CCS Guideline/Position Statement Workshop as Presented at CCC 2019

CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS HEART FAILURE GUIDELINES RAPID REVIEW: HF UPDATEMichael McDonald MD and Sean Virani MDApril 18, 2020 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Disclosures•Michael McDonald•Honoraria: Novartis, Servier, Astra Zenica•Clinical Trials: Novartis•Unrestricted Educational Grant: Abbot, Medtronic•Sean Virani•Honoraria: Abbott, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Medtronic, Merck, Novartis, BMS/Pfizer, Servier, Takeda•Research: Abbott, AstraZeneca, Bayer, Boehringer-Ingelheim, Medtronic, Novartis, Pfizer CCS Guideline/Position Statement Workshop as Presented at CCC 2019 2019 HF Guideline Development•New evidence from randomized controlled trials published after the 2017 Update on key topics•4 topics of high relevance in terms evolution in the care of patients with HF: •Transcathetermitral valve repair•New treatments for ATTR cardiac amyloidosis•Prevention/management of HF in patients with type 2 diabetes•Clinical trial update in HFpEF CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Case•60 F, (non-ischemic) heart failure, NYHA III symptoms•Bp108/60, HR 66bpm (sinus rhythm), narrow complex QRS, creatinine 120•Echo shows LVEF 30%, severe mitral regurgitation•SacubitrilValsartan 100mg bid•Carvedilol 25mg bid•Eplerenone25mg/d•Furosemide 20mg/d•Metformin for DM2•Prophylactic ICD in situ What else could be considered to improvethis patient’s symptoms and prognosis? CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Percutaneous Mitral Valve Repair CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Whether interventions to reduce secondary MR improve prognosis ? CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Transcatheter Mitral Repair•The MitraClipis a transcatheter leaflet repair device for the treatment of degenerative and functional mitral regurgitation.•Use of the device in patients with end-stage heart failure has demonstrated a reduction in mitral regurgitation and improved QOL. FranzenO et al. EurJ Heart Fail 2011;13:569-76. $ 35 000 intervention CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Mitral Regurgitation : Before & After Mitraclip CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Percutaneous Mitral Valve Repair for Patients with HFrEFand Severe Functional MR -The Data:•In 2018, two RCTs comparing the efficacy of MitraClipin addition to Guideline-Directed Medical Therapy (GDMT) compared with GDMT alone in patients with Functional MR for whom mitral valve surgery was not deemed appropriate were published CCS Guideline/Position Statement Workshop as Presented at CCC 2019 MITRA-FR304 patients1 year follow upVery dilated LVMod-Severe MR CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Cardiovascular Outcomes Assessment of the MitraClipPercutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation: The COAPTTrial •614 patients after optimization of GDMT •1/3 of the screened patients randomized•2 year follow-up CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Comparison of Trial Patients and Outcomes in the MITRA-FR and COAPT StudiesTrial and Patient CharacteristicsMITRA-FRCOAPTComparisonMitraClip vs GDMTMitraClip vs GDMTHeart team evaluation and GDMTHeart team evaluation, GDMT not described over timeHeart team evaluation, GDMT described over timeStudy period2013-20172012-2017Follow-up period, year 1 2Patients enrolled/Patients considered for trial (%)307/452 (67.9)665/1576 (42.2)LVEDVI, mean (SD), mL/m2 135 (35) 101 (34)Baseline EROA, mm2, mean (SD) 31 (10) 41 (15)LVEF, mean (SD), %33 (7)31 (9)OutcomesProcedural complications*21/144 (14.6)25/293 (8.5)MR grade ³2 at discharge30/123 (24.4%)46/260 (17.7)MR grade ³2 at 1-year 48/97 (49.5)65/210 (31.0)All-cause mortality/ HF hospitalization at 1 yearNo/Total (%)MitraClip arm83/151 (54.6)102/302 (33.9)GDMT arm78/152 (51.3)145/312 (46.5)p value 0.53 < 0.001Modified from: GHL Tang, et al. JAMA Cardiology 2019;4:307-308. CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Comparison of Trial Patients and Outcomes in the MITRA-FR and COAPT StudiesTrial and Patient CharacteristicsMITRA-FRCOAPT Follow-up period, year 1 2Patients enrolled/Patients considered for trial (%)307/452 (67.9)665/1576 (42.2)LVEDVI, mean (SD), mL/m2 135 (35) 101 (34)Baseline EROA, mm2, mean (SD) 31 (10) 41 (15)OutcomesProcedural complications*21/144 (14.6)25/293 (8.5) * Mitraclipgroup onlyModified from: GHL Tang, et al. JAMA Cardiology 2019;4:307-308. Positive Clinical Trial Outcomes Associated With:•Longer follow –up•Highly selected, medically optimized patients•Less dilated ventricles•Proportionally more MR•Better procedural success CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS HF Guidelines 2019: Recommendations1.We recommend that maximally tolerated GDMT, including CRT and revascularization where appropriate, be implemented before consideration ofpercutaneous mitral valve repair for patients with HFrEFand severe functional MR (Strong Recommendation; High-Quality Evidence).2.We recommend that a multidisciplinary dedicated heart-team (including interventionalists, cardiac surgeons, imaging specialists, and HF specialists) perform the evaluation and care of potential candidates forpercutaneous mitral valve repair (Strong Recommendation; Low-Quality Evidence). CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS HF Guidelines 2019: SomePractical Tips•Patients with severe LV dilatation (> 70mm) and less than severe MR might be poor candidates •Patients with FMR should first receive maximally tolerated medical therapy for a minimum period of time (3 months), before intervention considered•Patients considered for PMVR should be referred to centres with:oexperience in the evaluation of patients with advanced HFohigh volumes of patients with valve disease managed medically and surgically ohigh likelihood of achieving the volume of PMVR (e.g. 2-4 per month) required for developing and maintaining competence in well-selected patients CCS Guideline/Position Statement Workshop as Presented at CCC 2019 2019 Update of SGLT2 Inhibitors for Prevention and Management of HF:New Information Since the 2017 HF Guidelines UpdateSean A. Virani MD, MSc, MPH, FRCPC, FCCSAssociate Professor of Medicine, UBCPast-President and Chair, Canadian Heart Failure Society CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Primary MACE endpoint by CV status CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Hospitalization for HF endpoint by CV status CCS Guideline/Position Statement Workshop as Presented at CCC 2019 2019 CCS HF Recommendation CCS Guideline/Position Statement Workshop CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Dapa-HF vs Recent Trial Participants: Baseline medical therapySHIFT (N=6505)PARADIGM-HF(N=8442)ATMOSPHERE(N=7063)COMMANDER-HF(N=5022)DAPA-HF(N=4744)Diuretic73808010094ACEi or ARB-1001009394a β-blocker9093929296MRA6060377771IvabradineN/A1.51.0-5Digitalis glycoside223032919CRT176-8ICD41515-26 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 2019 HF Guidelines Update CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Practical Tips•The most common adverse effect of this class of medications are genital mycotic infections (GMI). Typically, GMI can be managed with antifungal and do not require discontinuation of therapy.•SGLT2i may result in temporary reduction of eGFR up to 15% which generally resolves within 1-3 months. SGLT1i have also been associated with acute kidney injury and increase monitoring is warranted in those at risk.•SGLT2 inhibitors do not cause hypoglycemia in the absence of concomitant insulin and / or secretagogues therapy. These background therapies may need to be adjusted to prevent hypoglycemia. These agents are contraindicated in Type 1 diabetes. CCS Guideline/Position Statement Workshop as Presented at CCC 2019 •SGLT2i should be held in the setting of concomitant dehydrating illness as part of ‘Sick Day’ management according to the Canadian Diabetes Association Recommendations for ‘Sick Day’ management (ref: CDA, Canadian J Diabetes, 2018; 42: S316) •These agents have been associated with diabetic ketoacidosis (incidence 0.1%). Patient may present with normal or only modestly elevated blood glucose (< 14 mmol/L). On rare occasions, it may be associated with normal anion gap acidosis, which is best detected by measurement of serum ketones. Non-specific symptoms associated with DKA include: shortness of breath, nausea, vomiting, abdominal pain, confusion, anorexia, excessive thirst and lethargy.•Caution should be exercised when combining SGLT2 inhibitors, ARNI and diuretics given their concomitant effects on diuresis. Practical Tips … CCS Guideline/Position Statement Workshop as Presented at CCC 2019 Therapy NNT Mortality 1 yearNNT Mortality 5 yearsMedicationsACEi/ARB9218Beta blocker408MRA7515SNI-Ivabradine459ARNi8014SGLT2i 6716DevicesICD7014CRT pacing7014 There are now 6 medications and 2 devicesthat reduce all cause mortality in patients with HF Fonarow, JAMA Cardiol, 2018; 3(12);1226-31.Swedberg Lancet 2009 CCS Guideline/Position Statement Workshop as Presented at CCC 2019 •Novel therapies for HFrEF improve HF related morbidity and mortality!•Percutanousmitral valve repair –patient selection and appropriate expertise is key•SGLT2 inhibitors for patients with AND without diabetes•SGLT2 inhibitors for prevention AND treatment of HF•Future studies will inform optimal timing, patient population and limitations of these therapies Summary