Dr Vivek Baliga Cardiologist – Sacubitril/Valsartan In Heart Failure (Presentation)

Dr Vivek Baliga cardiologist Bangalore –

It’s all right doc be able to change into this is the second year i’m so going to the last talk i know you’re already hungry so i’ll only take about ten minutes and be talking on newer therapies in the treatment of systolic heart failure i’d like to invite and of the organs that kindly chair this session so i will probably take no more than ten minutes to talk

About this and after this we can have lunch so what i’ll be discussing i know there’s been a lot of the micro talk this is just going to be a brief clinical talk be talking about newer therapies in systolic heart failure now this is not anything new i’m sure all of you are aware of what treatments are given for patients who have heart failure but to just give you

A brief introduction heart failure is a well it’s a fatal well it is a fatal condition where only about 50% of patients are alive five years after the diagnosis has been made it is a major public health concern affects over 23 million people across the globe with high hospitalization rates and cost of care the goal of treatment there are multiple goals that we

Look at one is the we want to improve the patient’s clinical status looking at improving their functional capacity quality of life trying to reduce hospital admissions and to reduce mortality so this is what all the treatment that we give for in heart failure is aimed towards currently i’m only talking about medical therapy i won’t be talking about device therapy

We are currently prescribing ace inhibitors beta blockers m-ras that is mineral cortical aldosterone receptor antagonists digoxin and diuretics is part of the therapeutic strategies just one slide about each of them ace inhibitors have been shown to reduce mortality and morbidity in patients with heart failure the reduced ejection fraction and they have to be up

Titrated clinical trials have looked at up titrating these doses so you have to make sure that you try and reach the maximum achievable dose and get adequate inhibition of the ross system and also make note that you have to use ace inhibitors in patients with asymptomatic left nicolay dysfunction to reduce the risk of heart failure development hospitalization and

Death so ace inhibitors are extremely important beta blockers is well reduce morbidity in morton despite treatment with ace inhibitors in most cases a diuretic the use is complementary with an ace inhibitor so make sure that you start a beta blocker as soon as possible again it’s all about starting it at low dose and operating the dose gradually and in those at

Heart failure or cute heart failure you may want to wait a little while before introducing a beta blocker particularly you need to consider them if you have heart failure with atrial fibrillation then we move on to manila coracoid and aldosterone receptor antagonists against panel act on a platinum block the receptors that bind to arrested on and with different

Degrees and affinity to have the steroid hormones and they are recommended for all symptomatic patients despite therapy you the nez inhibitor a beta blocker with heart failure with the destruction fraction and an ef of less than 35% again it is reduce mortality and to reduce hospitalizations but always be careful and monitor their creatinine and the potassium values

Especially potassium values and consider choosing an alternate medication if their potassium levels are elevated diuretics of course are recommended to reduce the signs and symptoms of heart failure but don’t really have any strong mortality and morbidity data loop diuretics are used more frequently than thiazide diuretics obviously the effect that we get with

Them is better the aim of direct therapy is to try and maintain you bulimia and you may want to stop a long term diuretics if a patient is maintained in the euvolemic state or if they achieve some degree of hypovolemia what are we primarily talking about in newer therapies is the angiotensin receptor naturalize and inhibitors this is been around since for the last

Five years and a bit less than that actually four years or so 2014 was the study that is published now currently we know that blockade of the renin-angiotensin-aldosterone tree system is the cornerstone in the treatment of heart failure but when you add in inhibition of leptin lies in the benefits that you reach or receive are a lot more so what happens in heart

Failure is an increase in the number of the nitro active peptides and what nebulizing normally does is it breaks down these peptides these peptides are actually helpful in when it comes to managing heart failure talking about the np is not the program bnp is just the normal n piece so a and p bn p and c and v so in 2015 july the fda approved a capital in valsartan

Which was previously known as else is at six nine six for patients who had chronic and stable but symptomatic heart failure inverted left and color ejection fraction of less than forty percent they did recommend using the drugs in conjunction with other heart feel authorities but in place of ace inhibitors and or arvs and it is contraindicated in patients who have

A history of angioedema so this is the mechanism action that was published in the paper as you can see there are two main mechanisms involved one is the the ross system over here and one is the np system what happens is never lights and breaks down the natural errific peptide so it can cause all the opposite effects to this so if you block it what can happen is

You can get reduced fibrosis reduced hypertrophy better naturally races and irises and slightly reduced blood pressure and if you bought obviously the angiotensin system you get again the same sort of effects this is the actual effect of the angiotensin system in is in a harmful way so the briefly to talk about the paradigm heart failure study this is the landmark

Study that was published about four years ago in the new england journal it compared a maximum dose of 200 milligrams twice a year a total of 400 milligrams of elsie’s at six nine six verses in a little nano field was chosen because most data looking at hartfield it looks at in an uphill there are some studies looking at ramipril as well but mostly in a no-till

Was the landmark studies assault trial looked at enalopril so what they did was they had patients who are already on existing ace inhibitor therapy for at least four weeks and those who had seen a symptomatic heart failure so they’re in noh8 class two to four they had a reduced ejection fraction of 40% and the bnp of more than 150 or an nt probably np or more

Than 600 this dependent of course if they were on hospitalized with the bnp valley’s changed a little bit they looked at giving patients or randomizing them to lcz 200 pd and enalapril 10 mil games biddy and what they eventually wanted to study was the all cause mortality renal progression which is very important and clinical summary score they looked at something

Called the kansas city card in my for the questionnaire which is sometimes used in evaluating symptoms of patients so what they did was they started off with the water running period and they run in periods they wanted to make sure that patients are able to tolerate the doses or that they were going to give before randomizing them so they gave them about one to two

Weeks of enalopril these are patients already on treatments of their own already on a different days inhibitor they were shifted over tune a little and righted up the ten milligrams eg this is actually continued for a period of four weeks and then they moved them on to alice’s i hundred million billion two hundred million pd and this was to make sure that there

Was no cross in action and one particular point that is made very clear is that the transition from enalapril to and c’s it was done after stopping the ace inhibitor for 36 hours and this is because there’s a risk of an jad might give this so that is very important even in clinical practice that you stop your ace inhibitor first for 36 hours allow the washout of

This inverter and then move on to else is at six nine six once the running period was done the double-blind the double blinded them to else is a two hundred million bd and in a little 10 milligram bd and they followed them up for a period of 30 to 32 months in the results were quite remarkable they found that the primary composite outcomes looking at death from

All cardiovascular causes were reduced by 20% and if you look at the hartfield hospitalizations as well 21% similarly the deaths from any cost was about 16% reduction and all of these reductions were significant the p-values were remarkable 0.0009 so this is the sort of values that we got or they got sorry there are the things that they look at was improving the

Quality of life they looked at patients surviving at four months eight months and at 12 months and in all groups they looked at quality of life looking at the kcc q score that i mentioned earlier and they found that there was a significant improvement in all the quality of life scores at early on with treatment with dr. burton and valsartan combination they also

Looked at my it’s a class the lower proportion of heart failure patients receiving this medication were considered by this their physicians to have a worsening of a noisy class so the paper patients actually did a lot better again we looked at four eight and twelve months and as you can see the change between all of them yeah they looked at clinical deterioration

So intensification emergency department visits for heart failure hospitalization for heart failure and the requirement for intravenous ionotropic medication and also the need for ci he icd implanted sorry bad the implantation in our our transplant and again in all cases except in the last one there was a significant reduction in the requirement progress though in

This one it was trending towards reduced requirement for crpd though it is not significant one concern always with the use of a scene because they are peas and even this sacral valsartan his hypotension while the walls are about 3mm more drop the this group and lcz group were they didn’t really consider it was really significant the difference between the enalapril

Alone and the alc said the one six nine six true once again angie lima is a big concern there was slightly more cases of and edema in the else’s head group but again it was not a significant difference so amongst these four thousand or so patients only sixteen of them actually had and jd mother only nine had it with enalopril again looking at symptomatic hypotension

Increase in the potassium increase in creatinine cetera there was no significant diskant difference between the two groups and neither of the discontinuation offered for any adverse event so the patient’s actually stopped actually quite good this is the same thing that i proved from the journal just briefly a couple of slides that you were bryden both hearted by

Inhibiting a specific sinus node pacemaker without affecting my hair i will contract lee a relaxation and the trial looked at about 6,500 plus patients it’s stable symptomatic heart failure and olivia jackson fraction of below 35% and those who are in sinus rhythm because as you know ava brandon can’t be given if there’s actual fibrillation and they also looked at

A heart rate of at least 70 beats per minute because the studies have found that keeping a heart rate above that has a poorer prognosis so they reduce the trial even run significantly reduced the primary endpoint or a depth in hospital admissions and it also found that by reducing the heart rate the patients did a lot lot better the only problem with this study was

That not all the patients were on this in this study were on target doses of beta blockers so this is when you should consider it when there’s an ejection fraction less than 35 percent if the patient is in sinus rhythm and if the heart rate is above 70 despite maximal dose or evidence-based those of beta blockers all the maximum tolerated dose of beta blockers and

It should be considered in the above indication if the patient is intolerant to beta blockers so this is the last line just to conclude the heart failure therapies have advanced beyond standard therapies over the years shackleton valsartan therapy has resulted in a paradigm shift which keeps you in the file name in outcomes of patients and fortunately scientific

Profiles are minimal and the results are promising with that i conclude my talk and today’s meeting any comments most of the party of the sitting year used all these drugs army is in drag actually some of the points which we should remember italy you stressed upon that and it’s most of the people i’m karthik feel they are already giving ace inhibitors when you are

Sitting on to this particular type of arvs at least 36 hours caption today similarly if they don’t found rate this drug again if you want to come back these inhibitors again there should be a gap after six hours it’s one thing should not be given to pregnant women and if you are using this hard drugs particularly in young ladies who are likely to go four against

One should be careful to stop that hurt at that level and about the other drug they evoke ready me useful for the experience of others my patients will make this confession all the senior consultants and my mentors and all of you in the audience particularly to professor vijay rahman sir for making it all the way from kerala and i also like to thank my friend my

Dear it’s the frame as well as made it from manga through the top and all of you for attending on a sunday morning as is again i wouldn’t take too much of your time i would like to again stress the point that i’d like if it’s okay for all of you encourage you to become members of the indian academy waco dr. cohen’s is already asked you informed about the journal as

Well so that general before it used to email every time it is published should be sending it out through email so if you have to deceive the email or you feel like given a similar i only leave it at the desk at the front and i haven’t written our database just to make sure all of you get the image and again anybody with a gmail account these account these emails

Are sort of designed up redesigned and what happens is when we send them out in bulk the gmail takes it as a promotional email and puts it in spam folders or in the promotions for tab so can you look out for them and just just drag them along to the inbox and you should receive all the emails they’re hopefully going to do a lot more of these master classes in the

Few months coming we are hoping also to do a little more along the education route for different groups so kindly do make sure that you’re a part of our community thank you once again for being a part of today’s meeting at just a quick word from dr. koh in disparities one of applause – dr. vivek is putting a lot of effort and has gone through a lot of effort and

A lot of passion into it i think thank you vic it’s been a good job

Transcribed from video
Dr Vivek Baliga Cardiologist – Sacubitril/Valsartan In Heart Failure (Presentation) By Dr Vivek Baliga B