Congestive 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 for symptomatic heart failure is more than beta blockers and ACE-inhibitors or ARBs. Effective outpatient management involves persistent heart failure education to the patient and their family. Cardiology co-management is beneficial in outpatient heart failure management.

Take Home Points Spironolactone Torsemide and bumetanide Think beyond the salt shaker Cardiology co-management

Epidemiology Your patients have heart failure People die (a lot) from heart failure Heart failure management is crazy expensive

Definitions Classification Heart Failure with Reduced Ejection Fraction (HFrEF) Heart Failure with Preserved Ejection Fraction (HFpEF) Ejection Fraction Description 40% AKA systolic HF Only in these patients that efficacious therapies have been demonstrated to date 50% AKA diastolic heart failure To date, efficacious therapies have not been identified HFpEF, borderline or HFmrEF 41% to 49% Borderline or intermediate group. Characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF

Classification A B C D ACC/AHA Stages of HF At high risk for HF but without structural heart disease or symptoms of HF. Structural heart disease but without signs or symptoms of HF. Structural heart disease with prior or current symptoms of HF. Refractory HF requiring specialized interventions. None I I II III IV NYHA Functional Classification No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

Initial Evaluation History and Physical ECG CXR CBC, CMP, Mg++, TSH, Ferritin BNP (NT-proBNP) Echocardiogram Yancy CW, et al. JACC. 2013;62(16):1495-1539.

B-type Natriuretic Peptide Specificity with BNP > 400 BNP- or NT-proBNP guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients followed in a well-structured HF disease management program. The usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patients with HF is not well established. Maisel AS et al. N Engl J Med. 347 2002:161-167.

HFrEF Goal Directed Medical Therapy

HFrEF Stage A I IIa IIb III Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF. I IIa IIb III Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided. Yancy CW, et al. JACC. 2013;62(16):1495-1539.

HFrEF Stage B Recommendations COR LOE In patients with a history of MI and reduced EF, ACE inhibitors or ARBs should be used to prevent HF I A In patients with MI and reduced EF, evidence-based beta blockers should be used to prevent HF I B In patients with MI, statins should be used to prevent HF I A Blood pressure should be controlled to prevent symptomatic HF ACE inhibitors should be used in all patients with a reduced EF to prevent HF Beta blockers should be used in all patients with a reduced EF to prevent HF An ICD is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 d post-mi, have an LVEF 30%, and on GDMT Certain calcium channel blockers (verapamil, diltiazem) may be harmful in patients with low LVEF I I I IIa III: Harm A A C B C Yancy CW, et al. JACC. 2013;62(16):1495-1539.

HFrEF Stage C HFrEF Stage C NYHA Class I IV Treatment: Class I, LOE A ACEI or ARB AND Beta Blocker For all volume overload, NYHA class II-IV patients For persistently symptomatic African Americans, NYHA class III-IV For NYHA class II-IV patients. Provided estimated creatinine >30 ml/min and K+ <5.0 meq/dl Add Add Add Class I, LOE C Loop Diuretics Class I, LOE A Hydral-Nitrates Class I, LOE A Aldosterone Antagonist Yancy CW, et al. JACC. 2013;62(16):1495-1539.

Evidence GDMT RR Reduction in Mortality NNT for Mortality Reduction (Standardized to 36 mo) RR Reduction in HF Hospitalizations ACE inhibitor or ARB 17% 26 31% Beta blocker 34% 9 41% Aldosterone antagonist 30% 6 35% Hydralazine/nitrate 43% 7 33% Yancy CW, et al. JACC. 2013;62(16):1495-1539.

Diuretics Loop Diuretics (1C) Lasix 20-40mg daily/bid (max 600mg) Torsemide* 10-20mg daily/bid (max 200mg) Bumetanide* 1-2mg daily/bid (max 10mg) Yancy CW, et al. JACC. 2013;62(16):1495-1539. * Longer t 1/2 and/or bioavailablity

Aldosterone Antagonist (Efficacy vs. effectiveness) COMPARE-HF N=5887 Medicare Claims 2005-2010 Side Effects: Hyperkalemia Risk of K + with ( NNH-23 ) GFR < 60 DM2 ACE-I or ARB Gynecomastia Hernandez AF et al. JAMA. 2012; 308(20):2097-2107.

Starting spironolactone ACC/AHA Class C HFrEF patients Cr < 2.5 K < 5 Check BMP in 2 and then 6 weeks Document

PARADIGM-HF Valsartan-sacubitril (Entresto) N=8442, LVEF < 40% and NYHA II-IV Study 200mg BID vs. Enalapril 10mg BID Excluded Hypotension (SBP < 100) GFR < 30 K + > 5.2-5.4 Angioedema

Valsartan-Sacubitril Yancy CW, et al. JACC. 2017;1137(6).

Treatment Odds and Ends Sacubitril/valsartan Ivabradine Digoxin Nutritional Supplementation Adjunctive statins

HFpEF Yancy CW, et al. JACC.

HFpEF Diastolic HF Complex patients Advanced Age Multiple Comorbidities HTN, DM2, CAD, PAD, AFIB, CKD, OSA Volume sensitive Dyspnea is a difficult symptom to quantify Difficult to prove incremental benefit

HFpEF Recommendations COR LOE Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines I B Diuretics should be used for relief of symptoms due to volume overload Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic HF Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF ARBs might be considered to decrease hospitalizations in HFpEF Nutritional supplementation is not recommended in HFpEF I IIa IIa IIa IIb III: No Benefit C C C C B C

HFpEF and Spironolactone 2017 Targeted Update IIb B-R In appropriately selected patients with HFpEF (with EF 45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 ml/min, creatinine <2.5 mg/dl, potassium <5.0 meq/l), aldosterone receptor antagonists might be considered to decrease hospitalizations. NEW: Current recommendation reflects new RCT data. CAVEAT: SUBGROUP ANALYSIS SUGGGESTS THERAPY MAY ONLY BENEFIT WOMEN Yancy CW, et al. JACC. 2017;1137(6).

Non-Pharmacologic Management

The No Added Salt Cop-Out

Non-Medical Interventions Daily weights Call for 2lb/day or 5lb/week CLOSE FOLLOW-UP Sleep disorders Cardiac Rehab

Cardiology Co-Management Initial work-up & continuity of care Change in functional status Serial evaluations ICD and Cardiac Resynchronization Therapy (CRT-D/P) Advanced heart failure evaluation and referral

Advanced HF Device Therapy ICD: LVEF < 35% on Med Rx +/- revascularization Bi-V pacing: LVEF < 35%, NYHA II-IV, LBBB Stage D HF Ventricular Assist Device Cardiac Transplantation Palliative Care Hospice

LVAD 1 year survival for LVAD DT now 80-90% Rose EA et al. N Engl J Med 2001; 345:1435-1443

Cardiology Co-Management Initial work-up & continuity of care Change in functional status Serial evaluations ICD and Cardiac Resynchronization Therapy (CRT-D/P) Advanced heart failure evaluation and referral Not all dyspnea is heart failure

Thank you E. Philip Lehman MD, MPP