Top Things to Know: 2022 Guidelines for the Management of Heart Failure

Aug 26, 2023

Top Things to Know: 2022 Guidelines for the Management of Heart Failure

American Heart Association Get With The Guidelines®-Heart Failure is excited to share that updated guidelines for the management of heart failure were released in 2022. Heart Failure (HF) remains a leading cause of morbidity and mortality globally and the 2022 HF Guidelines provide new recommendations and updates based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach for managing HF patients with a focus on improving quality of care. This webinar will feature Dr. Clyde Yancy and Dr. Gregg Fonarow.

Content

0.38 -> - Good afternoon and welcome.

2.2 -> My name is Kelly Macheska,

3.72 -> and I'm the national senior manager

5.46 -> of the Get With The Guidelines-Heart Failure program.

7.89 -> We would like to welcome you to today's webinar.

10.63 -> It's titled the Top Things to Know

12.35 -> for the 2022 Guidelines for the Management of Heart Failure.

16.29 -> Thank you all for attending.

18.5 -> Before we get started, I'd like to go over a few items

21.77 -> so you know how to participate in today's recorded webinar.

24.7 -> As you just heard, today will be recorded,

26.73 -> and we will be sending you out a link within 24 hours also.

31.09 -> There are slides and handouts for today's presentation,

34.1 -> and they can be downloaded.

36.11 -> They're on the right-hand side of your screen.

37.94 -> If you look down, it says Handouts

40.52 -> in the GoToWebinar Control Panel.

42.81 -> So you can see it over there.

44.82 -> All participants will be muted

46.5 -> to allow the speakers to present without interruption.

50.24 -> However, there will be a Q&A session

52.27 -> at the end of today's presentation,

54.42 -> and we can actively have a great discussion

57.33 -> related to the presentation.

59.55 -> You will have the opportunity

60.88 -> to submit text questions ahead of time

63.13 -> by typing them in the Questions Pane of the Control Panel.

66.87 -> You can send in those questions during the presentation,

69.61 -> and we will go ahead and pull those together,

72.25 -> that we can share in the active Q&A panel discussion.

76.55 -> If you would happen to have any technical issues

78.76 -> during the presentation,

80.44 -> most can be resolved by refreshing your browser.

82.76 -> If not, you can go to the GoToWebinar Customer Service Team,

86.54 -> and also we have Melissa Clarke on here.

89.12 -> So please just send a message in the chat,

90.86 -> and we'll try to help you in any way we can.

94.1 -> Now, without further ado, I'd like to introduce today

97.08 -> our esteemed speakers and champions for the webinar.

100.86 -> Dr. Clyde Yancy, he's the professor, chief of cardiology,

105.14 -> vice dean of diversity and inclusion

107.32 -> of Northwestern University Feinberg School of Medicine.

110.71 -> And Dr. Gregg Fonarow

112.24 -> is the professor of cardiovascular medicine and science

115.3 -> at UCLA.

116.61 -> He serves as the chief of UCLA's Division of Cardiology

120.93 -> and the director of the Cardiomyopathy Center

122.99 -> and co-director of UCLA's Preventative Cardiology Program.

127.25 -> Please see their full bios and their disclosures

130.62 -> that are included in the handout.

132.67 -> Both physicians have graciously shared their passion,

136.14 -> extensive expertise, and leadership

138.36 -> with the American Heart Association over the years,

140.54 -> and I'd like to thank them for that.

142.83 -> They both have served in a variety of roles

146.15 -> and leadership capacities

147.67 -> and have helped transform heart failure care.

150.08 -> So please give Dr. Yancy and Dr. Fonarow a warm welcome,

154.02 -> and I'm gonna turn it over to you guys, thank you.

159.15 -> - Great, so thank you so much.

161.48 -> If we could get this in presentation mode,

164.81 -> that would be awesome.

167.49 -> And then give me control, and we'll get started.

171.88 -> So Clyde and I have had that privilege

174.77 -> of actually serving on the guideline-writing group.

179.86 -> And so in April 1st of this year,

183.85 -> the 2022 AHA/ACC/HFSA guidelines

189.62 -> for the management of heart failure were released.

194.88 -> If I could get the next slide or be given control,

197.68 -> that would be awesome.

200.22 -> The citation for the guidelines

205.01 -> will come up shortly.

208.08 -> There we go.

209.86 -> Presentation mode would be great, if possible.

212.44 -> Here's the citation for the guidelines.

215.81 -> So we will be referring to those,

218.07 -> but you can find these online on circulation

221.83 -> in "Journal of American College of Cardiology,"

224.44 -> as well as the Heart Failure Society of America.

229.04 -> The guidelines themselves were chaired

232.8 -> by Paul Heidenreich for the writing group,

235.33 -> and vice chair was Biykem Bozkurt,

238.47 -> Slides aren't advancing for me,

240.31 -> so if we could- - Did you try clicking...

243.23 -> I'm sorry, Dr. Fonarow.

244.35 -> Did you try clicking twice

246.09 -> to see if that helps you gain control of the screen.

249.51 -> - Yeah, there may be a lag.

251.07 -> We're still not in

252.013 -> presentation mode though. - Okay, I can-

253.64 -> - Showing this (audio skips) view.

255.98 -> So if you wanna take control and advance,

257.88 -> that'd be probably good at this moment.

263.66 -> Okay, so here's the writing committee members

266.64 -> that you can see here.

268.25 -> And as mentioned, Clyde and I had the privilege

270.82 -> of serving on this group.

272.36 -> So, next slide.

276.878 -> (person speaking faintly)

278.73 -> So we're gonna go through the nuts and the bolts

280.7 -> of heart failure care.

282.36 -> So, the next slide.

285.1 -> Importantly, the guidelines built upon

289.27 -> the staging system

293.09 -> for heart failure.

295.33 -> And the previous Stage A, B, C, and D

301.14 -> were slightly modified.

305.21 -> And recognizing...

307.14 -> If we could get the next slide, that would be great.

309.62 -> There we go.

310.76 -> So Stage A remains the same,

313.53 -> but now referred to, at-risk for heart failure.

315.747 -> And these are individuals with risk factors

318.08 -> for heart failure

319.23 -> but who do not have structural abnormalities

321.46 -> and never have heart failure symptoms,

323.66 -> but recognizing there are risk factors

325.67 -> in heart failure can be prevented: hypertension,

328.5 -> atherosclerotic cardiovascular disease, diabetes.

331.3 -> Next.

333.43 -> Stage B are those that are with structural abnormalities,

338.44 -> but now referred to as pre-heart failure.

342.25 -> Individuals also at elevated natriuretic peptide levels,

346.27 -> but again, no symptoms, also in this Stage B.

350.19 -> Next, Stage C is those patients

353.37 -> with current/prior symptoms of heart failure.

355.287 -> And as we'll talk about,

356.47 -> they can encompass the full range of ejection fractions.

360.17 -> Next.

361.16 -> Stage D are those patients

363.3 -> with advanced refractory symptoms,

365.92 -> now referred to as advanced heart failure.

370.47 -> Click again, and you can see that in Stage C heart failure,

374.13 -> we now recognize the trajectories,

376.28 -> that there will be those patients

377.64 -> with new onset or de novo heart failure;

380.27 -> some patients that in response

381.9 -> to guideline-directed medical therapy

383.79 -> will have resolution of symptoms,

386.68 -> those patients are not referred to

390.35 -> as having remission of heart failure,

394.457 -> but really need to be carefully considered

397.41 -> and guideline-directed medical therapy continued;

400.32 -> those with persistent heart failure

401.857 -> and those where things progress

403.63 -> and have worsened heart failure.

405.15 -> So the trajectory is very important here.

407.52 -> Next slide, please.

410.71 -> The diagnostic algorithm very much utilizes

415.63 -> clinical diagnosis of heart failure assessment.

419.33 -> Natriuretic peptides are important, echocardiography.

422.89 -> Next.

424.24 -> Importantly, classification of heart failure

426.88 -> once the diagnosis is confirmed

429.06 -> still utilizes ejection fraction.

431.52 -> So it's important to determine the cause and classify,

434.36 -> evaluate for precipitating factors, initiate treatment,

438.12 -> and perform serial assessment.

439.77 -> Next.

440.75 -> And what you can see builds here is, with ejection fraction,

444.52 -> that classification is heart failure

447.07 -> with reduced ejection fraction 40% or below.

450.34 -> Next.

451.173 -> The medical category

452.31 -> that previously was considered mid-range

454.53 -> is now referred to as heart failure with mildly reduced

457.24 -> but still defined as EF 41 to 49,

460.37 -> next, and heart failure preserved EF, EF 50% or above.

464.82 -> But importantly, and especially

466.78 -> in response to medical therapy,

468.38 -> there can be improvements in ejection fraction.

470.97 -> So we now have that group of patients

473.12 -> that are still categorized as heart failure, reduced EF,

476.81 -> but where their EF is now above 40%.

479.6 -> And this is a group where it is critically important

482.35 -> to maintain guideline-directed medical therapy.

486.01 -> So this classification by EF, you'll see,

489.05 -> will be critically important for the specific medications

492.7 -> that are recommended for the patient population.

495.67 -> Next slide.

496.89 -> So from our diagnosis and classification, of course,

501.43 -> that clinical diagnosis, critically important,

504.08 -> and thus there's a Class 1 recommendation

506.35 -> regarding a complete history and physical exam,

509.79 -> with tips here, especially with focus on identifying

513.1 -> cardiac and non-cardiac diseases that may contribute.

516.73 -> Also, evaluation of social determinants of health

519.84 -> is important.

520.87 -> Class 1 recommendations for laboratory and ECG testing,

524.71 -> including CBC and other critically important labs,

528.66 -> 12-lead EKG consideration and morphology,

532.81 -> as well as QRS duration, as well as rhythm.

536.12 -> And then for patients presenting with heart failure,

538.45 -> the specific cause of heart failure should be explored

541.83 -> with additional laboratory testing

544.13 -> for appropriate management.

545.6 -> Next, please.

549.65 -> Now, there is, for evaluation of patients with dyspnea,

554.476 -> natriuretic peptides have a recommendation,

557.94 -> being useful to support a diagnosis

560.21 -> or help exclude heart failure.

562.56 -> For individuals at risk for heart failure,

564.64 -> there is a recommendation at the 2a level

567.15 -> for natriuretic peptides

569.04 -> as a way of screening those at increased risk,

571.53 -> and then guide referral to a cardiovascular specialist

575.03 -> to then assist with risk factor modification

577.59 -> and treatment to prevent heart failure.

579.69 -> Hospitalized patients for risk stratification and diagnosis,

584.19 -> there were recommendations,

585.55 -> and likewise in chronic heart failure.

587.66 -> But what you'll not see is recommendations

590.12 -> around serial testing for natriuretic peptides,

593.4 -> since clinical trials have not demonstrated improvement

596.65 -> in outcome with that.

597.96 -> And there are reminders about potential non-cardiac causes

601.16 -> for elevated natriuretic peptides.

603.1 -> Next slide.

606.42 -> With regards to cardiac imaging,

608.43 -> there's specific recommendations

610.19 -> regarding chest X-ray, transthoracic echocardiography,

615.48 -> in select patients, the use of cardiac CT, MRI,

619.72 -> SPECT and PET.

621.18 -> Ischemia evaluation gets a 2a recommendation.

624.98 -> And then it's important, you know,

626.69 -> in the absence of any clinical status change

631.72 -> or being considered for additional procedures or otherwise,

636.31 -> routine serial echocardiography is not recommended.

640.27 -> There needs to be specific reasons.

642.47 -> Next slide.

646.34 -> As we look at the invasive evaluation of patients,

649.23 -> invasive hemodynamics,

651.68 -> there's a recommendation at a 2a level

654.47 -> for select patients with persistent or worsening symptoms

658.89 -> in whom where hemodynamics are uncertain.

661.8 -> Invasive hemodynamic monitoring may be useful

665.08 -> to guide management, but routine use not recommended,

668.63 -> and also recommendations for endomyocardial biopsy.

671.58 -> Next slide.

674.76 -> Now, importantly, the treatment

676.43 -> for Stage C and D heart failure

679.37 -> has really undergone substantial evolution here.

683.23 -> And most important,

684.22 -> moving beyond triple therapy is now the SGLT2 inhibitors,

688.72 -> our heart failure with reduced EF

690.75 -> getting a Class 1 recommendation.

693.3 -> Another important change is the recommendation

695.98 -> to start with sacubitril/valsartan,

698.8 -> the angiotensin receptor-neprilysin inhibitor

701.685 -> preferentially over an ACE inhibitor or ARB,

704.82 -> and concomitant use of beta blocker and MRA therapy

709.67 -> after having a diagnosis

711.29 -> and confirming an EF of 40% or below.

714.37 -> Guidelines actually recommend

716.23 -> trying to start these therapies early

718.31 -> and as soon as possible in stabilized patients.

721.94 -> They do not specify the exact order or sequence

725.71 -> that they'd be initiated.

726.74 -> In some patients, at low dose,

728.8 -> starting all at once may be appropriate.

731.24 -> In others, a serial strategy can be utilized.

734.54 -> That exact ordering is left

736.9 -> to individual clinician judgment.

741.345 -> Loop diuretics have Class 1 recommendation,

743.69 -> but as needed to manage volume overload.

746.37 -> So this is the top-line therapy, quadruple therapy,

749.44 -> all eligible patients without contraindications

752.3 -> with heart failure, with reduced EF.

754.5 -> Next, you can see that building upon this,

757.91 -> we need to then up-titrate to target dosing,

761.73 -> and once achieving that,

763.56 -> to then reassess ventricular function

765.85 -> and then make further determination.

767.81 -> So throughout the management

769.51 -> and trajectory of these patients,

770.84 -> we wanna continue guideline-directed medical therapy,

773.79 -> have serial reassessment,

775.3 -> and optimize dosing adherence and patient education.

778.55 -> Next, we can see building upon this, though,

781.82 -> there are additional therapies that may be considered

784.48 -> based on specific patient phenotype or characteristics,

788.03 -> based on their New York Heart Class and other factors.

791.63 -> And then we can consider things like hydralazine nitrates,

794.78 -> ICD and CRT, all with Class 1 recommendations,

798.33 -> but in very select patients.

800.26 -> And then further consider, next,

802.6 -> select therapies for patients.

805.02 -> And importantly, patients who remain refractory,

808.06 -> then, next, we need to consider the more advanced therapies,

813.51 -> or palliative care if considered.

816.14 -> So this outlines the foundation

818.62 -> in a management of Stage C and D heart failure

821.42 -> with reduced ejection fraction.

823.11 -> Next slide.

826.49 -> So to emphasize, there are now four major classes of therapy

831.36 -> that get the Class 1 recommendation,

834.14 -> can refer to these as foundational medical therapies

837.26 -> for heart failure, reduced EF,

839.09 -> can refer to them as the four pillars of heart failure,

842.76 -> medications for heart failure, reduced EF,

845.44 -> can refer to them

846.58 -> as comprehensive disease-modifying medical therapy.

849.54 -> But these are now the national standard of care

852.37 -> with a Class 1 level of evidence recommendation for each.

857.31 -> So, sacubitril/valsartan recommended

859.58 -> to reduce morbidity and mortality,

861.35 -> one of the three evidence-based beta blockers;

864.02 -> MRA, as long as renal function is meeting the criteria

868.28 -> as specified in no hyperkalemia.

871.55 -> And importantly, this new recommendation,

873.77 -> symptomatic chronic heart failure, reduced EF,

876.84 -> SGLT2 inhibitor recommended to reduce hospitalization

880.41 -> for heart failure and cardiovascular mortality,

882.35 -> and importantly,

883.92 -> irrespective of the presence or absence of type 2 diabetes,

887.453 -> that is a fundamental heart failure,

889.42 -> reduced ejection fraction treatment.

891.54 -> Next slide.

894.73 -> So if we look at the additional therapies

897.17 -> that may be considered after you optimize

899.53 -> the foundational guideline-directed medical therapy,

902.76 -> ivabradine gets a 2a recommendation;

904.81 -> vericiguat, a new 2b recommendation;

907.481 -> digoxin, omega-3 fatty acids,

910.62 -> and then potassium binders for managing hyperkalemia

914.37 -> at a 2b recommendation,

916.23 -> so these additional therapies that may be considered.

919.06 -> None of these, however,

920.67 -> are recognized as foundational therapies

923.23 -> that would be routinely applied as the quadruple therapy

927.42 -> that I reviewed with you.

929.4 -> Next slide.

934.21 -> Now, there are specific recommendations

936.38 -> regarding cardiac resynchronization therapy.

938.86 -> These are very much in line with what previously exists

942.11 -> in the guidelines.

942.943 -> What is critically important,

944.18 -> the emphasis with regards to optimizing

948.1 -> guideline-directed medical therapy

950.01 -> being very important for these patients.

952.95 -> And so the general health status,

955.26 -> evaluation of comorbidities

956.93 -> such that there's nothing that's gonna limit survival

959.68 -> to less than one year from a non-cardiovascular comorbidity,

964.36 -> the guideline-directed medical therapy should be continued,

967.19 -> next slide, across the board here.

970.36 -> So in those patients where that EF meets a specification,

975.49 -> we can consider the therapies

979.24 -> for these patients.

980.66 -> Next slide.

983.72 -> So mainly the Class 1 recommendation

986.38 -> is Class II to ambulatory Class IV heart failure

989.69 -> with left bundle branch block, QRS 150 and above,

992.93 -> CRT being now recommended.

994.69 -> And then there's some 2a and 2b-level recommendations.

998.36 -> Next slide.

1001.3 -> So there are some special circumstances to consider

1004.73 -> that are highlighted here, next slide,

1008.93 -> and for EFs 36 to 50 only,

1012.2 -> if there's high-degree or complete heart block

1014.22 -> at a 2a level with CRT recommended.

1016.61 -> Next.

1018.1 -> So these are the recommendations regarding CRT.

1021.47 -> There are additional therapies that may be considered,

1024.37 -> so surgical revascularization in patients

1027.51 -> that meet the criteria specified here,

1030.54 -> severe secondary MR, that critically,

1034.06 -> after optimization of guideline-directed medical therapy,

1038.04 -> can consider then edge-to-edge device repair

1042.09 -> in these patients;

1043.39 -> and then for those patients with New York Heart Class III,

1048.12 -> history of hospitalization for heart failure

1050.15 -> or elevated natriuretic peptide levels,

1052.67 -> wireless PA pressure monitoring at a 2b level.

1055.92 -> Next slide.

1060.21 -> With regards to the approach to treatment of secondary MR,

1063.33 -> the guidelines really emphasize, critically important,

1066.69 -> guideline-directed medical therapy,

1068.55 -> optimized and supervised by a heart failure specialist,

1072.13 -> before considering a secondary MR intervention.

1076.97 -> Patients undergoing CABG may be considered

1079.77 -> at that time, next slide,

1080.98 -> but if meeting all these criteria

1082.96 -> and very consistent with the valve guidelines

1086.2 -> that then patients may be considered

1088.8 -> for edge-to-edge repair.

1090.06 -> Click again for me.

1092.65 -> And you can see here, then the EF less than 50%,

1095.92 -> persistent symptoms despite optimization,

1099.17 -> and then can consider the interventions.

1102.89 -> Next slide.

1106.67 -> So here, if yes, that edge-to-edge repair at a 2a level.

1111.38 -> Okay, next.

1113.44 -> So what about patients with mildly reduced LEVF?

1117.36 -> We now have specific recommendations for them.

1120.5 -> So these are the mildly reduced with EFs 41 to 49,

1124.28 -> symptomatic heart failure, diuretics as needed,

1126.73 -> but here, an important 2a recommendation

1129.7 -> for the SGLT2 inhibitor.

1131.91 -> So this is really critically important.

1134.8 -> So patients now have a specific therapy recommended

1138.49 -> to reduce cardiovascular death, heart failure,

1140.97 -> hospitalization for heart failure

1142.6 -> with mildly reduced ejection fraction.

1145.05 -> At the 2a level, that is the only med recommendation.

1148.96 -> At 2b level, ACE, ARB,

1152.13 -> or sacubitril/valsartan, MRA,

1154.98 -> and in specific circumstances, evidence-based beta blockers.

1158.92 -> So really important for this patient population,

1162.51 -> and we want to prevent these patients from,

1167.36 -> you know, progressing, and reduce events.

1170.05 -> Very importantly, though, I wanna emphasize,

1172.58 -> as it is on this slide,

1174.12 -> for those where the EF started off 40 or below

1178.18 -> and is now improved,

1179.98 -> those patients need to continue on the full contingent

1183.24 -> of guideline-directed medical therapy.

1185.16 -> That's a Class 1 recommendation.

1187.5 -> Next slide.

1189.52 -> For patients with heart failure, preserved EF, shown here,

1192.77 -> so these are symptomatic heart failure,

1194.6 -> EF 50% or above, diuretics as needed.

1197.58 -> And here again, the 2a recommendation

1199.977 -> for the SGLT2 inhibitors

1202.41 -> and recommendations for sacubitril/valsartan;

1205.046 -> at 2a, MRA or ARB.

1207.79 -> So we really have now specific medication recommendations

1211.29 -> for the patient population,

1212.65 -> really importantly, at a 2a level,

1215.29 -> a recommendation for SGLT2 inhibitors,

1217.29 -> given the really important findings

1219.93 -> from the EMPEROR-Preserved trial

1221.96 -> So really, you know, landmark and breakthrough

1224.67 -> to now have specific medication recommendations

1227.905 -> at the 2a level or higher

1230.55 -> for those with mildly reduced

1232.43 -> and preserved ejection fraction heart failure.

1235.08 -> Next slide.

1238.17 -> So with that, let me now turn it over to Clyde,

1241.01 -> who's gonna take us through

1241.843 -> the adjunctive therapies, comorbidities,

1244.58 -> and the acute decompensated heart failure patient.

1247.49 -> So Clyde, let me turn it over to you.

1250.47 -> - Gregg, thank you very much.

1251.78 -> I hope everyone can hear me without difficulty,

1254.06 -> and terrific job bringing us through the nuts and bolts

1256.85 -> in the treatment of heart failure

1258.55 -> and reviewing the setup

1259.65 -> of the new AHA/ACC/HFSA

1264.13 -> heart failure clinical practice guidelines.

1266.71 -> You know, repetition is the best way of learning,

1268.88 -> and let me just highlight some things that I hope

1270.79 -> what is now about 700 attendees

1273.58 -> will take away from the brilliant information

1275.57 -> Gregg just transferred to you.

1277.72 -> Start with where he ended.

1279.51 -> We now have this new phenotype of heart failure

1281.78 -> with improved ejection fraction.

1284.02 -> That is for the good.

1284.95 -> We need to keep that in mind as we go forward.

1287.74 -> Also, think about the definitions of heart failure,

1291.74 -> the partitioning of the ejection fraction,

1293.96 -> what we understand now about the patients we see

1296.23 -> and how we approach them.

1298.15 -> Emphasize, emphasize, emphasize

1300.35 -> the importance of foundational quadruple therapy.

1303.76 -> This is not just phraseology.

1305.67 -> We now have very effective therapies,

1308.21 -> all of which benefit patients and improve outcomes.

1312.05 -> And in aggregate,

1313.48 -> we have any number of data sets now to tell us

1316.34 -> that our patients can do better with heart failure

1318.95 -> than they've ever done before.

1321.87 -> Collectively between the two of us,

1323.52 -> we have over six decades invested in heart failure care,

1327.1 -> and it's never been as good as it is right now.

1328.73 -> And so this is great information for you to digest

1331.72 -> and move forward.

1332.82 -> And finally, realize that these guidelines

1335.22 -> were developed directly with patient input,

1338.99 -> specific with patient participants,

1342.28 -> as part of the guideline-writing committee.

1343.9 -> So I think you should know this

1346.06 -> and recognize the uniqueness of this guideline statement.

1349.5 -> Let me extend these conversations further

1352.27 -> by discussing adjunctive therapies, important comorbidities,

1355.65 -> and then hospitalized heart failure

1357.67 -> to give you the complete picture

1359.73 -> as it appears in these guidelines.

1361.9 -> The first thing I'll deal with

1363.51 -> is a very important comorbidity,

1365.98 -> which is cardiac amyloidosis.

1368.69 -> It oftentimes presents

1370.43 -> as if the patient has conventional heart failure,

1373.98 -> but it takes an index of suspicion

1377.01 -> to understand the necessity,

1378.58 -> to look for what we call TTR cardiac amyloid.

1382.76 -> The algorithm is developed for you on the screen.

1385.9 -> I won't dwell much,

1387.07 -> but I will tell you that this is not an orphan illness.

1390.2 -> Every major activity

1393.05 -> that is referral practice for heart failure

1396.29 -> has a representation of a patient cohort

1398.8 -> with cardiac amyloidosis, particularly TTR,

1402 -> it starts with a suggestive history.

1403.9 -> One takeaway: bilateral carpal tunnel syndrome,

1407.41 -> think very carefully about obtaining

1410.71 -> a light chain assessment

1412.25 -> to see if there might be reason or rationale

1414.72 -> to go forward with a study

1416.79 -> for the evidence of cardiac amyloid,

1419.67 -> specifically a technetium pyrophosphate scan,

1422.77 -> quickly involving hematology, oncology,

1424.8 -> especially if the scan is negative

1426.16 -> but the light chains are positive,

1427.85 -> making the verification between AL amyloidosis

1431.327 -> and TTR amyloidosis.

1434.18 -> We do have an effective therapy for amyloidosis

1437.16 -> as depicted on the screen, as you see it.

1439.69 -> That is specifically tafamidis.

1441.84 -> It is of low economic value.

1444.85 -> That's not to say that it's not effective.

1446.78 -> It does change the natural history,

1448.7 -> but value as a function of cost and benefit

1452.17 -> unfortunately weighs more towards low value

1454.73 -> because of what continues to be a very high-cost profile.

1459.32 -> But if we're able to identify the likelihood of TTR amyloid,

1463.36 -> again, based on the history, the light chains,

1466.72 -> the demonstrable light chains, and a positive scan,

1469.87 -> then we should go forward

1471.13 -> and understand TTR gene sequencing.

1474.14 -> This helps us understand if it's wild type,

1476.16 -> or if it's mutant,

1477.38 -> and we can then advise the family members.

1479.82 -> This elegant algorithm is embedded within the guideline set.

1484.2 -> You should be able to download it

1485.4 -> from the right side of your screen,

1486.86 -> as Kelly mentioned earlier.

1488.39 -> But this is worthy information.

1490.07 -> And tafamidis is only the first

1492.23 -> of therapies targeting amyloidosis.

1495.36 -> Tafamidis prevents the misfolding.

1497.85 -> Future therapies will silence the production of amyloid

1501.47 -> at the level of RNA.

1502.91 -> Exciting times in science,

1504.83 -> and certainly exciting times for patients

1506.74 -> that have a condition that previously was untreatable.

1510.66 -> Let's go beyond

1511.71 -> that one particular concomitant other illness

1514.61 -> and think about the patients with advanced heart failure.

1517.77 -> For some for some number of years now,

1520.74 -> we introduced different iterations

1523.35 -> of this very important patient-centric algorithm,

1526.2 -> I-Need-Help.

1529.52 -> If you deconstruct the algorithm,

1531.64 -> you can see how important each letter needs to be,

1534.88 -> as each letter serves independently

1537.97 -> as a prompt for consideration of referral

1540.09 -> to advanced heart failure.

1541.93 -> These guidelines endorse once again

1543.7 -> the importance of this patient-centric algorithm,

1546.67 -> I-Need-Help.

1550.47 -> Let me also share with you

1551.84 -> that this guideline really exercised

1555.23 -> a rigorous review of available evidence.

1557.82 -> Why do I say that?

1559.16 -> Because for two things that are incredibly important,

1562.33 -> one is sodium restriction,

1564.02 -> and the other is fluid restriction,

1566.05 -> we realized that after decades of advocating

1568.66 -> the importance of both of these lifestyle adjustments,

1572.43 -> we have very little data

1573.67 -> to say they actually change the natural history.

1576.13 -> The most impressive data on sodium was just released

1579.24 -> by Justin Ezekowitz and colleagues in the SODIUM-HF trial.

1583.2 -> The clinical outcome

1584.24 -> on mortality and hospitalization was null,

1586.93 -> but the benefit on quality of life was modestly important.

1591.46 -> This does not mean that we should liberalize salt intake,

1594.3 -> but it demonstrates how difficult it is

1596.25 -> to do this kind of lifestyle-based research.

1599.72 -> We are unable, let me say this again,

1602.25 -> we're unable to specify

1604.66 -> the extent to which salt restriction should occur,

1607.84 -> but clinical judgment should prevail.

1609.95 -> By the same token, we're unable to be clear

1613.83 -> on the exact amount of fluid restriction.

1615.73 -> No patient should be allowed to go thirsty,

1618.07 -> but we should understand

1618.996 -> that hyponatremia is a major problem.

1621.39 -> In previous guidelines, we've advocated use

1623.86 -> of the vasopressin antagonists,

1625.44 -> and that may be something that you want to consider.

1629.1 -> What about patients hospitalized

1630.72 -> with decompensated heart failure?

1632.95 -> This is vitally important.

1634.71 -> Dr. Fonarow and I will tell you that the events

1636.97 -> are still well over 1 million episodes per year.

1640.11 -> It's critical that the evaluation include

1642.55 -> a search for precipitating factors,

1644.96 -> understanding the severity of congestion,

1647.14 -> and identifying the adequacy of perfusion,

1649.02 -> if you will, a good bedside exam.

1650.83 -> Did you feel the extremities? Did you check for edema?

1653.59 -> Did you raise questions about belt marks?

1655.81 -> Did you raise questions about sacral edema,

1658.19 -> for those that are lying down or seated all the time?

1661.03 -> What are your goals of care?

1662.48 -> How many times did we have this conversation?

1665.1 -> What are your goals of care,

1666.21 -> not just end of life, but upon admission?

1669.13 -> Optimize the volume status.

1670.99 -> Address the reversible factors.

1673.08 -> And critically important,

1674.37 -> continue or initiate guideline-directed medical therapy.

1678.06 -> You should know that amongst the quadruple platform

1681.03 -> that Dr. Fonarow advocated, we have precise evidence

1684.62 -> that the earlier those drugs are instituted, the better.

1688.04 -> The lines of distinction in the clinical trials

1691.16 -> began to deviate within the first 30 days.

1694.32 -> And so the hospitalization environment is an excellent place

1698.01 -> to consider initiating quadruple therapy,

1701.07 -> if not already in place.

1702.97 -> What are the usual factors

1704.05 -> precipitating heart failure and hospitalization?

1706.34 -> Well, the guideline becomes a primer

1708.24 -> and tells you what kinds of things to suspect.

1710.91 -> Frequently, at my own clinical practice,

1712.67 -> as I remain clinically active, just like Dr. Fonarow,

1715.7 -> we see a acute coronary syndromes.

1717.3 -> We see atrial fibrillation.

1718.73 -> We especially see valvular heart disease.

1721.07 -> These are important considerations

1722.99 -> for your understanding and appreciation

1725.82 -> as you're managing these patients.

1727.85 -> What is a decongestion strategy?

1729.83 -> Well, first, what do you monitor?

1731.72 -> Daily weights have always been important, but beyond that,

1734.99 -> we need to pay careful attention to renal function,

1737.98 -> electrolytes, and clinical evidence of hypoperfusion.

1742.54 -> How do we do this?

1744.16 -> Almost invariably it's with loop diuretics,

1746.42 -> unless we're already dealing with

1747.62 -> renal replacement strategies.

1750.93 -> What are the ways in which we do this?

1753.4 -> This is a key consideration,

1755.05 -> and I'm delighted that we were able to place this

1756.95 -> in the guidelines.

1758.87 -> Take the daily loop diuretic dose, double it,

1762.06 -> and make that the initial IV loop diuretic dose.

1764.91 -> This is evidence-based

1766.63 -> from the Heart Failure Clinical Trials Research Network.

1770.06 -> If we go beyond that,

1771.68 -> then we begin to think about sequential nephron blockade,

1774.6 -> which is a thiazide loop diuretic.

1777.61 -> That is a thiazide plus a loop diuretic

1779.81 -> and/or a continuous infusion of loop diuretics,

1782.94 -> a frequent strategy we employ

1784.58 -> in our critical care unit here.

1786.83 -> The addition of an MRA can add to diuresis

1790.34 -> independently of the life-sustaining effect.

1793.79 -> And then sometimes the adjunctive administration

1796.23 -> of low-dose dopamine,

1797.85 -> you can see by color scale, not as highly regarded,

1800.95 -> is a plausible consideration.

1803.87 -> At the time of discharge,

1805.15 -> it's very important to offer diuretic flexibility.

1808.89 -> Let me reiterate something very important.

1811.89 -> Diuretics have never been shown

1813.8 -> to change the natural history of heart failure.

1815.75 -> This is for decongestion and for patient comfort.

1819.07 -> They do threaten renal function.

1820.81 -> So having a flexible strategy

1822.41 -> that allows us to deescalate diuretics

1825.02 -> is incredibly important.

1827.68 -> What about guideline-directed medical therapy

1829.59 -> during hospitalization?

1831.44 -> Admission, as I've already identified;

1834.09 -> during the inpatient process,

1835.939 -> understanding there may be some mild reduction

1839.02 -> in renal function.

1839.853 -> Please don't call this AKI.

1842.36 -> Please recognize that it's highly variable.

1844.55 -> If it's a significant change, that's important,

1847.01 -> but we expect to see some fluctuation.

1849.46 -> But then pre-discharge,

1850.93 -> make certain the diuretics have been reestablished

1853.6 -> as necessary to maintain a euvolemic state and are working

1857.73 -> in concert with guideline-directed medical therapy.

1860.87 -> You see the four Class 1 recommendations

1864.92 -> of the leveled evidence A

1866.91 -> for the use of the foundational therapies.

1868.91 -> We can't reiterate that enough.

1871.13 -> An appropriate diuretic regimen

1873.18 -> on the backdrop of quadruple therapy is state of the art

1877.19 -> for the treatment of heart failure.

1880.33 -> What about transitions of care?

1882.02 -> We've realized this is where we've lost many patients.

1884.957 -> And so this should include early follow-up,

1887.55 -> evidence-based within seven days.

1889.41 -> That can be a phone call if necessary.

1891.23 -> A multidisciplinary heart failure management program

1894.62 -> should be an active process.

1898.2 -> It's a Class 1 recommendation.

1900.69 -> Not always available in every center,

1902.77 -> and different iterations may qualify

1905.26 -> as a multidisciplinary heart failure management program,

1908.17 -> but it's a Class 1 recommendation.

1910.4 -> Class 2a is to participate in benchmarking programs

1914.45 -> that identify quality of care.

1916.67 -> The others you can see there for your perusal.

1920.96 -> What are the additional therapies

1922.46 -> in patients with heart failure and comorbidities?

1924.98 -> Almost invariably, this is the thought process

1927.27 -> for that hospitalized patient.

1929.27 -> What about when concomitant hypertension is present?

1931.85 -> What about when type 2 diabetes is present?

1934.52 -> What about the patients that have reduced EF heart failure

1937.24 -> and suitable coronary anatomy?

1939.51 -> What about those that have valvular heart disease?

1943.41 -> What about those that have obstructive sleep apnea?

1947.03 -> What about those that have atrial fibrillation?

1949.77 -> There are a variety of opportunities

1952.96 -> to change the natural history of our patients

1955.6 -> by paying careful attention

1957.45 -> to their concomitant comorbidities.

1959.42 -> Let me speak even more explicitly.

1961.71 -> There are 10 additional therapies depicted on this graphic

1966.75 -> for different clinical representations

1970.03 -> that are common in everyday practice.

1972.357 -> And so we should all be as facile

1974.83 -> with these 10 guideline-directed steps,

1978.22 -> five of which are Class 1, five of which are Class 2a,

1982.49 -> for the purposes of improving the natural history

1985.36 -> of our patients with heart failure.

1989.08 -> What about managing those comorbidities?

1991.16 -> Do recognize the importance of identifying iron deficiency,

1995.54 -> understanding the importance of hypertension;

1997.93 -> management of sleep disorders, if for no other reason

2000.23 -> than it improves sleep architecture and rest;

2002.7 -> and management of diabetes,

2003.86 -> particularly with the SGLT2 inhibitors available.

2008.28 -> What about atrial fibrillation?

2009.63 -> This is team medicine, team management.

2013.09 -> So quickly incorporate your peers in electrophysiology.

2016.61 -> But there are two Class 1 recommendations,

2019.49 -> predominantly for the use of anticoagulant therapy.

2022.74 -> Another conversation, both Dr. Fonarow and I can tell you

2026.48 -> with great certainty that this is still a recommendation

2029.51 -> for which there is failure to see adequate adherence.

2033.98 -> And unfortunately, that adherence is many times

2035.96 -> a function of age, a function of sex, a function of race.

2040.5 -> And so please recognize the importance of anticoagulation

2043.28 -> in those with atrial fibrillation.

2045.32 -> You can see the 2a recommendations here as well.

2049.83 -> This is a part of a guideline for which I am quite enthused.

2055.12 -> We've not ever before been able

2058.4 -> to incorporate value statements

2060.92 -> in a clinical practice guideline.

2062.69 -> This heart failure guideline is the first iteration

2065.91 -> of this new model.

2066.87 -> I briefly mentioned in the conversation about tafamidis

2070.01 -> that value was the relationship

2071.86 -> between the clinical benefit and cost.

2074.13 -> Obviously, some things will have a very high value.

2077.64 -> Others will have an intermediate value,

2080.12 -> and others will have a low value.

2081.93 -> Tafamidis is the prototype for low value.

2084.65 -> What about intermediate value?

2086.08 -> Well, it turns out the SGLT2 inhibitor falls in that space.

2089.49 -> Still proprietary, prices are still high.

2092.91 -> It's important for us to work carefully

2095.45 -> with all the resources available

2097.04 -> to make this drug available.

2098.85 -> But the value statement is at intermediate value.

2101.69 -> The benefits are unquestioned. Cost is a concern.

2104.79 -> But for all the other therapies

2106.45 -> that are particularly a part of quadruple therapy,

2109.17 -> the value statement indicates a high value.

2112.27 -> And this oftentimes is necessary

2114.19 -> when we are appealing questions of cost

2116.46 -> with third-party carriers.

2118.53 -> This is another space

2119.65 -> for which I think we've done an incredible job

2122.78 -> in the generation of the clinical practice guidelines.

2125.187 -> But first, we've talked about the vulnerable populations.

2129.05 -> When you go through the vulnerable populations,

2131.19 -> it goes beyond the prototypical populations

2135 -> identified as a function of race or ethnicity.

2136.93 -> What about persons with movement disorders?

2139.6 -> What about persons in the LGBTQI categories?

2143.35 -> What about patients that are transgender?

2146.05 -> There are an increasing number of patients

2148.23 -> that represent a broad diversity

2150.43 -> of those who have cardiovascular disease,

2152.68 -> including heart failure.

2153.563 -> There's a Class 1 recommendation

2155.07 -> to be fully aware of the diversity of our patient cohort

2158.89 -> and a Class 1 recommendation

2160.79 -> to seek evidence of health disparities,

2162.75 -> monitor that evidence and move forward.

2165.73 -> Certainly, if this question comes up in our Q&A,

2168.21 -> there's new information I can give you

2170.09 -> about strategies to help mitigate disparities.

2174.08 -> Performance measures, Dr. Fonarow and I were co-authors

2177.85 -> of the foregoing heart failure performance measures document

2182.01 -> that now has been incorporated

2183.18 -> into the clinical practice guidelines.

2185.47 -> These are the measures

2186.81 -> against which your hospital's quality of care

2189.72 -> for heart failure will be judged.

2191.69 -> So all of you, as representatives of your hospital,

2194.96 -> should be facile with these performance measures.

2199.6 -> What are the goals of care?

2200.54 -> You've heard this word before,

2201.88 -> but this particularly looks at the back end.

2204.32 -> The first was upon admission to the hospital.

2207.23 -> But looking at patients that have more advanced disease

2210.33 -> and realizing that these are necessary,

2212.88 -> even obligatory conversations,

2215.01 -> the guidelines give you a template

2217.71 -> for how do you approach goals of care,

2219.77 -> what are the important conversations that you should host.

2223.05 -> Patient-reported outcomes, we were ecstatic

2226.2 -> in the development of the performance measures

2227.94 -> that for the first time we could bring forward,

2230.6 -> as a measurable performance measure,

2233.01 -> a better-calibrated and a more specific assessment

2236.8 -> of patient-reported outcomes.

2238.47 -> We are specifically making reference

2240.67 -> to using the KCCQ enterprise or instrument.

2245.65 -> This is in addition to your NYHA classification.

2248.97 -> But it gives us an opportunity to start with NYHA class

2252.74 -> and extend as necessary.

2254.44 -> There's brilliant information

2255.82 -> within the heart failure with preserved EF space

2258.99 -> that we can use the KCCQ

2261.47 -> to not only study the symptom burden

2264.8 -> but also to gauge the response to medical therapy.

2267.83 -> So this is a new aspect of heart failure care

2269.81 -> that should be incorporated in your practices.

2273.49 -> This is another space that I am particularly enthused

2276.59 -> to see in the guidelines.

2278.28 -> We decided not to guess.

2280.02 -> And we decided to step away from empiric statements

2283.06 -> and rather say there are some things,

2285.45 -> some issues in heart failure,

2286.75 -> for which we simply don't have evidence,

2289.01 -> for example, dietary interventions,

2291.9 -> for example, invasive therapies,

2295 -> interventional approaches to arrhythmias,

2298.99 -> nerve stimulation and ablation.

2300.73 -> There are any number of therapies

2303.12 -> that actually carry FDA approval

2304.94 -> for which we're not able to articulate

2307.11 -> how best to use it in a guideline,

2308.49 -> because the evidence base doesn't meet that bar.

2311.36 -> And so recognize that we're already setting the stage

2314.61 -> for ongoing research in the next iteration

2316.82 -> of the clinical practice guidelines.

2319.05 -> I'm gonna finish this up by going through the top 10 things

2322.07 -> to know about the guidelines.

2323.42 -> This will be fairly quick,

2325.63 -> because we'd like to preserve at least 10 or 15 minutes

2329.16 -> for your questions.

2330.53 -> And I hope that you are capturing questions

2334.02 -> as Gregg and I have gone through this information.

2336.79 -> So top 10 things to know, let's think about Jimmy Fallon,

2340.63 -> and this is "The Tonight Show."

2341.85 -> Here are the top 10 things to know.

2342.97 -> Or was that David Letterman, Gregg, used to do that?

2345.003 -> I think it was Letterman.

2348.05 -> All right, let's start.

2349.54 -> Number one,

2350.49 -> guideline-directed medical therapy for heart failure

2353.06 -> now is four-compartment approach.

2355.72 -> There is clear evidence

2358.24 -> that quadruple therapy changes natural history.

2361.36 -> SGLT2 inhibitors go beyond the therapy for HFrEF

2366.01 -> and now include heart failure

2367.45 -> with mid-range ejection fraction.

2369.3 -> For the first time, we can articulate a therapy

2373.27 -> with evidence to suggest benefit.

2375.59 -> There are additional other therapies for heart failure

2377.73 -> with mid-range ejection fraction

2379.38 -> that Gregg summarized that appear here.

2382.54 -> Number three, HFpEF, this really is a pause moment.

2386.7 -> Any of you in the audience

2388.38 -> that have been involved in heart failure

2389.99 -> as long as either Gregg or myself

2392.36 -> understand that we've not ever been able to say anything

2394.9 -> other than treat the concomitant comorbidity.

2397.69 -> We had a soft indication in the previous guidelines

2399.493 -> for the MRA therapies,

2402.17 -> but now we have a more solid recommendation

2404.56 -> for the SGLT2 inhibitors,

2406.76 -> for the mineralocorticoid antagonists at 2b,

2408.83 -> and for the ARNi compounds at 2b.

2412.07 -> We still don't have a therapy that improves mortality,

2415.91 -> that is cardiovascular mortality,

2418.25 -> but heart failure-related cardiovascular morbidity

2421.61 -> now demonstrates responsiveness

2423.61 -> to the therapies as you see here.

2425.76 -> What's the fourth take-home message?

2430.76 -> It's very important to understand

2432.96 -> that there is this new profile

2435.37 -> that we never really identified before.

2437.71 -> Patients that have heart failure with improved EF, remember,

2440.88 -> that start with an EF of less than 40%, substantially so,

2444.61 -> realize at least a 10-point increase,

2446.36 -> and that 10-point increase yields an EF greater than 40%,

2451 -> Not only should you respect exactly what Dr. Fonarow said,

2454.6 -> continue evidence-based therapy,

2457.02 -> but also appreciate that the natural history for this group

2459.86 -> may be slightly different, a lesser risk for mortality,

2463.85 -> a lesser risk hospitalization, but not zero,

2465.599 -> and certainly not a zero risk

2469.02 -> for sudden cardiac death events.

2470.92 -> So ICDs remain intact.

2473.19 -> Evidence-based therapies remain in place.

2475.22 -> Perhaps simplified, but suffice it to say

2478.61 -> this patient population has a better natural history.

2481.36 -> And once we understand the biology at play

2483.63 -> and can manipulate it,

2484.5 -> this might be another frontier for heart failure.

2487.21 -> What's number five?

2488.51 -> I've already highlighted the importance

2489.517 -> of the value statements.

2491.43 -> What's number six?

2492.51 -> I've already highlighted the importance

2494.06 -> of thinking about amyloid heart disease

2496.087 -> and realize that we're right at the precipice

2498.61 -> of a sequential series of new therapies

2500.58 -> to address this one therapy that's available now,

2503.05 -> but others are to come.

2504.56 -> It starts with a clinical assessment.

2506.5 -> In the screening, we're looking for light chains,

2508.58 -> followed by bone scintigraphy and genetic sequencing.

2511.81 -> This is fairly sophisticated stuff,

2513.98 -> but it's available in most major medical centers.

2516.57 -> Number seven,

2518.45 -> understanding that evaluating evidence

2522.75 -> of congestion in patients

2524.94 -> with ejection fractions above 40% is important.

2529 -> We have some tools,

2530.94 -> but we don't have definitive evidence

2533.09 -> that those tools change the natural history,

2535.41 -> but they do inform what we should do,

2538.24 -> specifically thinking about noninvasive assessment

2542.44 -> of diastolic performance

2544.16 -> and thinking about invasive testing

2546.45 -> up to and including implantation of the pulmonary monitor.

2550.49 -> Even invasive measurement in a cath lab

2554.42 -> has an informative position, yes,

2557.61 -> but the ability to change the natural history is not clear.

2560.66 -> Nevertheless, we believe it is important

2563.37 -> to seek evidence of congestion

2566 -> with patients with an EF greater than 40%,

2568.64 -> and then use best clinical judgment.

2571.15 -> Number eight, for patients with advanced heart failure,

2574.31 -> who wish to prolong survival,

2576.33 -> this falls into the realm of I-Need-Help.

2579.33 -> Those patients should clearly be seen by a specialized team

2583.19 -> that can go through the entire portfolio

2586.02 -> of advanced heart failure therapies.

2587.62 -> It goes beyond just organ transplantation.

2590.29 -> Palliative inotropes are not inappropriate

2592.64 -> for an older patient or a patient that is not amenable

2596.32 -> to major surgical procedures.

2598.24 -> This may be a way to improve quality of care,

2601.27 -> meet the patient's goals of care,

2603.28 -> and not extend survival but extend quality time.

2607.77 -> Number nine, primary prevention is key.

2611.16 -> We have evidence like we've never had before

2613.55 -> that if we initiate the early use of SGLT2 inhibitors,

2617.45 -> if we screen with natriuretic peptides

2619.36 -> in patients that are cardiovascular risk

2621.97 -> and start evidence-based therapies

2623.69 -> in the Stage A population, we can make a difference.

2626.94 -> In the Stage B population,

2628.41 -> particularly when the natriuretic peptides are elevated,

2631.46 -> Once again, we have evidence that we can make a difference.

2633.527 -> And in certain Stage B cohorts,

2635.72 -> we know that we can make a difference,

2637.86 -> even if they're asymptomatic.

2639.22 -> So this should not be overlooked.

2641.75 -> And a 10th one,

2643.4 -> understand that for select patients with heart failure

2647.1 -> and a number of other concomitant conditions,

2650.24 -> again, we have therapies with evidence to indicate

2653.87 -> that we can improve the outcomes for those patients.

2657.68 -> Before I go into questions,

2658.89 -> let me thank Kelly for her opening comments

2662.63 -> attributed to both Gregg and me.

2665.56 -> We have been at this a while,

2666.82 -> but we've been at this a while because we have a passion

2669.41 -> for treating patients with heart failure.

2670.93 -> We appreciate the partnership

2672.88 -> with American Heart Association.

2674.34 -> We appreciate the contribution

2676.61 -> of the Get With The Guidelines-Heart Failure platform

2678.87 -> and its different iterations to improving care.

2681.34 -> And Gregg and I would be delighted

2682.66 -> to spend the last 10 to 15 minutes answering your questions.

2685.34 -> Thank you.

2687.12 -> - Wonderful. Thank you, Dr. Yancy and Dr. Fonarow.

2690.53 -> Now we'll begin answering the question-and-answer period

2696.09 -> that were submitted during today's presentation.

2698.44 -> As a reminder, you guys can still go ahead and submit them,

2701.21 -> and we'll be answering them.

2702.72 -> We did get a lot of questions throughout the presentation,

2705.23 -> so I will start and kick it off.

2707.73 -> So one of the first ones that came through

2709.97 -> are the contraindications for SGLT2, what are they?

2715.76 -> - Great. I'll start with that, and Clyde can add.

2719.09 -> So importantly, there are very few.

2722.67 -> Type 1 diabetes, which is a very small proportion

2726.1 -> of our patients with heart failure,

2727.67 -> we really don't have enough evidence of safety yet.

2730.93 -> So that's an important consideration.

2733.36 -> These agents can be started

2735.13 -> down to a GFR of 20 or higher.

2739.12 -> So we don't have data for those on dialysis.

2742.2 -> But really, from that standpoint,

2744.07 -> those are the contraindications.

2745.67 -> There are very few.

2746.503 -> Now, side effects, they were, in the clinical trials,

2749.95 -> as well tolerated as the placebo.

2751.65 -> There were actually more adverse events with placebo

2755.17 -> in some of the trials.

2756.64 -> There is a very small risk

2759.39 -> of diabetes-related ketoacidosis

2762.69 -> that was not seen in those without type 2 diabetes.

2766.66 -> And likewise, a risk of hypoglycemia was not seen

2770.92 -> in those without type 2 diabetes.

2773.08 -> There is a modest increase

2775.49 -> in genital fungal infections,

2778.27 -> just need to discuss that with patients.

2780.39 -> But these are incredibly safe and well tolerated,

2783.44 -> but importantly, highly effective drugs

2785.99 -> that work within days of being initiated

2788.53 -> in patients with both mildly reduced

2792.05 -> and preserved ejection fraction.

2795.51 -> - What I'll add to this is not an extension of the risk

2799.3 -> but a heightened awareness

2800.64 -> of the importance of this question.

2802.38 -> Just early this morning, as I was beginning my day,

2804.97 -> there was a television advertisement for empagliflozin.

2809.59 -> And the list of potential consequences or side effects

2813.43 -> was very plain spoken,

2815.23 -> and quite frankly, a little bit disconcerting.

2818.28 -> And so you can expect that your patients will come in

2820.86 -> because they indeed have been informed through public media

2824.61 -> to be very concerned about infections,

2826.79 -> to be very concerned about severe episodes of acidosis.

2830.24 -> And so be prepared for these questions.

2832.45 -> Understand that the limitation

2834.64 -> really is for type 2 diabetes,

2836.91 -> which reduces that incidence of acidosis.

2839.53 -> Understand that the severe infections

2841.1 -> are perineal infections.

2843.44 -> Frankly, appropriate hygiene prevents most of that.

2845.94 -> But be prepared,

2846.773 -> because the patients are already pre-informed,

2849.26 -> just courtesy of public media.

2853.75 -> - Okay, great, a next question is,

2856 -> it's along the medication line for that, too,

2857.857 -> "How can Get With The Guidelines help

2859.68 -> to monitor the use of these new medications

2862.24 -> in the guidelines?"

2864.83 -> - Yeah, so Get With The Guidelines is in sync

2867.83 -> with the new guideline update.

2869.66 -> So all of the Class 1 recommendations are there

2873.35 -> as quality or achievement measures.

2876.04 -> There actually is a quadruple therapy measure.

2879.02 -> So you can look in aggregate

2881.24 -> regarding the use for eligible patients.

2884.95 -> The monitoring detection of comorbidities,

2887.77 -> that data is collected.

2888.96 -> So really, all of the key elements of the guidelines

2891.92 -> have been integrated in Get With The Guidelines.

2893.7 -> Tracking your progress and compared to benchmark groups,

2897.91 -> so it's interesting, the guidelines themself recognize

2901.62 -> and recommend participating

2903.81 -> in performance improvement systems

2905.65 -> like Get With The Guidelines-Heart Failure.

2908.05 -> So there's been a very close synchronization.

2910.44 -> This can really be critical way for you to,

2915.15 -> you know, really make a major effort

2917.45 -> to improve the implementation of the guidelines,

2919.47 -> be able to track that and provide feedback,

2921.9 -> benchmark feedback to all clinicians.

2925.28 -> - And to extend that one step further,

2927.68 -> I'd love for this audience to know that there is

2929.58 -> an extension of Get With The Guidelines-Heart Failure

2931.99 -> known as IMPLEMENT-HF,

2934.34 -> a program that is capturing additional data points,

2937.11 -> particularly 30 days after hospitalization.

2940.32 -> We will be better informed than we've ever been before

2943.24 -> about the adequacy of alignment with the guidelines.

2947.04 -> And we will specifically evaluate

2949.2 -> not only quadruple therapy

2951 -> but quality of care for patients with HFpEF

2953.74 -> and mildy reduced eject fraction.

2955.87 -> So this will be a very interesting project.

2958.64 -> And our overt pre-specified goal

2962.05 -> is an absolute reduction in the risk of death by 5%,

2965.84 -> because we have that much conviction

2967.47 -> that quadruple therapy will work.

2969.41 -> And so whomever raised that question,

2971.76 -> it will be also informed by the results of IMPLEMENT-HF.

2977.67 -> - Great. Thank you for that, Dr. Yancy and Dr. Fonarow.

2980.36 -> Another question came in,

2981.487 -> "Why is LVSD now considered

2985.12 -> with an EF of 40% or higher?

2988.76 -> Why does the 1% make a difference with the change?"

2994.82 -> - So we obviously, in categorizing EF,

2998.16 -> need to make a cut point, and that's very important.

3001.43 -> The clinical trials have enrolled

3003.27 -> in heart failure, reduced EF for EFs 40% or below.

3007.4 -> Some guidelines were a little loose with that

3009.77 -> and used to say less than 40.

3011.53 -> So 40 and below, we have very strong evidence

3015.05 -> in those recommendations.

3016.69 -> 41 to 49, now that's a degree of precision

3020.29 -> where often the echo is read within a 5% range,

3024.57 -> where they'll say 40 to 45.

3027.12 -> So you need to use some judgment there,

3029.17 -> but based on the criteria for clinical trials,

3032.1 -> based on the actual results we've seen with these therapies,

3035.86 -> that is why the categories exist.

3037.74 -> But it's important for the clinician to understand

3039.99 -> there is some variability that exists

3043.04 -> on who's reading that echocardiogram,

3045.12 -> or whether you're comparing EF from an echo versus a CT,

3049.38 -> versus MRI, versus a LV gram,

3052.12 -> and take that into account utilizing your clinical judgment.

3055.35 -> So there is a degree of precision implied here

3058.67 -> down to single digits that may not fully exist

3061.45 -> but as a general guide can help frame the therapies

3065.25 -> that are being applied.

3067.1 -> - And then recognize that this question really opens up

3069.963 -> just a brief statement about our efforts

3072.41 -> to go beyond the measurement of the ejection fraction,

3074.56 -> to qualify LV dysfunction,

3077.06 -> whether we're talking about systolic or diastolic.

3079.64 -> Increasingly, we're becoming facile

3081.45 -> with global longitudinal strain measurements

3083.52 -> from the echo lab.

3084.76 -> Increasingly, we're paying careful attention

3087.01 -> to the cardiac MRI.

3088.71 -> What is the extracellular volume?

3091.02 -> What is the replacement fibrosis?

3093.18 -> What do we know about delayed enhancement?

3095.7 -> I think we will emerge into a space

3098.28 -> where we look at a portfolio of assessments

3101.08 -> of ventricular integrity, as opposed to performance,

3104.38 -> and use that to enable our decision-making about ICD use,

3108.26 -> about the rapidity with which we institute

3111.11 -> evidence-based therapy,

3112.12 -> even about the decision to proceed forward

3114.4 -> with advanced therapies.

3115.89 -> The ejection fraction is not sufficient

3118.63 -> to really calibrate prognostically

3121.17 -> what will happen to that patient.

3122.62 -> So an insightful question, I believe,

3125.51 -> and an answer that we continue to explore.

3129.555 -> - Okay, great.

3131.007 -> "Can you speak to the strategies to increase MRA usage?

3135.01 -> Any model-sharing best practices on how to support providers

3139.19 -> in remembering to consider the MRAs?"

3143.56 -> - So I'll start.

3144.393 -> You know, we highlight in Get With The Guidelines

3146.97 -> that despite the Class 1 recommendation,

3149.1 -> only about a third of perfectly eligible patients

3151.98 -> were being treated.

3152.813 -> And part of this was gaps in knowledge and awareness,

3155.3 -> but a lot of it was fear of hyperkalemia

3158.417 -> and the importance of monitoring.

3160.48 -> So building in systems to where you can reliably follow up

3164.77 -> and measure potassium in these patients

3168.04 -> is key for prescription.

3170.05 -> Starting off on lower doses,

3172.256 -> spironolactone 6.25 or 12.5,

3175.47 -> in those with moderately impaired renal function

3178.77 -> can be another strategy that can be utilized.

3181.25 -> And we have seen progress within Get With The Guidelines.

3183.5 -> There are many centers now

3185.22 -> where about 50% of their eligible patients are treated.

3188.96 -> And in Europe, there are many centers

3190.797 -> who are up in the 80 or 90% range.

3193.56 -> There are now the class of potassium binders

3196.12 -> that get a 2b recommendation in the guidelines.

3199.05 -> So, so much of this is building that reliable system

3202.22 -> to be aware, to initiate an appropriate patient

3204.6 -> to an appropriate dose,

3206.12 -> but also have that follow-up in monitoring

3208.78 -> and education of patients

3210.66 -> regarding avoiding the risk of hyperkalemia,

3213.46 -> detecting it, and being able to manage it

3215.98 -> with appropriate dose adjustments or adjunctive therapy.

3220.27 -> - And the only two things to add to this is that, yes,

3222.96 -> we do have the potassium binders,

3224.29 -> but we still are waiting for clinical outcomes data

3226.88 -> with those drugs.

3228.08 -> But importantly, there was a statement I made earlier

3231 -> that I'd like to highlight,

3232.01 -> the importance of transitioning the care of a patient

3235.51 -> to a multidisciplinary team.

3238.23 -> That is the best strategy to capture these episodes

3242.3 -> of hyperkalemia after initiating an MRA agent.

3246.51 -> And so if there is, in fact, a system in place,

3249.9 -> Gregg and I are both champions of process improvement.

3252.95 -> Build the process first,

3254.32 -> and the process will take care of the downstream assessment

3257.72 -> of potassium, critically important.

3260.08 -> But I think the fear that was expressed

3262.55 -> some 15 years ago about hyperkalemia

3266.14 -> has yielded to the benefit of these agents.

3269.14 -> And we should not hesitate to use them

3271.4 -> and use the strategies that are available,

3273.54 -> potassium binders, if necessary,

3275.69 -> but in particular, the multidisciplinary team

3278.48 -> to really massage this concern.

3281.23 -> - And one other critical point I will add:

3283.42 -> sacubitril/valsartan,

3285.37 -> a lower risk of hyperkalemia with MRAs

3288.07 -> compared to ACE inhibitors and SGLT2 inhibitors,

3291.56 -> a lower risk of hyperkalemia with MRAs when used together.

3295.4 -> So actually, all four medications together

3299.18 -> help modulate that risk

3300.81 -> and can give clinicians more confidence in their use.

3305.67 -> - Okay, another question that just came in, along the MRAs,

3309.15 -> so we'll stay on that, they're asking,

3310.787 -> "Is one MRA more effective than the other?"

3316.26 -> - Well, I'll give you the guideline answer,

3318.02 -> and I'll appreciate Clyde's input as well,

3319.94 -> and that is we're considered...

3321.55 -> We don't have head-to-head comparative trials.

3324.15 -> If we look at the two major trials done

3326.6 -> with regards to heart failure, reduced EF,

3328.9 -> both lowered all-cause mortality roles, and emphasis HF,

3332.93 -> so spironolactone or eplerenone.

3335.7 -> From a tolerability standpoint,

3337.46 -> clearly less issue with regards to gynecomastia

3342.11 -> with the eplerenone.

3343.25 -> And of course, there are some newer non-steroidal-based MRAs

3347.56 -> that will be studied in patients with heart failure,

3350.61 -> currently indicated in patients with type 2 diabetes

3354.83 -> and chronic kidney disease.

3356.15 -> So more information will be forthcoming

3358.4 -> about classes within MRA,

3360.09 -> but currently the guidelines make that class recommendation.

3363.34 -> Clyde?

3364.2 -> - Yeah, stay tuned for data using finerenone.

3367.02 -> But also look out for

3368.49 -> the TRANSFORM-HF clinical trial results.

3371.83 -> That is another way of trying to manipulate potentially

3375.57 -> an anti-aldosterone-like effect

3377.46 -> from other indicated therapies.

3379.04 -> So this question will continue to evolve.

3384.37 -> - Okay, great. Another question just came in.

3387.327 -> "Any changes in recommendations for advanced therapies?"

3392.95 -> - So Gregg, let me go with this one first,

3394.637 -> because I think everyone needs to appreciate the following.

3398.22 -> There's never been a randomized control trial

3400.3 -> for heart transplantation.

3402.861 -> And so it is an accepted strategy,

3405.71 -> because patients are so desperately ill.

3408.9 -> For mechanical circulatory support,

3411.77 -> let me again speak very clearly to this.

3413.84 -> There is only one platform available for clinical use.

3418.81 -> The field is narrow because of ongoing concerns of,

3423.56 -> and I'll say this delicately, harm.

3426 -> That's not to say that research doesn't continue.

3429.27 -> In fact, a large grant was just awarded

3431.25 -> to a major university

3433.12 -> to explore a wireless mechanical circulatory support system.

3437.58 -> Where we continue to acquire evidence, though,

3440.32 -> is in quality of life with mechanical circulatory support.

3443.96 -> The field has come far,

3445.63 -> and though we have only one platform,

3447.75 -> we have much less risk of stroke.

3450.7 -> We are improving rates of infection

3452.56 -> just by process improvement.

3454.88 -> We are managing the bleeding complications

3457.63 -> just by process improvement,

3459.21 -> by continuing to explore the science behind this.

3461.757 -> And so recognize that life

3464.42 -> with a mechanical circulatory support device is not easy,

3468.65 -> but it's better than it's been before.

3470.91 -> Nothing, nothing could be more important

3473.79 -> than a shared decision-making moment

3476.03 -> and a well-informed team

3477.62 -> that really respects the wishes of the patient.

3480.83 -> There are some non-branded patient education materials

3484.27 -> out of the University of Colorado.

3485.81 -> We've supported those.

3487.29 -> They really allow patients to have an unbiased view

3490.95 -> of the potential benefits and risk

3492.83 -> of mechanical circulatory support.

3495 -> Avail yourself of these products.

3497.47 -> An LVAD is irrevocable. Once it's in place, it's in place.

3501.07 -> So this is a very important conversation.

3504.02 -> I usurped our order, because I've seen too many cases

3508.88 -> where patients, in retrospect,

3511.02 -> probably didn't have the benefit

3514.78 -> of a full educational experience before going forward.

3518.75 -> That's not to impune or lie to anyone.

3521.56 -> It's simply to say these are tough conversations,

3524.72 -> and teams need to be prepared

3526.3 -> to spend whatever time is necessary

3528.69 -> to allow a patient to become fully informed,

3530.8 -> up to and including speaking to other patients with devices,

3534.77 -> and importantly, to family members of patients

3537.75 -> who succumbed to devices

3539.93 -> so that patients can make an informed decision.

3543.12 -> This really is key for the American Heart Association,

3545.9 -> for patients to have a voice

3547.24 -> in critical decisions like this.

3551.11 -> - That was brilliantly stated, and I would just add, I mean,

3554.51 -> the onus is upon us to prevent patients

3557.3 -> from getting to this stage,

3558.77 -> preventing heart failure in the first place,

3561.55 -> and really maximizing

3563 -> our guideline-directed medical therapies

3565.05 -> and management of comorbidities

3566.73 -> so patients do not advance the Stage D.

3570.28 -> And never have we had more tools

3572.54 -> to be able to do that.

3573.63 -> If we effectively implement the guidelines,

3576.6 -> we will dramatically reduce the number of patients

3579.46 -> where even device therapies

3582.88 -> or transplant are considerations.

3585.17 -> And that onus should be upon all of us

3588.33 -> to really implement these guidelines aggressively.

3591.93 -> - So Kelly, without the prompt,

3593.067 -> Gregg just dropped the mic on this webinar.

3595.982 -> - [Kelly] (laughs) Okay. Well, thank you.

3600.14 -> We will continue to answer the questions

3603.32 -> that we have received,

3604.36 -> and we've received a lot of great questions.

3606.18 -> So thank you all.

3607.21 -> And I want to thank Dr. Yancy and Dr. Fonarow

3611.19 -> for the wonderful presentation today.

3613.06 -> I think it was very informative.

3614.6 -> We all learned a lot, and I would just like to thank you

3617.39 -> on behalf of the American Heart Association

3619.81 -> and our presenters.

3621.09 -> Thank you for joining us today.

3622.64 -> And I hope you have a great rest of your day.

3624.85 -> The recording will be available within 24 hours,

3628.04 -> and also the handouts and the PowerPoint

3631.01 -> that they shared today on the new guidelines for 2022

3633.67 -> will also be available, so we will send those out.

3636.54 -> And once again, thank you for today. Have a great day.

Source: https://www.youtube.com/watch?v=1Q4Ba79BZY8