welcome and - amazon s3...lesyuk et al. bmc cardiovasc disord 2018; 18:74; cihi, national health...
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Welcome and IntroductionsSerge LepageMD, FRCPC, CSPQ
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FacultySerge Lepage, MD, FRCPC, CSPQ (Chair)Full ProfessorDirector, Heart Function Clinic, Department of cardiology, Université de SherbrookePast President, Quebec Heart Failure SocietySherbrooke, QC
Douglas Lee, MD, PhD, FRCPCCardiovascular Program Lead & Senior Scientist, ICESTed Rogers Chair in Heart Function OutcomesDivision of Cardiology, Peter Munk Cardiac Centre, University Health NetworkProfessor of Medicine, University of TorontoToronto, ON
Nadia Giannetti, MDCM, FRCPCAssociate Professor, Department of MedicineMedical Director, Heart Failure and Heart Transplant ProgramChief, Division of CardiologyMcGill University Health CentreMontreal, QC
Mark Liszkowski, MD, FRCPCCardiologist in advanced heart failureCardiac intensivistDirector cardiac intensive care unitPresident of the Clinical Ethics committeeMedical coordinator for organ and tissue donationMontreal, QC
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Conflict of InterestSerge Lepage, MD, FRCPC, CSPQ • Consulting Fees/Honoraria: Novartis, AstraZeneca, Jenssen,
Servier, Bayer, Amgen, Sanofi• Clinical Trials: Novartis, Amgen
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Conflict of InterestDouglas Lee, MD, PhD, FRCPC• Consulting Fees/Honoraria: N/A• Clinical Trials: COACH Trial funded by the Ontario SPOR
Support Unit
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Conflict of InterestNadia Giannetti, MDCM, FRCPC• Funding/Honoraria/Research: Novartis,
Servier, Amgen, Pfizer, BoehringerIngelheim, Astra, Merck
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Conflict of InterestMark Liszkowski, MD, FRCPC• Consulting Fees/Honoraria: Servier, Bayer, Novartis,
CardiacAssist, Abbott medical, Boehringer, Mallinkrodt, BMS, Otsuka
• Clinical Trials: Bayer
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Disclosure of Commercial SupportSpecific details of relationship:• This program has received financial support from Novartis Pharmaceuticals Canada in
the form of an educational grant
Potential for conflict(s) of interest:• Speakers have received honoraria from Novartis Pharmaceuticals Canada• Novartis is the manufacturer and benefits from the sale of Entresto
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Mitigating Potential BiasPotential biases are acknowledged and are mitigated by presenting data supported by national and international guidelines, and as follows:• Information presented is evidence-based• Material has been developed and reviewed by a Planning Committee
Off-label uses of drugs will be discussed and identified as such by the speaker
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Learning ObjectivesAfter attending the symposium, participants will be able to:
• Discuss the burden of heart failure (HF) in Canada with an emphasis on the burden of disease and societal impact of HF hospitalizations
• Recognize the high risk of recurrent events and deterioration after hospitalization for acute HF decompensation and the need to optimize treatment before discharge
• Translate current clinical data into daily practice and evaluate the impact on patient outcomes
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Agenda
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TIME TOPIC SPEAKER
9:55 a.m. Welcome and Introductions Serge Lepage, MD
10:00 a.m.Burden of the Disease: Health Expenditure, Costs of Hospitalization, Diagnosis, and Management of HF Douglas S. Lee, MD
10:15 a.m. Question and Answer Period All
10:20 a.m. Optimizing HF Therapies During Hospitalization: Time Matters Nadia Giannetti, MD
10:40 a.m.Question and Answer Period All
10:45 a.m. Best Practices and Practical Tips for Optimizing HF Patient Care in Hospital Mark Liszkowski, MD
11:00 a.m Question and Answer Period All
11:05 a.m Closing Remarks and Evaluations Serge Lepage, MD
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Situation At My Hospital
• Consecutive patients with ADHF
• EF 40% and below
• Mean stay 10 days
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Mortality• 1 month
3%• 3 month
10%• 6 month
17%• 1 year
25%
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HF Re-hospitalization• 1 month 11%
• 3 month 21%
• 6 month 32%
• 1 year 40%
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Burden of the Disease: Health Expenditure, Costs of Hospitalization, Diagnosis, and Management of HF
Douglas S. LeeMD, FRCPC
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Objectives:1. To examine potential strategies to improve earlier diagnosis of
heart failure
2. To explore the importance of coronary artery disease in heart failure
3. To understand the challenges in preventing heart failure readmissions and potential solutions
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Lesyuk et al. BMC Cardiovasc Disord 2018; 18:74; CIHI, National Health Expenditure Trends 1975 to 2010; Tran et al. CMAJ Open 2016; 4:E365-70
Cost of HF Care: International Comparison
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Annu
al C
ost p
er In
divi
dual
($U
S)
0
5,000
10,000
15,000
20,000
25,000
S. Korea Nigeria Czech Sweden Greece Spain Canada Ireland Italy Germany US
HF patientPer capita
**
* N/A
HF patient - CanadaPer capita - Canada
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Lesyuk et al. BMC Cardiovasc Disord 2018; 18:74
Spending on HF Patients Correlate with More Spent on HF Hospitalization
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0
5,000
10,000
15,000
20,000
25,000
30,000
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
% of HF Costs due to Hospitalization
Per P
atie
nt C
osts
of H
F ($
US)
More hospitalizations Higher costsa) Room & board (43%)b) Procedures (dialysis)c) Imagingd) Laboratory tests
Medication costs
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Improving Diagnosis of HF
Ezekowitz et al. Can J Cardiol 2017; 33:1342-43319
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de Boer et al. JAMA Cardiol 2018; 3:215-24
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Only BNP and hs-Troponin improved the c-statistic and NRI compared with clinical, echocardiographic and ECG variables
de Boer et al. JAMA Cardiol 2018; 3:215-24
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Welsh et al. J Cardiac Fail 2019; 25:230-7
HS-Troponin and Incident HF: British Regional Heart Study (7735 men, 40-59 yrs)
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Free of Coronary Artery Disease History of Coronary Artery Disease
TnT Tertiles:
Lowest:≤ 9.7 ng/L
Middle:9.8-14.2 ng/L
Highest:≥ 14.3 ng/L
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Ischemic Heart Disease and HF
Lamblin N, et al. J Cardiac Fail 2018; 24:815-22
• CORONOR study (Nord-Pas-de-Calais, France)
• Registry of 4184 outpatients with stable CAD:• Prior MI (> 1 year)• Prior coronary
revascularization• ≥ 50% obstruction of at least
1 V• Baseline LVEF categorized
as ≥ 50% vs. < 50%
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Ischemic Heart Disease and HF
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• CORONOR study (Nord-Pas-de-Calais, France)
• Registry of 4184 outpatients with stable CAD:• Prior MI (> 1 year)• Prior coronary
revascularization• ≥ 50% obstruction of at least
1 V• Baseline LVEF categorized
as ≥ 50% vs. < 50%
Lamblin N, et al. J Cardiac Fail 2018; 24:815-22
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Ezekowitz et al. Can J Cardiol 2017; 33:1342-433
Assessment for CAD
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0.5
0.6
0.7
0.8
0.9
1.0
0 500 1000 1500
Normal coronaries
Non-obstructive
Obstructive
Days
% S
urvi
val
Outcomes of Normal, Non-obstructive or Obstructive Lesions on Coronary Angiography in HFrEF
Braga et al. JACC HF 2019 [in press]
0.5
0.6
0.7
0.8
0.9
1.0
0 500 1000 1500
Normal coronaries
Non-obstructive
Obstructive% S
urvi
val f
ree
of C
V de
ath
or C
V ho
spita
lizat
ion
Days
26
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• 2,962,554 hospitalizations for HF• U.S. Medicare beneficiaries• 2009: readmission performance provided• 2012: financial penalties applied
• For HF:• - 0.05% change in risk-adjusted
readmission rates per month after HF hospitalization
• 0.008% change in risk-adjusted mortality rates per month after dischargeDharmarajan K, et al. JAMA 2017; 318:270-8
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Khera R, et al. JAMA Network Open 2018; 1:e182777
Readmission vs. Mortality
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• 4,000,000 HF patients• U.S. Medicare
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Risk-adjustedpost-discharge mortality rate
Risk-adjustedIn-hospital mortality rate
Khera R, et al. JAMA Network Open 2018; 1:e182777
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Sud et al, JACC HF 2017; 5:578-88
Length of Stay and Readmission Risk
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Strategies to Reduce Readmissions
ED
Discharge Transition
Hospital 30-days ED
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Lee DS, et al. Circulation HF 2010; 3:228-35
Need for Improved Safety and Efficiency of Acute HF Decision-Making in the ED
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Admitted Discharged
Low-risk acute hospital stays (Efficiency)
High-risk ED discharges (Safety)
Discharged
Admitted
Freq
uenc
y (#
Pat
ient
s)
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Date of download: 6/15/2012
Copyright © The American College of Physicians. All rights reserved.
From: Prediction of Heart Failure Mortality in Emergent Care: A Cohort StudyAnn Intern Med. 2012;156(11):767-775. doi:10.7326/0003-4819-156-11-201206050-00003
EHMRGEmergencyHeart failureMortalityRiskGrade
Derivation Cohort (n=7433)5254 Admitted2179 Discharged
Validation Cohort (n=5158)3560 Admitted1598 Discharged
https://ehmrg.ices.on.ca
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EHMRG: Emergency Heart Failure Mortality Risk Grade
Lee DS, Am Heart J 2016; 181:60-65
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ED visitDiagnosed with HF?
Exclusions?Dialysis, DNR or
Invalid HCN
MD Questionnaire:1) Estimate PER2) Plan for patient
CompletedQuestionnaire?
Enter parametersfor EHMRG
Does MD want to view score
results?
DisplayEHMRG
score
Data linkage formortality, admission,& ED discharge for passive follow-up
Does notqualify forthe ACUTE
study
Yes
NoNo
Yes
No
YesNo
Yes
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Lee et al. Circulation 2019; 139:1146-56
ACUTE: Acute Congestive heart failure Urgent and Transitional care Evaluation
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Prospective validation ofEmergency HF MortalityRisk Grade (EHMRG):• 1983 acute HF pts• 9 hospitals
7-day risk score available at:https://ehmrg.ices.on.ca
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Lee et al. Circulation 2019; 139:1146-56
Physician Estimated vs Model-Predicted Mortality
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ClinicalTrials.gov NCT02674438
Comparison of Outcomes and Access to Care for HF (COACH trial)
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Short Stay
<48-72hr
Discharge
Admit
PCP
Spec
HFC0 30d
EHMRG7/30 d
RiskStratification
HigherRisk
LowerRisk
ED
RAPIDHF
Clinic
RapidAmbulatory Care
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Conclusions• The economic burden of HF is high and correlates with higher rates of
hospital admission
• Strategies to improve early diagnosis of HF: • Reduce the need for acute emergency department presentation:• May be improved with BNP and hs-Troponin
• Coronary artery disease:• Important antecedent for HF prevention target• Even minimal CAD is associated with higher risk of readmissions and
CV death
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Conclusions• Readmissions:
• Global problem• Highest rates of readmission are in North America
• Better risk stratification strategies may reduce readmissions and hospitalizations by improving efficiency and safety of acute decision-making for HF
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Question and Answer
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Optimizing HF Therapies During Hospitalization: Time MattersNadia GiannettiMD, FRCPC
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Overview• What is our goal for therapy?• Are we achieving this goal?• How quickly we need to get there?• How can we do better?
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What is Our Goal for Therapy?
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Medical Therapy Benefits
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Incremental Benefit of Drug Therapies for Heart Failure
Komajda M, et al. Eur J Heart Fail 2018.
All-cause Mortality Cardiovascular Mortality
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HR(95% Credible Interval)
ARNI+BB+MRA vs Placebo 0.38 (0.2;0.65)
ACEI+BB+MRA+IVA vs Placebo 0.41 (0.21;0.7)
ACEI+BB+MRA vs Placebo 0.44 (0.27;0.67)
ARB+BB vs Placebo 0.48 (0.24;0.86)
ACEI+ARB+BB vs Placebo 0.52 (0.32;0.8)
BB vs Placebo 0.58 (0.34;0.95)
ACEI+MRA vs Placebo 0.58 (0.36;0.9)
ACEI+BB vs Placebo 0.58 (0.42;0.73)
ACEI+ARB vs Placebo 0.83 (0.52;1.23)
ACEI vs Placebo 0.84 (0.67;1.01)
ARB vs Placebo 0.89 (0.61;1.27)0 1
HR2
HR(95% Credible Interval)
ARNI+BB+MRA vs Placebo 0.36 (0.16;0.71)
ACEI+BB+MRA+IVA vs Placebo 0.41 (0.19;0.82)
ACEI+BB+MRA vs Placebo 0.45 (0.25;0.75)
ACEI+ARB+BB vs Placebo 0.47 (0.24;0.82)
ARB+BB vs Placebo 0.5 (0.19;1.12)
ACEI+MRA vs Placebo 0.56 (0.31;0.95)
ACEI+BB vs Placebo 0.56 (0.37;0.75)
BB vs Placebo 0.62 (0.27;1.32)
ACEI+ARB vs Placebo 0.8 (0.43;1.33)
ACEI vs Placebo 0.81 (0.6;1.04)
ARB vs Placebo 0.85 (0.51;1.28)0 1
HR2
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Medical Therapy Benefits
McMurray NEJM 2014 Swedberg Lancet 2010
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Are We Achieving This Goal?
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Adherence to Guidelines Score by Geographic Zone
71 70
61
71
60.5
2419
2922
34.1
511 9 7 5.4
Western Europe +North America +
Australia, n=1411
Asia, n=1283 Central + EasternEurope, n=3117
Rest of the world,n=1197
Canada
Good Moderate Poor
%
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Giannetti et al. ccs 2016
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CHAMP-HF Registry: Use of Therapy
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Greene, S.J. et al. J Am Coll Cardiol. 2018;72(4):351-66.
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How Quickly Do We Need To Get There?
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Hospitalization For HF
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PARADIGM –HF trial (NEJM 2014); SHIFT Trial (LANCET 2010)
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Medical Therapy During Hospitalization
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How Can We Do Better?
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N Engl J Med 2019; 380:539-548
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Study Design
*Target DoseHF, Heart Failure. EF, Ejection Fraction
Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
Sacubitril/valsartan 97/103 mg twice daily*
Enalapril10 mg twice daily*vs
In-hospital initiation
Hospitalized with Acute Decompensated HF with Reduced EF
While hospitalized
• Evaluate biomarker surrogates of efficacy• Evaluate safety and tolerability• Explore clinical outcomes
Study Drug for 8 weeks
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PIONEER-HF
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• Hospitalized for Acute Decompensated Heart Failure (ADHF)• LVEF ≤40% within the last 6 months• NT-proBNP ≥1600pg/mL or BNP ≥400 pg/mL* • While hospitalized:
• SBP ≥100 mmHg in prior 6h; no symptomatic hypotension• No increase in IV diuretics in prior 6h • No IV vasodilators in prior 6h• No IV inotropes in prior 24h
*At screeningA complete list of inclusion and exclusion criteria has been previously published at Velazquez et al. Am Heart J 198 (2018) 145-151LVEF, Left Ventricular Ejection Fraction. NT-proBNP N-terminal pro–Brain Natriuretic Peptide. BNP, Brain Natriuretic Peptide. SBP, Systolic Blood Pressure. IV, Intravenous
Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
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PIONEER-HF Key Entry Criteria
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Primary endpoint: • Time-averaged proportional change in NT-proBNP from baseline at 4 and 8 weeks
Safety• Worsening renal function• Hyperkalemia• Symptomatic hypotension• Angioedema
Exploratory Clinical Outcomes• Serious Clinical Composite: Death, Hospitalization for HF, LVAD or listing for
cardiac transplant*A more complete list of PIONEER study endpoints has been previously published at Velazquez et al. Am Heart J 198 (2018) 145-151 NT-proBNP N-terminal pro–Brain Natriuretic Peptide. HF, Heart Failure. LVAD, Left Ventricular Assist Device. HF, Heart FailureData on File: PIONEER-HF Protocol, Novartis Pharmaceutical Corp; October 2018
Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
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PIONEER-HF Study Endpoints*
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Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 MED/ENT/0380
PIONEER-HF Baseline Characteristics
Sacubitril/Valsartan(n=440)
Enalapril (n=441)
Age (years) 61 (50.5, 71) 63 (54, 72)
Women (%) 25.7 30.2
Black (%) 35.9 35.8
Prior HF diagnosis (%) 67.7 63.0
LVEF, median (25th, 75th) 0.24 (0.18, 0.30) 0.25 (0.20, 0.30)
Systolic pressure, median (25th, 75th) mm Hg 118 (110, 133) 118 (109, 132)
NT-proBNP median (25th, 75th) pg/mL at randomization 2883 (1610, 5403) 2536 (1363, 4917)
ACEi/ARB therapy (%) 47.3 48.5
Beta-adrenergic blockers (%) 59.6 59.6
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10
0
- 10
- 20
Perc
ent C
hang
e fr
om B
asel
ine
- 30
- 40
- 50
- 60
- 70
Week since Randomization
Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8
HR 0.71 (95% CI 0.63, 0.80) P<0.001
Enalapril
Sacubitril/Valsartan
Time-average proportional change of NT-proBNP from baseline*
*Percentage (%) change from baseline to mean of weeks 4 and 8
Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
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PIONEER-HF Primary Endpoint
MED/ENT/0380
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Endpoint Nr. (%) Sacubitril/Valsartan (n=440)
Enalapril (n=441)
RR Sac/Val vs Enalapril(95% CI)
Composite of serious clinical events * 41 (9.3) 74 (16.8) 0.54 (0.37 to 0.79)
Death 10 (2.3) 15 (3.4) 0.66 (0.30 to 1.48)
Re-hospitalization for HF 35 (8.0) 61 (13.8) 0.56 (0.37 to 0.84)
Requirement of LVAD 1 (0.2) 1 (0.2) 0.99 (0.06 to 15.97)
Inclusion on list for heart transplantation 0 0 n/a
*Exploratory Serious Clinical Composite endpoint consisted of death, rehospitalization for heart failure, implantation of a left ventricular device, and inclusion on the list of patients eligible for heart transplantation
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MED/ENT/0380
PIONEER-HF Exploratory Clinical Endpoints
Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
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• The study was powered for changes in NTproBNP and interpretation of secondary and exploratory endpoints should be viewed with caution
• Safety data were collected for only 12 weeks, therefore adverse events that take longer to transpire may not have appeared in this study. Safety information should be interpreted in the context of prior trials with longer duration
• In-hospital initiation included 2 placebo doses in the sacubitril/valsartan group and 6 hours of mandatory observation after the 3rd dose of study medication in both arms, which may have prolonged length of stay
• The 8 week double-blind study duration could limit the ability to fully assess long-term outcomes such as death, cardiac transplantation, and LVAD implantation
MED/ENT/0380 Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851
PIONEER-HF Study Limitations
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Effect of HR Upon Normal and Failing LV
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European Heart Journal (1994) 15, 164-170
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Early Co-administration of Ivabradine and β-blockers During Hospitalization is Safe and May Improve HF Parameters (effects at 12 months)
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Early co-administration of ivabradine and ß–blockers During Hospitalization May Reduce Mortality
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Lopatin et al., Int. J Cardiol., 2018, 260, 113-117
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Summary • Heart failure has a high morbidity and mortality, with a high re-admission rate• Medical therapy can reduce all of the above with benefits achieved early on• Medical therapy is under-utilized • There is a better way to approach these patients• In well selected patients, can initiate therapy and titration in hospital
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Question and Answer
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Best Practices and Practical Tips for Optimizing HF Patient Care in HospitalMark LiszkowskiMD, FRCPC
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Conflict of InterestMark Liszkowski, MD, FRCPC•Consulting Fees/Honoraria: Servier, Bayer, Novartis, CardiacAssist, Abbott medical, Boehringer, Mallinckrodt, BMS, Otsuka.•Clinical Trials: Bayer, Boehringer
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Tips and tricks to optimize CHF patients• What the guidelines say• Heart failure hospitalization: time to act!• In-hospital medical optimization• In-hospital risk identification
• CVP, optimal medical therapy, HR, ntBNP• Post-discharge early surveillance and follow up
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Reality of treating heart failure in hospital• 1- Older frail patients• 2- Multiples co-morbidities • 3- Acute renal failure• 4- Hypotension• 5- Complex polypharmacy• 6- Often maximally treated CHF patients• 6- Multiple possible precipitants of decompensation
• Non-compliance to Rx or follow-up• Rx stopped by other healthcare professionals• ER visit or off-service hospitalization• Septic precipitants
CHF medications not-toleratednot starteddecreased
StoppedCannot be increased
-Not your standard CHF trial patient-May explain why some patients not onFull/maximal CHF triple therapy
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Circ Heart Fail. 2013;6:1095-1101
CHF hospitalization is the time to act!
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BA C D
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A- Treat CHF• First phase (acute hypervolemia and neuro-hormonal activation)• Hospitalize (10-15% mortality)
• Volume control (IV diuretics)• Vasodilatation• Inotropic support (rare)• Rhythm control (AF, AV block, VT, PVCs)
• Search for ischemia/valvular disease• Myocardial dysfunction (review LVEF - <40%?)• Search for precipitants• Review complete list of medications• Realize that current therapy might be ineffective!
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A
Circ Heart Fail. 2013;6:1095-1101
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B- Stabilize CHF• Identify and manage precipitants
• Ischemia (revascularize)• Valvular heart disease (repair/replace)• Rhythm (rate or rhythm control)• Non-compliance (understand/teach)• Infection • Harmful medications (DPP4, glitazones, NSAIDS, steroids, alpha-
blockers, CCB)• Was current medical therapy adequate to improve prognosis?
• Triple therapy? (BB, ACEi/ARB, and MRA)• Quadruple therapy (BB, Ivabradine, ACEi/ARB/ARNi, and MRA)• Restart / Switch / Up titrate doses with daily monitoring of vital signs and
biochemistry
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B
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C- Optimize CHF therapyntBNP as a modifiable predictor of outcome
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C
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C- Optimize CHF therapyHeart rate as a modifiable predictor of outcome
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C
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C- Optimize CHF therapy• How can I improve current CHF therapy?• Switch/Add therapies proven to further reduce morality and rehospitalizations
• 1- Monitor nt-BNP at admission and near discharge• 2- Follow resting heart rate• 3- Diabetes control
• Switch ACEi/ARB for Sacubitril/Valsartan (ARNI)• Add Ivabradine to lower HR a goal of 50-60/min if >77/min• Consider adding an SGLT2i to oral Db therapy
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C
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C- Optimize CHF TherapySacubitril/Valsartan• ADCHF: volume overload and neuro-hormonally activated state
• Hold ACEi x48h and restart ARNi at equivalent dose• Stop ARB and immediately start ARNi at equivalent dose
• Do this while the patient is still congested• Within 48-72 hours of stopping IV diuretics (before PO)
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ACEi Sacubitril/Valsartan
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C- Optimize CHF TherapyHeart rate: a marker of risk• During ADCHF: continue same Beta Blocker dose unless hypotensive/in shock• Look at heart rate as prognostic indicator
• If already on maximal beta blocker dose• If not tolerating beta blocker dose (hypotension/low output)• Clinical profiles:
• Hypotensive female• Symptomatic low cardiac output patient• Older patient needing reduction of dose due to excessive fatigue
• HR >77 beats/min• Add starting dose of 2.5 mg po bid of Ivabradine atop beta blocker dose• Uptitrate Ivabradine to 5 mg po bid then 7.5 mg po bid is needed• Combination therapy to lower resting HR 60/min• Goal to lower heart rate<70 beats/min at discharge
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C- Optimize CHF therapy
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C- Optimize CHF therapyManagement of diabetes in CHF
Thiazolidinediones (glitazones) – contra-indicated in CHFDeclare TIMI 58 Dapagliflozin Placebo Reduced HF Hospit
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C- Optimize CHF therapycomplete care with a checklist
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• Baseline discharge parameters• Teaching• Reminder for full medical therapy• Standardized approach
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C- Optimize CHF therapycomplete care with a checklist
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• Baseline discharge parameters• Teaching• Reminder for full medical therapy• Standardized approach
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D- Predict and prevent• How to identify and follow up the vulnerable population after discharge?• 1- Biomarkers of risk at discharge (ntBNP, CVP, HR)• 2- Biomarkers of risk at 1 week post-discharge
• If nt BNP and/creatinine increase needs FASTER follow up• 3- Patient self surveillance
• Document daily symptoms/weight/HR• 3- Outpatient rapid follow up 2-4 weeks
• CHF clinic• Nurse led rapid reassessment clinic
• 4- Pharmacist or nurse driven protocolized CHF medication up titration (every 3-4 wks)• tends to be faster and more complete than if MD driven
• 5- Refer to CHF specialist if needed or if not improving with standard therapy
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See 1-4 days
ntBN
P/C
rea
t
1 week
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D- Predict and preventWhat do patients want?
• Improved symptoms• Fewer pills• Fewer hospitalizations• Do not want to die/suffer• Contact person in case of questions or concerns
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Take home points• In-hospital CHF optimization is practical• Assure at least standard triple CHF therapy is started
(BB, ACEi/ARB and MRA)• If worsening CHF on standard therapy
• Identify precipitants• Consider ADCHF as a failure of current therapy• Switch/add more aggressive evidence based therapy
− Sacubitril/Valsartan− Ivabradine− SGLT2i
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Take home points• Identify vulnerable patients that you can improve
• ntBNP remains elevated (less than 30% decrease from admission)• Remains with HR >77/min in spite of maximally tolerated BB• Sub-optimal Db control
• Required clinical follow-up within 2-4 weeks post-discharge• Faster follow-up if ntBNP and/or creatinine increase within 7 days
post-discharge
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Question and Answer
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Closing Remarks and EvaluationsSerge LepageMD, FRCPC, CSPQ
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Question #1Heart Failure Management in CanadaCompared to other countries…
a. Canada is a leader in acute decompensated heart failure(ADHF) = 15%
b. Canada is in the middle of the pack for management of ADHF = 75%
c. Canada is doing poorly in ADHF management = 10%
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Question #2:The US Has Established a Policy to Decrease30 Day ReadmissionThey have in fact
a. Decreased 30 day readmission = 45%b. Increased 30 day readmission = 16%c. Increased 30 day death = 25%d. Reduced 30 day death = 14%
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Question #3:Regarding In-hospital Stay…
a. All our interventions are evidence-based medicine (EBM) = 4%
b. Our efforts are aimed at relieving symptoms = 16%
c. As long as the patient is not in acute kidney injury (AKI) = 2%
d. We all should do better = 78%
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