Dr. Badiye is a Heart Failure Specialist with Sentara Heart Hospital. He presents the 2022 guidelines suggesting patient-centric recommendations for clinicians diagnosing and managing heart failure.
on behalf of Sentara Heart Hospital in Eastern Virginia Medical School. I would like to welcome dr Amit Doctor barriers talk this morning is entitled New Age H. A. A. C. C. Clinical care guidelines for heart failure dr body completed his medical degree at Government Medical College and Hospital in Nagpur. Then residencies in internal medicine at Grant Medical College and government hospitals, Mumbai University and at Orlando Health Arnold Palmer Hospital where he also served as chief resident. He went on to complete fellowships in cardiology, interventional cardiology and advanced heart failure, transplant all at the University of Miami. It was an assistant professor of clinical medicine at the University of Miami Miller School of Medicine prior to joining centering cardiology as a member of the advanced heart failure mechanical circulatory support and transplant program and interventional cardiology team. Dr Barnier has authored numerous articles on a range of topics including heart failure, coronary intervention, VAD and impeller support and gene expression in cardiomyopathy. And I understand he's also an accomplished photographer uh the A. C. C. And A. H. A. H. F. S. A. Have released new heart failure guidelines for 2022. As many of you may be aware these replaced the 2013 guidelines in the 2017 focus update and we appreciate dr body joining us this morning to provide this important update for all of us. Welcome and we're looking forward to your talk this morning. Thank you dr Bernstein and good morning everyone. Um It's a huge um to discuss some of the salient features of these guidelines. It's almost about 1 38 page document but you know it's three um access. So you can go to um H. A. Or a C. C. Website and you can download the uh entire document. Um So you know I don't have any disclosures actually still remains a major cause of morbidity and mortality. And this guideline is really intended just like other guidelines to give a patient centric recommendation to the clinicians who are providing care for this um complex disease heart failure. As dr Bernstein said it will replace the 2013 guideline and the 2017 focused update which predominantly talked about introduction of um uh angiotensin receptor and neutralizing innovator Arnie um induction and also talked about evaporating treatment of engineer and also to sleep apnea. Uh intent of all the guidelines is to provide you know quality of care to improve the quality of care of patients and align these treatment modalities with patients interests. This guideline also is slightly different that it has added value statements to certain treatments um by using high quality published economic analysis so whatever we do in medicine what value it carries Low high medium or intermediate. That's kind of the guideline also focus on. So uh we need to know this the class or sense of recommendation as we know. Class one is the highest recommendation and class three harm. It all depends on. There is benefit ratio also the level of the evidence. You know whether it's multiple randomized control trials um meta analysis which are high quality our cities and then there is A level C. Evidence E over which is just like an expert opinion. What is the weighting of the evidence? So we are using a lot of uh you know a lot many of us are using this term G. D. M. T. Guideline directed medical therapy and this doesn't just income in compass or include treatment which is just pharmacological treatment. It also includes clinical evaluation of the patient diagnostic testing and both pharmacological and procedural treatments. So G. D. M. D. Just doesn't mean centimeters beta blockers. And it includes extensive and comprehensive evaluation of patients. Just wanted to mention that. And the areas of focus of this guidance our first time that talking about prevention of heart failure um management of heart failure strategies in state C. And as we know that everybody much awaited uh digital innovators and um our knees are kind of the main focus as far as we are concerned. Also touches based on simulation including ablation therapies for as dr generalist walks in. Also management of heart failure with secondary including trans catheter age to asia fair. Uh It's a focus of this guideline and on top of that treatment of treatment and evaluation of amyloidosis and cardio oncology which was not in any of the guidelines. And also the guideline has focused on implantable devices like cardamom system uh and other devices used for monitoring. Also some focus on advanced heart failure that is HD heart failure. So it tries to define heart failure is a complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of love. Now they divided heart fell into A. And D. And stage A. And B. Really asymptomatic stages. Right? So um the heart feeling destination really doesn't include these stages. You know, these are asymptomatic stages. So the signs and symptoms part doesn't fit there. So basically what stage A species at risk And state B is what we call three heart failure. Um And this is really the theme of these guidelines that they want you to divide your patient in different stages. Try to focus on the trajectory of the heart failure and then see what treatment is available for the patient and how you can optimize them. For example, if we start from the left of the screen, um stage heart failure as a patient who are addressed for heart failure for this patient. These are the patients, they have no symptoms. They have no signs of heart failure and they do not have any structural or functional heart disease um or have abnormal biomarkers. So who are these patients? These are patients with hypertension, cardiovascular disease, diabetes, obesity patients who are exposed to cardiac agents. They may have a genetic variant um for cardiomyopathy. Or they have a family history of cardiomyopathy. So these are the patients who are at risk. Then moving forward. You go to stage B. These are the patients who are pre heart failure. Now these are the patients who are they have some they don't have any signs or symptoms but they have evidence of one of the following meaning. They may have some structural heart disease. They may have mitral regurgitation which is completely asymptomatic. They may have evidence of increased filling pressures on the echo. When you do issue, Doppler E prime is elevated. Um And then although they don't have any symptoms, you may still have uh lab evidence like increasing act theoretic peptide levels or cardiac troponin levels. Specifically if you see cardio oncology patients, one Biomarker which is closely followed in them as proponents. So they may not have any symptoms just getting the chemotherapy, but they will have elevated troponin that patients getting chemotherapy um without any other, you know completing diagnosis moving forward the moment these patients become symptomatic, they come to state C. Right, so once they see they're always they cannot go to stage B. R. A. Because they always have some signs and symptoms of heart failure and then when your guideline directed medical therapy fails, they have persistent heart failure symptoms um you know, which interferes with their daily life. They have recurrent hospitalization. These are really the end stage and then now moving forward the entire guideline will really start talking about these stages and you know how to manage them and what is the level of evidence for each therapy and evaluation which we do. Um the other important thing in this guideline is they want us to focus on the trajectory of H. C. Heart failure. Heart failure. As you can see here it could be new onset or dino heart failure. Every one of us see these new diagnosed heart failure patients. They don't have any prior heart failure history. And then the first time come to the hospital with a diagnosis of heart failure. Um The next stage is you treat them you know you diaries them, put them on medical therapy and then their symptoms get better. So who are these? There are some patients um who have persistent heart failure LV dysfunction and then their patients who cannot go in remission without resolution with or without resolution, prior structural or functional heart disease meaning they may have functional michael regurgitation. Now you treated them with medical therapy the L. V. Now remodels and then you have reduction in lbc and the functional M. R. Goes away. But this heart failure is kind of in resolution. Then there are patients who are in persistent heart failure. So despite you know your treatment they're always symptomatic. They always come to your office elevated DVD hard feeling symptoms peripheral edema, exertion Disney. A or 40 and then there are some patients who despite all these things they continue to worsen. You know now you're withdrawing medical therapy or you're not able to escalate their G. D. M. T. And and they obviously have signs of worsening heart failure. So this is the trajectory of the they see heart failure which Um these guidelines are really emphasizing on now they are also classified heart failure by left ventricular ejection fraction. As we know. The threshold for reduced ejection fraction is 40 preserved. Ejection fraction is 50. And then heart failure with mildly reduced ejection fraction is okay. And then the category of heart failure with improved ejection fraction where the EF has gone um about 40% and there's like a 10% increments in ejection fraction why it's important to conduct an eye on this heart failure with improved ejection fraction vision because they cannot stop their medicine. You know they cannot stop their G. D. M. T. Because there's enough evidence that they will get worse. Um And then the diagnosis of heart failure needs evidence of elevated filling pressures. Whether it will be by labs that is theoretic peptide elevation or one can do resting echocardiogram or you can do exercise echocardiogram to see if they have evidence of elevated filling pressures. Um one can also use invasive human dynamics like left and right to see what are their filling pressures address and on exercise. I see this most often that a patient comes for a right hard cast and then the hard cap numbers are normal and then we celebrate success and we send them home oh you're fine but um you know they're not fine because you exercise this vision and suddenly you see that the peer pressures are in the sixties. The veg goes into the forties and then they have flash pulmonary edema because they have that they may have which is low dependent and that may need further evaluation. And then as we all know the diagnosis of heart failure preserved ejection fraction is really challenging. You know. Um the guideline paper talks about this X two F. P E F score it really integrates predictive variables like obesity if age more than 60 years treatment with more than two antihypertensive medications, abnormal E to E prime ratio and echocardiogram bs systolic pressure of more than 35 millimeters of mercury. So the scores less than two low likelihood of path and scores more than represent high likelihood of And scores between 2-5 may require for the evaluation like exercise dynamics. Um Just mentioned and and believe me, we see these patients all the time and we are questioning we label them as non cardiac Disney A or pulmonary hypertension and we send them to other physicians but really um what we're dealing with. So you know just like every other medical condition or God a condition. You know the guideline talks about initial evaluation of this vision, a thorough history and physical lab testing E. K. G. Um And obviously in heart failure use of biomarkers prevention, diagnosis and risk stratification is extremely important. I just want to mention here that you know patient who presents who are presented with Disney to anti pro BNP testing and the pro BNP level is class one um indication. Also patients who have chronic heart failure for risk factor, risk stratification and also hospitalized patients at uh admission is you can use BNP levels because they have prognostic value very high ME and P levels. Um You should not use BNP levels to alert your treatment meaning you should not titrate your therapy according to the incremental BNP levels or detrimental BNP levels. You know it's not helpful. Um patients you know who have nuance and heart failure when they are at risk for heart failure. Anti pro BNP levels can be used to start treating them more aggressive. Right? So we are we were talking about stage A our stage B patients and now you have a stage be patient where they have elevated BNP, you will treat them more aggressively so that they don't progress and you can use the G. D. M. T. To do that. And patients who are in the hospital who are waiting to be discharged. You know you can use um BNP because around 50% of the patients are discharged and just you know you can definitely use BNP levels to see where they are at and decide like okay maybe we should keep this patient one more day because the NT pro BNP is 15,000. Um When we talk about history and physical it's recommended that somebody who you are suspecting familial cardiomyopathy you really should do three generation family history. You should go back like not just don't stop at your parents go to grandparents, their parents, right. Great grandparents. So you have to really do three um levels of family history. Taken to really see if there is a genetic cardiomyopathy is hiding. You know. And then once you have a patient with genetic cardiomyopathy the first degree relative should get generating screening and from consideration of treatment if they have you know heart failure It's a class two a indication that patients with non ischemic cardiomyopathy who may have you know family members who may get benefited from genetic testing to refer them from for genetic counseling. And we do all these at our heart failure clinic here in Sentara um which patients you would really kind of have a suspicion that they may have probably genetic cardiomyopathy. They could have a weird cardiac morphology like echo with mark hypertrophy or typical hypertrophy very prominent. You know basal septum or very prominent popularly muscles. You may see LV non compaction it looks like non compaction cardiomyopathy. But there are so many genetic mutations we know who have like a hypertrophic background like TTN mutation. You see these are they look like non compaction se non compaction after looking at the echo do genetic testing and patients have T. T. And we just transplanted to patients like that last year. Um patients who have right ventricular thinning or fighting infiltration um suspicious for a Rbc abnormal. You're really fragmented KG. Or uh Echo has L. V. Eight and EKGs low voltage. There are some reforestation abnormalities. These patients could have long duty or Brugada syndrome. So patient with weird frequent arrhythmias. You know PVC is multifocal pvcs um BTS early onset a fib loan before age 65. You know early onset conduction system disorder. Somebody who's really young for no reason develops hardblogger needs a pacemaker. And patients with cutaneous stigmata or skeletal myopathy. Um We've seen lamin mutation. They have like this weird box like fingers. They have some mala prominence is so this facial dysmorphia is um should make you you know think about genetic regarding my appetite. You can take more history and you know figure out if they need more genetic counseling obviously um chest X ray echo for initial evaluation or um any significant clinical change. You're repeating the echocardiogram if the echo is not enough and you want more data and in those cases M. R. I. Or CT scans there are class one indication. But if you're just doing echo for routine follow up. You know if you're doing anything as a routine which is not going to change your management. You're just um trying to do it because patient is following up with you. Um then it's a class three, it's no benefit. You know, patients with coronary artery disease who need revascularization. The victim is if they have a chemical um apathy, they should get re vascular, you know, shall you do uh threat testing on them to realize um Ischemia to help guide revascularization is kind of weaker indication is to be um just wanted to kind of focus invasive evaluation. Um It's pretty interesting that most of the invasive evaluation is either to a our new benefits. And by that we mean endo myocardial biopsy do biopsy if it's going to change management like giant cell myocarditis, rapidly progressing cardamom Abati permanent course with hard blocks. Arrhythmias probably could be feminine. My priorities for giant cells. Yes, biopsy is indicated. But just because you have in honest cardamom participation, you don't have a history. They always say that they have flu like symptoms. I would not go with the bio dome. Uh doing biopsy on the patient, you know, routine. Right? Hard cash on a patient just because they're diagnosed with heart failure, it's not indicated. It won't benefit you. You might as well just clinically see signs of congestion, really gallop physical exam. Another interesting update is about variable and remote monitoring. As we know that vitamins got um the pulmonary artery sensor got FDA approval. Just because it's FDA approved doesn't mean that every patient should get implanted with these devices. Um doesn't mean that it's a class one indication actually. It's a class to be indication. Um And as you can see the level of evidence is B. R. Um only one randomized trial. And the initial study was like an open label study. So what the recommendation is selected adulteration with class three and history of heart failure hospitalization in the past year with our elevated theoretic peptide levels and maximally tolerated stable doses of GMt with optimal device therapy. The usefulness of sensor monitoring to reduce the risk of subsequent heart failure. Hospitalization is uncertain. So basically you have to meet all the criteria first to even talk about device implant. You know don't put it on a guy who just got admitted he's on baby doses of medicines and doesn't even have an I. D. Don't put cardamom in this patient you know because he may just recover with G. D. M. D. And get better and does not need to be subjected for this procedure. But yes I find it very useful in a lot of my patients who are borderline for not doing well. They are these you know state C patients remember like we talked about the trajectory of states uh patients who are not doing well who have worsening heart failure or they're always symptomatic. You know I would not use it in a stable um patients with C. But at least struggling patients definitely I would say that the ph sensor monitoring has a lot of value and as you can see the value statement. Um you know, um uh as done by the guidelines is kind of uncertain. You know, how much dollar amount you can save by doing this is uncertain because I think it all depends on the patient selection. If you don't select the right patients, then you're not going to get value for your intervention exercise and functional capacity. Every patient is advised to exercise and do what they can, We can do cardiopulmonary exercise testing to see if they need transplant or the magic number. If one has to remember is 14 if it's less than that, they they have worse prognosis and they need to be evaluated for Albert and transplant. Then beta blockers. The number is 12 um patients um you know who you can do six minute work on these patients to see how they're performing. The magic number for that is the threshold is 300 m less than that, you know. Um uh they have higher morbidity and mortality. Um Again, patients with unexplained Disney, a cardiopulmonary exercise testing can be really a good um just to see their functional capacity and at times also can differentiate between cardiac and non cardiac causes. I had a patient who had um, trachea Malaysia and you know, the cardiopulmonary exercise just being kind of um showed that on spy rama tree. Another patient at your preliminary type three pulmonary hypertension and under the Ec. Two slope which we can see on the keypad and the figure helped us figure out that this is not cardiac, this is something else. So keep, keep it in mind for guidelines. Um there are several heart failure risk scoring calculators. Um and the guidelines mentioned their class to a recommendation to have a dialogue with your patient. Okay, what's their prognosis like? You know what their survival for one year, three years. So that then you can talk to them about for the therapy. For example, I had a patient who thought that he needed a transplant, you know. So we sat down and did the Seattle heart failure risk model and his survival first year was 99% per this risk model. Right? And if you say the best center heart transplant survival at one year is Average in us is 90-92%. So I was like, listen, your survival now is better than a heart transplant recipients. You don't need heart transplant, you know, you're fine with your medications. And as you can see there are different scores which have been validated for different conditions. Um chronic have left. There are the HF action in paradigm HF scores for half past predominantly the top cat and I preserve score. So there are all these links available on the guidelines statement um, stage a tsunami. We're starting with the stages what to do at every stage. So these are at risk patients, right Treat their hypertension, right, treat their diabetes. And here they are saying 32 innovators rather than Metformin especially to prevent hospitalization for heart failure. Um So that's I think kind of interesting to see here in general they are advising you know healthy lifestyle diet, exercise, Um avoiding smoking, excessive drinking. Uh these interventions as class one again the diuretic peptide biomarker based studies. There was only one study and which showed that you know if you look at the BNP and follow these patients you can prevent heart failure. So as the evidence is limited, the evidences recommendation is a BNP in this asymptomatic address patients. Um um moving forward, this is kind of the team everywhere in the guidelines where they would have a stage of heart failure and then they would recommend what to do. For example, we just went through stage a on the left side you can see high participation, control their blood pressure and all the greens. I mean this is one recommendation diabetes situation gives them a guilty to innovators. CVD patient optimal management of cardiovascular disease patients were exposed to a toxic agents, have a multidisciplinary evaluation discussed with the oncologist cardiologist and other team members to see what's the best next step for them. The chemo needs to be hearted are continue chemotherapy, you know containing G. D. M. T. Um lab based assessment of these patients and then if you go on the other side stage be heart failure. These are the patients as we said they have some structural abnormalities. As you can see here patient with the f Less than 40% or anime patient with less than 40% year but they don't have heart failure yet you know. Um What do you do for these patients? There's no data yet about Arnie in these asymptomatic patients. There is a paradise trial which will give us that data in patients with you know E. F. Less than 30% more than one year survival. More than 40 days. Am I consider them for my C. D. Even though they're asymptomatic patients with non ischemic cardiomyopathy. As we thought about like you know if they have some evidence of familial or genetic cardiomyopathy. Do genetic testing. So this is how the guideline wants us to follow right Step one is to establish the diagnosis of heart failure with reduced ejection fraction, address condition with diuretics initiative Gmd. Moving Forward Step two target dozing. You have to optimize to maximize their G. D. M. T. Highest doses better outcome, better survival. That's the data. You know. Then once you have optimized them right Um either those patients they improve that you have becomes more than 40%. That's the heart improve ejection fraction and then you just follow them, make sure they are there to their treatment plan. Right? Those patients who still have low E. F. Then you see these scenarios if there are african americans consider authority high dollars in combination. Right? Um If they have More than one year survival is still less than 35 classes 123 consider icD. If they meet the criteria Less than 35 Q. R. S. More than one could see left bundle branch. Consider CRT moving forward after this device therapy. What is next? Consider additional therapies. What are those? I'll show you in the next slide. That means you know consider evaporating or consider very sick. All these agents they have just shown readmission benefit and they have certain indications. So you can try this therapies. You can try potassium binders in your patients hyper Columbia from you know giving them um Arnie or spironolactone at the same time. And then if these patients become refractory stage D then you're thinking about other therapies. Okay referred to an advanced heart failure center especially for additional therapy. Are they candidates for durable mechanical support, circulatory devices Like or they are a transplant candidate or they really need to be uh palliative care and the guidelines also kind of tell you to look for investigational studies um Start you know commonly recommended restriction. We I really have no evidence for that. I mean this is what it shows us away and we just had the results from sodium HF trial that is no mortality benefit but again all these trials and data is like all small sample size actually many of the trials they have done just to give an example if you eat chinese um uh super bull. Um the sodium content uh would be somewhere around 7000 mg. Okay. But these so one can have a super mega lower of sodium with this food, right? Are dire a pickle for example. Right? So 7 to 8000 mg of sodium. And if you look at this clinical trials, the highest sodium load they received were like 2500 to 2600 mg. So just below what uh you know H. A. Um recommends uh or sodium for an average person. So again, these trials were done with very different variable small sample sizes. So we don't have evidence for simple dietary intervention. What are you going to tell? You know, your patient sodium? But it does say that, you know, although the data is limited patients with it's a heart failure, avoiding excess sodium is reasonable to reduce congestive symptoms. And I've seen this a lot in my Clinical practice, especially three and 4 patients, they should really stay away from what are the barriers to effective heart failure of self care. The guideline also is switching more towards comprehensive patient evaluation. Just not far. Mako therapy, just not procedures and micro clips and cardamom. It wants us to see that cognitive impairment, depression, substance abuse clarity, financial burden, food insecurity, homelessness, partner violence, limited english proficiency or other language barriers, low health literacy social isolation. Which so it has done a lot or transport limitations. All these can be barriers. Care for heart failure patients. And we see this all the time, but we don't address them because it's not our problem. But it's I mean euros to the guideline writers that now they want us to think about this. You know, obviously um this is my least favorite slide because um although we recommending class one for exercise training and regular physical activity, cardiac rehab program is class to a uh indication. And because the trials are non randomized, I really think that cardiac rehab is underutilized less than the data is less than 2% of heart failure patients get sent to cardiac rehab. You know, who meet the indication for cardiac. So something to focus on. We already know the diuretics. Um this flight talks about a CRB Arnie. What I want to focus is every patient who is on a boat or RV. Obviously a centimeters were favored before A. R. Bs. But now um patients who are um you know, begin with chronic symptoms, two or three who are tolerating A. S. R. A. R. B. They're indicating replacement by Arnie. This is to give them additional morbidity and mortality benefits. So switch them to Arnie whenever can write as you can see Arnie is always now the class one indication, those patients who are intolerant because of Angela lima. Obviously you can do our jobs. Um, caution is do not give a centimeters with Arnie do not give our need to patient with Angelina and do not give aid to any patient with um thanks Cost effectiveness. So the trial was conducted for 27 months. So it's considered a higher value. Um so after 27 months who severed survives and who served it doesn't get re admitted right um this as high value. Um uh you will get more but for uh playing for your book when you give patients Arnie even patients um who were initiated after the hospitalist they benefited from the cost effectiveness. So um these drugs are very very useful. So if you write in your notes okay we'll consider Arne when patient is home and this and that anything is cheeseburger. It's never going to happen. Just do it. You know there's enough data now that if you don't initiate G. D. M. T. Before they go home uh they don't do well I mean you have a patient who has borderline blood pressure and you are not persistent and not putting them on the G. D. M. T. Before discharge. You're just waiting for them for these things to happen. As outpatient. It's never gonna happen. So you have to make them make sure that they are on these medicines because it's not gonna happen. And the data is really I mean we should be ashamed 50% of this patient for one year after first heart failure hospitalization never gets started on any medicine. 50% Imagine the plight of other patients how the Gmt must be getting up where the guidelines want us to be decision every two weeks and their medicine so that before they get to the I. C. D. Mark or before they get to a device mark you know they are on school medical therapy you know um we already know the importance of beta blockers. Same story. Do not send them home without beta blockers. Those patients who go home with beta blockers live longer do not come back to the hospital, those who go out without beta blockers um mineral receptor antagonist. Same story. Lot of inertia. You know all these studies and trials and registries. The use of um spironolactone was like 35% of the patient population. Even in randomized trials there's a lot to do in this patient. Just be careful. Don't give it to patients who are hyper kalinic and they brought a very important point which we all and observe but we don't think about it like this. So the document says that high potassium on this patient with cameras is it really a side effect or they're hiding something meaning if these patients develop worsening renal failure or hyper Columbia. This could reflect actually an acute clinical change or progressive disease rather than just a side effect or drug interaction. So be careful think twice before quickly stopping the spironolactone because your patient is going into renal failure or is going through the roof. This patient might be progressing to the next stage of heart failure. So that's what the guidelines is kind of trying to tell us to think now a G. R. T. Two inhibitors. That's I think the highlight of this, the sodium glucose transporters. Um so the ugly flows in and flows in order to agents which are available again. Class one agent. I was very reluctant a year and a half ago I would Do the same mistake. I would write in my notes consider SGL two inhibitors. We'll talk to the primary care physician. I was super worried about urinary tract infection and being a cardiologist, I have to treat it and whatnot. Um but now I want these drugs to be in drinking water because they make such a phenomenal difference in the volume status of this patient. And right now as your new agent, they're expensive. That's why the value statement is kind of intermediate but just like undressed. So now it's available with all the um you know um insurance companies soon we would see because of guidelines, the insurance companies will give probably less pushback. And the Dapa HF and the emperor reduced trials were the landmark trial which showed you know, reduction of Hospitalization and death by 25% greater than 30% reduction in heart failure, hospitalization in both trials really this is gonna get every hospital number the readmission rate to the bottom, you know, if we really start using these agents and it's a great thing that we have uh formulary here in Norfolk general. And these were the composite outcome graphs of uh the flows in and um you know from the emperor trial for the flows in. You can see nice deviation of Girls right before like 30 day mark. Um So um moving forward hydrology and we know that african american patient population um has been, you know, class one indication. Other non african american patient population. We don't have enough data um of the use of these, you know, agents, those who are intolerant to any of the other agents. You can definitely use hydrogen in the last class to be agent. Um patients who are class 2-4 symptoms, polyunsaturated fatty acid is couple trials which show some benefit with reduced mortality and cardiovascular hospitalizations. Um There are these protection binders I was talking about at the roemer and sodium zirconium silicate. So these agents are being promoted um to help us continue right? M. R. A. And Arnie. But whether using these agents to continue M. R. N. Arnie, do they change the natural history of the disease? That data is not strong enough? That's why it's uh that's to be indication. And um similarly patients, you know with heart failure, reduced ejection fraction if they don't have any indication for anti coagulation. Don't give it. This is very important slide. Um I think we should also know when not to do harm. We see this recurrently patients getting di hydro pirate in calcium channel blockers with reduced E. F. And then they come in with you know profound shock. Multivitamins. Uh I'm low dipping just for heart failure. Um More attacks in patients with low ejection fraction. Right? All these things are contraindicated. Your Lipton's the diabetic agents. They cause uh Alima and fluid retention and insects so they're harmful. Please make sure that you scream your patients medalists reconciliation when you go through these agents. So there's just a list of medicines which they want us to avoid. Um This is again very important. Class one that the patient should get the tight relation of guideline directed medical dozing to achieve the target doses to be efficacy in randomized controlled trials to reduce cardiovascular mortality and heart hospitalization unless not wear it already. So don't then your patient with blood pressure of 140 over 100 with a baby dose of 24 26 Arnie right? You have to strive to get them to the third year of Arnie. You have to make sure they go to 25 twice a day of carpet a lot. You know the US carvedilol trial, the carvedilol was given for weight. If I have a patient with B. M. I. 40 I give them 50 sometimes 75 twice a day of carpet. A lot. Do not hesitate to do that because that's recommended in guidelines as well. You know It's a class two indication to See them every 1-2 weeks. And what do we do? We see them as follow up from hospital. They're still struggling. The blood pressure is whatever. You don't make any medication changes. And you say follow up in six months. So what happens? The EF is still 10% gets defibrillator. And then after six months they are showing up in the transplant clinic. But look use of all these four drugs have been estimated to reduce all cause mortality by 73%. In which intervention reduces mortality by 73%. So we should really be a bit with our Gmt and this slide clearly shows us. Look Arnie Um 16% reduction in mortality. Beta blockers, 34 mari. 30% I realize in nitrate 43% CRT 36%. i. c. d. 22. There's no reason we should not give these patients the GMt. Right. Um Moving Forward Evaporating. Class two indicators. I call it the expensive option if you have a patient who is intolerant to beta blockers detriments. About 70 E. F. Is less than 35. And by check last two or three um you can use um evaporating. Um This is a new kid on the block. Um The victoria trial. Um The use of very cigar which is a valuable guanine cyclist simulator gives cyclic GMP. Which has always benefits of industrial um function improvement. Dilator function and the patients who have heart failure admission. Ny class 2 to 3 elevated pro BNP very can then be added for symptom relief and reducing hospitalization and cardiovascular death To do this 2.5 mg and after two weeks you can title it 25 and 10 mg. So I showed you in the past that flight where there was this orange block which considered additional therapies amongst the G. D. M. C. Is optimized. So these are the therapies right? Evaporating for your patients with heart. More than 70 very cigars for your patients with class 2-4 45% recent heart failure admission or need for outpatient ivy diuretics and elevated levels. Deduction as you know is class to be to be is in my mind to be or not to be so be careful, narrow therapeutic index, poly unsaturated fatty acids and protest in binders carry the same kind of level I. C. D. N. C. R. D. I think there are no new things here so I will continue moving um forward with these. Just some special consideration. Some patient with class 2 to 3 with E. F. Of 46% unless who undergo a V nodal ablation. PRT did improve their six minute walk walk test and LVF as compared to those who were only RV pace. Right? Those who are more than 40%. Um R. V. P. A. C. R. D. Can be used to reduce the mortality and hospitalization. So new device interrogation. Keep an eye on how much percentage there are we facing there are some exceptions to the G. D. M. D. Treatment and LVF 35% rule. There are some genetic cardamom but these which are arrayed Majdanek so these are the kind of islam in gene mutation, clemency mutations. These patients uh they should get preemptive defibrillators. Okay uh so if you have a patient with genetic cardiomyopathy who have lemon or rbc uh send them for a box um valvular heart disease. So obviously it should be a multi disciplinary decision to you know fix this valve. It should not be a surgeon or structural heart disease physicians. Um Decision patient with chronic if your secondary M. R. And heart failure with reduced ejection fraction once they're optimized um you know they have to be optimal before any intervention is recommended for LV dysfunction. Don't do micro clip before optimizing them. And we have a great program. All these patients they come to us we optimize them. Then they get their echo. I would play around 25% of them. I see the emerges disappears and then they don't need my clip. So there's just a flow chart of the same. You have apparently secondary manager. Re graduation do strong G. D. M. T. At least 2 to 3 months of G. D. M. T. And then if the M. R. Is still you know severe Your volume is 60 ml or fraction is more than 50 More than 40. If the EF is more than 50%. You know they are symptomatic if F. Is treated and then for mitral valve surgery it's still to be is low. They are symptomatic, their favorable anatomy meaning um L. V. I. D. D. Is less than seven centimeters. They have permit hypertension which is manageable and Ef is 20 to 50%. Um Then they will be candid for trans catheter age to age repair. This is from the coop trial um if they have severe symptoms and an atom is not favorable. Then again mitral valve surgery can be considered. So treatment of midrange ejection fraction these are the 40 to 50% patients, everything like G. D. M. T. Um But you can give them almost everything these patients could be those patients who are recovering from their low E. F. So that's what they need to be continued on the G. D. M. D. As well. And I think this is the more important thing for a long period. We didn't have anything for health best patients. And um you know now that have been like class indicator indication for help in addition to management of a favor and treating their hypertension. As you can see spironolactone is to be. Um And then A R. B. Can be to be um Arnie um May be considered but these are specifically for women and those with the F on the lower low range of the normal. So don't use my trick amyloid. Those who there should be a strong clinical suspicion. We already talked about that. You know L. B. H. On echo local D. G. Kg. This may not be present in all the patient. Only 25 to 30% patients have these classic findings but you can have a pickle sparing on strain imaging on the echocardiogram. Get there screening with serum and urine monoclonal light chains also to immune a fixation and then with the high index of suspicion you can then go to the next level. So if your light chains and monoclonal urinary monoclonal chains are negative to do bone skin geography. Generally I ordered it at the same time. And because L amyloid can also light up on pY B. Scan. Okay so you don't want to miss that. So that's why you have to do uh serum and those those who have positive transparent in in cardiac amyloidosis on the previous scan. You can do genetic testing to see if they have T. T. R. G. Mutation or not because then you can screen the family members of class one indication. Again the scheme to just I mentioned I generally do the monoclonal change and the scan at the same time. There is a monoclonal chain positive psychology if they want to do bone marrow or sometimes they are not convinced and they want us to do myocardial biopsy and then we proceed from there um treatment there's one agent for it right now. It's the families. It's the class one indication. And it's an expensive therapy. As you can see It has low value. You really see symptomatic change after 18 months therapy. And the graph starts kind of separating for morbidity and mortality around that time. So it takes a lot of time for this to get better. They are kind of hyper competitive level. So low treasure to anti coagulate them. Um A. D heart failure that our domain. Please refer these patients to us. That's what the guidelines are telling. Don't waste their time working them. We do extensive work up including everything colonoscopy. Dental psychology. I mean you name it and we do it. Don't waste. I'm thinking too much. Just send this to us and we'll take care of them. These are good in the morning. So remember these kinds of patients who are failing G. D. M. T. Or E. F. Is low there. Ny check last three they have given. I know tropes in some of the prior admissions so they're getting multiple ai cd shocks more than one hospitalization in a year. They persistently are congested with edema. They have low blood pressure. They have end organ damage like you know kidneys and liver abnormal um Send them to us. They need help. Um And we need to help them in a topic Support. As we know is harmful if you just do it without palliative care or a bridge. Um mechanical circulatory support, durable HVAC R plus one indication. And temporary L bags are plus two a indication. The value to that is uncertain transplant. We know about that patients were admitted with heart failure. Again you know adequate de congestion. Get them on Gmt right? Continue the Gmt and have a plan. That's what the guidelines are telling us and maintenance of optimization of G. D. M. T. During hospitalization. We talked about it right If you stop something make sure you restart it. If the kidneys are um not doing well around 10 to 15% of elevated creatinine is expected. Don't get scared. Continue their G. D. M. T. You know do not send them without better blockers and Arnie at home. Um then they focus on cardiogenic shock. I mean it's just really comprehensive goes on and on talked about you know transitions of care how a seven day visit with a nurse or a phone call or a telehealth visit is important for these patients. It's important that they know they should get their medications and have a way for their refills and have a multidisciplinary evaluation for more abilities. Um Anemia sleep apnea has been discussed before. This is not new. Again this is the team they follow with all these greens Are your class one indication right? The revascularization management, anti coagulation With those who have a fever and heart failure. There's nothing new here. They did talk about disparities and vulnerable populations populations which we talked about which are not able to self care for them to focus on their hurdles and then have an evidence to monitor them with more focused care and have created a system level care for this vision. That's what the guidelines are recommending um carry oncologists and other you know feel they kind of touch based upon. You have to have a multidisciplinary management plan for these patients and those when the F goes down you should start them on a centimeters or and beta blockers to prevent the progression. Some of these uh conditions depend on the oncological asian like for example you can really continue GmT and the cardamom recovers. But with checkpoint innovators for example you will have progressive cardiomyopathy. So that agent means to be stopped. So um you know this is really needs a multidisciplinary approach. You cannot take care of this cardio oncology patient in a silo um heart failure and pregnancy similarly, you know you have to follow this patient make sure when uh to figure out when they deteriorate which agents to be stopped right? You're going to stop their R. D. R. B. D. Two innovators evaporating and spironolactone when they become pregnant. They also are actually advising quality and performance measure which we do have here in Sentara every hospital and system can compare themselves with a nationally based organization to see how they are doing? Are they doing? G. D. M. T. Or not? What's their G. D. M. D. Rate? What are the goals of care? You know this talks about more like palliative care, how important that is in this vision because not everybody is candidate for advanced therapies. So to have a multidisciplinary approach with palliative care is also highly recommended. Especially those who have less than six months arrival. So this is the final slide. This is how the stuttering course of heart failure is. You know you start with a good quality of life and then you have admissions and readmissions and decompensation and then you really become advanced age. This black blob here your stage D then either you become candidates for M. C. S. Or transplant or you become uh you know candidate for nothing and your to embrace end of life care. And then some of these patients, they have sudden cardiac death because of their risk factors. So um I think the take home message is you know the four pillars uh is added. Um They also have class to recommendations for midrange, mildly reduced ejection fraction and have have some indication now. Um The improved F. Is the term used specifically not to stop their gmt value statement are created for different therapies. Amyloid um uh treatments and algorithms have been added emphasis is made on increased filling pressures and work to do to evaluate them and um patient should be referred to advanced heart failure team. Those who wish to prolong their survival from heart failure. So remember my team um and then also focus on primary prevention and Selected patient with I think that kind of summarizes these 2022 guidelines. There's a lot of gaps and a lot of things to do. We still don't have a lot of answer for a lot of new therapies we're seeing. Um So it's just fascinating how heart failure is evolving. Thank you so much for your time to listen. I know we are over time but if you have any questions I'll be happy to answer them. Uh Thank you for an outstanding and timely review of the current guideline recommendations for heart failure management across the spectrum. I'd like to invite our audience to submit any questions or comments via the fat function. Or you can text me directly for those that are able to hang around for some additional moments. Have a audience question If you're if you have borderline hyper Kaleem mia is starting an S. G. LT two ahead of your mra a good strategy with the hopes that S. G. L. T. Two inhibitor will decrease serum potassium. So generally what I do is I do baseline labs on these patients to see where they stand because if these patients are volume depleted they can go into pre rina lazo Tamia because you know they get a lot of um like area because of the the mechanism of action of the drug and they can quickly get dehydrated. So I generally get baseline labs before starting a guilty to innovators and then make my decision accordingly but there's no reason to hold them back. Mostly what I see is patients you know they know that they're on diuretics so they are on high potassium diet eating bananas and oranges and sometimes coconut water. So there's a lot of dietary issues with potassium than just the medicines. Okay. Um with without any S. G. L. T. Two. Is that just a checkbox if you put them on a low dose therapy? Is that adequate or is tight trading to the higher doses of those agents? Is that provide additional benefit? We titrate for heart failure. So it's definitely a very big check box one of the four pillars so definitely that but if you have you need more you know glycemic control and you know weight loss is another positive benefit from this agent. So yeah you can titrate it for your anti diabetic therapy but you know for heart failure. Just making that big check box is very important. Okay. Uh Doctor raised a common frustration about diagnosing chronic volume overload in dialysis patients as where cardiology doesn't have a lot to add there. Uh Can you comment on treatments and cardiology role and and what we do in terms of now are the enhanced guidelines in that setting. Yes and actually I ignored that part in the guideline because the guidelines themselves. They said there's limited data. Uh and I think the problem is there's less collaboration between cardiology and nephrology on these patients and many of these patients just inadequately dialyzers. You know, three times a week, dialysis is not enough for many of these patients. We know that. And that's why you see patients who are getting peritoneal dialysis or getting home hemodialysis. They do much better than those who are getting inadequate dialysis in outpatient center. And these CKD patients, whether they're 34 or five, they are the most ignored patients. Um although they unfortunately die from cardiovascular complications. So yeah, that's one of the most ignored field. Um uh you know, on on our side in the improved eF category for those that had reduced uh function that have now seen improvement on their medical regimen. There's obviously a very high recidivism rate if their guideline directed medical therapy is uh subsequently stopped with just improvement up into the 40s 50 range. Is there a ejection fraction that you think then is at some point will be safe to be able to stop some of those therapies? You know, it's strongly recommended that we should not do that. They did a trial on these uh improve ejection fraction patients where they randomized patients to stop their medicines and other group would continue. Those who stop their medicines had de crimen Tal ejection fraction and some of them unfortunately progress to stage the heart failure and eve did not recover. So we strongly recommend not stopping these medicines. Very few patients like maybe cardiomyopathy and some patients with myocarditis they may get by uh stopping the medicines, but otherwise others they would not because I think many of the incidents of um at risk of heart failure patient is so high hypertension is like you know, several million patients, diabetes, several million patients re diabetic, you know, so all these are risk factors for heart failures. Once you have this patient with you know, improved ejection fraction, if they have this a kind of phenotype, then we know that they are going to regress at some stage. Thank you. Uh The hours is getting laid and on behalf of all of today's participants again, thank you for terrific talk and discussion.
