October 2022

October Introduction

ROP 2022 October20 Chapters

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Summary
Conversation (5)
CME Credits (6)

October Introduction

Heidi James, MD, and Vanessa Cardy, MD

As requested by a listener, Heidi and Vanessa discuss quadruple therapy for reduced ejection fraction (HFrEF) heart failure, as laid out in the ACC/AHA/HFSA (American College of Cardiology/American Heart Association/Heart Failure Society of America) 2022 Guideline for the Management of Heart Failure.

Quadruple therapy consists of
- Beta blocker
- Mineralocorticoid antagonist
  - Spironolactone
- Angiotensin receptor-neprilysin inhibitors (ARNi)
  - Actually 2 medications
    - Neprilysin inhibitor (sacubitril) + angiotensin receptor blocker (ARB) (valsartan)
- Sodium-glucose cotransporter-2 inhibitor (SGLT-2i)
Key takeaways
- ARNi
  - Replace angiotensin-converting enzyme (ACE) or ARB alone
  - Improve quality and quantity of life
- SGLT-2i
  - Recommend regardless of whether or not patient has diabetes
  - Studies show
    - Are well tolerated
    - Are associated with fewer admissions
    - Result in improved cardiovascular outcomes
    - Show a mortality reduction at 2 years
    - Slow progression of renal dysfunction
Heidi’s and Vanessa’s concerns
- Hypotension
  - How many BP-lowering meds can one body handle?
- Polypharmacy
  - Most patients with heart failure (HF) are already on a lot of meds and we’re now supposed to add 4 (actually 5!)?
- Cost
  - Medications are expensive—who can afford this?
- Real-world implementability
  - Can we actually follow through on these recommendations?
  - It’s a lot of work!
  - Back when HF was managed with triple therapy, only one-third of patients were started on all 3 meds; of those, <1% were at target doses of all 3 meds.
Stay tuned
- Steve and Ken will discuss and dissect this guideline in an upcoming PCMA!

PEARL: The latest ACC/AHA/HFSA guidelines recommend quadruple therapy, consisting of a beta blocker, mineralocorticoid antagonist, angiotensin receptor-neprilysin inhibitor, and sodium-glucose cotransporter-2 inhibitor, for patients with HFrEF. This is an ambitious goal that is likely beyond the financial and physical tolerability of many patients.

REFERENCES:

Quadruple medical therapy for heart failure: medications working together to provide the best care
Greene SJ, Khan MS. J Am Coll Cardiol. 2021;77(11):1408-1411. doi: 10.1016/j.jacc.2021.02.006. PMID: 33736822

In-hospital initiation of quadruple medical therapy for heart failure: making the post-discharge vulnerable phase far less vulnerable

Greene SJ, Butler J, Fonarow GC. Eur J Heart Fail. 2022;24(1):227-229. doi: 10.1002/ejhf.2382. PMID: 34779112

La tripla/quadrupla terapia antineurormonale nello scompenso cardiaco tra dubbi, evidenze scientifiche e buon senso clinico [Triple/quadruple therapy in heart failure: integrating scientific evidence with clinical reasoning]
Sinagra G, Sabbadini G, Zecchin M, et al. G Ital Cardiol (Rome). 2007;8(9):559-567.

PMID: 17972425

2022 AHA/ACC/HFSA Heart Failure Guideline: Key Perspectives

https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/03/29/19/53/2022-aha-acc-hfsa-heart-failure-guideline-gl-hf

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Heidenreich PA, Bozkurt B, Aguilar D, et al. Circulation. 2022;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063.

John Michael B. - October 1, 2022 7:06 AM

With respect to SGLT2 inhibitors please consider discussing the following paper with respect to patients that we had met with myocardial infarction. This seems to be a signal that it will help preserve ejection fraction and this high risk group.

von Lewinski D, Kolesnik E, Tripolt NJ, et al. Empagliflozin in acute Myocardial Infarction: the EMMY trial. Eur Heart J. 2022 Aug 29. pii: 6677315. doi: 10.1093/eurheartj/ehac494. (Original study)

Heidi J., MD - October 20, 2022 5:04 AM

Thanks for the suggestion - looks like a good one! Will make sure Ken and Steve see this.

John Michael B. - October 1, 2022 7:07 AM

had met= admit -dictation error

Please also consider covering a paper that reviews dictation errors and their consequences and medical records

Kimberly O. - October 13, 2022 2:12 PM

I was just listening to the ROP October segment Reflections on Diet Culture and was frankly shocked by the overall message. Of course I am against shaming our patients, and "fat bias" as they put it, is a real thing. But for them to suggest that being over weight is not the most likely underlying reason for most of the deadly chronic diseases we see in medicine today, is I feel uniformed, at the least. Obesity leads to DM, HTN, CAD, CKD, CVAs, you name it, and is costing the health care system dearly. At one point Dr. James actually said she didn't want to tell her patients to lose weight because she knew it was too hard for them to do, and after all, we have medications we can give them. Is that the message we should be teaching? Common, we are supposed to be doing better than this. If the doctors are not giving patients the correct information, who is going to do it?

Heidi J., MD - October 20, 2022 5:20 AM

Hello - Thanks for much for taking the time to listen to the piece and share your thoughts. Agreed, it is a divergent viewpoint on weight management and we expected it to generate feedback; yours is noted and appreciated. As weight management and obesity are complex topics, we strive to approach it from various perspectives on the show. I'd invite you to check out our past pieces and paper reviews on the topic and stay tuned for more.