Helen Williams. Consultant Pharmacist for CVD, South London

Transcription

1 Helen Williams Consultant Pharmacist for CVD, South London

2 Key aims of management prolong life delay disease progression improve symptoms and quality of life Risk factor advice : smoking cessation, exercise, alcohol consumption, diet Blood pressure control, diabetes management

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4 Diuretics Routinely used for relief of congestive symptoms and fluid retention in patients with heart failure Titrate up or down according to need following the initiation of subsequent heart failure therapies (NICE 2003)

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6 ACE Inhibitors Reduce mortality in HF by ~ 25 to 30% CONSENSUS-I, VeHFt-II, SOLVD, GISSI-3, AIRE Initiate early in the disease in pts: With or without symptoms of HF With reduced Ejection Fraction on ECHO (<40%) Benefit established across all NYHA classes Optimise dose (ATLAS) Continue indefinitely

7 Managing ACE inhibitor therapy Start at low dose to avoid first dose hypotension Increase dose to maximum tolerated i.e. Rampril 10mg daily, lisinopril 20mg twice daily Monitor renal function and potassium Advise low K+ diet if potassium high Monitor BP - but can increase dose if sbp 90mmHg Symptomatic hypotension may limit dose titration Common side effects cough, hypotension, rash

8 Beta-Blockers ~30% reduction in mortality (additive to ACE-I) Reduction in hospitalisations US Carvedilol Trials, MERIT-HF, CIBIS-II, COPERNICUS Data in NYHA class II, III & IV HF Initiate in all patients with LV systolic dysfunction - regardless of whether or not symptoms persist Introduce in a start low, go slow manner, assessing HR, BP and clinical status after dose titration Withdrawal of beta-blockers has been shown to: increase risk of worsening heart failure increased risk of early death Circulation 1989; 80, ; AmHeartJ 1999; 137,

9 Offer BBs to. older adults patients with: peripheral vascular disease erectile dysfunction diabetes mellitus interstitial pulmonary disease and chronic obstructive pulmonary disease (COPD)

10 k NICE Quality statement 7 People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase

11 Limitations to uptitration: Beta-blockers Symptomatic hypotension Bradycardia Evidence of reversible airways disease Tiredness / fatigue Weight gain due to increased congestion Erectile dysfunction ACE inhibitors Symptomatic hypotension Worsening renal function (increasing creatinine or potassium) Dizziness Persistent, intolerable dry cough that interferes with sleep - Uncommon

12 And ivabradine.(nice 2012) uk

13 HF due to LVSD Standard Regimen Diuretics (for symptom control) ACE Inhibitors to improve outcome optimise dose Beta-blockers to improve outcome optimise dose +/- Spironolactone if more severe HF (class III/IV) Or eplerenone if less severe HF (class II) or post-mi Ivabradine if HR remains >75bpm (Or candesartan?) (Or Hydralazine /nitrates if black African or Caribbean origin)

14 Dimitrios Karagkounis Specialist Cardiac Pharmacist Croydon University Hospital / Croydon CCG

15 Heart Failure QOF HF 1: The practice can produce a register of patients with HF HF 2: % of patients with a diagnosis of HF confirmed by an echocardiogram or by specialist assessment HF 3: % of patients with a current diagnosis of HF due to LVSD who are currently treated with an ACEI / ARB, who can tolerate therapy and with no C/I HF 4: % of patients with a current diagnosis of HF due to LVSD currently treated with an ACEI or ARB, additionally treated with a BB licensed for HF, or recorded as intolerant to or having a C/I to BB

16 Croydon HF patients on ACEI/ARB = 34% HF patients on ACEI/ARB+BB = 22%

17 Croydon - HF Meds Opt Project Objectives To confirm the diagnosis and type of HF, and ensure the correct coding of patients To advise on appropriate investigations and facilitate communication of results between settings To assess current treatment against evidence based guidelines and identify opportunities for optimisation of HF therapies To address other CV issues (BP, lipids, thrombotic risk) To ensure adequate monitoring is undertaken

18 For 368 patients reviewed to date Number of patients (%) Removed from HF register 79 (21%) Referred for confirmation of diagnosis 51 (14%) Required: Initiation of ACEI / ARB Up-titration of ACEI / ARB Required: Initiation of BB Up-titration of BB 24 (7%) 67 (18%) 35 (10%) 74 (20%) CV management recommendations made 172 Monitoring recommendations made 124

19 Establishing the Diagnosis HF Reduced Ejection fraction - LVSD Raised BNP Moderately reduced LV ejection fraction on Echo < 40% (some say <45%) Code as LVSD (585f) Treat with traditional HF medication Contribute to QOF HF3 and 4 Accounts for ~60-70% of HF patients HF Preserved Ejection Fraction Raised BNP Normal or mildly reduced LV function Evidence of structural heart disease (+/- diastolic dysfunction) Code as HFPEF (G583) Manage fluid overload Control co-morbidities and CV risk factors Accounts for ~ 30-40% of HF patients

20 ACEI & BB: Key issues Symptomatic management vs optimal medical therapy Is there objective evidence that titration will be a problem? Consider whether titration will contribute towards managing other co-morbidities Review drug therapy as a whole: Can we achieve more with less? In HFPEF, consider the co-morbidities

21 Mean & target doses in RCTs Drug Initial dose Target dose Mean dose achieved in trials Enalapril 5mg/ day 20-40mg/ day 16.6mg/ day Lisinopril 2.5-5mg/ day 20-40mg/ day mg/ day Candesartan 4-8mg/ day 32mg/ day 24mg/ day Losartan 25-50mg/ day mg/ day 129mg/ day Spironolactone mg/ day 25-50mg/ day 26mg/ day Eplerenone 25mg/ day 50mg/ day 42.6mg/ day Bisoprolol 1.25mg/ day 10mg/ day 8.6mg/ day Carvedilol 6.25mg/ day 100mg/ day 37mg/ day H-ISDN mg/ day mg/ day mg/ day

22 Monitoring HF QS9: People with stable chronic heart failure receive a clinical assessment at least every 6 months, including a review of medication and measurement of renal function Key issues HEART RATE should be documented as often as BP Carefully review repeat Rx- particularly diuretics Ensure renal function is checked more closely during titration phase