ACUTE DECOMPENSATED HEART FAILURE, POST STABILISATION MANAGEMENT

1. Treatment optimization for
stabilized ADHF patient

2. • Nearly 44% of all HF patients are readmitted for any cause within 1
year after discharge
• Thirty day re-admission rates are >25%
• Mortality during readmission period - up to 10%
• Hospitalisation for HF worsens the prognosis for HF patients
• The hospital is a safe environment for optimising chronic HF therapy
and provides an opportunity to set the patient on the right path
• Treatment optimization following discharge is essential to prevent
readmission

3. Criteria to discharge
Exacerbating factors addressed
Near optimal volume status observed
Transition from intravenous to oral diuretic successfully completed
No intravenous vasodilator or inotropic agent for 24 hours
Left ventricular ejection fraction (LVEF) documented
Smoking cessation counseling initiated
Near optimal pharmacologic therapy achieved, including ACE inhibitor/ARNI and beta blocker (for patients with reduced LVEF), or
intolerance documented
Follow-up clinic visit scheduled, usually for 7 to 10 days
Evaluation and management of patients with acute decompensated heart failure. J Card Fail 2010;

4. Diuretics
• It is often difficult to predict an effective outpatient diuretic regimen
• Convert from intravenous to oral diuretics two or more days prior to
discharge
• Education about salt and fluid restriction

5. ARNI
• Relatively newer drug in the armamentarium of HFrEF therapy
• Available drug Sacubitril-Valsartan
• PARADIGM HF trial
• PIONEER trial
PARADIGM-HF McMurray JJ, et al. N Engl J Med 2014;371:993-1004
PIONEER HF N Engl J Med 2019; 380:539-548

6. 0
15
30
CV death or hospitalization for heart
failure
PARADIGM-HF
• CV death or hospitalization for heart
failure: 21.8% of LCZ696 group vs.
26.5% of the enalapril group (p < 0.001)
• CV death: 13.3% vs. 16.5% (p < 0.001),
respectively
• Hospitalization for HF: 12.8% vs. 15.6%
(p < 0.001), respectively
Trial design: Participants with NYHA class II-IV and LVEF ≤40% were randomized to LCZ696 200 mg
twice daily (n = 4,187) vs. enalapril 10 mg twice daily (n = 4,212).
Results
Conclusions
• Among participants with reduced EF and NYHA class
II-IV symptoms, the use of LCZ696 was beneficial
compared with enalapril
• LCZ696 was associated with a reduction in CV death
or hospitalization for heart failure
McMurray JJ, et al. N Engl J Med
(p < 0.001)
LCZ696 200 mg twice daily
21.8
26.5
Enalapril 10 mg twice daily
%

9. ARNI
• For patients hospitalized with acute HF: BNP level ≥400 pg/mL or NT-
proBNP ≥1600 pg/mL during current hospitalization
• ●Systolic blood pressure (SBP) ≥100 mmHg
• ●Estimated glomerular filtration rate ≥30 mL/min/1.73 m2
• No h/o angioedema
• ARNI can be initiated as a component of initial therapy for HFrEF
,including during hospitalization for acute HF after hemodynamic
stabilization
PIONEER HF N Engl J Med 2019; 380:539-548

10. • Hemodynamic stability is defined as a
• Systolic blood pressure (SBP) ≥100 mmHg for the preceding six
hours,
• No intravenous vasodilators and
• No increase in dose of intravenous diuretics in the preceding six
hours, and
• No intravenous inotropes in the preceding 24 hours (PIONEER HF)
PIONEER HF N Engl J Med 2019; 380:539-548

11. PIONEER HF
sacubitril/valsartan enalapril
vs
In-hospital initiation
Hospitalized with ADHF (HFrEF)
Stabilized
 Evaluate biomarker surrogates of efficacy
 Evaluate safety and tolerability
 Explore clinical outcomes
Titration algorithm over 8 weeks

12. Primary Endpoint: % Change in NT-proBNP
29% greater reduction with
sacubitril/valsartan
CI 19%, 37%; P < 0.0001
10
0
–10
–20
PercentChangefromBaseline
–30
–40
–50
–60
–70
Week since Randomization
Baseline 1 2 3 4 5 6 7 8
enalapril
sacubitril/valsartan

13. sacubitril/
valsartan (n=440)
enalapril
(n=441)
HR P-value
Serious Composite, % 9.3 16.8 0.54 0.001
Death, % 2.3 3.4 0.66 0.311
Re-hosp for HF, % 8.0 13.8 0.56 0.005
LVAD, % 0.2 0.2 0.99 0.999
Cardiac Transplant, % 0 0 - -
Expanded Composite*, % 56.6 59.9 0.93 0.369
Unplanned IV diuretics, % 0.5 0.5 0.99 0.997
Addition of HF med, % 17.7 19.1 0.92 0.58
>50% diuretic increase, % 49.6 50.3 0.98 0.812
Exploratory Clinical Endpoints
*Serious composite + addition of HF med, no unplanned outpatient IV diuretics or >50% increase in dose

15. ACEI
• Symptomatic improvement, reduced hospitalization, and enhanced
survival in patients with heart failure with reduced ejection fraction
• One suggestion is to check serum electrolytes and renal function at
one week and at one month following increases in ACE inhibitor dose
• Initiate ACE inhibitor or ARNI therapy prior to beta blocker therapy
CONSENSUS Trial Study Group N Engl J Med. 1987;316(23):1429
SOLVD N Engl J Med. 1992;327(10):685

16. Beta Blockers
• Used cautiously in patients with decompensated HFrEF because of
the potential to worsen acute HF
• Beta blockers are started at low doses and are generally started later
than ACE inhibitors or ARBs, when the patient is euvolemic, usually
shortly before discharge
• Particular caution is indicated in patients who have required
inotropes during their hospitalization

17. • Patients with HFrEF with no or minimal current evidence of fluid
retention should be treated with one of the following three beta
blockers: carvedilol (immediate release or extended release),
extended release metoprolol succinate, or bisoprolol
• During the first year, it was estimated that beta blocker therapy saved
3.8 lives per 100 patients treated and was associated with four fewer
hospitalizations per 100 patients treated
Beta-blockers in congestive heart failure. A Bayesian meta-analysis

18. • The hemodynamic benefits of beta blockers are delayed (and there
may be a transient worsening in cardiac function when therapy is
initiated

19. • Start with a low oral dose of an ACE inhibitor (Ramipril 1.25 mg/day
)or ARNI (24 mg of sacubitril with 26 mg of valsartan twice daily),
increase to a moderate dose (eg, Ramipril 5 mg/day or 49 mg of
sacubitril with 51 mg of valsartan twice daily) at one- to two-week
intervals, and then begin a beta blocker, gradually increasing toward
the target dose
• When the beta blocker titration is completed, the ACE inhibitor or
ARNI titration is completed

20. • Complications that develop during dose titration of the beta blocker
should be treated
• For example, the diuretic dose should be increased for fluid overload
• Hypotension can occur with carvedilol than metoprolol
• If hypotension with Carvedilol consider switching to metoprolol

21. Mineralocorticoid receptor Antagonist
• In addition to ACEI/ARNI/ ARB
• NYHA functional class II HF and an left ventricular ejection fraction
(LVEF) ≤30 percent
• NYHA functional class III to IV HF and an LVEF <35 percent
• Post-ST elevation myocardial infarction, have an LVEF ≤40 percent,
and have either symptomatic HF or diabetes mellitus
PITT et al N Engl J Med. 1999;341(10):709
EPHESUS J Am Coll Cardiol. 2005;46(3):425