uptitrated max dose max tolerated ACEi by BP/renal function B-blocker by BP/HR K+ level and creatinine Initiation and 2/52 after ACEi/ARB (ARNI) dose

7 Issues with ACEi + B-blocker ACEI Cough ARB Angioedema cross effect on ARB, alternative hydralazine/nitrate combination Renal dysfunction anticipate rise in creatinine (<20%), reflects beneficial effect on renal hemodynamics B-blocker Mild symptom exacerbation can happen (uncommon, not cause for alarm) Only exacerbates most brittle asthma or COPD Fatigue typically short lived, tolerable Symptomatic bradycardia

8 How to start MRA Start low and go slow! 12.5mg to start Up-titration after 4 weeks Check K+ at 1-2 weeks after starting/dose change Once stable rechecking U+E recommended 3 month intervals for a year Then 6 monthly If K+ >5.5mmol/l or creatinine >200umol/l = half dose If K+ >6mmol/l or creatinine>250umol/l = stop

9 Medications to watch out for Advice to patient K+ sparing diuretics e.g. Frumil NSAIDs Trimethoprim prophylaxis for UTI Low salt substitutes with high K+ content Months to notice change in symptoms (if any) Avoid OTC NSAIDS If diarrhoea and vomiting stop MRA If gynaecomastia on spironolactone switch to eplerenone

10 Add on medications B-blocker max tolerated, HR still >70 Ivabradine B-blocker max tolerated, AF rates poorly controlled Digoxin HTN, requiring high dose diuretics Nitrates

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12 Thank you for your participation To apply for the CME Certification: Return signed CME form to: Ms Lisa McCudden