00:00
Let’s talk about
treatment for our patient.
00:03
He is currently –
if you remember,
he was New York
Heart Association class III,
so significant symptoms,
reduced ejection
fraction heart failure.
00:11
He’s taking a
furosemide 40 mg daily,
lisinopril 20 mg daily,
and he doesn't have any contraindications
to other heart failure treatment.
00:20
So, what is the best choice
for the next drug to add
to improve this patient's risk of heart failure
complications and mortality as well?
Is it metoprolol XL,
sacubitril/valsartan,
spironolactone, or isosorbide
dinitrate with hydralazine.
00:37
Metoprolol XL, beta
blockers, ACE inhibitors,
foundational drugs for heart failure
and I will go over that in depth.
00:45
All right.
00:46
So, when we think
about treating heart failure,
a lot of times we have to
think about using diuretics.
00:52
For this gentleman, with his
symptoms and his edema,
he’s going to –
he’s already on Lasix.
00:57
He needs to stay on a diuretic,
so that's just to treat
symptoms and signs.
01:02
That doesn't necessarily have
an effect on mortality, in particular.
01:08
Something else, if it’s left
ventricular ejection fraction,
it remains below 35%
despite having them on OMT,
or optimized medical therapy.
01:17
Or if he has a history
of significant arrhythmia,
he needs an
implanted defibrillator.
01:23
Okay.
01:24
So, those span the
distance for treatments.
01:27
So, that’s always a consideration
no matter where your patient stands.
01:30
These are recommendations from
the European Society for Cardiology,
but they stand up.
01:35
They make sense
in clinical practice.
01:38
Do remember that ACE inhibitors
or angiotensin receptor blockers
because they work about the same among patients
with heart failure, it’s just that the ARBs are associated with
less cough than an ACE inhibitor.
01:52
That drug, along
with beta blockers,
are your foundational drugs
and they work most effectively for
when they’re increased
to at least moderate doses,
up to high doses.
02:03
We’re talking
about lisinopril 40 mg,
benazepril 40 mg, we’re
talking about beta blockers
such as carvedilol
25 mg twice daily,
or metoprolol XL up to 200 mg daily.
02:16
And they also work most effectively for
patients with more severe heart failure.
02:21
So, the more severe
their symptoms are,
the worse their ejection fraction,
the more likely they're going to
get a benefit with these drugs.
02:29
So, really try to
get them on board.
02:30
The challenge is just managing
so many different drugs in patients
who are usually a
little more frail with, say,
chronic kidney disease
and diabetes and hypertension.
02:41
Now, with those foundational drugs,
if the patient is still symptomatic and
still has a low ejection fraction,
next one to add is probably a
mineralocorticoid receptor antagonist.
02:52
A drug like spironolactone
is the most commonly used.
02:55
That also reduces mortality
outcomes in heart failure.
03:00
If they're doing fine at
that point, at any point,
stop the polypharmacy and you
don't need to add more drugs because,
usually, when I diagnose
somebody new with heart failure,
it's an automatic prescription
for at least four to five drugs.
03:14
What would those be?
ACE inhibitor, beta blocker and,
because of comorbid conditions,
oftentimes they’ll need an
aspirin and they’ll need a statin.
03:23
I’d be surprised if they
don’t have diabetes or hypertension.
03:25
So, there's probably
three or four more drugs
they’re going to be getting,
and that's a lot of
burden for the patient
to take all those
drugs every day
and follow-up for potential
side effects and go to a lab,
it's a lot of work.
03:39
So, while these
are all good agents
and really improve
heart failure outcomes,
do keep patient burden
in mind as you go through.
03:47
And that's why it’s nice to
use this algorithm because
it adds drugs on as they’re needed.
03:52
Say, the patient is now on
three drugs for heart failure,
still symptomatic.
03:57
Well, now you’ve got
some options in front of you.
03:59
They might qualify for
cardiac resynchronization therapy
if they have this wide QRS.
04:07
Instead of using an ACE or
an ARB for these patients,
it may be time to consider switching
to a brand-new
kid on the block,
the angiotensin
receptor neprilysin inhibitor.
04:19
And there's only one
of those available right now,
sacubitril/valsartan.
04:23
But in the PARADIGM-HF trial,
replacing enalapril with
sacubitril/valsartan was
associated with better outcomes
for hospitalization
and for mortality –
both overall mortality
and cardiovascular mortality.
04:36
So, that could be a good
option for patients
and doesn't add
to the patient burden.
04:41
On the other hand,
if they really have an
elevated heart rate
despite that heavy
dose of beta blocker,
you can add a
drug like ivabradine,
which has also been associated
to help particularly with
heart failure hospitalization.
04:54
However, I would caution –
for those patients
who have a pulse of 80
and they're taking a beta blocker,
really look as to whether
the patient is actually
using their beta blocker because
it's hard to get a pulse that high with a
moderate to high dose of a beta blocker.
05:13
Usually, it's the opposite and
their pulse rate is more like 52.
05:18
So, you can combine those treatments.
05:21
But if there are resistant symptoms,
you’re definitely involving a
cardiologist at this point.
05:26
You could think about things
like isosorbide dinitrate hydralazine,
digoxin or even heart transplantation.
05:32
But I think the main thing for
USMLE is that centerpiece of
what are the foundational drugs,
ACE inhibitors or ARBs,
beta blockers and
then a drug like spironolactone.
05:42
Those are really the
three key ones to get on board.
05:47
All right.
05:48
So, what we talked about was some
of the keys to diagnosis of heart failure
and a lot about the
management of heart failure.
05:54
Hopefully, it was really helpful and that algorithm
is something that you can use over time.
05:58
Thanks.