2. INTRODUCTION
• Heart failure in India
constitutes one of the huge
health burdens
• Heart failure according to
American College of
Cardiology/ American Heart
Association (ACC/AHA) is
a ‘complex clinical
syndrome that results from
any structural or functional
impairment of ventricular
filling or ejection of blood.’
3. • For practical therapeutic purposes, we can consider
heart failure under two different pathophysiological
states:
1. Heart failure with reduced ejection fraction (HFrEF) and heart
failure with preserved ejection fraction (HFpEF)
2. Acute decompensated heart failure (ADHF) and chronic heart
failure (CHF) with varying symptoms
• Optimal medical therapy (OMT) is the major
component of treatment of heart failure.
4.
5.
6. What is OPTIMAL MEDICAL THERAPY ?
• OMT is to choose and optimize cardiac medications at
doses that has shown benefits in clinical trials (both
morbidity and mortality)
• It is not only about optimizing drugs but also includes
other nonpharmocological components that reduce
morbidity, which includes:
Patient and family education
Nutritional modification (including fatty acid
supplementation)
Exercise-based cardiac rehabilitation, and
Mind-body interaction
7. Possible reasons for SUBOPTIMAL
TREATMENT
• Except for β-blockers where the heart rate can be kept
as a target to uptitrate the dose, other drugs especially
drugs acting on renin-angiotensin system/neprilysin
system, there is no target effect or a biomarker up to
which it can be uptitrated is available.
• So, the physicians/cardiologists hesitate to uptitrate as
they are doubtful about the patient tolerating the
doses (though not documented) in the absence of
these markers.
8. Treating physicians concern about
HYPOTENSION and AZOTEMIA
• In one unpublished single center study on this aspect
• 18 patients were taken for follow-up in the last 2
years
• Uptitration of the carvedilol up to 12.5-25mg twice
daily and Ramipril to 10mg once daily was done in
spite of their BP being persistently 80 mmHg systolic
but they still tolerated and they have shown
significant improvement in symptoms and cardiac
functions
9. • The same scenario happens during optimizing
diuretics during ADHF, especially when the systolic
BP is <80 mmHg.
• In ADHF, diuretics actually causes pulmonary
venous pressure to come down and hence improves
the filling pressures. This often improves the
contractility and hence stroke volume thereby
actually improving the BP.
• The diuretics can cause hypotension, but hypotension
per se is not an absolute contraindications for
optimizing diuretic therapy and it has to be
individualized depending on the fluid status and
symptoms.
10. • Mild increase in urea and creatinine is known after
startling patients with drugs affecting RA axis for
patient with heart failure, especially when the renal
function is borderline.
• But this should not be a concern to uptitrate the doses
unless there is a progressive increase in renal
parameters or worsening electrolyte imbalances, on
periodic monitoring.
• Once the target dose is achieved without significant
worsening of renal parameters, they usually tolerate
and hence help in the improvement in cardiac
function.
11. Focus on Invasive Procedures
• Today physicians/cardiologists running heart failure
clinic focus on devices and transplantations.
• The bias in performing procedures is so great that
National Institute of Health (NIH)- sponsored trail
comparing left ventricular assist device (LVADs)
versus medical management in ambulatory patient
was stopped because of slow recruitment.
12. • Randomized Olmesartan and Diabetes
Microalbuminuria Prevention (ROADMAP) study
reported in favor of patients who chose LVAD
compared to optimal medical management.
• One of the major limitation of the study was the
actual doses of different drugs given in OMT arms
who crossed over to receive LVAD was not known.
• So, one really cannot comment about the inferiority
of real OMT.
13. • Following aspects could be included as part
of OMT:
A.Educating the patient and the family
B.Dietary modification
C.Exercise training improves endothelial function
and functional capacities(HF ACTION STUDY
show 3 day a week exercise reduse 11%
mortality)
D.Energetics/metabolic modulators(CoQ,carnitine)
E.Mind-body interaction(supervised YOGA)
F.Etiologically targeted drugs
14. Conclusion
• Optimizing therapy for cardiac failure as much is
an art as it is an evidence-based science.
• Optimal medical therapy, hence, starts from the
patient and family education, periodic follow-up,
and uptitrating the doses to the tolerable level,
whenever possible to have a maximum benefit
before consideration for device-based therapies
or transplantation, especially in developing
countries like India.
