ESC Congress 2016 - 15A

ADVERTORIAL Sponsored Session Highlights The Next Stage in Heart Failure Management: Optimizing Treatment to Improve Outcomes Despite proven therapeutic advances, the burden and prevalence of heart failure (HF) are increasing worldwide, and suboptimal treatment results in increased mortality and hospitalization for HF (HFH), reduced quality of life, and a growing financial burden for both patients and health care systems. Increasingly, the focus is on strategies to increase utilization of optimal treatments, especially during the critical "vulnerable phase" when patients are at the highest risk for hospital readmission. Multidisciplinary HF teams are one strategy designed to optimize treatment and to ensure coordinated transitions of care at hospital discharge to reduce readmissions. The importance of a heart team was the spotlight of the European Society of Cardiology (ESC) 2016 Congress, underscoring its importance in managing all cardiovascular (CV) diseases. The new ESC guidelines also call for multidisciplinary team management of HF.1 The armamentarium of treatment for HF has been expanded with the approval of new drugs. Sacubitril/ valsartan was shown to reduce mortality and HFH (12.8% of patients taking sacubitril/valsartan were hospitalized for HF, compared with 15.6% for enalapril; HR, 0.79; 95% CI, 0.71 to 0.89; P < .001) in the PARADIGM-HF study. 2 Ivabradine is another agent that improves systolic function by reducing heart rate (HR) and provides further reduction of CV outcomes in addition to other proven HF therapies, said Michael Böhm, MD, University of Saarlandes, Homburg, Germany. Heart rate is a modifiable risk factor, no longer a risk marker, in HF, stated Prof Böhm. Discharge HR predicts 1-year mortality, with a 41% increase with a HR ≥ 70 beats per minute (bpm; and a more marked increase in mortality with a HR ≥ 75 bpm). 3 According to data from the SHIFT study, every additional heart beat per minute increases the risk of CV death or HFH by 3%, and an extra 5 beats per minute increase the risk by 16%.4 Truly, said Prof Böhm, every beat matters, with HR predicting incident HF, as shown in the Rotterdam study, 5 outcomes in stable HF and post myocardial infarction (2-year reduction in life expectancy with HR > 90 bpm vs 70 bpm as shown in the DIAMOND study 6), and after hospital discharge (EVEREST study 7). In the SHIFT study of patients with stable HF, sinus rhythm, HR ≥ 70 bpm, and systolic dysfunction (ejection fraction < 35%), a step-wise increase in the risk of the primary composite outcome of CV death or HFH was found with increasing HR.4 A doubling of the risk was found with a baseline HR of 87 bpm versus 70 bpm. 4 What's New in the ESC Guidelines for Heart Failure A new clinical entity called HF with mid-range (40% to 49%) ejection fraction (HFmrEF) was introduced in the ESC guidelines for the treatment and management of HF,1 released in May 2016, to encourage further research into understanding the characteristics and treatment of HFmrEF, said Andrew Coats, MD, Monash University, Melbourne, Australia. The main treatment algorithm for symptomatic HF with reduced ejection fraction (HFrEF) has important new features, with a series of options for further optimizing treatment, after treatment with angiotensinconverting enzyme inhibitors (ACEI), ß-blockers, and mineralocorticoid receptor antagonists have been uptitrated to maximal levels. As shown in Figure 1, an angiotensin-receptor neprilysin inhibitor (ARNI) can replace an ACEI or angiotensin-receptor blocker (ARB; Class Ib) in patients with an elevated plasma natriuretic peptide level, and ivabradine can be used in patients who are in sinus rhythm with a HR remaining at ≥ 70 bpm. Also, patients in sinus rhythm with QRS duration > 130 msec may be evaluated for cardiac resynchronization therapy. Notably, Prof Coats stated these new choices are not mutually exclusive, and more than one can be undertaken for a patient. In fact, the ARNI sacubitril/valsartan and the HR-lowering agent ivabradine could have complementary effects that enhance outcomes in these patients. The guideline states ivabradine can be used in addition to ß-blockers (Class IIa) or when ß-blockers are contraindicated (Class IIa). The vulnerable phase of the patient journey after HFH, either de novo or for worsening HF, is recognized in the new guideline, highlighting the high risk of readmission during the transition phase and calling for optimization of pharmacotherapy and disease management processes. For the first time, specific recommendations are made for predischarge management, including initiating and uptitrating disease-modifying therapies and organizing care and follow-up after discharge; criteria for discharge and follow-up have also been established: * hemodynamic stability * euvolemia * stable renal function for ≥ 24 hours * evidence-based oral medication established ≥ 24 hours * provision of tailored education and advice for self-care The influence of comorbidities in HF is prominently recognized in the guidelines, acknowledging that they worsen HF through concomitant drug use, polypharmacy contributing to drug interactions, and reducing adherence to evidence-based therapies. This peer-reviewed article was based on scientific-clinical content presented at the ESC (European Society of Cardiology) Congress 2016. The content of this article was entirely developed by Content Ed Net Medicom, and the opinions expressed herein do not necessarily represent those of the European Society of Cardiology, nor of SERVIER. The development of this article was supported by SERVIER. This material is intended for educational purposes.

Table of Contents for the Digital Edition of ESC Congress 2016