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: NETWORK: EC-CTR PASSWORD: westgate252 Add Event Logo if exists 1
Mark Your Calendar: Insert Future Event Logos Disclosure Heidi Burres, PharmD, BCACP reports no actual or potential conflicts of interest associated with this presentation Learning Objectives Upon successful completion of this activity, pharmacists should be able to: Describe new heart failure medications and their place in therapy. Apply treatment guidelines to a patient case. 2
HFrEF vs HFpEF DE, McMurray JJV, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL, 2013 ACCF/AHA Guideline for the Management of Heart Failure, Journal of the American College of Cardiology (2013), doi: 10.1016/j.jacc.2013.05.019. Heart Failure Classifications DE, McMurray JJV, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL, 2013 ACCF/AHA Guideline for the Management of Heart Failure, Journal of the American College of Cardiology (2013), doi: 10.1016/j.jacc.2013.05.019. DE, McMurray JJV, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL, 2013 ACCF/AHA Guideline for the Management of Heart Failure, Journal of the American College of Cardiology (2013), doi: 10.1016/j.jacc.2013.05.019. 3
New Medications Entresto (sacubitril/valsartan) Fixed-dose combination of neprilysin inhibitor and ARB MOA neprilysin inhibitor Counters neurohormonal overactivation Indication Reduce the risk of CV death and hospitalization for HF in patients with chronic HF (NYHA class II-IV) and reduced EF McMurray J, et al. Angiotensin-Neprilysin Inhibition vs Enalapril in Heart Failure. N Engl J Med 2014; 371: 993-1004. Entresto prescribing information New Medications Entresto (sacubitril/valsartan) Concerns Need washout period of 36 hours between ACE-I and sacubitril/valsartan à high risk of angioedema when neprilysin inhibitor is used with ACE-I Clinical Pearl Can increase BNP levels, no impact on NTproBNP McMurray J, et al. Angiotensin-Neprilysin Inhibition vs Enalapril in Heart Failure. N Engl J Med 2014; 371: 993-1004. Entresto prescribing information New Medications Corlanor (ivabradine) MOA Reduces spontaneous pacemaker activity of sinus node by selectively inhibiting the I f current Indication Reduce the risk of hospitalization of worsening HF in patients with stable, symptomatic, chronic HF with LVEF 35% who are in NSR with resting HR 70bpm and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use Swedberg K et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010; 376: 875-85. Corlanor prescribing information 4
New Medications Corlanor (ivabradine) Concerns May increase the risk of A. Fib Phosphenes à transient brightness in limited area of visual field Swedberg K et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010; 376: 875-85. Corlanor prescribing information 120 HF Studies NNT - All Cause Mortality 100 100 80 60 NNT 40 22 22 33 25 36 20 0 SOLVD-T US Carvedilol EMHASIS A-HeFT SHIFT PARADIGM Enalapril vs Placebo Carvedilol vs Placebo Eplerenone vs Placebo ISDN/ Hydralazine vs. Placebo Ivabradine vs Placebo Sacubitril/ valsartan vs Enalapril Guidelines 2013 ACCF/AHA Guidelines for the Management of Heart Failure May 2016 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure 2016 ESC Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure 5
Guideline Recommendations on New Medications Recommendations only made for patients with Stage C HF: Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos G, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134: Guideline Recommendations on New Medications Continued Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos G, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134: Patient Case #1 AB is a 60 yo female with a diagnosis of HF. Her most recent EF was 55-60%. She s currently taking atenolol 100mg daily, lisinopril 40mg daily and furosemide 20mg daily. She monitors her weight daily and it has been stable. She closely monitors her sodium intake. Her BP in clinic today is 150/86mmHg, pulse is 80bpm. Electrolytes are WNL and she is not c/o sx of HF. 6
Patient Case #1 Which of the following would you recommend? 1) Change atenolol to carvedilol 2) Change atenolol to metoprolol tartrate 3) Add spironolactone Patient Case #2 CD is a 65 yo male with a diagnosis of HF. His most recent EF was 30%. He s currently taking carvedilol 12.5mg BID, lisinopril 40mg daily, furosemide 20mg daily, and spironolactone 25mg daily. He c/o ongoing edema and SOB with activity. His weight is overall stable, and he monitors his sodium intake closely. He s not taking any other offending agents. His BP is 130/76mmHg and pulse is 70bpm. Patient Case #2 What would you recommend? How would you implement the plan? 7
Questions? Heidi Burres, PharmD, BCACP hschult4@fairview.org 8