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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?