Welcome and

Welcome and Introductions Serge Lepage MD, FRCPC, CSPQ 2 Faculty Serge Lepage, MD, FRCPC, CSPQ (Chair) Full Professor Director, Heart Function Clinic, Department of cardiology, Université de Sherbrooke Past President, Quebec Heart Failure Society Sherbrooke, QC Douglas Lee, MD, PhD, FRCPC Cardiovascular Program Lead & Senior Scientist, ICES Ted Rogers Chair in Heart Function Outcomes Division of Cardiology, Peter Munk Cardiac Centre, University Health Network Professor of Medicine, University of Toronto Toronto, ON Nadia Giannetti, MDCM, FRCPC Associate Professor, Department of Medicine Medical Director, Heart Failure and Heart Transplant Program Chief, Division of Cardiology McGill University Health Centre Montreal, QC Mark Liszkowski, MD, FRCPC Cardiologist in advanced heart failure Cardiac intensivist Director cardiac intensive care unit President of the Clinical Ethics committee Medical coordinator for organ and tissue donation Montreal, QC 3 Conflict of Interest Serge Lepage, MD, FRCPC, CSPQ • Consulting Fees/Honoraria: Novartis, AstraZeneca, Jenssen, Servier, Bayer, Amgen, Sanofi • Clinical Trials: Novartis, Amgen 4 Conflict of Interest Douglas Lee, MD, PhD, FRCPC • Consulting Fees/Honoraria: N/A • Clinical Trials: COACH Trial funded by the Ontario SPOR Support Unit 5 Conflict of Interest Nadia Giannetti, MDCM, FRCPC • Funding/Honoraria/Research: Novartis, Servier, Amgen, Pfizer, Boehringer Ingelheim, Astra, Merck 6 Conflict of Interest Mark Liszkowski, MD, FRCPC • Consulting Fees/Honoraria: Servier, Bayer, Novartis, CardiacAssist, Abbott medical, Boehringer, Mallinkrodt, BMS, Otsuka • Clinical Trials: Bayer 7 Disclosure of Commercial Support Specific details of relationship: • This program has received financial support from Novartis Pharmaceuticals Canada in the form of an educational grant Potential for conflict(s) of interest: • Speakers have received honoraria from Novartis Pharmaceuticals Canada • Novartis is the manufacturer and benefits from the sale of Entresto 8 Mitigating Potential Bias Potential biases are acknowledged and are mitigated by presenting data supported by national and international guidelines, and as follows: • Information presented is evidence-based • Material has been developed and reviewed by a Planning Committee Off-label uses of drugs will be discussed and identified as such by the speaker 9 Learning Objectives After attending the symposium, participants will be able to: • Discuss the burden of heart failure (HF) in Canada with an emphasis on the burden of disease and societal impact of HF hospitalizations • Recognize the high risk of recurrent events and deterioration after hospitalization for acute HF decompensation and the need to optimize treatment before discharge • Translate current clinical data into daily practice and evaluate the impact on patient outcomes 10 Agenda 11 TIME TOPIC SPEAKER 9:55 a.m. Welcome and Introductions Serge Lepage, MD 10:00 a.m. Burden of the Disease: Health Expenditure, Costs of Hospitalization, Diagnosis, and Management of HF Douglas S. Lee, MD 10:15 a.m. Question and Answer Period All 10:20 a.m. Optimizing HF Therapies During Hospitalization: Time Matters Nadia Giannetti, MD 10:40 a.m. Question and Answer Period All 10:45 a.m. Best Practices and Practical Tips for Optimizing HF Patient Care in Hospital Mark Liszkowski, MD 11:00 a.m Question and Answer Period All 11:05 a.m Closing Remarks and Evaluations Serge Lepage, MD Situation At My Hospital • Consecutive patients with ADHF • EF 40% and below • Mean stay 10 days Mortality • 1 month  3% • 3 month  10% • 6 month  17% • 1 year  25% HF Re-hospitalization • 1 month  11% • 3 month  21% • 6 month  32% • 1 year  40% Burden of the Disease: Health Expenditure, Costs of Hospitalization, Diagnosis, and Management of HF Douglas S. Lee MD, FRCPC 15 Objectives: 1. To examine potential strategies to improve earlier diagnosis of heart failure 2. To explore the importance of coronary artery disease in heart failure 3. To understand the challenges in preventing heart failure readmissions and potential solutions 16 Lesyuk et al. BMC Cardiovasc Disord 2018; 18:74; CIHI, National Health Expenditure Trends 1975 to 2010; Tran et al. CMAJ Open 2016; 4:E365-70 Cost of HF Care: International Comparison 17 Annual Cost per Individual ($US) 0 5,000 10,000 15,000 20,000 25,000 S. Korea Nigeria Czech Sweden Greece Spain Canada Ireland Italy Germany US HF patient Per capita ** * N/A HF patient - Canada Per capita - Canada Lesyuk et al. BMC Cardiovasc Disord 2018; 18:74 Spending on HF Patients Correlate with More Spent on HF Hospitalization 18 0 5,000 10,000 15,000 20,000 25,000 30,000 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 % of HF Costs due to Hospitalization Per Patient Costs of HF ($US) More hospitalizations  Higher costs a) Room & board (43%) b) Procedures (dialysis) c) Imaging d) Laboratory tests Medication costs Improving Diagnosis of HF Ezekowitz et al. Can J Cardiol 2017; 33:1342-433 19 de Boer et al. JAMA Cardiol 2018; 3:215-24 20 21 Only BNP and hs-Troponin improved the c-statistic and NRI compared with clinical, echocardiographic and ECG variables de Boer et al. JAMA Cardiol 2018; 3:215-24 Welsh et al. J Cardiac Fail 2019; 25:230-7 HS-Troponin and Incident HF: British Regional Heart Study (7735 men, 40-59 yrs) 22 Free of Coronary Artery Disease History of Coronary Artery Disease TnT Tertiles: Lowest: ≤ 9.7 ng/L Middle: 9.8-14.2 ng/L Highest: ≥ 14.3 ng/L Ischemic Heart Disease and HF Lamblin N, et al. J Cardiac Fail 2018; 24:815-22 • CORONOR study (Nord-Pas-de-Calais, France) • Registry of 4184 outpatients with stable CAD: • Prior MI (> 1 year) • Prior coronary revascularization • ≥ 50% obstruction of at least 1 V • Baseline LVEF categorized as ≥ 50% vs. < 50% Ischemic Heart Disease and HF 24 • CORONOR study (Nord-Pas-de-Calais, France) • Registry of 4184 outpatients with stable CAD: • Prior MI (> 1 year) • Prior coronary revascularization • ≥ 50% obstruction of at least 1 V • Baseline LVEF categorized as ≥ 50% vs. < 50% Lamblin N, et al. J Cardiac Fail 2018; 24:815-22 Ezekowitz et al. Can J Cardiol 2017; 33:1342-433 Assessment for CAD 25 0.5 0.6 0.7 0.8 0.9 1.0 0 500 1000 1500 Normal coronaries Non-obstructive Obstructive Days % Survival Outcomes of Normal, Non-obstructive or Obstructive Lesions on Coronary Angiography in HFrEF Braga et al. JACC HF 2019 [in press] 0.5 0.6 0.7 0.8 0.9 1.0 0 500 1000 1500 Normal coronaries Non-obstructive Obstructive % Survival free of CV death or CV hospitalization Days 26 • 2,962,554 hospitalizations for HF • U.S. Medicare beneficiaries • 2009: readmission performance provided • 2012: financial penalties applied • For HF: • - 0.05% change in risk-adjusted readmission rates per month after HF hospitalization • 0.008% change in risk-adjusted mortality rates per month after dischargeDharmarajan K, et al. JAMA 2017; 318:270-8 27 Khera R, et al. JAMA Network Open 2018; 1:e182777 Readmission vs. Mortality 28 • 4,000,000 HF patients • U.S. Medicare 29 Risk-adjusted post-discharge mortality rate Risk-adjusted In-hospital mortality rate Khera R, et al. JAMA Network Open 2018; 1:e182777 Sud et al, JACC HF 2017; 5:578-88 Length of Stay and Readmission Risk 30 Strategies to Reduce Readmissions ED Discharge Transition Hospital 30-days ED 31 Lee DS, et al. Circulation HF 2010; 3:228-35 Need for Improved Safety and Efficiency of Acute HF Decision-Making in the ED 32 Admitted Discharged Low-risk acute hospital stays (Efficiency) High-risk ED discharges (Safety) Discharged Admitted Frequency (# Patients) Date of download: 6/15/2012 Copyright © The American College of Physicians. All rights reserved. From: Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study Ann Intern Med. 2012;156(11):767-775. doi:10.7326/0003-4819-156-11-201206050-00003 EHMRG Emergency Heart failure Mortality Risk Grade Derivation Cohort (n=7433) 5254 Admitted 2179 Discharged Validation Cohort (n=5158) 3560 Admitted 1598 Discharged https://ehmrg.ices.on.ca 33 EHMRG: Emergency Heart Failure Mortality Risk Grade Lee DS, Am Heart J 2016; 181:60-65 34 ED visit Diagnosed with HF? Exclusions? Dialysis, DNR or Invalid HCN MD Questionnaire: 1) Estimate PER 2) Plan for patient Completed Questionnaire? Enter parameters for EHMRG Does MD want to view score results? Display EHMRG score Data linkage for mortality, admission, & ED discharge for passive follow-up Does not qualify for the ACUTE study Yes No No Yes No Yes No Yes Lee et al. Circulation 2019; 139:1146-56 ACUTE: Acute Congestive heart failure Urgent and Transitional care Evaluation 35 Prospective validation of Emergency HF Mortality Risk Grade (EHMRG): • 1983 acute HF pts • 9 hospitals 7-day risk score available at: https://ehmrg.ices.on.ca Lee et al. Circulation 2019; 139:1146-56 Physician Estimated vs Model-Predicted Mortality 36 ClinicalTrials.gov NCT02674438 Comparison of Outcomes and Access to Care for HF (COACH trial) 37 Short Stay <48-72hr Discharge Admit PCP Spec HFC 0 30d EHMRG 7/30 d Risk Stratification Higher Risk Lower Risk ED RAPID HF Clinic Rapid Ambulatory Care Conclusions • The economic burden of HF is high and correlates with higher rates of hospital admission • Strategies to improve early diagnosis of HF: • Reduce the need for acute emergency department presentation: • May be improved with BNP and hs-Troponin • Coronary artery disease: • Important antecedent for HF  prevention target • Even minimal CAD is associated with higher risk of readmissions and CV death 38 Conclusions • Readmissions: • Global problem • Highest rates of readmission are in North America • Better risk stratification strategies may reduce readmissions and hospitalizations by improving efficiency and safety of acute decision- making for HF 39 40 Question and Answer 41 Optimizing HF Therapies During Hospitalization: Time Matters Nadia Giannetti MD, FRCPC 42 Overview • What is our goal for therapy? • Are we achieving this goal? • How quickly we need to get there? • How can we do better? 43 What is Our Goal for Therapy? 44 Medical Therapy Benefits 45 Incremental Benefit of Drug Therapies for Heart Failure Komajda M, et al. Eur J Heart Fail 2018. All-cause Mortality Cardiovascular Mortality 46 HR (95% Credible Interval) ARNI+BB+MRA vs Placebo 0.38 (0.2;0.65) ACEI+BB+MRA+IVA vs Placebo 0.41 (0.21;0.7) ACEI+BB+MRA vs Placebo 0.44 (0.27;0.67) ARB+BB vs Placebo 0.48 (0.24;0.86) ACEI+ARB+BB vs Placebo 0.52 (0.32;0.8) BB vs Placebo 0.58 (0.34;0.95) ACEI+MRA vs Placebo 0.58 (0.36;0.9) ACEI+BB vs Placebo 0.58 (0.42;0.73) ACEI+ARB vs Placebo 0.83 (0.52;1.23) ACEI vs Placebo 0.84 (0.67;1.01) ARB vs Placebo 0.89 (0.61;1.27) 0 1 HR 2 HR (95% Credible Interval) ARNI+BB+MRA vs Placebo 0.36 (0.16;0.71) ACEI+BB+MRA+IVA vs Placebo 0.41 (0.19;0.82) ACEI+BB+MRA vs Placebo 0.45 (0.25;0.75) ACEI+ARB+BB vs Placebo 0.47 (0.24;0.82) ARB+BB vs Placebo 0.5 (0.19;1.12) ACEI+MRA vs Placebo 0.56 (0.31;0.95) ACEI+BB vs Placebo 0.56 (0.37;0.75) BB vs Placebo 0.62 (0.27;1.32) ACEI+ARB vs Placebo 0.8 (0.43;1.33) ACEI vs Placebo 0.81 (0.6;1.04) ARB vs Placebo 0.85 (0.51;1.28) 0 1 HR 2 Medical Therapy Benefits McMurray NEJM 2014 Swedberg Lancet 2010 47 Are We Achieving This Goal? 48 Adherence to Guidelines Score by Geographic Zone 71 70 61 71 60.5 24 19 29 22 34.1 5 11 9 7 5.4 Western Europe + North America + Australia, n=1411 Asia, n=1283 Central + Eastern Europe, n=3117 Rest of the world, n=1197 Canada Good Moderate Poor % 49 Giannetti et al. ccs 2016 CHAMP-HF Registry: Use of Therapy 50 Greene, S.J. et al. J Am Coll Cardiol. 2018;72(4):351-66. How Quickly Do We Need To Get There? 51 Hospitalization For HF 52 PARADIGM –HF trial (NEJM 2014); SHIFT Trial (LANCET 2010) 53 Medical Therapy During Hospitalization 54 How Can We Do Better? 55 56 N Engl J Med 2019; 380:539-548 Study Design *Target Dose HF, Heart Failure. EF, Ejection Fraction Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 Sacubitril/valsartan 97/103 mg twice daily* Enalapril 10 mg twice daily*vs In-hospital initiation Hospitalized with Acute Decompensated HF with Reduced EF While hospitalized • Evaluate biomarker surrogates of efficacy • Evaluate safety and tolerability • Explore clinical outcomes Study Drug for 8 weeks 57 PIONEER-HF • Hospitalized for Acute Decompensated Heart Failure (ADHF) • LVEF ≤40% within the last 6 months • NT-proBNP ≥1600pg/mL or BNP ≥400 pg/mL* • While hospitalized: • SBP ≥100 mmHg in prior 6h; no symptomatic hypotension • No increase in IV diuretics in prior 6h • No IV vasodilators in prior 6h • No IV inotropes in prior 24h *At screening A complete list of inclusion and exclusion criteria has been previously published at Velazquez et al. Am Heart J 198 (2018) 145-151 LVEF, Left Ventricular Ejection Fraction. NT-proBNP N-terminal pro–Brain Natriuretic Peptide. BNP , Brain Natriuretic Peptide. SBP , Systolic Blood Pressure. IV, Intravenous Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 58 PIONEER-HF Key Entry Criteria Primary endpoint: • Time-averaged proportional change in NT-proBNP from baseline at 4 and 8 weeks Safety • Worsening renal function • Hyperkalemia • Symptomatic hypotension • Angioedema Exploratory Clinical Outcomes • Serious Clinical Composite: Death, Hospitalization for HF, LVAD or listing for cardiac transplant *A more complete list of PIONEER study endpoints has been previously published at Velazquez et al. Am Heart J 198 (2018) 145-151 NT-proBNP N-terminal pro–Brain Natriuretic Peptide. HF, Heart Failure. LVAD, Left Ventricular Assist Device. HF, Heart Failure Data on File: PIONEER-HF Protocol, Novartis Pharmaceutical Corp; October 2018 Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 59 PIONEER-HF Study Endpoints* Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 MED/ENT/0380 PIONEER-HF Baseline Characteristics Sacubitril/Valsartan (n=440) Enalapril (n=441) Age (years) 61 (50.5, 71) 63 (54, 72) Women (%) 25.7 30.2 Black (%) 35.9 35.8 Prior HF diagnosis (%) 67.7 63.0 LVEF,median (25th, 75th) 0.24 (0.18, 0.30) 0.25 (0.20, 0.30) Systolic pressure, median (25th, 75th) mm Hg 118 (110, 133) 118 (109, 132) NT-proBNP median (25th, 75th) pg/mL at randomization 2883 (1610, 5403) 2536 (1363, 4917) ACEi/ARB therapy (%) 47.3 48.5 Beta-adrenergic blockers (%) 59.6 59.6 60 10 0 - 10 - 20 Percent Change from Baseline - 30 - 40 - 50 - 60 - 70 Week since Randomization Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 HR 0.71 (95% CI 0.63, 0.80) P<0.001 Enalapril Sacubitril/Valsartan Time-average proportional change of NT-proBNP from baseline* *Percentage (%) change from baseline to mean of weeks 4 and 8 Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 61 PIONEER-HF Primary Endpoint MED/ENT/0380 Endpoint Nr. (%) Sacubitril/ Valsartan (n=440) Enalapril (n=441) RR Sac/Val vs Enalapril (95% CI) Composite of serious clinical events * 41 (9.3) 74 (16.8) 0.54 (0.37 to 0.79) Death 10 (2.3) 15 (3.4) 0.66 (0.30 to 1.48) Re-hospitalization for HF 35 (8.0) 61 (13.8) 0.56 (0.37 to 0.84) Requirement of LVAD 1 (0.2) 1 (0.2) 0.99 (0.06 to 15.97) Inclusion on list for heart transplantation 0 0 n/a *Exploratory Serious Clinical Composite endpoint consisted of death, rehospitalization for heart failure, implantation of a left ventricular device, and inclusion on the list of patients eligible for heart transplantation 62 MED/ENT/0380 PIONEER-HF Exploratory Clinical Endpoints Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 63 • The study was powered for changes in NTproBNP and interpretation of secondary and exploratory endpoints should be viewed with caution • Safety data were collected for only 12 weeks, therefore adverse events that take longer to transpire may not have appeared in this study. Safety information should be interpreted in the context of prior trials with longer duration • In-hospital initiation included 2 placebo doses in the sacubitril/valsartan group and 6 hours of mandatory observation after the 3 rd dose of study medication in both arms, which may have prolonged length of stay • The 8 week double-blind study duration could limit the ability to fully assess long-term outcomes such as death, cardiac transplantation, and LVAD implantation MED/ENT/0380 Velazquez EJ et al. nejm.org/doi/full/10.1056/NEJMoa1812851 PIONEER-HF Study Limitations Effect of HR Upon Normal and Failing LV 64 European Heart Journal (1994) 15, 164-170 Early Co-administration of Ivabradine and β-blockers During Hospitalization is Safe and May Improve HF Parameters (effects at 12 months) 65 Early co-administration of ivabradine and ß–blockers During Hospitalization May Reduce Mortality 66 Lopatin et al., Int. J Cardiol., 2018, 260, 113-117 Summary • Heart failure has a high morbidity and mortality, with a high re-admission rate • Medical therapy can reduce all of the above with benefits achieved early on • Medical therapy is under-utilized • There is a better way to approach these patients • In well selected patients, can initiate therapy and titration in hospital 67 Question and Answer 68 Best Practices and Practical Tips for Optimizing HF Patient Care in Hospital Mark Liszkowski MD, FRCPC 69 Conflict of Interest Mark Liszkowski, MD, FRCPC •Consulting Fees/Honoraria: Servier, Bayer, Novartis, CardiacAssist, Abbott medical, Boehringer, Mallinckrodt, BMS, Otsuka. •Clinical Trials: Bayer, Boehringer 70 Tips and tricks to optimize CHF patients • What the guidelines say • Heart failure hospitalization: time to act! • In-hospital medical optimization • In-hospital risk identification • CVP, optimal medical therapy, HR, ntBNP • Post-discharge early surveillance and follow up 71 Reality of treating heart failure in hospital • 1- Older frail patients • 2- Multiples co-morbidities • 3- Acute renal failure • 4- Hypotension • 5- Complex polypharmacy • 6- Often maximally treated CHF patients • 6- Multiple possible precipitants of decompensation • Non-compliance to Rx or follow-up • Rx stopped by other healthcare professionals • ER visit or off-service hospitalization • Septic precipitants CHF medications not-tolerated not started decreased Stopped Cannot be increased -Not your standard CHF trial patient -May explain why some patients not on Full/maximal CHF triple therapy 72 Circ Heart Fail. 2013;6:1095-1101 CHF hospitalization is the time to act! 73 BA C D A- Treat CHF • First phase (acute hypervolemia and neuro-hormonal activation) • Hospitalize (10-15% mortality) • Volume control (IV diuretics) • Vasodilatation • Inotropic support (rare) • Rhythm control (AF, AV block, VT, PVCs) • Search for ischemia/valvular disease • Myocardial dysfunction (review LVEF - <40%?) • Search for precipitants • Review complete list of medications • Realize that current therapy might be ineffective! 74 A Circ Heart Fail. 2013;6:1095-1101 B- Stabilize CHF • Identify and manage precipitants • Ischemia (revascularize) • Valvular heart disease (repair/replace) • Rhythm (rate or rhythm control) • Non-compliance (understand/teach) • Infection • Harmful medications (DPP4, glitazones, NSAIDS, steroids, alpha- blockers, CCB) • Was current medical therapy adequate to improve prognosis? • Triple therapy? (BB, ACEi/ARB, and MRA) • Quadruple therapy (BB, Ivabradine, ACEi/ARB/ARNi, and MRA) • Restart / Switch / Up titrate doses with daily monitoring of vital signs and biochemistry 75 B C- Optimize CHF therapy ntBNP as a modifiable predictor of outcome 76 C C- Optimize CHF therapy Heart rate as a modifiable predictor of outcome 77 C C- Optimize CHF therapy • How can I improve current CHF therapy? • Switch/Add therapies proven to further reduce morality and rehospitalizations • 1- Monitor nt-BNP at admission and near discharge • 2- Follow resting heart rate • 3- Diabetes control • Switch ACEi/ARB for Sacubitril/Valsartan (ARNI) • Add Ivabradine to lower HR a goal of 50-60/min if >77/min • Consider adding an SGLT2i to oral Db therapy 78 C C- Optimize CHF Therapy Sacubitril/Valsartan • ADCHF: volume overload and neuro-hormonally activated state • Hold ACEi x48h and restart ARNi at equivalent dose • Stop ARB and immediately start ARNi at equivalent dose • Do this while the patient is still congested • Within 48-72 hours of stopping IV diuretics (before PO) 79 ACEi Sacubitril/Valsartan C- Optimize CHF Therapy Heart rate: a marker of risk • During ADCHF: continue same Beta Blocker dose unless hypotensive/in shock • Look at heart rate as prognostic indicator • If already on maximal beta blocker dose • If not tolerating beta blocker dose (hypotension/low output) • Clinical profiles: • Hypotensive female • Symptomatic low cardiac output patient • Older patient needing reduction of dose due to excessive fatigue • HR >77 beats/min • Add starting dose of 2.5 mg po bid of Ivabradine atop beta blocker dose • Uptitrate Ivabradine to 5 mg po bid then 7.5 mg po bid is needed • Combination therapy to lower resting HR 60/min • Goal to lower heart rate<70 beats/min at discharge 80 C- Optimize CHF therapy 81 C C- Optimize CHF therapy Management of diabetes in CHF Thiazolidinediones (glitazones) – contra-indicated in CHF Declare TIMI 58 Dapagliflozin Placebo Reduced HF Hospit 82 C- Optimize CHF therapy complete care with a checklist 83 • Baseline discharge parameters • Teaching • Reminder for full medical therapy • Standardized approach C- Optimize CHF therapy complete care with a checklist 84 • Baseline discharge parameters • Teaching • Reminder for full medical therapy • Standardized approach D- Predict and prevent • How to identify and follow up the vulnerable population after discharge? • 1- Biomarkers of risk at discharge (ntBNP, CVP, HR) • 2- Biomarkers of risk at 1 week post-discharge • If nt BNP and/creatinine increase  needs FASTER follow up • 3- Patient self surveillance • Document daily symptoms/weight/HR • 3- Outpatient rapid follow up  2-4 weeks • CHF clinic • Nurse led rapid reassessment clinic • 4- Pharmacist or nurse driven protocolized CHF medication up titration (every 3-4 wks) • tends to be faster and more complete than if MD driven • 5- Refer to CHF specialist if needed or if not improving with standard therapy 85 See 1-4 days ntBNP/Cr eat 1 week D D- Predict and prevent What do patients want? • Improved symptoms • Fewer pills • Fewer hospitalizations • Do not want to die/suffer • Contact person in case of questions or concerns 86 D Take home points • In-hospital CHF optimization is practical • Assure at least standard triple CHF therapy is started (BB, ACEi/ARB and MRA) • If worsening CHF on standard therapy • Identify precipitants • Consider ADCHF as a failure of current therapy • Switch/add more aggressive evidence based therapy − Sacubitril/Valsartan − Ivabradine − SGLT2i 87 Take home points • Identify vulnerable patients that you can improve • ntBNP remains elevated (less than 30% decrease from admission) • Remains with HR >77/min in spite of maximally tolerated BB • Sub-optimal Db control • Required clinical follow-up within 2-4 weeks post-discharge • Faster follow-up if ntBNP and/or creatinine increase within 7 days post-discharge 88 Question and Answer 89 Closing Remarks and Evaluations Serge Lepage MD, FRCPC, CSPQ 90 Question #1 Heart Failure Management in Canada Compared to other countries… a. Canada is a leader in acute decompensated heart failure (ADHF) = 15% b. Canada is in the middle of the pack for management of ADHF = 75% c. Canada is doing poorly in ADHF management = 10% Question #2: The US Has Established a Policy to Decrease 30 Day Readmission They have in fact a. Decreased 30 day readmission = 45% b. Increased 30 day readmission = 16% c. Increased 30 day death = 25% d. Reduced 30 day death = 14% Question #3: Regarding In-hospital Stay… a. All our interventions are evidence-based medicine (EBM) = 4% b. Our efforts are aimed at relieving symptoms = 16% c. As long as the patient is not in acute kidney injury (AKI) = 2% d. We all should do better = 78%