Upping the Pace in Acute Decompensated Heart Failure Therapy

April Stempien-Otero, MD, discusses new approaches in uptitration for GDMT and progressive physical rehabilitation in acute decompensated heart failure treatment.
https://www.medscape.com/viewarticle/...

TRANSCRIPT
Hi. I'm April Stempien-Otero, associate professor of cardiology at the University of Washington, where I practice as an advanced heart failure transplant cardiologist and translational scientist. I'm here today to talk to you about new approaches in acute decompensated heart failure (ADHF) treatment.

I'm going to limit this discussion to the patient who comes in to the emergency room short of breath, with newly diagnosed heart failure, and is admitted — usually to the floor and not to the cardiac care unit. You're pretty sure that the patient is nonischemic, you're not working up coronary disease in them, and you just want to treat them and get them on the best medications possible.

Guideline-directed medical therapy (GDMT) of angiotensin-converting enzyme (ACE) inhibition, spironolactone, beta-blockade, and now the addition of sodium-glucose cotransporter-2 (SGLT2) inhibitors is our cornerstone of therapy. The question I want to address is, how do we get patients on this therapy when they've come in to the hospital acutely congested and decompensated in heart failure?

Some great studies have come out over the past 5 years that have really given us the data to guide our use of these medications and how to best treat patients who come in short of breath, congested, and decompensated.

The first priority is decongestion. We have a patient who comes in and they're obviously volume overloaded. Multiple studies have shown that the approach to decongestion, be it continuous infusion or direct bolus infusions of diuretics, doesn't make a difference. What's more important is that you get patients decongested, and that you get them decongested following their N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a marker as opposed to their creatinine levels.

One thing I'm going to emphasize is that for years we've used creatinine as a stopping point in our uptitration of medications. The data show that this has not been the best approach for our patients. Recent studies show that patients who leave the hospital with a creatinine level higher than it was when they came in do better to avoid rehospitalizations than those who have normal creatinine levels or no change in renal function, likely because they were not adequately decongested during their hospitalization.

Put these patients on diuretics and keep it going until their weight goes down. Here at the University of Washington, we like to use Archimedes' principle: that no matter the intake and output of fluids charted, if the weight of the patient does not change, that means that the volume has not come off.

I highly encourage the use of a set diuretic protocol as we do here. We use the protocol that was used in the CARRESS study, and then have added on subsequently acetazolamide as an augmentation and boluses of 3% saline in certain patients. A protocol keeps the patient going even when the creatinine level may be increasing and the medical team may be getting nervous.

If the patient is not losing weight, then you are clearly in a situation that is more severe, and augmentation of therapy with loop diuretics plus metolazone or Diuril (chlorothiazide) is indicated. If you're really hitting a wall after 3-4 days, right heart catheterization to see if the patient is truly volume overloaded, or if cardiac index is low, is indicated.

Optimizing GDMT in ADHF Patients
Once you have your patient on decongestive therapy, it's time to get them on their heart failure therapies. I recommend that everyone read the STRONG-HF study, which came out recently in The Lancet. This study included patients who were selected right before hospital discharge and randomly assigned them to an aggressive therapy of uptitration of their heart failure GDMT drugs vs usual care.

I will admit that the protocol was very intensive for outpatient therapy. It's a challenge for all of us to get our patients in to see us, but the structure of the study made it such that the time they would need to spend in the outpatient clinic was brief.

Essentially, 2 days before discharge, they were randomly assigned to these two strategies. If they had not reached a half-dose of GDMT, they were put on a half-dose of GDMT — so that would be 100 mg/d of Toprol (metoprolol), about a 45/50 -mg dose of Entresto (sacubitril/valsartan), or equivalent doses of generic ACE inhibitors, angiotensin II receptor blockers (ARBs), or beta-blockers.
https://www.medscape.com/viewarticle/...