EU-RICA - ARNI
Summary
TLDRThe presentation 'Early and Upfront: Rapid Initiation Campaign for Iron' discusses guidelines for heart failure treatment, emphasizing the importance of early recognition and rapid initiation of the 'Fantastic Four' therapiesβiron, beta-blockers, MRAs, and SGLT2 inhibitors. It highlights the benefits of these treatments, including reduced hospitalizations and improved heart function, and addresses the management of patients with varying ejection fractions. The talk also covers recent trials and the significance of the unique formulation of sacubitril/valsartan in improving cardiovascular outcomes for heart failure patients.
Takeaways
- π The presentation focuses on the rapid initiation campaign for iron in heart failure treatment, emphasizing early intervention with directed medical therapy.
- π The 'Fantastic Four' of heart failure treatment includes iron, beta blockers, MRA (mineralocorticoid receptor antagonists), and SGLT2 inhibitors, which are crucial for disease management.
- π Early and upfront initiation of these four medications is recommended for better outcomes in heart failure patients, regardless of ejection fraction levels.
- π There is no fixed order for the sequence of therapies; the priority is to start and observe the application of the medications as quickly as possible.
- π Benefits of the combined therapy include rapid improvement in health, reduction in hospitalizations, and better quality of life for patients.
- π The 2022 AHA/ACC Heart Failure Society of America guidelines suggest starting these medications simultaneously at low doses, especially for patients with heart failure.
- π Subcutaneous sacubitril/valsartan has shown significant benefits in reducing cardiovascular and renal events in patients with heart failure, including those with mild reduced or preserved ejection fraction.
- π Cost-effectiveness analysis indicates that rapid initiation of therapy, either pre-discharge or early post-discharge, is supported by Class 1 evidence.
- π¬ Recent trials, such as the PIONEER and VITALEAN trials, have demonstrated the efficacy of sacubitril/valsartan in reducing cardiovascular death and rehospitalization in heart failure patients.
- β οΈ Sacubitril/valsartan is not to be halved due to its unique formulation, and patients should be enrolled in a hard care program for better access and adherence.
- π The importance of early recognition and treatment of heart failure, including the management of diuretics and the initiation of MRA and SGLT2 inhibitors, even in areas with limited lab access, is highlighted.
Q & A
What is the main topic of the presentation?
-The main topic of the presentation is the 'Early and Upfront, Rapid Initiation Campaign for Iron' in the context of directed medical therapy for heart failure.
What are the primary goals of the guideline Director Medical Therapy for heart failure?
-The primary goals are to prevent disease progression and improve the patient's clinical status.
What are the 'Fantastic Four' in the context of heart failure treatment?
-The 'Fantastic Four' refers to Iron, Beta Blockers, Mineralocorticoid Receptor Antagonists (MRA), and SGLT2 inhibitors, which are key components of heart failure treatment.
According to the 2022 AHA/ACC Heart Failure Society of America guidelines, how should medications for heart failure be initiated?
-The guidelines suggest that medications should be started simultaneously at low doses, especially for patients with heart failure, or alternatively, started sequentially with the sequence guided by clinical or other factors.
What are the benefits of using the combination of Iron, Beta Blocker, MRA, and SGLT2 inhibitor in heart failure treatment?
-The benefits include rapid improvement in health, reduction in heart failure hospitalizations, improvement in symptoms, and better quality of life for patients.
What is the recommended starting dose for Iron in the context of rapid initiation?
-The recommended starting dose for Iron is 50 mg once or twice daily.
What is the significance of the term 'EF' in the context of heart failure?
-EF stands for Ejection Fraction, which is a measure of how well the heart is pumping blood and is a key factor in determining the type and severity of heart failure.
What is the rationale for the 36-hour washout period when switching from an ACE inhibitor to an ARNI?
-The 36-hour washout period is necessary to prevent angioedema, a potentially serious side effect that can occur when transitioning from an ACE inhibitor to an ARNI.
What does the term 'subcubital' refer to in the context of Vasartan?
-Subcubital refers to a unique formulation of Vasartan that combines a sacubitril and valsartan in a specific 1:1 molar ratio, enhancing vasodilation and inhibiting vasoconstriction.
What is the significance of the term 'LVEF' in heart failure treatment?
-LVEF stands for Left Ventricular Ejection Fraction, which is a measure of the heart's ability to pump blood from the left ventricle and is crucial in assessing heart function and treatment outcomes.
What is the role of diuretics in the management of heart failure according to the script?
-Diuretics are a cornerstone in the management of heart failure, helping to reduce fluid overload and symptoms, but their use should be reassessed post-discharge to allow newer medications to work effectively.
How does the script address the management of patients with unknown eGFR when considering the use of SGLT2 inhibitors?
-The script suggests that SGLT2 inhibitors can be initiated regardless of eGFR, with monitoring of renal function to ensure there is no worsening of kidney function.
What is the importance of early recognition and treatment in heart failure management as emphasized in the script?
-Early recognition and treatment are key to preventing disease progression and achieving better outcomes in heart failure patients, including the use of the 'Fantastic Four' medications.
Outlines
π Rapid Initiation of Heart Failure Medication
The script discusses the importance of early and upfront treatment for heart failure, focusing on the 'Fantastic Four' therapies: iron, beta blockers, MRA, and SGLT2 inhibitors. It emphasizes the 2022 AHA/HFSA guidelines that recommend starting these medications simultaneously or in rapid sequence without waiting to achieve target doses. Benefits include rapid symptom improvement, reduced hospitalizations, and improved quality of life. The script also covers the correct dosing and titration of these medications, highlighting the significance of early intervention in managing heart failure.
π Clinical Trials and Heart Failure Management
This paragraph delves into recent clinical trials that have shaped the approach to heart failure treatment. It mentions studies like the Pioneer Heart Failure Trial and the Vericiguat Heart Failure Trial, which have shown significant benefits in reducing hospitalizations and cardiovascular deaths. The discussion also touches on the use of sacubitril/valsartan, a novel medication that has demonstrated positive outcomes in patients with reduced, mildly reduced, and preserved ejection fractions. The importance of early recognition and treatment, including the use of EP device therapies and transplant considerations, is also highlighted.
π Subcubital Vasartan's Role in Heart Failure
The script provides an in-depth look at subcubital vasartan, a unique formulation that combines sacubitril and valsartan, and its role in improving cardiovascular outcomes for heart failure patients. It discusses the benefits of this medication in reducing the risk of symptomatic hypotension and worsening renal function compared to other treatments. The paragraph also summarizes the results of the PIONEER and VIALITE-HF trials, emphasizing the significant risk reduction in cardiovascular events and the importance of early treatment initiation.
π Early Recognition and Treatment in Heart Failure
This paragraph underscores the importance of early recognition and treatment in managing heart failure, focusing on the 'Fantastic Four' therapies. It discusses the stages of heart failure and the different types, including the newly recognized improved ejection fraction category. The script also addresses practical considerations in clinical practice, such as the management of diuretics and the challenges of initiating therapy when lab results are not readily available. It concludes with the message that early and upfront treatment can lead to better outcomes in heart failure patients.
π‘ Managing Heart Failure Medications in Clinical Practice
The final paragraph addresses common clinical questions and considerations when managing heart failure patients. It discusses the use of diuretics, the importance of not reducing the dose of sacubitril/valsartan, and the challenges of initiating medications like MRAs and SGLT2 inhibitors when eGFR levels are unknown. The script emphasizes the need for proper patient assessment and the importance of continuing medications to prevent relapse, while also acknowledging the financial considerations and the role of healthcare programs in facilitating access to these treatments.
Mindmap
Keywords
π‘Heart Failure
π‘Ejection Fraction (EF)
π‘Directed Medical Therapy
π‘Rapid Initiation Campaign
π‘Fantastic Four
π‘Angiotensin Receptor Neprilysin Inhibitors (ARNIs)
π‘Mineralocorticoid Receptor Antagonists (MRAs)
π‘SGLT2 Inhibitors
π‘Renal Function
π‘Cardiovascular Outcomes
π‘Diuretics
Highlights
Topic of the presentation is 'Early and Upfront, Rapid Initiation Campaign for iron' in heart failure treatment.
Guidelines focus on directed medical therapy for heart failure, emphasizing rapid initiation of treatment.
Discusses treatment strategies for patients with varying levels of ejection fraction (EF).
Primary goal of treatment is to prevent disease progression and improve patient quality of life.
Introduction of the 'Fantastic Four' in heart failure treatment: iron, beta blockers, MRA, and SGLT2 inhibitors.
There is no fixed order for the sequence of therapies; prioritization and observation are key.
2022 AHA/HFSA guidelines recommend simultaneous initiation of medications at low doses for heart failure patients.
Benefits of the 'Fantastic Four' include rapid health improvement and reduced hospitalizations.
Initiation of medications can be done simultaneously or through rapid sequencing.
Example dosing for iron, beta blockers, MRA, and SGLT2 inhibitors in heart failure treatment.
Special considerations for patients transitioning from ACE inhibitors to ARNI.
Recent trials show the effectiveness of sacubitril/valsartan in acute heart failure.
Cost-effectiveness analysis supports rapid initiation of iron therapy in heart failure patients.
Subgroup analysis of heart failure patients with improved EF shows benefits of sacubitril/valsartan.
PIONEER-HF trial results indicate a significant reduction in cardiovascular death and rehospitalization with sacubitril/valsartan.
VICTORIA trial demonstrates the efficacy and safety of sacubitril/valsartan in patients with mild reduced EF.
Subcubital valsartan's unique formulation enhances vasodilation and inhibits vasoconstriction.
Early recognition and treatment of heart failure are crucial for better patient outcomes.
Management of diuretic use in heart failure treatment, emphasizing the importance of reassessing patients post-discharge.
Discussion on the management of patients with unknown eGFR when considering the use of MRA and SGLT2 inhibitors.
Transcripts
topic for tonight is entitled early and Upfront
Rapid Initiation Campaign for iron
okay so the outside of the presentation are as follows
are the giving the guideline
directed medical therapy for heart failure
how do we treat patients with hephra
and how do we initiate rapidly
how do we initiate rapidly the design mine
so particularly
how do we treat patients for who have more than 40% EF
we have mildly reduced EF
we serve EF and those with include EF
so in the guideline Director Medical Therapy
our primary general Sarah Stylos
prevent disease progression
and improve the patient child status
so this was discussed by Doctor Richard Bruce earlier
the most common signs and symptoms of heart failure
so again the primary treatment
goals is to prevent the disease progression
so how do we do this so specially for your arrhythmias
you will have our heart transplant now
and then
we decrease
the recompensated state of our heart failure patients
and for the improvement of patients and status
who want to lessen the symptoms
improve the quality of life of these patients
so this was discussed as a fantastic four
so of course you have your irony
your beta blocker the MRA
and then the accidental
medicine for your heart failure
as TLDP inhibital
so in the order of sequence of therapies of this cast
there is no fixed order
or no preference for the sequence used
so he prioritize administration
and observe application of the
those and speed matters of course
so in the 2022 ahacc
Heart Failure Society of America guidelines
it was stated that we need to start this medicine
simultaneously at no doses
especially for your health breath patients
alternatively
this medications will be started sequentially
with sequence guided by clinical or other factors
without the need to achieve target nursing
before initiating your medication
so
here are the benefits of your irony plus beta blocker
plus MRA and then your SG and T2 in medical
so first
would be a rapid improvement in health
as early as 8 weeks
rapid reduction in your heart failure
hospitalizations within 2 to 4 weeks
so we would not want our patients to be visiting
the emergency room
rapid reduction in your mentality
as early as 2 to 4 weeks
rapid improvement in your LV
ejection production within 12 weeks
rapid reduction in your heart failure
rehauspitalization and improve use tolerability
adherence persistence and overcoming ineration
so this is your comprehensive
disease modifying medical therapy
wherein we start simultaneously
or rapid sequencing of your fantastic 4 medicines
so an example is a pre one for your irony beta blocker
MRA and s G l t t inhibitor
we start them at a low dose or your illustration
so say for example your iron knee
you can start them at D1 with 50 mg once
twice daily dosing low dose of your makeup locker
low dose of your MRA and your s G L D2 inhibitor
so it is stated that for
if you want to convert creatency detour to your army
so
you need to wait for 36 hours as you wash out period
so that dose of your self
VARs or pivotal
vasartar should be doubled after 2 to 4 weeks
to target dose of 200 mg twice daily dose
so uh for your beta blockers
so you also start low low and slowly
so you have your examples of esoperolol or vadiloyal
no acting metoporolol succinate and your medievalol
so on the deep 7 to 14 which is yourself
uh first to
to second with to continue your medications
they treat them as tolerate them
so here we optimize our uh medicines
now as long as their patients
tolerate the effects of this medicines
so on the end of your first month to your uh
third month
maintain this an additional type of titration
however for patients who want to uh lessen the death
we consider EP device therapies
or transplatory micro valve repair
so
the recent trials for hospitalised patients as emerged
particularly your pioneer heart failure trial
your Fireglide heart failure trial were in secumetal
Vasal Tan was used
so in here the undertakens in the previous inhibitor
irony as used in your acute
the compensating heart failure
has shown to decrease as much as 71%
in the outcomes of these patients
with regards to their tolerability
worsening renal function hyperkalimia
symptomatic hypertension and
and Angie edema were all compatible with the placebo
so with regards to
the patients hospitalized with heart failure
those who are symptomatic and show if fluid overload
especially
for those patients who have reduced ejection fraction
it has shown that there
has 46% relative breast reduction
so with regards to a rapid illustration
for your eye knee
it has shown 42% relative risk reduction
with regards to the cardiovascular death or hospital
readmissions due to your heart failure
so moving on so
the cost effectiveness analysis was examined for
patients who are on rapid initiation of your ironing
so the intensive in
the intensive strategy of initiation of rapid
up titration
are shown to have a class 1 evidence already
when initiated on pre discharge
or early post discharge fails
so what about your heart failure
patients with improved EF
mild reduced EF or to serve ejection production
so for this patient
especially for your improved ejection fraction
so this is defined as a baseline EF of 40%
an increase of 10 points from your baseline LVEF
honor
the second measurement of your LVEF to be more than
40% already
so with this regards
it has shown that subcubital Vasar Tan
reduce total heart failure
hospitalizations in cardiovascular death
and 25% related risk production
in total heart failure patients
versus your Vasar Tan alert
so comparing your paradigm heart failure
with a paradigm heart failure trial
so your therapeutic benefits of yourself
while with respect to heart failure patients on
has shown robust evidences that may extend
the patients to be
the use of your subcrimetal vasar tan
for below normal Egyptian fraction
so moving on the pirate line heart failure trial
so in the pirate line to heart failure trial
this aims to show the efficacy
safety and tolerability of subterminal Vasar Tan
for those patients of mild
reduced EF episode
ejection fraction
with patients with a recent worsening heart failure
even
so this was their status design
with the primary employment of time
average proportional change of your NP
Pro BNP from this line from width 4 to eight
so it has shown that there was 15% greater adoption
with your security advisor
done with regards to the change of your NP Pro bnb
which is arrogate marker for your heart failure
so a pre specified participant level
food analysis was also used for this study
so in the Pirate Light heart failure trial
there's a million follow up here of top six months
and went for a part ago on heart failure
triangles of median follow up of almost three years
so this showed to us of a primary code analysis
for in your total worsening heart failure events
and cardiovascular debt
there was a 22% relative risk reduction
and for your report analysis of all participants
there was 14% relative risk reduction
favored in your secretary field via site plan
so in summary security
Vasar Tan reduced cardiovascular and renal events
compared with Vasar Tan
among patients with heart failure
with mild reduced or preserved ejection fracture
so benefits appeared to up uh
who rapidly
with statistically
significant reductions in cardiovascular events
first observed within the first 2 weeks of treatment
initiation and cardiovascular benefits
most apart in patients with an LVEF below normal
so this is an important uh
sentence here that's accumulated
bicyrtan increased risk of symptomatic hypotension
but reduced risk of
worsening renal function when compared with bicyrtan
so again
the unique formulation of a saccubutal Vasor
done consistently improves the cardiovascular outcomes
with R B E
for your hospitalized patients across the spectrum
so for your pioneer heart failure
it has shown red
31% reduced cardiovascular death and reignation
for patients with reduced EF
so that's less than 40%
and the viral glide heart failure
and part of one heart failure
which consisted of your mildly reduced EF
and preserved ejection fraction at 22%
reduce hospitalization and cardiovascular death
for those patients for symptomatic ambulatory patients
the paradigm heart failure is proven
for patients reduce ejection fraction
will have a reduction as much as 20%
for the reduced total heart failure
hospitalizations and cardiovascular death
as well as a 22% relative risk reduction
for those patients who have more than 40% rejection
fraction
so why is subcubital vasartan verifications
so this is the molecule of sectorbital
vasartan is designed to be different
so this is a combination of your subcubital and your
so arresting hibitor and your neprelacene inhibitor
so your LCC696 so the active molecule of your uh
occubital valsar Tan
simultaneously delivers your succubital and valsar tan
in a specific one is to 1 molar ratio
so you enhance your vassal relaxation
and you inhibit your vassal construction
so the power of subcubital vasircan is
with its unique forulation
so
it has shown robust evidences for both outpatient and
uh
admitted patients
so with regards to the cardiovascular outcome trials
so the rapid initiation campaign for irony
has shown to be very efficacious
and has been already recommended by your aha
ACC and Heart Failure Society of America
so the uh in conclusions
early recognition of the patient
with heart failure is key to early treatment
the rapid initiation of the Fantastic Four
which consists of your army as United inhibitor
MRA and beta blocker
is key to early and maximum benefits
in heart failure patients
and army in the full spectrum of heart failure
and we used
early and upfront initiation
leads to better heart failure outcomes
so uh this is make ways so you recover
so the early and upfront use of iron in heart failure
is exception to the rule so with that
thank you
before shifting your or your age or your vision or any
what's the rationale of the time
of course aside from the overlapping effect of your
ace inhibitor in your irony
which may affect your lemodynamic status
we want to prevent the
the effect of andro edema
now for patients who are
initially on your ace inhibitor
and to be shifted on your army
so that is a seat window
period at 36 to 48 hours to prevent anti
edema for these patients
thank you
uh requests from the audience uh
make for those so
um Madam President
thank you very much Doctor Zan
so we both listen to the two speakers
uh they emphasize
early recognition is the key to prevent heart failure
so we really have to encourage our patient at risk
those who are on stage a
who are those patients
those are newly diagnosed diabetes
and controlled hypertensive patient
whether they are old or young
um those have recent MRI
recent stroke so as to avoid
to have a structural abnormality in the future
because once they develop it
they would really develop symptoms later on
they also emphasize that we have to remember
the four pillars of management
the army use
if it's the patients are not do not tolerate the army
we can ship it to ace inhibitor or Arbs
the importance of a better blocker
the mineral corticoid antagonist and the SCL2 inhibitor
we um
they also emphasize uh
Doctor Richie emphasize that there is a new type of um
heart failure uh
we we knew only the preserve EF
reduce EF the mid range EF
but now there is an improved EF they want
these are the patients who have
at first 40% less of ejection fraction
and then after treatment
has an improvement of 10% from the baseline
the message
is to continue the medications to avoid relapse
Redell
it's a magic four
by the magic number for tonight is four
so there are four pillars
the treatment of hearts filler
there are four stages there are
those are two ways
stage B is a pretty heart failure
stage C is those who are symptomatic
and stage d is the advanced heart failure
another four is the four types of heart failure
so for our residence for the younger colleagues
so please take note of those things
and of course
the recent trials mentioned by the third time
so it's very helpful actually in our practice
hi okay
so there's a question Doctor Radelle about um
diuretic use
so let me ask you Doctor Radelle in your practice
um how do you manage your patient
uh we know that the diuretic is a cornerstone um
in the management of heart failure
how do you manage with the use of the diuretic
because they give
they have given the emphasis on their lecture
as much as possible of course India
it's it depends on the clinical picture of the patient
if the patient is about to be discharged
well you have been really assessed the patient
so sometimes I still feel for oral diabetics uh
post discharge
but I have to reassess the patient at least 5 days
for maximum plan for 1 week
for me to know if I'm going to take out the diuretic
already because of us
what Doctor Richards mention
uh we do not give uh
whom they read it as maintain and stuff
we we have to give way to the newer uh
medications for them to work
so we really uh it's a case to case basic statues
and we really have the assessment patient here
because sometimes we over diabetes our patient
which is also what is harmful to the kidneys
I think we
are
I have a um doctor that I have a question
there's a question in the check box
they uh
they would like to ask the how do you um manage do
are we allowed to lessen the dose of the interest tone
because you mentioned that ideally
that should be 50 milligram twice a day now
so is there an incense that most of that time
patient become hypotensive
so so what can you say about this
so in the landmark trial of interests of occupital
balcytan so we're only allowed
actually it was not mentioned
if we're allowed to lessen or decrease the dose
no so
as low as the patient has not presented symptomatic
hypertension and so
you can still use the full dose of your 50 mg
twice a day
those things
now with regards to the common questions
and since seccupital website
and interest is relatively expensive now
so a common question is
are we allowed to uh half the the tablet
no so actually no
no because as I have discussed no
so uh the subcubitrial and then the uh
pulsite time is integrated as one molecule
so once you uh half if no
so
you might disintegrate the full effect of the medicine
so anyway I think know why this
Philippines has a hard care program
no where in they give back uh
so the number of tablets now to the patients
once enrolled to this program
so that makes it easier for the patients also
and the family
anyway so the question was
these medications are elite effective
other options for patients who are illegal
guy for in there
actually
so it's a manner of delivering it to the patient now so
if you tell them the landmark trials
and the possible benefits of these medicines so
we have to remember that this 4 medicines already
the mainstream
or the four pillars of your heart failure
it's the aim to have our
okay then okay let me keep the question
may I ask regarding the use of MRA
in SGLT2 inhibitors among patient with unknown EGFR
uh
financial consult where labs are not easily accessible
can we still initiate this class of labs
or wait for it
for labs to be done prior to its initiation
okay so definitely need this line laboratories now
so we need to establish the uh
kidney function of the patient
the urinal function of the patient
so that includes your BRP as well as your electrolytes
if you are considering to use also your MRI
so emerging studies for the s G
L T 2 inhibitor a show that irregardless of the EGFR
so you may still use or initiate your s G
L t to inhibitor then just monitor their
renal function
so to see if there is work
but
recent studies of your SGLB to inhibitor has
established that there is a beneficial impact
on the worsenic kidney function of the patients
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