heart failure care: managing modern era of gdmt failure care gdmt อ_ภู...2013 accf/aha...

Heart Failure Care: Managing Modern Era of GDMT

Assist Prof. Poukwan Arunmanakul MSc (Clinical Pharmacy), PharmD, BCPS

Pharmaceutical Care Department

Chiang Mai University

Goal of Medical Treatment in HF care

97 YO HF patient. Old anterior wall MI with apical aneurysm, Severe LV systolic dysfunction

Definitions

• HFrEF: Clinical diagnosis of HF and LVEF ≤40%.

• GDMT: Guideline-directed medical therapy

• Optimal therapy: Treatment provided at either the target or the highest-tolerated dose for a given patient

• Target dose: Doses targeted in clinical trials

European Heart Journal, Volume 37, Issue 27, 14 July 2016

Evidence-based doses of disease-modifying drugs in heart failure with reduced ejection fraction


The Progress and Complexity of Heart failure Treatment

RAAS blockades and Beta-blocker in all patients, mineralocorticoid antagonist

Hydralazine-Isosorbide mononitrate, Ivabradine, digoxin

NYHA class I NYHA Class II-III (Previously or current) NYHA Class IV

Yancy et al. JACC 71 (2) 201-230; 2017

Pivotal issue in HFrEF

• 1.How to initiate, add, or switch therapy to new evidence-based guideline-directed treatments for HFrEF

• 2. How to achieve optimal therapy given multiple drugs for HF (including augmented clinical assessment that may trigger additional changes in guideline-directed therapy)

Yancy et al. JACC 71 (2) 201-230; 2017

57 YO M with Ischemic DCM

• Multiple readmission in 2015 with NSTEMI, ADHF

• CAG 3/7/2015: TVD • Dyslipidemia, Type II

DM, CKD • NYHA class II

Left main: normal LAD: proximal stenosis 70%, long lesion, mid stenosis LCX: Mid stenosis 50% RCA: dominant, proximal occluded, collateralized from LAD

Initial Phase 57 YO M with Ischemic DCM

3/7/2015 BP 92/60 (symptomatic)

HR 81

EF 16%

Scr 2.03

K 4.0

Beta-blockers ?

ACEI ?

MRA ?

Diuretic Furosemide 40 mg 2-2-0

Other medication

ASA, Clopidogrel, Nitrate, Atorvastatin

Medical Therapy for Stage C HFrEF

2013 ACCF/AHA Guideline for the Management of Heart Failure

Yancy et al. JACC 71 (2) 201-230; 2017

Initial Phase 57 YO M with Ischemic DCM

3/7/2015 BP 92/60 (symptomatic)

HR 81

EF 16%

Scr 2.03

K 4.0

Beta-blockers Carvedilol 6.25 mg ¼ x 2

ACEI wait

MRA Spironolactone 25 mg 1x1


Other medication

ASA, Clopidogrel, Nitrate, Atorvastatin

Starting and Target Doses of Select Guideline-Directed Medical Therapy for HF

• HF is a complex syndrome typically associated with multiple comorbidities; most patients are on multiple medications.

• To assess tolerability of medications and best assess the trajectory of HF, it is often necessary for patients to have more frequent follow-up, especially after initiation or titration of therapy.

Titration Phase 57 YO M with Ischemic DCM

3/7/2015 18/7/2015 BP 92/60 (symptomatic) 95/67

HR 81 78

EF 16% -

Scr 2.03 1.75

K 4.0 4.2

Beta-blockers Carvedilol 6.25 mg ¼ x 2 ?

ACEI wait ?

MRA Spironolactone 25 mg 1x1 ?


?

Other medication ASA, Clopidogrel, Atorvastatin

ASA, Clopidogrel, Atorvastatin

Titration Phase 57 YO Male with Ischemic DCM

3/7/2015 18/7/2015 BP 92/60 (symptomatic) 95/67

HR 81 78

EF 16% -

Scr 2.03 1.75

K 4.0 4.2

Beta-blockers Carvedilol 6.25 mg ¼ x 2 Carvedilol 6.25 mg ¼ x 2

ACEI wait Enalapril 5 mg ½ x 2

MRA Spironolactone 25 mg 1x1 Spironolactone 25 mg 1x1


Furosemide 40 mg 1-0-0 + flexible diuretic

regimen


ASA, Clopidogrel, Atorvastatin

Digoxin was added to help control heart rate

The most important tool in HF management

Self daily weight monitoring :

If weight increases > 1 kg within 1 or 2 days

double the dose of diuretics , until returns to ideal BW

• Weigh every morning

• After going to toilet

• Before getting dressed

• Before breakfast

Property Furosemide Bumetanide Torsemide

Bioavailabilty (%) 10-90 (average 50)

80-100 80-100

Affect by food Yes ( AUC 30-40%)

Yes No

Metabolism 50% renal conjugation

50% hepatic 80% hepatic

Half life (hr) Normal Renal dysfunction Hepatic dysfunction Heart failure

1.5-2 2.8 2.5 2.7

1

1.6 2.3 1.3

3-4 4.5 8 6

Onset (min) Oral iv

30-60

5

30-60

2-3

30-60

unavailable

Duration 7 4-6 12-16

Start dose (iv) mg 40-80 1-2 10-20

Dose equivalent 40 20 1

Pharmacokinetic of loop diuretic

Ann Pharmacolher 2009;43:1836-47., https://www.radcliffecardiology.com/articles/diuretic-therapy-heart-failure-current-approaches

Change in Diuretic regimen (2 weeks later)

57 YO M with Ischemic DCM 3/7/2015 18/7/2015

BP 92/60 (symptomatic) 95/67

HR 81 78

EF 16% -

Scr 2.03 1.75

K 4.0 4.2

Beta-blockers Carvedilol 6.25 mg ¼ x 2 Carvedilol 6.25 mg ¼ x 2

ACEI wait Enalapril 5 mg ½ x 2

MRA Spironolactone 25 mg 1x1 Spironolactone 25 mg 1x1


Furosemide 40 mg 0-0-1 at 8pm + flexible

diuretic regimen (another 1 tab at 11 pm)


ASA, Clopidogrel, Atorvastatin, Digoxin

Optimized Phase (Current Regimen) 59 YO M with Ischemic DCM

6/3/2018 BP 97/65

HR 65

EF 35.5% , no readmission since 2016

Scr 1.60

K 4.1

Beta-blockers Carvedilol 6.25 mg 1 ½ x 2

ACEI Enalapril 5 mg ½ -0- 1

MRA Spironolactone 25 mg 1x1

Diuretic Furosemide 40 mg 0-0-1 at 8pm + flexible diuretic regimen

(another 1 tab at 11 pm)

Other medication Digoxin 0.25 mg ½ EOD ASA, Clopidogrel, Atorvastatin,

Yancy et al. JACC 71 (2) 201-230; 2017

Expectation vs. Reality

Other Medications that can Exacerbated HF symptoms


GDMT Intensification Phase 2-4 months, 1-4 week cycles

• Serial evaluation and titration of medication • Clinical visit with clinical symptoms evaluation,

vital sign, exam, lab • If volume status required treatment, adjust

diuretic • If euvolumic and stable, start

increase/adjusted/switch GDMT, follow up every 2 weeks

• Repeat clinic visit with electrolytes and metabolic panel as indicated

GDMT Stabilized phase (Follow up approximately 3 months)

• Repeat lab test and metabolic panel

• Ongoing clinical symptoms assessment

• Empower patients and care givers to ensure adherences, medication reconciliation

• Evaluation of Echocardiogram anually and EKG as needed

• Consult EP for device therapy as needed

Thank you for your attention

heart failure care: managing modern era of gdmt failure care gdmt อ_ภู...2013 accf/aha...

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