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

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

3. 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.

4. 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).

5. 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

6. 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.

7. 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%.

8. 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

9. Poor Donkey

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

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

13. Diuretics
Loop Diuretics

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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.

23. 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.

24. Let’s see how that Donkey is Doing

25. Donkey is feeling Better

26. Questions