Heart Failure: How to Incorporate the Latest Guidelines Into Your Practice LESLIE L DAVIS, PHD, RN, ANP-BC, FAANP, FAHA ADULT NURSE PRACTITIONER ASSOCIATE PROFESSOR OF NURSING 1 Disclosures I have no disclosures relevant to this presentation. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 2 2 1
Topics to Cover ▪ Discuss implications of recent clinical practice guidelines of pharmacologic treatment of heart failure (HF) with reduced ejection fraction. ▪ Determine how to titrate optimal therapy using the most appropriate pharmacologic agents for treating adults with reduced ejection fraction. ▪ Review what circumstances would trigger a referral to a HF specialist. ▪ Share new tools available for clinicians who treat patients with HF THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 3 3 Definition: Heart failure with Reduced Ejection Fraction ▪ Clinical diagnosis of heart failure and a left ventricular ejection fraction of 40% or less ▪ Abbreviated as HFr HFrEF Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230 . THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 4 4 2
Established Therapies for Chronic HF • Angiotensin Converting Enzyme inhibitors (ACE-Is) • Angiotensin receptor blockers (ARBs) • Beta-blockers (only the ones approved) • Loop diuretics • Aldosterone antagonists • Hydralazine/isosorbide dinitrate (HYD/ISDN) • All ( except loop diuretics) have been shown to improve symptoms, reduce hospitalization, and/or help patients live longer. Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 5 5 New treatment Guidelines for Heart Failure with Reduced Ejection Fraction • Updated recommendations on biomarkers* • Two ne new med medicati tions for or pat patients ts with th HFr HFrEF* • Angi giot otens ensin n recep eptor or nepr prilysi sin n inhibi bitor or (ARN RNI) (sac acub ubitril/v /valsar sartan) n) • Sinoa oatrial node de modu dulator or (ivab abrad adine ne) • Info on heart failure with preserved ejection fraction (HFpEF) • Info on comorbidities including sleep apnea, anemia and hypertension • Insights regarding HF prevention *We will foc ocus us on the hese for r this pre resenta tati tion (abou bout t HF with th redu duced d EF) Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi: 10.1161/CIR.0000000000000509. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 6 6 3
Updated recommendations on biomarkers: PREVENTION • For patients at risk of developing HF, natr natriuretic pep peptide bi biomarker – base ba sed screening followed by team-based care (including a cardiovascular specialist optimizing GDMT) can be be us useful to pr prevent the de development t of left ventricular dysfunction (systolic or diastolic) or new onset HF. Includes B-type natriuretic peptide ( BNP ) or N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi: 10.1161/CIR.0000000000000509. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 7 7 Updated recommendations on biomarkers: DIAGNOSIS In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is us useful l to to su supp ppor ort t a diag diagnosis is or exclu lusio ion of f HF HF . Includes B-type natriuretic peptide ( BNP ) or N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi: 10.1161/CIR.0000000000000509. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 8 8 4
Updated recommendations on biomarkers: Prognosis • Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (unc ncha hanged ed from 2013) 13) • Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (mod odified) ed) • During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a post-discharge prognosis (new) • In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (mod modified ed) Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi: 10.1161/CIR.0000000000000509. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 9 9 Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 10 10 5
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 11 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment Writing Committee Clyde W. Yancy, MD, MSC, MACC, Chair James L. Januzzi, JR, MD, FACC, Vice Chair Larry A. Allen, MD, MHS, FACC Javed Butler, MD, MBA, MPH, FACC Leslie L. Davis, PHD, RN, ANP-BC Gregg C. Fonarow, MD, FACC Nasrien E. Ibrahim, MD, FACC Mariell Jessup, MD, FACC JoAnn Lindenfeld, MD, FACC Thomas M. Maddox, MD, MSC, FACC Frederick A. Masoudi, MD, MSPH, FACC Shweta R. Motiwala, MD J. Herbert Patterson, PHARMD Mary Norine Walsh, MD, FACC Alan Wasserman, MD, FACC Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 12 6
Treatment Algorithm for Guideline-Directed Medical Therapy Including Novel Therapies Excerpted from: Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure with Reduced Ejection Fraction December 2017 DOI: 10.1016/j.jacc.2017.11.025 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 13 Beta Blockers Drug Starting Dose Target Dose Bisoprolol 1.25 mg q day 10 mg q day Carvedilol 3.125 mg bid 25 mg bid (if wt < 85 kg); otherwise 50 mg bid Metoprolol succinate 12.5-25 mg q day 200 mg daily Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 14 14 7
ACE-I (some examples) Drug Starting Dose Target Dose Captopril 6.25 mg tid 50 mg tid Enalapril 2.5 mg bid 10- 20 mg bid Lisinopril 2.5-5 mg daily 20 - 40 mg daily Ramipril 1.25 mg q day 10 mg daily Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 15 15 ARBs (some examples) Drug Starting Dose Target Dose Candesartan 4 – 8 mg q day 32 mg daily Losartan 25 – 50 mg q day 150 mg daily Valsartan 40 mg bid 160 mg twice daily Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways . J Am Coll Cardiol 2018;71(2): 201-230. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 16 16 8
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