Updates on Heart Failure 2018 from Abbott, Amgen, AstraZeneca, - PowerPoint PPT Presentation

6/18/2018 Presenter Disclosure Information: UCSF Advances in Internal Medicine 2018 • Financial Disclosure – J.R. Teerlink has received research grants and/or consulting fees Updates on Heart Failure 2018 from Abbott, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Cytokinetics, Janssen, Medtronic, Novartis, Relypsa. John R. Teerlink, M.D. • Unlabeled/unapproved uses disclosure FACC, FAHA, FESC, FHFA, FHFSA, FRCP(UK) – I will be discussing investigational therapies that are not Professor of Clinical Medicine, approved by the FDA. University of California San Francisco Director of Heart Failure, San Francisco Veterans Affairs Medical Center San Francisco, CA, USA Welcome to UCSF… Heart Failure Evidence-base Home of Evidence-based Medicine! • 2013 ACC/AHA Heart Failure Guideline (Yancy CW, et al. J Am Coll Cardiol 2013;62:e147–239. 924 references ) • 2016 ACC/AHA Focused Update on New Pharmacological Therapy for Heart Failure (Yancy CW, et al. J Am Coll Cardiol 2016;68:1476-88. 40 references ) • 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (Yancy CW, et al. J Am Coll Cardiol 2017;70:776-803. 205 references ) 1

6/18/2018 Updates on Heart Failure 2018 Updates on Heart Failure 2018 • Definition, Nomenclature, Epidemiology Goal to: • Remind you of what you know you should be doing • Evaluation and Diagnosis • Discuss what you may not know that you should be • Treatment of Stages of Heart Failure doing • Co-morbidities • Share what you may be doing in the future • Future directions Updates on Heart Failure 2018 Heart Failure • HF is a complex clinical syndrome that results from any structural or • Definition, Nomenclature, Epidemiology functional impairment of ventricular filling or ejection of blood. • May result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels or from certain metabolic abnormalities, but most patients with HF have symptoms due to impaired left ventricular (LV) myocardial function. • No single diagnostic test for HF; a clinical diagnosis based on careful history and physical examination, supplemented by diagnostic studies. • Heart failure (not Congestive Heart Failure) 2

6/18/2018 Heart Failure with Reduced/Preserved Heart Failure: Here Comes Everybody Ejection Fraction (HFrEF and HFpEF) Benjamin EJ, et al. Circulation 2018;137:e67–e492. Yancy CW, et al. J Am Coll Cardiol 2013;62:e147–239. • Lifetime risk of developing HF is 20% for Americans 40 years of age • >1,000,000 new HF cases diagnosed annually • Approximately 6.5 million persons in the US have clinically manifest HF • Blacks have the highest risk for HF and a greater 5-year mortality rate than whites • Absolute mortality rates for HF remain approximately 40-50% within 5 years of diagnosis • Cost of heart failure in 2012: $71-$127 billion (Voigt J, et al. Clin Cardiol 2014 37, 5, 312–321.) ACCF/AHA Stages Stages of Heart Failure Compared to NYHA Functional Class Yancy CW, et al. J Am Coll Cardiol 2013;62:e147–239. Yancy CW, et al. J Am Coll Cardiol 2013;62:e147–239. 3

6/18/2018 Updates on Heart Failure 2018 Physical Exam in Heart Failure • Definition, Nomenclature, Epidemiology “First, strike for the jugular • Evaluation and Diagnosis and let the rest go” - Oliver Wendell Holmes, Jr. Natriuretic peptide Biomarker-based Diagnosis of Heart Failure Screening Yancy CW, et al. J Am Coll Cardiol 2017;70:776-803. • Physical Exam • Symptoms – Edema (Legs, Abd, Sacral) – Dyspnea (Exertional, – Rales, Effusion PND, Orthopnea) – JVP, HJR/AJR – Cough – Weight – Fatigue – Cool extremities – Abd discomfort – MR murmur (bloating, anorexia) – S3 (S4) – Sleep disturbances – Blood/ pulse pressure – Pulsus alternans 4

6/18/2018 St Vincent’s Screening to Prevent Heart Failure Indications for Use of Biomarkers in Heart Failure (STOP-HF) Study Ledwidge M, et al. JAMA 2013;310:66-74. Yancy CW, et al. J Am Coll Cardiol 2017;70:776-803. • 1374 participants with CV risk factors, ≥40 years and had a history of ≥1 of the following: Hypertension; Obesity; Hypercholesterolemia; Vascular disease; Diabetes mellitus; Arrhythmia requiring therapy; Moderate to severe Valvular disease. • Randomized to:  Usual care  BNP Screening. If BNP≥50, Echo and Collaborative Care Guiding Evidence Based Therapy Using Biomarker Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT) Intensified Treatment in Heart Failure (GUIDE-IT) • 894 (1100 planned) pts with HFrEF: Felker GM, et al. JAMA 2017;318:713-720. Felker GM, et al. JAMA 2017;318:713-720. Secondary Outcomes  LVEF ≤40%  h/o HF event within the prior 12 months,  NT-proBNP >2000 pg/mL or BNP >400 pg/mL within prior 30 days. • Randomized to:  NT-proBNP–guided strategy (n=446): HF therapy titrated with target NT- proBNP <1000 pg/mL.  Usual care (n=448): Intensive guideline-based care Primary endpoint: time-to-first HF hospitalization or cardiovascular mortality (stopped early for futility) 5

6/18/2018 Selected Potential Causes of Elevated CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III HF Patients (CHAMPION) Natriuretic Peptide Levels Yancy CW, et al. J Am Coll Cardiol 2017;70:776-803. Abraham WT, et al. Lancet 2011;377:658-66. • 550 pts with heart failure:  ≥18 years old  NYHA III for at least 3 months  Any LVEF  HF hospitalization within past 12 months,  On optimal GDMT • All patients implanted and take daily readings. Randomized to:  Physician access (n=270)  Usual care (n=280) Primary endpoint: rate of heart failure- related hospitalizations at 6 months CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Ambulatory Hemodynamic Monitoring Reduces Heart Failure Outcomes in NYHA Class III HF Patients (CHAMPION) Hospitalizations in “Real-World” Clinical Practice Abraham WT, et al. Lancet 2011;377:658-66. Desai AS, et al. J Am Coll Cardiol 2017;69:2357-65. • Retrospective cohort study, U.S. Medicare Cumulative HF-related Hospitalizations All-cause Death or HF-related Hospitalization claims data from patients undergoing pulmonary artery pressure sensor implant (June 1, 2014-December 31, 2015) • 1114 pts with full 6-month pre-implant data Pre-Implant 480 pts with full 12-month pre-implant data Post-Implant 6

6/18/2018 Stage A Heart Failure: Updates on Heart Failure 2018 “ When you ’ re a Hammer, Everything looks like a Nail! ” • Definition, Nomenclature, Epidemiology • Evaluation and Diagnosis • Treatment of Stages of Heart Failure Stages of Heart Failure Risk Factor Modification in HF • Weight loss • Smoking cessation • Hypertension therapies • Diabetes management • Lipid control • Sleep apnea • Exercise 7

6/18/2018 Stages of Heart Failure Essential Topics in Patient Education Dickstein K, et al. Eur Heart J 2008;29:2388-442. Treatment of Heart Failure with reduced Ejection Stages of Heart Failure Fraction (HFrEF) Stage C and D Yancy CW, et al. J Am Coll Cardiol 2017;70:776-803. 8

6/18/2018 Use of Diuretics in Use of Diuretics in Heart Failure Patients Heart Failure Patients-Redux • Self-titration: need “dry” weight on patient’s scale • Often increasing creatinine can be evidence of worsening heart failure, – Daily weights (routine; daily log with symptoms, etc.) elevated CVP and need for more diuretics – If weight increased by >3-5 lbs, take double diuretic • Furosemide’s poor bioavailability is worse in the setting of abdominal – If patient requires supplemental potassium, also double edema/ congestion. – If worsening at any time or no improvement after 2-3 days, call • Diuretic resistance may be treated with switch to bumetanide/ torsemide, • Some patients can be maintained on thiazides (i.e. HCTZ) metolazone, (or adding spironolactone). • Many patients will require loop diuretics; furosemide has short duration • Sequential nephron blockade with loop diuretic and metolazone very of action, should be dosed b.i.d. (AM and mid-afternoon/ early evening) effective for diuresis, but should be done VERY cautiously or by specialist • • Many patients may not require diuretics when ACE inhibitor, beta Frequent monitoring of electrolytes is imperative; HYPOkalemia is as dangerous as HYPERkalemia blocker, mineralocorticoid receptor antagonist, etc. are optimized; (maintain K + ≥4.0). reassess diuretic requirements after time on stable regimen Use of ACE Inhibitors in Importance of Afterload Reduction Heart Failure Patients • Indicated in potentially ALL pts with HF and EF≤40% • Some ACE Inhibitor is better than none • Start low dose, up-titrate q2 wks or so; check labs within 1-2 weeks of dose adjustment, then about q4 months • Asymptomatic low blood pressure: usually no change • Symptomatic Hypotension: Re-evaluate other meds (nitrates, diuretics, etc.); may improve with time (reassure); • Cough: Other causes, rechallenge, consider ARB • Worsening renal function: Increase in creatinine up to 50% above baseline is acceptable; K<5.5 • ARBs may be INFERIOR to ACEi in CHF/ • Sacubitril/Valsartan BETTER than ACEi 9