1. What’s New For Heart Failure in 2017?
Jennifer Goerbig-Campbell MD
Advanced Heart Failure Cardiologist
Iowa Heart Center
What’s New For Heart Failure in 2017?

2. Disclosures Medtronic Milestone Pharmaceuticals, Inc.
National Institutes of Health
Employee-Iowa Heart Center/Mercy-Des Moines

3. Heart Failure Impact 5.7 million Americans ≥20 years of age have HF
Projected prevalence of HF will increase 46% from 2012 to 2030,
870,000 new HF cases annually
Mozaffarian D, et. al. Heart Disease and Stroke Statistics—2015 Update:A Report From the American Heart Association.Circulation ;131:e29-e322 .

4. What’s new New medications Electronic devices for remote monitoring
Mechanical Circulatory Support
New strategies
Heart Failure clinic and hospital service
Cardiac rehab
Community resources
Palliative Care services

5. Stages of Heart FailureD
Refractory Heart Failure C
Prior, current symptoms B
Structural heart disease
LVH, MI, low LVEF, dilatation, valvular disease A
High-risk patients
Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs

6. 2013 ACCF/AHA Guidelines on Management of Heart Failure
Beyond HFrEF…
Put this in your literature library:
Yancy C, et. al ACCF/AHA Guideline for the Management of Heart Failure, Circ.2013;128:e240-e327

7. Stage C - HFrEF

8. Newly Approved Treatments
Entresto (LCZ-696)
A combination Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
Colanor (Ivabradine)
An If channel inhibitor that slows HR
CardioMEMS
A wireless PA pressure monitor for remote case management

9. Entresto: PARADIGM HF-Trial
8442 stable class II-IV HFrEF patients (EF <40%)
Compared LCZ-696 to enalapril 10 mg BID with composite end point of CV death or HF hospitalization
Stopped by DSMB at 27 months f/u for overwhelming efficacy
More hypotension and non- serious angioedema but less renal impairment, hyperkalemia and cough than enalapril
McMurray J, et. al. Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure,N Engl J Med 2014;371:

10. Sacubitril/Valsartan Mechanism of Action
Orly Vardeny, Ryan Miller, Scott D. Solomon. Combined Neprilysin and Renin-Angiotensin System Inhibition for the Treatment of Heart Failure, JACC: Heart Failure, Volume 2, Issue 6, 2014, 663–670

11. Corlanor: The SHIFT Trial
6558 subjects with stable NYHA class II-IV HFrEF (EF <35%) and HF hospitalization in past 1 yr.
SR with resting HR ≥ 70 bpm. 90% on beta-blocker
Composite endpoint of cardiovascular death, hospital admission for HF, or admit for non-fatal MI
These channels have a tetrameric composition, with single subunits belonging to the Hyperpolarization-activated Cyclic Nucleotide-gated (HCN) channel family. The HCN family includes 4 members (HCN1-4) that are differentially expressed in excitable tissues.
Several biological studies have shown that ivabradine inhibits the pacemakers hyperpolarization- activated current in the SAN.
Treatment with ivabradine was demonstrated to improve endothelial function in several dyslipidemic mouse models with oxidative stress as a possible mediator for these effects
Median f/u 22 months
Positive results were mostly driven by lower HF admission rates
Low adverse event rate, with most frequent SE being symptomatic bradycardia in 5 vs. 1% (1% study withdrawal rate for same), visual disturbances in 3 vs. 1%, and atrial fibrillation 8.3 vs 6.6%
Swedberg K, et. al. Ivabradine and outcomes in chronic heart failure (SHIFT), Lancet. 2010; 376: 875–85

12. New Drugs - Paradigm Shifting?
No difference in CV mortality with ivabradine
Swedberg K, et. al. Ivabradine and outcomes in chronic heart failure (SHIFT), Lancet. 2010; 376: 875–85
Jessup M. Neprilysin Inhibition — A Novel Therapy for Heart Failure N Engl J Med. 2014; 371:

13. 2016 ACC/AHA/HFSA guideline update

14. 2016 ACC/AHA/HFSA guideline update

15. CardioMEMS - The Champion Trial
Approved by the FDA April 2014, 3.5 yrs after initial filing for approval
NYHA class III HF (all LVEF, all cause) with hospitalization within a year
550 implanted and randomized 1:1 to remote PA pressure monitoring vs. usual care
Analysis at 6 mo and end of study; mean f/u 15 month
Abraham WT, et. al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial, Lancet. 2011; 377: 658–66

16. CardioMEMS Remote Monitoring System
First to show sensor technology to improve outcomes in a “randomized" trial.
Very reliable - NO sensor failures
Safe - No pulmonary embolism or infarction related to the device
ASA 81 mg daily continuous and clopidogrel 75 mg daily x 1 mo for thrombosis prophylaxis
Concerns regarding bias in the study delayed approval for 3.5 yrs after initial application for approval
Likely to be post market refinement of patient populations who benefit

17. ACT - Advanced Cardiac Therapies
Yancy C, et. al ACCF/AHA Guideline for the Management of Heart Failure. Circ. 2013;128:e240-e327

18. Advanced Heart Failure Services
Patients with 2 more indicators:
LVEF ,35%
NYHA class III or IV
Heart failure admission in past 6 months
Intolerance to ACEI/ARB/ Beta Blockers
Furosemide dose > 1.5mg/kg/day
CRT non-responders
Worsening reanl function with diuresis
Na < 136, BUN >40, Cr > 1.5
Inotrope Dependent

19. Shock Percutaneous MCS and VA ECMO

20. VAD Bridge to Transplant, Bridge to Recovery, or Destination Therapy

21. Survival with LVAD

22. VAD for Recovery

24. Non pharmacological Rx
Treat sleep disorders
OSA and weight loss recommendations
Exercise training
or formal cardiac rehabilitation
CMS coverage decision for stable heart failure
Heart Failure Academy

25. Palliative Care and Heart Failure
NYHA class III/IV symptoms
Frequent heart failure readmissions
Recurrent ICD shocks
Refractory angina
Anxiety or depression adversely affecting patient's quality of life or ability to best manage illness
VAD
Transplant
TAVR
Home inotropic therapy
Caregiver distress

26. Getting It From All Sides
Thank You
Questions?