Download Advanced Heart Failure: New Treatments

Jennifer Goerbig-Campbell MD
Advanced Heart Failure Cardiologist
Iowa Heart Center
What’s New For Heart
Failure in 2017?
Disclosures
❖
Medtronic
❖
Milestone Pharmaceuticals, Inc.
❖
National Institutes of Health
❖
Employee-Iowa Heart Center/Mercy-Des Moines
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 . 2015;131:e29-e322 .
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
Stages of Heart Failure
D
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
2013 ACCF/AHA Guidelines
on Management of Heart
Failure
Beyond HFrEF…
Put this in your literature library:
Yancy C, et. al. 2013 ACCF/AHA Guideline
for the Management of Heart Failure,
Circ.2013;128:e240-e327
Stage C - HFrEF
Newly Approved
Treatments
Entresto (LCZ-696)
A combination Angiotensin ReceptorNeprilysin Inhibitor (ARNI)
Colanor (Ivabradine)
An If channel inhibitor that slows HR
CardioMEMS
A wireless PA pressure monitor for
remote case management
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 nonserious 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;371:993-1004
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
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
❖
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
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: 1062-64
2016 ACC/AHA/HFSA guideline update
2016 ACC/AHA/HFSA guideline update
CardioMEMS - The Champion Trial
❖
❖
❖
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
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
ACT - Advanced Cardiac Therapies
Yancy C, et. al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circ. 2013;128:e240-e327
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
Shock
Percutaneous MCS and VA ECMO
VAD
Bridge to Transplant, Bridge to Recovery, or Destination Therapy
Survival with LVAD
VAD for Recovery
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
❖
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
Getting It From All Sides
Thank You
Questions?