Heart Failure through the Ages Christine Anderson, MS, APRN, ACNS

Heart Failure How Did We Get Here? Improved Treatment of CVD Increase in Risk Factors Aging Population

Heart Failure How Are We Doing? Increase Survival New Pharmacologic Treatment Gender, Age and Race Disparities Growing Elderly Population Mortality 30day: 10.4% 1 year: 22% 5 year: 61% Lifetime risk for women 1 in 5 compared to 1 in 8 for breast cancer About 1 in 8 U.S. women (about 12.4%) will develop invasive breast cancer over the course of her lifetime. In 2018, an estimated 266,120 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 63,960 new cases of non-invasive (in situ) breast cancer.

Disparity in Drug Trials The reasons for this are multi-fold. Clinical trials require clear pre-determined eligibility criteria and rigorous follow-up. While some trials like SOLVD[2]and MERIT-HF[3] excluded those > 80 years of age, other key trials (without age as a specific exclusion criterion) also failed to recruit significant numbers of older patients. This may be due to the presence of other co-morbidities (such as chronic kidney disease) being exclusion criteria, a refusal of elderly patients committing to multiple study visits over several years of follow-up (limited mobility and functional impairment) or even investigator bias (deeming patients unsuitable or unlikely to participate).

Heart Failure Why Do We Care? Growing number of heart failure patients Number 1 discharge diagnosis CMS Imposed penalties Guideline Directed Therapy Estimated 8 million heart failure patients by 2030 CMS penalties for 30 day readmission rate Drag on Medicare and Medicaid Hospitalizations > 1 million/annually Readmission Rate 20% annually Cost Direct: $ 21 Billion to $53 Billion in 2030 Total: $30 billion to $70 Billion in 2030 Medicare: 14% FFS Medicare Recipients 34% annual expenditure GDT is available and not adhere to

Heart Failure American Heart Association (2013) defines Heart failure (HF) as complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. Contributing factors to the development of HF are coronary heart disease, diabetes, hypertension, obesity and other heart related issues.

Heart Failure HFpEF includes ejection fraction 50% or greater, clinical signs and symptoms of HF and evidence of abnormal left ventricular diastolic dysfunction. As a group, patients with HF with preserved EF are older, are more likely to be female, and have greater hypertension, obesity, and anemia than those with HF with reduced Ejection Fraction HFrEF Heart failure with reduce ejection fraction incorporates clinical diagnosis of heart failure and reduced ejection fraction 40%.

Heart Failure Cardiac Function Decrease in Cardiac Output Decrease in stroke volume Systolic Dysfunction Loss of inotropy (contractility) Diastolic Dysfunction Less Compliant (stiffer) higher ventricular end diastolic pressure

Poor Donkey

Heart Failure Goals of Therapy Manage episodes of decompensation During periods of compensation decrease symptoms disease progression Improving quality of life

Heart Failure Treatment Diuretics Symptom Management Improve Quality of Life No Evidence Mortality

Diuretics Loop Diuretics

Diuretics Thiazide Diuretics Adjunct Therapy with Loop Diuretics Generic Trade Initial Dose Dose Schedule Dose Range Metolazone Zaroxolyn 2.5 mg 30-60minutes before loop diuretic 2.5 mg -20mg

ACEI Class 1 recommendation HFrEF Generic Trade Strating Dose Titration Target Dose Lisinopril Prinivil/Zestril 2.5 mg Daily 2.5-5 mg every 2wks 40 mg Daily Enalapril Vasotec 2.5 mg BID 20 mg BID Captopril Capoten 6.25 mg TID 6.25 mg TID every 2wks 50 mg TID Quinapril Accupril 5 mg BID 5 mg BID every 2wks Ramipril Altace 1.25 mg BID 1.25 mg BID every 2wks Trandolapril Mavik .5mg Daily .5mg Daily every 2wks 4 mg Daily Fosinopril Monopril 5 mg Daily 5 mg Daily every 2wks 20 mg Daily

ARBS Class I recommendation intolerant to ACEI HFrEF Generic Trade Starting Dose Titration Target Dose Valsartan Diovan 40 mg BID 40 mg every 2wks 320 mg Daily Candesartan Atacand 4 mg Daily 4 mg every 2wks 32 mg Daily Losartan Cozaar 25 mg Daily 25 mg every 2wks 150 mg Daily

Beta Blockers Class I recommendation HFrEF Generic Trade Strating Dose Titration Target Dose Carvedilol Coreg 3.125 mg BID 3.125 mg every 2wks 25mg BID Carvedilol Phospate Coreg SR 10 mg Daily 10 mg every 2wks 80 mg Daily Metoprolol Succinate Toprol XL 12.5 mg Daily 12.5 in 2wks then 25 mg 200 mg Daily Bisoprolol Zebeta 1.25 mg Daily 2.5 mg in 2wks then by 2.5 mg

Combined Vasodilator Therapy Class I recommendation in symptomatic African American patients (either on ACEI or ARB and BB or in situation of intolerance) Generic Trade Strating Dose Titration Target Dose Isosorbide Mononitrate Imdur 30 mg Daily 30 mg mg every 2wks 125 mg Daily Isosorbide Dinitrate Isordil 10 mg BID or TID 10 mg every 2wks 270 mg Daily in divided doses Hydralazine Apresoline 10 mg TID 10 mg 2wks can be given QID 300 mg Daily in divided doses Hydralazine/ Bidil ½ tab TID 37.5/20 mg tab ½ tab in 2wks 2 tabs TID

Aldosterone Antagonist Recommended in HFrEF and inconclusive in HFpEF Generic Trade Starting Dose Titration Target Dose Spironolactone Aldactone 12.5 mg – 25 mg Daily Consider increasing to 50 mg if needed for HTN 25 mg Daily Eplerenone Inspra Increase to 50 mg 2-4 weeks 50 mg Daily

New Therapy Ivabradine Selectively reduces heart rate without effecting ventricular depolarization and myocardial contractility HFrEF 35% On Triple Therapy Heart rate greater than 70 Generic Trade Starting Dose Titration Target Dose Ivabradine Corlanor 5 mg BID Increase 7.5 mg in 2 weeks if HR > 60 if HR, 60 decrease 2.5mg BID 7.5 mg BID

New Therapy Sacubitril/Valsartan HFrEF Maximum tolerated dose ACEI/ARB ACEI stopped for 48 hours Elevates BNP Generic Trade Starting Dose Titration Target Dose Sacubitril/Valsartan Entresto 50mg (24/26) Increase as tolerated 100mg (49/51) 200mg (97/103)

Heart Failure Preserved EF Risk Factors Female Hypertension Obesity CAD Afib DM Hyperlipidemia Diagnosis Clinical signs and/or symptoms consistent with heart failure Normal or mildly abnormal LV systolic function Evidence of LV diastolic dysfunction The burden of concomitant non–cardiovascular disease is high, and includes renal impairment, chronic lung diseases, anemia, cancer, liver disease, peptic ulcer disease, and hypothyroidism. The presence of these co-morbidities make diagnosing HFPEF more difficult and they often complicate therapy. Exertional dyspnea is the most common presenting complaint, and often the earliest symptom. Some patients may also present with fatigue. HFPEF is a common cause of unexplained pulmonary hypertension in the elderly. Elderly patients with pulmonary hypertension and normal LV chamber size and systolic function on transthoracic echocardiogram should be evaluated for HFPEF.

Heart Failure Preserved EF Long Term Management Heart rate control Atrial Fib Management Blood Pressure Control Revascularization/Valve replacement Diet and Weight Management Long-term management of HFPEF focuses on the management of a specific cause (hypertension, diabetes, myocardial ischemia), modification of factors that affect the LV diastolic function (heart rate, blood pressure, circulating blood volume), and symptom reduction. Hypertension and diabetes mellitus lead to LV diastolic dysfunction either directly or indirectly via an increased risk of coronary artery disease. It is important to manage these conditions regardless of the presence of HFPEF, and according to standard guidelines. Patients with HFPEF commonly have underlying coronary artery disease. Myocardial ischemia can adversely affect the LV systolic and diastolic function; the presence of angina pectoris can reduce the exercise capacity in these patients. Therefore, coronary revascularization should be considered when symptomatic myocardial ischemia in patients with coronary artery disease is thought to adversely affect LV diastolic function. Tachycardia reduces coronary perfusion (by reducing the ventricular filling time) and cardiac relaxation. In addition, there is also loss of atrial enhancement of ventricular filling in supraventricular tachyarrhythmias. Rate control agents (beta-blockers, non–dihydropyridine calcium channel blockers, digoxin) might be useful in minimizing the symptoms in patients with HFPEF and AF. Restoring and maintaining sinus rhythm (and hence, the atrial kick) might be useful for symptom reduction. Apart from rate and/or rhythm control, it is important to address the issue of thromboembolism in these patients. Unless contraindicated, patients with HFPEF and atrial fibrillation should be anticoagulated to reduce the thromboembolic risk.

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