HOW AND WHEN TO STOP CARDIAC MEDICATIONS

HOW AND WHEN TO STOP CARDIAC MEDICATIONS IN YOUR HEART FAILURE PATIENTS Is there ever a time? May 10, 2019 Dr. Elizabeth Swiggum M.D. FRCPC Medical Director HFC Royal Jubilee Hospital, Victoria BC Clinical Associate Professor UBC Disclosures •Grants/research support: Boehringer-Ingelheim •Speaker or Consulting fees: Boehringer-Ingelheim, Eli Lilly, Novartis, Servier, Akea Therapeutics •No conflict with respect to the current topic Objectives How and when to stop cardiac medications in your heart failure patients Elizabeth Swiggum, MD After this workshop, participants will be able to: 1.Understand the implications for withdrawal of evidence-based therapy in patients with recovered ejection fraction 2.Identify clinical scenarios where withdrawal of therapy is likely to be safe 3.Formulate a practical approach to discussing medical withdrawal with HF patients Case1 WL •49 Female Jan 2010 •2 d fever, chills, NV, RUQ pain •Cardiogenic shock •VT •ECG STE ANT •Trop elevated •Echo LVEF 15-20% (biventricular) •Angiogram Normal coronaries •EMBx performed •Lymphocytic myocarditis •ECMO •emboli to leg •fasciotomy •transfer to higher level of care •Heart Mate II LVAD •GI bleed •Acute renal injury Case WL 6 mo later •Referred to home HFC •Echo VAD insitu •April 2010 EF 70% •Post Explant VAD 1 mo •June 2010 EF 60% •Physical •110/60, HR 60 Sinus •JVP +3cm ASA •Medications •Carvedilol 6.25 mg BID •Esomeprazole 40 mg OD •Trazodone 100 qhs •Calcium 500 mg TID •Ferrous gluconate 600 mg qhs •Colace 200 mg daily •Immune 7 BID •Zinc 50 mg daily Case WL 6 mo later •NYHA I-II •Trainer 1 hr per day •Laboratory •NT proBNP 2025 pg/mL (14,004) •eGFR 54 WHERE DO WE GO FROM HERE? Where do we go from here? •Increase guideline directed medication •Reduce medication •which ones? •Surveillance of heart function The Lancet Volume 393, Issue 10166, Pages 61-73 (January 2019) Withdrawal of pharmacologic therapy in patients with dilated CMO •Inclusion •Prior CMO LVEF <40% •Asymptomatic on therapy •Current LVEF >50% •Normal LVEDVi •NT proBNP <250 ng/L •51 patients randomized open label trial •stepwise withdrawal •continued therapy •single X-over at 6 mo for withdrawal 6 mo follow up 1º Brian Halliday, senior author Sanjay Prasad Bromptom Hospital, London Withdrawal of pharmacologic therapy in patients with dilated CMO Endpoint measure Relapse of dilated CMO LVEF worse by 10% and <50% LVEDV increase by 10% 2X rise in NT-pro BNP and >400 ng/L Clinical HF Lessons from TRED HF •40% had relapse within 6 mo of medication withdrawal •majority had deterioration within 16 weeks •50% of patients had successful medication withdrawal •is 6 mo long enough? Lessons from TRED HF •Recovery ≠ Cure •But does it mean Remission? How does this apply to my patient? Case WL 7 yr later •Periodic follow up in HFC •Echo EF 50-55% •apical aneurysm from VAD •Physical •102/59, HR 66 Sinus •JVP ASA •wide split 2nd HS •Medications •Cipralex 20 mg •Trazodone 25 qhs eGFR 47 NT proBNP 386 pg/mL What would you recommend for surveillance? >80g per day for 5 yr or longer >6 drinks per day 141 patients ACM 716 DCM 445 controls Case 2 SL •2005 woman 25 y.o. •Right Breast CA - ductal carcinoma •ER+, PR+, Her/neu+ •Excision, CEF x 6, radiation •Herceptin x 9 weeks •EF 33% •Herceptin discontinued •Ramipril •Bisoprolol •LVEF 55% Case SL Can I Stop my cardiac medications? •2007 woman 27 y.o. •REALLY??? •Well…ok let’s try one •Bisoprolol weaned off EF dropped within 3mo •Ramipril •Bisoprolol •LVEF 55% Case SL Doctor I’m pregnant…with twins •2009 woman 29 y.o. •REALLY??? •Well…ok let’s not panic •Ramipril stopped •Tamoxifen stopped •Fetal screening •Everyone was ok •Medications •NTG/Hydralazine •Bisoprolol •LVEF 40-45% •Returned to usual Rx post delivery •LVEF 50% Ware JS et al. N Engl J Med 2016;374:233-241 THERE IS A PLACE AND TIME Mr. Tu Lo Mr. P. Lee Yate Case 3 Tu Lo 2016 •Bilateral carpal tunnel 2005 •Spinal stenosis •HHF 2014, stents x 2 LAD for 80% disease •HTN age 34 •Afib converted on amiodarone •Echo EF 55-60% •LVd 4.4/ LVs 3.5 •IVS/PW 16/16 mm •SInus rhythm •SBP 90, HR 65, JVP ASA •eGFR 25 Tu Lo 2017 •RHC and biopsy 2016 •wt ATTR CA •Medications •nebivolol •Ramipril 1.25 •furosemide 120 mg BID •amiodarone •apixaban •rosuvastatin Tu Lo 2017 •He tells you he is fatigued and dizzy upon standing •Should the medications be adjusted? •Medications •nebivolol •Ramipril 1.25 •furosemide 120 mg BID •amiodarone •apixaban •rosuvastatin Tu Lo 2017 •He tells you he is fatigued and dizzy upon standing •Should the medications be adjusted? •Medications •spironolactone 12.5 mg daily •furosemide 80 mg BID •amiodarone •apixaban renal dose •rosuvastatin LAST CASE Case 4 Mr. P. Lee Yate •74 y.o male •MI, CABG age 43 •EF 35% RV impaired •Afib, prior stroke •PVD, CVD •CKD eGFR 18 •MPO vasculitis •Bladder CA •T2DM •NYHA IV •Abdominal ascites •poor appetite •BP 137/57, HR 61 •JVP mandible in sitting position Mr. P. Lee Yate •Medications •NTG patch 0.4 mg •Hydralazine 50 mg TID •Amlodipine 10 mg •Furosemide 80-120 mg BID •Metalozone •spironolactone 12.5 mg daily •Atorvastatin 20 mg daily •ASA 81 mg •Insulin •Pantoprazole 40 mg •Azathioprine 12.5 mg daily •Alpha calcidiol 0.25 mug MWF •Ferrous fumarate 300 mg qhs •hydromorphone 1-3 mg daily pen Can we deprescribe anything? Mr. P. Lee Yate •Medications •NTG patch 0.4 mg •Hydralazine 50 mg TID •Amlodipine 10 mg •Furosemide 80-120 mg BID •Metalozone •spironolactone 12.5 mg daily •Atorvastatin 20 mg daily •ASA 81 mg •Insulin •Pantoprazole 40 mg •Azathioprine 12.5 mg daily •Alpha calcidiol 0.25 mug MWF •Ferrous fumarate 300 mg qhs •hydromorphone 1-3 mg daily pen • Can we deprescribe anything? Not on a beta blocker… What if your patient has symptomatic hypotension? Mr. P. Lee Yate with symptomatic hypotension •Medications •NTG patch 0.4 mg •Hydralazine 50 mg TID •Amlodipine 10 mg •Furosemide 80-120 mg BID •Metalozone •spironolactone 12.5 mg daily •Atorvastatin 20 mg daily •ASA 81 mg •Insulin •Pantoprazole 40 mg •Azathioprine 12.5 mg daily •Alpha calcidiol 0.25 mug MWF •Ferrous fumarate 300 mg qhs •hydromorphone 1-3 mg daily pen • Can we deprescribe anything? PRACTICAL DEPRESCRIBING Commitment to the patient Wean off Reassess Wean off Reassess Ongoing surveillance Can you delegate the surveillance? Comments and Considerations •Medication withdrawal has a high likelihood of relapse •When considering it requires a tailored approach •Information •Surveillance •Willingness to re-engage