Optiminsation after ADHF
- 1. Treatment optimization for stabilized ADHF patient
- 2. • Nearly 44% of all HF patients are readmitted for any cause within 1 year after discharge • Thirty day re-admission rates are >25% • Mortality during readmission period - up to 10% • Hospitalisation for HF worsens the prognosis for HF patients • The hospital is a safe environment for optimising chronic HF therapy and provides an opportunity to set the patient on the right path • Treatment optimization following discharge is essential to prevent readmission
- 3. Criteria to discharge Exacerbating factors addressed Near optimal volume status observed Transition from intravenous to oral diuretic successfully completed No intravenous vasodilator or inotropic agent for 24 hours Left ventricular ejection fraction (LVEF) documented Smoking cessation counseling initiated Near optimal pharmacologic therapy achieved, including ACE inhibitor/ARNI and beta blocker (for patients with reduced LVEF), or intolerance documented Follow-up clinic visit scheduled, usually for 7 to 10 days Evaluation and management of patients with acute decompensated heart failure. J Card Fail 2010;
- 4. Diuretics • It is often difficult to predict an effective outpatient diuretic regimen • Convert from intravenous to oral diuretics two or more days prior to discharge • Education about salt and fluid restriction
- 5. ARNI • Relatively newer drug in the armamentarium of HFrEF therapy • Available drug Sacubitril-Valsartan • PARADIGM HF trial • PIONEER trial PARADIGM-HF McMurray JJ, et al. N Engl J Med 2014;371:993-1004 PIONEER HF N Engl J Med 2019; 380:539-548
- 6. 0 15 30 CV death or hospitalization for heart failure PARADIGM-HF • CV death or hospitalization for heart failure: 21.8% of LCZ696 group vs. 26.5% of the enalapril group (p < 0.001) • CV death: 13.3% vs. 16.5% (p < 0.001), respectively • Hospitalization for HF: 12.8% vs. 15.6% (p < 0.001), respectively Trial design: Participants with NYHA class II-IV and LVEF ≤40% were randomized to LCZ696 200 mg twice daily (n = 4,187) vs. enalapril 10 mg twice daily (n = 4,212). Results Conclusions • Among participants with reduced EF and NYHA class II-IV symptoms, the use of LCZ696 was beneficial compared with enalapril • LCZ696 was associated with a reduction in CV death or hospitalization for heart failure McMurray JJ, et al. N Engl J Med (p < 0.001) LCZ696 200 mg twice daily 21.8 26.5 Enalapril 10 mg twice daily %
- 9. ARNI • For patients hospitalized with acute HF: BNP level ≥400 pg/mL or NT- proBNP ≥1600 pg/mL during current hospitalization • ●Systolic blood pressure (SBP) ≥100 mmHg • ●Estimated glomerular filtration rate ≥30 mL/min/1.73 m2 • No h/o angioedema • ARNI can be initiated as a component of initial therapy for HFrEF ,including during hospitalization for acute HF after hemodynamic stabilization PIONEER HF N Engl J Med 2019; 380:539-548
- 10. • Hemodynamic stability is defined as a • Systolic blood pressure (SBP) ≥100 mmHg for the preceding six hours, • No intravenous vasodilators and • No increase in dose of intravenous diuretics in the preceding six hours, and • No intravenous inotropes in the preceding 24 hours (PIONEER HF) PIONEER HF N Engl J Med 2019; 380:539-548
- 11. PIONEER HF sacubitril/valsartan enalapril vs In-hospital initiation Hospitalized with ADHF (HFrEF) Stabilized Evaluate biomarker surrogates of efficacy Evaluate safety and tolerability Explore clinical outcomes Titration algorithm over 8 weeks
- 12. Primary Endpoint: % Change in NT-proBNP 29% greater reduction with sacubitril/valsartan CI 19%, 37%; P < 0.0001 10 0 –10 –20 PercentChangefromBaseline –30 –40 –50 –60 –70 Week since Randomization Baseline 1 2 3 4 5 6 7 8 enalapril sacubitril/valsartan
- 13. sacubitril/ valsartan (n=440) enalapril (n=441) HR P-value Serious Composite, % 9.3 16.8 0.54 0.001 Death, % 2.3 3.4 0.66 0.311 Re-hosp for HF, % 8.0 13.8 0.56 0.005 LVAD, % 0.2 0.2 0.99 0.999 Cardiac Transplant, % 0 0 - - Expanded Composite*, % 56.6 59.9 0.93 0.369 Unplanned IV diuretics, % 0.5 0.5 0.99 0.997 Addition of HF med, % 17.7 19.1 0.92 0.58 >50% diuretic increase, % 49.6 50.3 0.98 0.812 Exploratory Clinical Endpoints *Serious composite + addition of HF med, no unplanned outpatient IV diuretics or >50% increase in dose
- 15. ACEI • Symptomatic improvement, reduced hospitalization, and enhanced survival in patients with heart failure with reduced ejection fraction • One suggestion is to check serum electrolytes and renal function at one week and at one month following increases in ACE inhibitor dose • Initiate ACE inhibitor or ARNI therapy prior to beta blocker therapy CONSENSUS Trial Study Group N Engl J Med. 1987;316(23):1429 SOLVD N Engl J Med. 1992;327(10):685
- 16. Beta Blockers • Used cautiously in patients with decompensated HFrEF because of the potential to worsen acute HF • Beta blockers are started at low doses and are generally started later than ACE inhibitors or ARBs, when the patient is euvolemic, usually shortly before discharge • Particular caution is indicated in patients who have required inotropes during their hospitalization
- 17. • Patients with HFrEF with no or minimal current evidence of fluid retention should be treated with one of the following three beta blockers: carvedilol (immediate release or extended release), extended release metoprolol succinate, or bisoprolol • During the first year, it was estimated that beta blocker therapy saved 3.8 lives per 100 patients treated and was associated with four fewer hospitalizations per 100 patients treated Beta-blockers in congestive heart failure. A Bayesian meta-analysis
- 18. • The hemodynamic benefits of beta blockers are delayed (and there may be a transient worsening in cardiac function when therapy is initiated
- 19. • Start with a low oral dose of an ACE inhibitor (Ramipril 1.25 mg/day )or ARNI (24 mg of sacubitril with 26 mg of valsartan twice daily), increase to a moderate dose (eg, Ramipril 5 mg/day or 49 mg of sacubitril with 51 mg of valsartan twice daily) at one- to two-week intervals, and then begin a beta blocker, gradually increasing toward the target dose • When the beta blocker titration is completed, the ACE inhibitor or ARNI titration is completed
- 20. • Complications that develop during dose titration of the beta blocker should be treated • For example, the diuretic dose should be increased for fluid overload • Hypotension can occur with carvedilol than metoprolol • If hypotension with Carvedilol consider switching to metoprolol
- 21. Mineralocorticoid receptor Antagonist • In addition to ACEI/ARNI/ ARB • NYHA functional class II HF and an left ventricular ejection fraction (LVEF) ≤30 percent • NYHA functional class III to IV HF and an LVEF <35 percent • Post-ST elevation myocardial infarction, have an LVEF ≤40 percent, and have either symptomatic HF or diabetes mellitus PITT et al N Engl J Med. 1999;341(10):709 EPHESUS J Am Coll Cardiol. 2005;46(3):425