ESC Congress 2016 - 15C

ADVERTORIAL Sponsored Session Highlights Table 1. Pre-Discharge Management and Criteria for Discharge Initiate and up-titrate disease-modifying pharmacological therapy Class Level Recommendations In case of worsening HFrEF, every attempt should be made to continue evidence-based, disease-modifying therapies in the absence of hemodynamic instability or contraindications. I C In the case of de novo HFrEF, every attempt should be made to initiate these therapies after hemodynamic stabilization I C HFrEF, heart failure with reduced ejection fraction. Reprinted from Ponikowski P et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail. 2016; 37:2129-2200. doi:10.1093/eurheartj/ehw128. By permission of John Wiley & Sons on behalf of the European Society of Cardiology. It is critical that early follow-up be scheduled prior to hospital discharge, with a general practitioner visit within one week and with the cardiologist within two weeks. Education for the patient and family must be provided. Established protocols and checklists enhance the delivery of discharge planning and post discharge care. Suggested components for structured discharge documents from the Optimize Heart Failure Care Program are shown in Figure 2. The use of checklists has been shown to reduce 30-day readmission by 69% and 6-month readmission by 46%.16 Optimizing Heart Rate Reduction The impact of an elevated HR (> 70 bpm) on mortality and HFH is clear. The EVEREST trial showed an association between post discharge HR and mortality, with an increased risk of 13% for every additional 15 bpm at Week 1 and 12% at Week 2.7 The SHIFT trial also showed that regardless of blood pressure level, reducing HR with the addition of ivabradine reduced CV death and HFH.17 Reducing HR also improves the ejection fraction, according to a meta-analysis of nine trials of ß-blocker therapy where HR was reduced to < 70 bpm, and this resulted in a lower risk of all-cause mortality.18 During the vulnerable phase of HF, a recent analysis by Komajda and colleagues showed that treatment with ivabradine resulted in a significant reduction in all-cause hospitalizations after a first HFH, with a significant 30% reduction at 1 month, 25% at 2 months, and 21% at 3 months (Figure 3).19 Research by Logeart and colleagues showed that discharge HR is a driver of mortality during the vulnerable phase.³ However, there is evidence that ß-blocker therapy alone may not be sufficient to achieve the required HR reductions to improve outcomes. Three registries of HF have shown about 55% of patients had a HR > 70 bpm, despite ß-blocker treatment in 80% of patients. Moreover, about 30% had a HR > 75 bpm, and about 20% had a HR > 80 bpm. This indicates that HR itself is independent of the ß-receptor, stated Prof Böhm. Further, an intrinsic regulation of HR has been suggested by a gene-dosing effect, where patients with more HR-associated loci had higher HRs; a genetic predisposition for a high HR has been identified by den Hoed and colleagues.20 Therefore, an approach to lowering HR that is independent of the ß-receptor and directly inhibits the activity of the sinus node, such as with ivabradine, may be beneficial in addition to ß-blockers, stated Prof. Böhm. As shown in the SHIFT trial, ivabradine reduced CV death and HFH by 18% in association with a HR reduction of 11 bpm versus 5 bpm with placebo.8 What is the optimal HR? A target of 50-60 bpm may be optimal, stated Prof Böhm. A 2-fold higher risk of CV death and HFH was associated with a HR > 70 bpm compared with a HR of 50-60 bpm in the SHIFT trial.⁴ Further, an adjusted analysis for the change in HR at 28 days showed that it was the HR itself that was responsible for the improved outcomes. Figure 3. SHIFT: Impact of Ivabradine on Repeat Hospitalizations During the Vulnerable Phase Figure 2. Optimize Heart Failure Care Program 1 Optimize before discharge *A USB key including slide data and interviews endorsing the rationale of the concept and tools for phamacological optimization *Examples of protocols for hospital discharge and patient follow-up 2 Pre- & post-hospital discharge checklist *A pre- and post hospital discharge checklist to complete at discharge and at the 2 early post-discharge follow-up visits as well *Summary checklist sticker 3 Patient education & follow-up *Two educational and follow-up tools are available for the patient: *MyHF smartphone application and the paper version *My Heart Failure Passport AF, atrial fibrillation; LAA, left atrial appendage; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; VKA, vitamin K antagonist. Reprinted from Komajda M et al. Efficacy and safety of ivabradine in patients with chronic systolic heart failure according to blood pressure level in SHIFT. Eur J of Heart Fail. 2014;16:810-816. By permission of John Wiley and Sons on behalf of the European Society of Cardiology. 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