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Breakfast Session at PHL Symposium

Expert’s opinion on managing
Heart Failure in 2018

FAISALABAD: Dr. Nouman Naseer was the guest speaker at the breakfast session on managing heart failure during the PHL symposium held here on February 25th 2018 sponsored by Novartis Pharma. This session was chaired by Prof.Hafeez Chaudhry along with Prof. Naeem Aslam and Prof. Shahbaz Kureshi. Dr. Nouman Naseer started his presentation with a case study of medical treatment of systolic heart failure. He first defined heart failure and then talked about ESC 2016 guidelines about clinical physiology of heart failure, use of diuretics and vasodilatation in wet and warm patients.

This patient after treatment was feeling good and wanted to go home. The chances of in-hospital mortality in such cases are 10% while mortality increases to 40% within a year. He then talked about new treatment modalities for heart failure. ACE Inhibitors, he said, have showed reduction in mortality. Oral nitrates, ACE Inhibitors and ARBs are being used but there is no new therapy for treatment of heart failure. He then gave details of SOLVD trial which enrolled 2569 patients. He suggested that one should start treatment with low dose ACE Inhibitors and then titrate it to the target dose. Aspirin is indicated in CAD but not in heart failure.

Continuing Dr.Nouman Naseer said that CIBIS trial showed 34% risk reduction with beta blocker. In case of fluid retention, one should add diuretics. If there is history of cough, one should use ARBs instead of ACE Inhibitors. However, it is not better than ACE Inhibitors. Combination of ACEIs and ARBs is not recommended. Risk reduction with ACEIs is 16%, with ARBs 17%, with Beta blockers 34% and with MRAs 24%. ARNIs is good, more useful and it offers 16% risk reduction. It keeps the patient out of hospital and the patient also feels better. One has to be very careful as it may increase hypertension. He then spoke about dosing and titration guide for Sacubitiril-Valsartan combination. One can use up to 200mg daily and use Warfarin as anticoagulant if indicated. Avoid use of NSAIDs in heart failure. Most anti arrhythmics, most CCBs and Glitazone should also be avoided.

While treating sleep apnea in patients with heart failure, it was suggested to individualize therapy. He also referred to nutrition sodium restriction. Weight reduction, regular physical activity, Dr.Nouman Naseer said will prevent or reduce hospitalization. He laid emphasis on drug compliance. Ensure stabilization of heart failure patient before discharge. He also suggested 7-10 days follow up after discharge. Studies have shown that almost 23% do get re-admitted within thirty days. He also emphasized on proper work up before discharge. ARNIs are recommended by AAC and AHF. The patient was provided detailed instructions on non-pharmacological treatment on discharge. His ejection fraction improved by 50%. While managing patients with chronic renal failure and diabetes, one should watch the potassium creatinine carefully. He further stated that in future someone may come up with another ARB combination. At present Valsartan has been well studied. Prof. Shahbaz Kureshi remarked that at present this drug was not available in Pakistan and patients have to get it from overseas. At this, it was stated by the company representative that price has been a problem. However, now it is hoped that it will be made available soon. Drug trial was published four years ago and we had immediately applied for its registration in Pakistan. It is affordable for the patients. It improves ejection fraction considerably. It was re-emphasized that one must check for hypertension and start this drug with a low dose. The company was advised to fix a reasonable price in Pakistan. Responding to a question it was pointed out that this drug has not been studied in diastolic heart failure. If the patient is feeling better, one should increase the dose to optimal level. Prof. Mansoor Ahmad remarked that it needs lot of education to come to the doctor. It is easy to say that increase the dose but it is difficult. Optimal dose is seldom reached. There has been withdrawal of certain drugs. It was also stated that there is 20% relative risk reduction with this combination in cardiovascular mortality and it is better than ACE Inhibitors. Prof. Shahbaz Kureshi remarked that we should go for maximum tolerated dose. High blood pressure is often associated with gestational hypertension; hence one should avoid patients developing OSA.

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