Initiating New Medications in the Management of Heart Failure

Transcription

1 Initiating New Medications in the Management of Heart Failure Sandra Oliver-McNeil DNP, MSN, ACNP-BC, CHFN Associate Professor (Clinical) Wayne State University College of Nursing Objectives The participant will increase their knowledge of the role of ACE- Inhibitors, ARBs and ARNI in the treatment of HFrEF. The participant will be able to apply recognize the adverse outcomes of guideline medical therapy in the treatment HFrEF. The participant will be able to integrate the concepts of HFrEF management into their practice. 1

2 Physiology of Cardiac Output Normal physiology of fluid management 2

3 Review medication development 1970 Diuretics Digoxin 2018 Beta-blockers ACE-Inhibitor/ARB/ARNI Aldactone antagonist Hydralizine/Nitrates ICD, Biventricular pacemaker LVAD Home IV Inotrops Digoxin Stage C Structural heart disease with prior or current symptoms of HF Known structural heart disease AND Shortness of breath and fatigue Reduced exercise tolerance For all patients: Diuretics for fluid retention ACE-Inhibitor, Angiotension Receptor Blocker (ARB) or Angiotensin receptorneprilysin (ARNI) Beta-blocker Drugs selected patients: Aldosterone antagonist, Digitalis, Hydralazine/nitrates Evaluate for Device: ICD or biventricular pacemaker 3

4 Updated recommendations Yancy,C.W., Januzzi, J.L., Allen,L.A., et. Al. (2018) ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology. 71 (2) ; DOI: /j.jacc Focus of lecture Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology 4

5 Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology ARNI Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology 5

6 All patients should be started Ivabradine, the other new kid on the block Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology Guideline-Recommended Indications for ARNI HFrEF (EF <40%) NYHA class II or III Heart Failure 6

7 How does it work? Dosing Sacubitril/valsartan Low Dose Intermediate Dose Target Dose 7

8 Recommendation starting Sacubitril/Valsartan Population Moderate or high-dose ACE I (>10mg enalapril BID) or ARB (>80mg BID) Initial Dose 49mg/51mg BID Recommendation starting dose of Sacubitril/Valsartan Population Low dose ACEI (<10mg enalapril BID) or ARB (<80mg BID) ACE/ARB naive Severe renal impartment (egfr< 30ml/min/1.73m2) Moderate hepatic impairment (Child-Pugh Class B) Elderly (age > 75 years) Initial dose 24/26 mg BID 8

9 Contraindications MUST HAVE 36 hour wash out ACE-Inhibitor Risk of angioedema significantly higher when Sacubitril is combined with ACE- Inhibitor History of Angioedema with an ACE-Inhibitor or ARB Pregnancy Lactation Severe hepatic impairment (Child-Pugh C) Concomitant aliskiren use in patients with diabetes Known hypersensitivity to either ARB or ARNI Caution Renal impairment with egfr <30ml/min start low dose at 24mg/26mg BID and titrate every 2-4 weeks to reach target dose 97/103mg BID. Hepatic impairment Child-Pugh A no starting dose adjustment required. Child-Pugh B reduce starting dose to 24mg/26mg BID, titrate every 2-4 weeks to target dose. Renal artery stenosis Hypotension Volume depletion Hyponatremia Post myocardial infarction 9

10 Parameters Monitor BP May become hypotensive Decrease diuretic Decrease non-hf Guideline therapy (Calcium Channel Blocker) Electrolyte/renal instability Eliminate potassium supplement Restrict Potassium in food angiodedma Role of adjunct therapy 10

11 Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology Team based care: Essential Skills for HF Team Heart failure diagnosis and monitoring for progression Treatment prescription, titration, and monitoring Patient and caregiver education on disease and treatments Lifestyle (e.g diet, exercise)prescription, education and monitoring Psychological and social support assessment, treatment and monitoring Palliative and end-of-life counseling and care Coordination of care for concomitant comorbidities. 11

12 Clyde W. Yancy et al. JACC 2018;71: by American College of Cardiology 12