scholarly journals Safety and Tolerability of Initiating Maximum-Dose Sacubitril-Valsartan in Patients on Target Dose Renin-Angiotensin System Inhibitors

2019 ◽  
Vol 2019 ◽  
pp. 1-6 ◽  
Author(s):  
Helena Norberg ◽  
Ellinor Bergdahl ◽  
Krister Lindmark
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Maximum Dose ◽  
Angiotensin Receptor Blockers ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Aim. Sacubitril-valsartan has proven beneficial in heart failure with reduced ejection fraction. Guidelines recommend initiating half-dose sacubitril-valsartan before up-titration even to patients already on target dose angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). To reduce the number of titration steps needed in order to simplify for the patient as well as the clinic, we aimed to investigate the safety and tolerability of switching patients on target dose ACE inhibitors or ARBs directly to maximum-dose sacubitril-valsartan. Methods. This prospective cohort study was conducted between April 2016 and November 2017. A total of 66 patients with heart failure and reduced ejection fraction already on guideline-recommended target dose ACE inhibitors or ARBs (equivalent to enalapril 10 mg twice daily) were switched to maximum-dose sacubitril-valsartan (200 mg twice daily). The patients were followed for twelve months. Results. Patients had a mean age of 72 ± 10 years, mean systolic blood pressure of 121 ± 17 mmHg, and 92% were male. At 12-month follow-up, nine patients (14%) had discontinued sacubitril-valsartan, four patients (6%) had a dose reduction, and 17 patients (26%) had developed symptomatic hypotension. No angioedema occurred within the 12-month follow-up and there were no hospitalizations or emergency room visits within the first 14 days. Conclusions. Switching directly from target dose ACE inhibitors or ARBs to maximum-dose sacubitril-valsartan was safe and generally well tolerated.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

2018 ◽  
Vol 52 (8) ◽  
pp. 724-732 ◽  
Author(s):  
Shubha Bhat ◽  
Mayank Kansal ◽  
George T. Kondos ◽  
Vicki Groo
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Chart Review ◽  
Ace Inhibitor ◽  
Angiotensin Receptor Blockers ◽  
Retrospective Chart Review ◽  
National Guidelines ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Abstract 17051: Relationship Between Neurohormonal Blockade Dose and Clinical Outcome in Patients With Heart Failure With Recovered Ejection Fraction

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Min-Seok Kim ◽  
Hyo-In Choi ◽  
Jin-Oh Park ◽  
Ju Hyeon Kim ◽  
Yeong jin Jeong ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Hazard Analysis ◽  
Angiotensin Receptor Blockers ◽  
Left Ventricular ◽  
High Dose ◽  
Target Dose ◽  
Receptor Blockers ◽  
Maintenance Group

Introduction: Heart failure (HF) patients who recover left ventricular function (HF-Recovered) have reported to have a different prognosis compared to HF with reduced or preserved ejection fraction (EF). However, no study has analyzed the dosage of neurohormonal blockade in these patients. Hypothesis: Higher dose of neurohormonal blockade might be important for better outcomes in HF-Recovered patients. Methods: HF-Recovered patients were defined with left ventricular EF ≥40% at time of study entry and retrospectively checked EF <40%. 256 patients were enrolled between Mars 2009 and September 2014. Results: Of the study population, 48.8% received <50% of the target dose of angiotensin-converting enzymes inhibitors (ACEIs)/angiotensin-receptor blockers (ARBs), whereas 51.2% received ≥50% of the target dose at time of EF ≥40%. 55.5% received <50% of the target dose of β-blockers (BBs), whereas 44.5% received ≥50% of the target dose. 31.3% increased the dose of ACEIs/ARBs or BBs at time of EF ≥40% (uptitration group), and 68.8% maintained the doses (maintenance group). During an average of 29.8 months of follow-up, 35 patients (13.7%) were died. In multivariable Cox proportional hazard analysis, ≥50% of the target dose of BBs was associated with lower all-cause mortality (HR=0.38, 95% CI 0.16-0.88, p=0.024). This dose-survival relationship was not the case for ACEIs/ARBs. Figure shows survival curves according to the uptitration or dose of BBs at time of EF ≥40%. Dose of BBs at time of EF ≥40% was lower among uptitration group than maintenance group. However, last follow-up doses of BBs between two groups were the same. Moreover, higher dose of BBs at time of EF recovery was associated with higher last follow-up dose. Conclusions: The dose of BBs was associated with mortality in HF-Recovered patients. High dose of neurohormonal blockade, especially BBs may prevent future adverse events, even if EF was recovered to ≥40% suggesting the importance of dose-uptitrating effort.

scholarly journals Heart failure medication dosage and survival in women and men seen at outpatient clinics

Heart ◽  
2021 ◽  
pp. heartjnl-2021-319229
Author(s):  
Sophie Heleen Bots ◽  
N Charlotte Onland-Moret ◽  
Igor I Tulevski ◽  
Pim van der Harst ◽  
Maarten J M Cramer ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cox Regression ◽  
Beta Blockers ◽  
Angiotensin Receptor Blockers ◽  
Target Dose ◽  
Electronic Health Record Data ◽  
Reduced Ejection Fraction ◽  
All Cause Mortality ◽  
Medication Dose

ObjectiveWomen with heart failure with reduced ejection fraction (HFrEF) may reach optimal treatment effect at half of the guideline-recommended medication dose. This study investigates prescription practice and its relation with survival of patients with HF in daily care.MethodsElectronic health record data from 13 Dutch outpatient cardiology clinics were extracted for HF receiving at least one guideline-recommended HF medication. Dose changes over consecutive prescriptions were modelled using natural cubic splines. Inverse probability-weighted Cox regression was used to assess the relationship between dose (reference≥50% target dose) and all-cause mortality.ResultsThe study population comprised 561 women (29% HFrEF (ejection fraction (EF)<40%), 49% heart failure with preserved ejection fraction (EF≥50%); HFpEF and 615 men (47% and 25%, respectively). During a median follow-up of 3.7 years, 252 patients died (48% women; 167 HFrEF, 84 HFpEF). Nine hundred thirty-four patients (46% women) received ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), 795 (48% women) beta blockers and 178 (42% women) mineralocorticoid receptor antagonists (MRAs). In both sexes, the mean target dose across prescriptions was 50% for ACEI/ARBs and beta blockers, and 100% for MRAs. ACEI/ARB dose of <50% was associated with lower mortality in women but not in men with HFrEF. This was not seen in patients with HFpEF. Beta-blocker dose was not associated with all-cause mortality.ConclusionPatients with HF seen in outpatient cardiology clinics receive half of the guideline-recommended medication dose. Lower ACEI/ARB dose was associated with improved survival in women with HFrEF. These results underscore the importance of (re)defining optimal medical therapy for women with HFrEF.

SGLT-2-Inhibitors in Heart Failure

2020 ◽  
pp. 1-4
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Enzyme Inhibitors ◽  
Therapeutic Option ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Effective Therapeutic Option ◽  
Receptor Blockers

Heart failure is a frequent and highly debilitating pathology. Angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers, β‐ blockers, mineralocorticoid receptor antagonists, and valsartan/sacubitril have been shown to reduce mortality in chronic heart failure with reduced ejection fraction. Recently, glifozines (SGLT‐2 inhibitors) have become another effective therapeutic option for heart failure with reduced ejection fraction, in patients with and without diabetes mellitus. The review presents the effects of SGLT‐2 inhibitors on the cardiovascular system and heart failure.

scholarly journals Rationale for and Practical Use of Sacubitril/Valsartan in the Patient’s Journey with Heart Failure and Reduced Ejection Fraction

2021 ◽  
Vol 7 ◽  
Author(s):  
Mauro Gori ◽  
James L Januzzi ◽  
Emilia D’Elia ◽  
Ferdinando L Lorini ◽  
Michele Senni
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Enzyme Inhibitors ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Electrolyte Imbalance ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Reverse Remodelling ◽  
Receptor Blockers

Sacubitril with valsartan (sacubitril/valsartan) is a relatively novel compound that has become a milestone in the treatment of patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) in the last decade. Contemporary data suggest that sacubitril/valsartan is associated with improved outcomes compared with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and has a greater beneficial effect on myocardial reverse remodelling. Additionally, two recent trials have shown that sacubitril/valsartan is well-tolerated even in the acute HF setting, thus enabling a continuum of use in the patient’s journey with HFrEF. This article summarises available data on the effectiveness and tolerability of sacubitril/valsartan in patients with HFrEF, and provides the clinician with practical insights to facilitate the use of this drug in every setting, with an emphasis on acute HF, hypotension, electrolyte imbalance and renal insufficiency.

scholarly journals Impact of sex-specific target dose in chronic heart failure patients with reduced ejection fraction

2020 ◽  
pp. 204748732092318
Author(s):  
Jesse F Veenis ◽  
Hans-Peter Brunner-La Rocca ◽  
Gerard CM Linssen ◽  
Ayten Erol-Yilmaz ◽  
Arjen CB Pronk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Dosing Schedule ◽  
Angiotensin System ◽  
Men And Women ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction ◽  
Β Blockers

Aims A recent study suggested that women with heart failure and heart failure reduced ejection fraction might hypothetically need lower doses of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers ( = renin-angiotensin-system inhibitors) and β-blockers than men to achieve the best outcome. We assessed the current medical treatment of heart failure reduced ejection fraction in men and women in a large contemporary cohort and address the hypothetical impact of changing treatment levels in women. Methods This analysis is part of a large contemporary quality of heart failure care project which includes 5320 (64%) men and 3003 (36%) women with heart failure reduced ejection fraction. Detailed information on heart failure therapy prescription and dosage were collected. Results Women less often received renin-angiotensin-system inhibitors (79% vs 83%, p < 0.01), but more often β-blockers (82% vs 79%, p < 0.01) than men. Differences in guideline-recommended target doses between sexes were relatively small. Implementing a hypothetical sex-specific dosing schedule (at 50% of the current recommended dose in the European Society of Cardiology guidelines in women only) would lead to significantly higher levels of women receiving appropriate dosing (β-blocker 87% vs 54%, p < 0.01; renin-angiotensin-system inhibitor 96% vs 75%, p < 0.01). Most interestingly, the total number of women with >100% of the new hypothetical target dose would be 24% for β-blockers and 52% for renin-angiotensin-system inhibitors, which can be considered as relatively overdosed. Conclusion In this large contemporary heart failure registry, there were significant but relatively small differences in drug dose between men and women with heart failure reduced ejection fraction. Implementation of the hypothetical sex-specific target dosing schedule would lead to considerably more women adequately treated. In contrast, we identified a group of women who might have been relatively overdosed with increased risk of side-effects and intolerance.

Abstract MP71: Socioeconomic Status, Guideline Directed Medical Therapy, and Prognosis in Heart Failure With Reduced Ejection Fraction: The Atherosclerosis Risk in Community (ARIC) Study

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Lena Mathews ◽  
Ning Ding ◽  
Amira Collison ◽  
Yejin Mok ◽  
Jung-Im Shin ◽  
...  
Keyword(s):  
Heart Failure ◽  
Socioeconomic Status ◽  
Ejection Fraction ◽  
Racial Differences ◽  
Medical Therapy ◽  
Angiotensin Receptor Blockers ◽  
Area Deprivation ◽  
Aldosterone Antagonists ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Introduction: Current research suggests racial differences exist in the utilization of guideline directed medical therapy (GDMT) and prognosis in heart failure with reduced ejection fraction (HFrEF). Whether individual and community level socioeconomic status (SES) impacts prescription patterns of GDMT and prognosis in HFrEF has not been studied. Methods: We studied 669 ARIC participants with incident HFrEF (EF<50%) (mean age 77.6 (SD 6.5) years; 39% black; 46% women) during 2005-2017 (median 1.8 years of follow-up). We assessed the proportion of patients on optimal GDMT (defined as ß-blockers [BB] and ACE inhibitors [ACEI] or angiotensin receptor blockers [ARB]) or adequate GDMT (one of either BB, ACEI/ARB, aldosterone antagonists [AA], or hydralazine and nitrates [H-ISDN]) at hospital discharge by individual SES (education and income), neighborhood SES (area deprivation index: ADI) and their combination (Table). We also examined the contribution of GDMT prescription to prognosis overall, and by SES. Subsequently, we quantified the association of SES with mortality and re-hospitalization for HFrEF. Results: The proportion of patients prescribed optimal and adequate GDMT was 54% and 81%, respectively. BB were most frequently prescribed (83%), followed by ACEI/ARB (61%), AA (11%), and H-ISDN (9%). Overall, BB were associated with lower mortality, while H-ISDN were associated with higher mortality, compared to their non-use counterparts. ACEI/ARB were associated with lower re-hospitalization, compared to non-users of ACEI/ARB. The prescription of GDMT and the effect of GDMT on prognosis did not significantly differ by SES. Despite that, lower SES was independently associated with higher risk of mortality and re-hospitalization (Table). Conclusions: Overall, optimal GDMT was low at discharge, but did not differ by SES. Despite that, there were significant differences in death and re-hospitalization by SES, suggesting a potential need for tailored approaches to HFrEF management for low SES individuals.

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