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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.

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LESLIE L DAVIS, PHD, RN, ANP-BC, FAANP, FAHA ADULT NURSE PRACTITIONER ASSOCIATE PROFESSOR OF NURSING

Heart Failure: How to Incorporate the Latest Guidelines Into Your Practice

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Disclosures

I have no disclosures relevant to this presentation.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

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

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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

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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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

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.

5 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

New treatment Guidelines for Heart Failure with Reduced Ejection Fraction

  • Updated recommendations on biomarkers*
  • Two ne

new med medicati tions for

  • r pat

patients ts with th HFr HFrEF*

  • Angi

giot

  • tens

ensin n recep eptor

  • r nepr

prilysi sin n inhibi bitor

  • r (ARN

RNI) (sac acub ubitril/v /valsar sartan) n)

  • Sinoa
  • atrial node

de modu dulator

  • r (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

  • cus

us on the hese for r this pre resenta tati tion (abou bout t HF with th redu duced d EF)

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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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Updated recommendations on biomarkers: PREVENTION

  • For patients at risk of developing HF, natr

natriuretic pep peptide bi biomarker– ba base 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)

  • r new onset HF.

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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.

Includes B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP)

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Updated recommendations on biomarkers: DIAGNOSIS

In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is us useful l to to su supp ppor

  • rt

t a diag diagnosis is

  • r exclu

lusio ion of f HF HF .

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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.

Includes B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP)

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

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

  • dified)

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)

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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 10 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

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

  • ptimization 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

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

Beta Blockers

Drug Starting Dose Bisoprolol 1.25 mg q day Carvedilol 3.125 mg bid Metoprolol succinate 12.5-25 mg q day Target Dose 10 mg q day 25 mg bid (if wt < 85 kg); otherwise 50 mg bid 200 mg daily

14 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

ACE-I (some examples)

Drug Starting Dose Captopril 6.25 mg tid Enalapril 2.5 mg bid Lisinopril 2.5-5 mg daily Ramipril 1.25 mg q day Target Dose 50 mg tid 10- 20 mg bid 20 - 40 mg daily 10 mg daily

15 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

ARBs (some examples)

Drug Starting Dose Candesartan 4 – 8 mg q day Losartan 25 – 50 mg q day Valsartan 40 mg bid Target Dose 32 mg daily 150 mg daily 160 mg twice daily

16 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Aldosterone Antagonists

Drug Starting Dose Eplerenone 25 mg q day Spironolactone 12.5 - 25 mg q day Target Dose 50 mg q day 25 – 50 mg q day

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  • New

ew recommen endatio ion: Aldosterone antagonists may reduce hospitalizations in some patients with HF HFpEF.

  • Important: Monitor kidney function and potassium within 2-3 days, again at 7 days

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

Vasodilators

Drug Starting Dose Target Dose Hydralazine 25 mg tid 75 mg tid Isosorbide DN 20 mg tid 40 mg tid_______ Fixed dose combo 20 mg/3.75 mg(one tab) tid 2 tabs tid

18 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Sacubitril/Valsartan (ARNI)

Indications

  • HFrEF (EF < 40%)
  • NYHA Class II or IV

Contraindications Cautions

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  • 1. 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.

  • 2. ENTRESTO [prescribing information]. East Hanover, NJ: Novartis

Pharmaceuticals Corp; November 2018. THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Sacubitril/Valsartain (ARNI)

Starting dose: 24/26 mg – 49/51 mg twice daily

  • When to start with lower dose
  • When to start with higher dose

Target dose: 97/103 mg twice daily

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Conversion of ACE-I to ARNI (*Sacubitril/valsartan)

  • Need 36-hour washout period of ACE-I to avoid angioedema
  • Would not need to do this if on an ARB
  • Ensure the patient has an adequate BP (contraindicated if symptomatic hypotension or

decompensated)

  • eGFR <30 mL/min/1.73 m2
  • Starting dose
  • If taking < 10 mg enalapril (or equivalent) start with 24/26 mg twice daily
  • If taking > 10 mg enalapril (or equivalent) start with 49/51 mg twice daily
  • Reassess in 2-4 weeks
  • If tolerates, up-titrate to 97/103 mg twice daily
  • Ongoing monitoring (BP, electrolytes/kidney function after initiation and each up

titration)

21 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Ivabradine

Indications:

  • HFrEF (EF < 35%)
  • On maximum tolerated doses of

beta-blocker

  • Sinus rhythm with resting HR of > 70 bpm
  • NYHA Class II or III HF

Contraindications Cautions

22 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.

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Ivabradine

Starting dose: 2.5 – 5 mg twice daily

  • Lower dose if hx of conduction defects or Age > 75

Target dose: titrate to heart rate 50-60 beats/per/minute. Maximum dose: 7.5 mg twice daily

23 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

Pearls for Starting Therapy

For new patients:

  • Starting ACE-I or ARBS = often better tolerated if

started when a little “wet”

  • Starting beta-blockers = often better tolerated if

started when a little “dry” (as long as heart rate is adequate)

  • Could start both (low doses)

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What’s the Role of Digoxin?

  • No survival benefit
  • When to start digoxin
  • Dosing is tricky, esp in patients with kidney

disease

25 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

HF with Preserved Ejection Fraction

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 clearance < 2.5 mg/dL, potassium < 5.0mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalization.

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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.

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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

Evaluation of the patient with heart failure

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

Triggers for HF Patient Referral to HF Program (or Specialist)

  • New onset HF
  • Chronic HF with high risk features
  • To assist with managing guideline directed medical therapy

(GDMT)

  • Persistently reduced LVEF (< 35%) despite GDMT for > 3

months

  • Need 2nd opinion
  • Annual review for established HF patients with advanced

disease

  • Participation in a clinical trial

28 Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for

  • ptimization of HF treatment: answers to 10 pivotal issues

about HF with reduced EF: a report of the ACC Task Force

  • n Clinical Expert Consensus Decision Pathways. J Am

Coll Cardiol 2018;71(2): 201-230.

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Case study

55-year-old male with HFrEF who has been seen in your HF clinic for past 6 months. PMH: Hx of 2 vessel coronary heart disease Last LVEF: 30% (after being on a stable dose of meds for ~4 months) Functional heart class: NYHA Class III Weight: 75 kg (euvolemic) Blood pressure 110/70 (lying & standing) HR 66 beats per min Labs: K+ 4.0, BUN 10, Creat 1.4 Current meds:

  • Ramipril 10 mg daily
  • Carvedilol 25 mg bid
  • Furosemide 40 mg bid
  • Spironolactone 25 mg bid

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Case study continued

Is he on guideline directed medical therapy (GMDT)? Are each of the meds at target dose? What other treatment could be added (since he remains symptomatic)?

  • Switch ACE-I to ARNI?
  • Add Ivabradine?
  • Add Hydralazine/Isosorbide dinitrate?

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New ACC Expert Consensus Decision Pathway Published 9/13/19 online ahead of print

Hollenberg SM, Stevenson LW, Ahmad T, et al. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure. J Am Coll Cardiol. Published online September 13, 2019. DOI: 10.1016/j.jacc.2019.08.001.

Focus on course of HF admission

  • 1st ED visit, hosp admission,

trajectory check, transition to

  • ral therapies, discharge, & 1st

discharge contact followed by 1st discharge visit Several algorithms, tables, worksheets Stresses communication:

  • Among team members, esp

surrounding hospital discharge

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Example of a Shared Decision-making Tool for ICDs (page 3 of 8) https://www.cardiosmart.

  • rg/SDM/Decision-

Aids/Find-Decision- Aids/ICD

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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

New Resources Avail: https://www.cardiosmart.org/MyHFActionPlan

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Other Tools to Use:

https://www.acc.org/tools-and-practice-support/quality- programs/succeed-in-managing-heart-failure-initiative

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Questions?

Leslie Davis LLDavis@email.unc.edu

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