Watch the slideshow for a better understanding: https://youtu.be/CsXvS1hA330
1. Learn the standard therapy in HFrEF
2. Learn its challenges
3. Learn the new drugs for HFrEF.
ARNI as new standard of care in Heart Failure SYEDRAZA56411
Angiotensin Receptor Blocker -Neprilysin Inhibitor combination has an important role to play in patients with Heart Failure with reduced ejection fraction. ARNI is now first line medication in HRrEF
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
ARNI as new standard of care in Heart Failure SYEDRAZA56411
Angiotensin Receptor Blocker -Neprilysin Inhibitor combination has an important role to play in patients with Heart Failure with reduced ejection fraction. ARNI is now first line medication in HRrEF
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Targeting lipids: a primary and secondary care perspectiveInnovation Agency
Presentations by Dr Sue Kemsley and Dr Gavin Galasko from the first webinar of the Mastering Cholesterol webinar series on Thursday 26 January 2023, focusing on lipid management from a primary and secondary care perspective.
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
ODYSSEY outcomes trial was a randomized double-blinded clinical trial on Alirocumab which is a PCSK9 inhibitor that showed its benefits in patients with CVD.
Cardiovascular disease (CVD) reduces the quality of life in patients and remains the leading cause of mortality globally.
Despite a number of preventive strategies for CVD, recommended by multiple scientific societies, there is a clear barrier to their effective implementation.2 In this regard, regular evaluation of the implementation of the CVD prevention guidelines may find the gaps in effective implementation of the guidelines that may help in reducing premature mortality and improving the quality of life in coronary heart patients.
Targeting lipids: a primary and secondary care perspectiveInnovation Agency
Presentations by Dr Sue Kemsley and Dr Gavin Galasko from the first webinar of the Mastering Cholesterol webinar series on Thursday 26 January 2023, focusing on lipid management from a primary and secondary care perspective.
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
ODYSSEY outcomes trial was a randomized double-blinded clinical trial on Alirocumab which is a PCSK9 inhibitor that showed its benefits in patients with CVD.
Cardiovascular disease (CVD) reduces the quality of life in patients and remains the leading cause of mortality globally.
Despite a number of preventive strategies for CVD, recommended by multiple scientific societies, there is a clear barrier to their effective implementation.2 In this regard, regular evaluation of the implementation of the CVD prevention guidelines may find the gaps in effective implementation of the guidelines that may help in reducing premature mortality and improving the quality of life in coronary heart patients.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
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AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
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of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Hurdles and new players in the management of chronic heart failure with reduced ejection fraction.
1. Hurdles and new players
in themanagementofchronicheart
failurewithreducedejectionfraction.
Dr. Dhriti Gupta, MBBS
ECFMG Certified
Clinical Observer
UM-CCU, Fl, USA
Aug 13, 2021
2. 1. Entresto
2. Hydralazine+
Isosorbide
Dinitrate
3. Renal
transplant
4.CRT
Q-stem 1: A 56-year-old man with dilated cardiomyopathy and recurrent
episodes of acute decompensated HF was admitted for same. He says he has
gained weight due to less activity.
PMH: CAD, severe hyperlipidemia, and CKD (a baseline creatinine level of 1.5–
2 mg/dl).
MR: furosemide, 60 mg in the morning and 40 mg in the evening; carvedilol,
12.5 mg twice daily; hydrochlorothiazide, 25 mg daily; digoxin, 0.125 mg daily;
aspirin, 81 mg daily. He was intolerant to ACE inhibitors.
PE: BP, 130/74 mmHg; heart rate, 84 bpm; respiratory rate, 18 cpm; and
weight, 88.7. JVP was elevated, abdominal was swollen and bilateral pedal
edema upto knees was present.
Lab: sodium, 131 mEq/L; potassium, 3.8 mEq/L; chloride, 89 mEq/L; BUN, 54
mg/dl; creatinine, 2.1 mg/dl; eGFR, 35 ml/min per 1.73 m2.
EF: 25%
The patient was started on Iv furosemide and paracentesis was performed
twice.
The patient was discharged with addition of spironolactone. Which other drug
will you add?
Mark J. Sarnak CJASN October 2014, 9 (10)
3. P r e v e n t
p r o g r e s s i o n
L e f t V e n t
r e m o d e l i n g
F l u i d
r e t e n t i o n
Diuretics
Loops, SGLUTS
ACEIs/ARB
Beta Blocker
Bisoprolol, Er
Metoprolol, Carvedilol
Aldosterone
antagonist
Spironolactone,
Eplerenone
ARNI
Sacubitril &
valsartan
Stan dard
(Background
therapy)
Stage C
Chronic HF Management
Braunwald's Heart Disease : a Textbook of Cardiovascular Medicine
4. 3 class with
mortality
benefit
butis that all?
1999
• 5-year
survival
• 25%
• 38%
2010
• 5-year
survival
50%
Present
• 2.4%
• 1 in 6
Worsen
HF
18
months
2030
• 3.0%.
• OPD:43%
of all HF
practices
Heart Disease and Stroke Statistics—2021 Update, Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the AHA. Circ Heart Fail. 2013;6(3):
5. 3 class with
mortality
benefit
butis that all?
Worsening heart failure
Low 2 year survival
50% on RAAS blockers
70% on Beta Blocker
25% on mineralocorticoid
receptor antagonist
20% none
42% monotherapy
43% dual therapy
14% triple therapy
PINNACLE Registry
11,255
17% (1.5 years)
High risk group:
Patients for whom
rehospitalization
or urgent outpatient
treatment for heart failure is
warranted
despite the use of guideline-
based medical therapy.
New treatment options
Butler J, Yang M, Manzi MA, et al. Clinical Course of Patients With Worsening HFrEF. JACC.2019;73(8)
6. Intolerance
ACEIs/ARB/ARNI
• Symptomatic
hypotension
• Renal
dysfunction
• Hyperkalemia
Beta blocker
• Symptomatic
hypotension
• Worsening fluid
retention
• Bradycardia (50
bpm)
• Heart block
• Severe fatigue
• Symptomatic
Asthma
Spironolactone
• Hyperkalemia
• Cr>2.5
• Ccr<30
• K>5.5
50% on RAAS blockers
70% on Beta Blocker
25% on mineralocorticoid receptor
antagonist
20% none
Braunwald's Heart Disease : a Textbook of Cardiovascular Medicine
7. Mechanical
circulatory
support
Procedures to
facilitate fluid
removal
Continuous
inotropic
infusions
VAD
Transplantation
Experimental
R e f r a c t o r y
Stage D
African american:
Hydralazine +
Isosorbide
Dinitrate
Ivabradine (7o bpm)
CRT: Cardiac
resynchronisation
therapy
ICD: Implantable
cardioverter-
defibrillators
Digoxin
n-3
Polyunsaturated
Fatty Acids
A d d on
•Diuretics
•ACEIs/ARB/ARNI
•Beta blocker
Aldosterone
antagonist
S t a n d a r d
Treatment
algorithm:
Stage C and D
Chronic heart
failure with
A reduced
ejection fraction.
A C C / A H A
R x H e a r t
F a i l u r e
Comorbidities
Complication
Systolicdysfunction
Goals:
Improve symptoms
Improve quality of life
Prevent disease progression
Prolong survival
Braunwald's Heart Disease : a Textbook of Cardiovascular Medicine
8. 1. LVAD
2.CRT
3. Vericiguat
4.Transplant
Q-stem 2: A 71-year-old man with advanced Heart failure due to
dilated cardiomyopathy with an ICD was admitted for worsening
HF.
MR: azosemide of 60 mg, losartan of 25 mg, sotalol of 80 mg,
pimobendan of 2.5 mg, metoprolol of 40 mg, eplerenone of
100 mg.
PE: 116/102 mmHg, 102 b.p.m., 36 b.p.m., and 88% @ RA. Pedal
edema was present and JVP was distended. S3 & HS murmur at
apex was heard.
Lab: serum creatinine was 1.49 mg/dL and plasma B-type
natriuretic peptide (BNP) was 542 pg/mL.
ECG: QRS=186 ms; EF= 20%.
Patient was started on inotropes. Over the course of
hospitalisation his hemodynamic stabilised but he was dependent
on inotropes.
What is the next best therapy for this patient?
Mitsuo Sobajima,et al. European Heart Journal - Case Reports, Volume 4, Issue 6, December 2020
9.
10. C R T:
Cardiac
resynchronisat
ion therapy
https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/2001012669/2003807212/gr1.jpg
11. CRT
NYHA Class I &
II
Sinus rhythm
Non-LBBB with
QRS
duration<150
<1 year survival
Good
functional
capacity
Not Suboptimal LV
lead
placement,
Ventricular scar
HF progression
25%
LVEF of 35% or less
sinus rhythm
LBBB with QRS duration of 150
msec or greater, and
NYHA Class II, III, or ambulatory IV
symptoms
Braunwald's Heart Disease : a Textbook of Cardiovascular Medicine
12. V a r i c i g u a t
•5050
•Symptomatic
•Chronic heart failure
•Within a year
•↑ natriuretic peptide
EF<45%
•Entresto
•Not on:
• nitrates, sGC, PDI 5,
•Inotropes, LVAD
SBP>100 •10.8 months
•10 mg OD
2.5mg OD
•↓ 10%
•Decrease total
hospitalization for HF
•↓ NT-proBNP
•EF: <35% & <40%
↓ BP, Hb
VICTORIA trial NEJM, 2020
FDA: Jan 2021
Soluble guanylate cyclase
stimulator
• ↓ HF hospitalisations
• & ↓ CVS or any cause death
• Refractory HF
The VICTORIA Trial. JACC. Heart failure, 6(2), 96–104.
13. V a r i c i g u a t
VICTORIA trial NEJM, 2020
FDA: Jan 2021
Soluble guanylate cyclase
stimulator
• ↓ HF hospitalisations
• & ↓ CVS or any cause death
• Refractory HF
https://cardiovascmed.ch/article/doi/CVM.2021.w10049
14. VERQUVO®
Cardiovascular death
Heart failure hospitalization
Dosage:
Orally once daily
Starting Dose: 2.5 mg
Doubling in 2 weeks
Target Dose: 10 mg
Safe in:
Geriatric
Renal Impairment (>15)
Hepatic Impairment
Pediatric (?)
Drug in interaction
sGC stimulators
PDE-5 inhibitors
Contraindication:
Pregnancy
UPT
Effective Contraception
Gap of 1 month
Adults
Symptomatic chronic HF and
ejection fraction less than 45%
Hospitalization for heart failure
or need for outpatient IV diuretics
https://www.merck.com/product/usa/pi_circulars/v/verquvo/verquvo_pi.pdf
15. Omecamtiv
mecarbil
GALACTIC-HF trial NEJM, Jan 2021
FDA Fastrack: 2020
Cardiac myosin activator
• Reverse remodeling
• Lower heart rate
• Refractory HF
• 8256
• Symptomatic
• Chronic HF
• Hospitalized (HF within < 1
year)
EF<35%
• 21.8 months
• 35 countries
• Pt profile:
ACEI,ARB,ARNI,BB, MRA,
SGLUT-2,CRT and ICD
25-50 mg BD • Primary outcome (CVS
death or HF event)
• Lower Heart rate
• Lower NT-proBNP
• Stable K+ and Creatinine
level
MI,Torsades
The New England journal of medicine, 384(2), 105–116.
16. Omecamtiv
mecarbil
What makesis
different?
Lower Heart rate
Lower NT-proBNP
Stable K+ and
Creatinine level
No vasodilation
No intra-
myocyte
Calcium change
No increase
oxygen
demand
Additional 2.1%
reduction
≈6.0 million Americans ≥20 years of age had HF This study provides real-world data on demographic
and clinical characteristics, treatment patterns, and
outcomes for patients with HFrEF who develop
worsening HF. We found that w17% of patients
developed worsening HF on average about 1.5 years
after the diagnosis of HFrEF. These patients had
worse ejection fraction and more prevalent comorbidities
compared with those without worsening HF.
The majority of these patients were not receivingt is estimated that by 2030, the prevalence of HF in the United States will increase by 25%, to 3.0%.
The number of underlying causes of deaths attrib-utable to HF was 47.1% higher in 2018 (83 616) than it was in 2008 (
44,679 Heart failure with a reduced ejection
fraction imposes a substantial
health care burden, particularly among
HF event requiring HF-related IV diuretic administration
and/or inpatient hospitalization;
Azotemia 10
Dizziness/hypotension 8
Cough 5
Non-compliance 2
Angioedema 1
Cramps 1
Headache 1
COLLAPSE INLINE VIEW POPUP
Table 2
Reasons for not starting an ACE inhibitor
Reason Number of patients
Renal impairment 6
Patient died first 6
Aortic stenosis 4
Probable mistake 3
Echocardiogram not believed 2
Delay 2
Diastolic heart failure
transvenous cardiac resynchronization
There are two potential drugs that has made its debut recently. for 1 year to prevent a primary-outcome event is
approximately 24 patients
NYHC 234
BNP PRO BNP, DIFFERENT FOR SINUS RHYTHM, AF,,,,, Exclusion criteria included a systolic blood
pressure of less than 100 mm Hg; concurrent or
anticipated use of long-acting nitrates, soluble
guanylate cyclase stimulators, or phosphodiesterase
type 5 inhibitors; and use of intravenous
inotropes or implantable left ventricular assist
devices.
There are two potential drugs that has made its debut recently.
May 4, 2020 FDA, We can use this drug in pts who have limited drug options with the available therapies (the drawbacks we saw) because it doesn’t cause significant vasodilation, hypotension, it doesn’t compete with other agents that alter renal function or potassium. So it provides a different therapeutic gateway where it works on the original, the primary defect and also has no previous drawbacks.
