Podcasts about gdmt

The BedMed trial of nighttime BP meds, SURMOUNT-5, Troponin URL, gene tests in patients with no disease, and guideline-directed medical therapy for HF are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I Timing of BP Meds – The BedMed RCT MAPEC https://doi.org/10.3109/07420528.2010.510230 Hygia https://doi.org/10.1093/eurheartj/ehz754 Turgeon et al https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.16501 TIME trial https://doi.org/10.1016/S0140-6736(22)01786-X BedMed https://jamanetwork.com/journals/jama/fullarticle/2833860 Time Antihypertensives Taken Doesn't Matter: New Trials https://www.medscape.com/viewarticle/time-antihypertensives-taken-doesnt-matter-new-trials-2024a1000g3z Timing of BP Dosing Doesn't Matter: BedMed and BedMed-Frail https://www.medscape.com/viewarticle/timing-blood-pressure-dosing-doesnt-matter-again-bedmed-and-2024a1000fz2 Timing of Blood Pressure Meds Doesn't Affect Outcomes: BedMed in Print https://www.medscape.com/viewarticle/timing-blood-pressure-meds-doesnt-affect-outcomes-bedmed-2025a1000cdm II Tirzepatide vs Semaglutide SURMOUNT 5 https://www.nejm.org/doi/full/10.1056/NEJMoa2416394 III Age-specific Troponins Coyle and McEvoy https://doi.org/10.1093/eurheartj/ehaf308 Mandrola/Foy JAMA-IM https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2777967 IV Return to Play for Gene Positive Phenotype Negative athletes Martinez et al https://doi.org/10.1016/j.jacep.2025.03.013 V Rapid Titration of GDMT in HF STRONG HF: More Beats Less After Discharge for Heart Failure https://www.medscape.com/viewarticle/983698 JACC-HF Substudy https://doi.org/10.1016/j.jchf.2025.02.020 STRONG HF https://doi.org/10.1016/S0140-6736(22)02076-1 AVID https://www.nejm.org/doi/full/10.1056/NEJMoa013474 EAST https://www.nejm.org/doi/full/10.1056/NEJMoa013474 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

This episode of Don't Miss a Beat, recorded at the American College of Cardiology (ACC) 2025 Annual Scientific Sessions, explores the evolving landscape of heart failure with preserved ejection fraction (HFpEF) treatment, focusing on the implementation of combination therapies. Hosts Steve Greene, MD, and Muthiah Vaduganathan, MD, MPH, discuss the transition from a previously limited treatment landscape to a new era with multiple proven therapeutic options. To open the episode, Greene argues in favor of rapid-sequence implementation of HFpEF therapies, drawing parallels to the established 4-pillar guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). He highlights 3 key classes of medications—SGLT2 inhibitors, non-steroidal mineralocorticoid receptor antagonists (MRAs), and incretin-based therapies—as the foundation of HFpEF treatment. He emphasizes the importance of early and aggressive therapy initiation to maximize clinical benefits and reduce the risk of delayed or missed treatment opportunities among this population. Vaduganathan acknowledges the strength of the data supporting combination therapy but suggests a more risk-based approach, considering the broad clinical variability among HFpEF patients. He advocates for prioritizing rapid implementation in high-risk patients, such as those recently hospitalized, while allowing a more measured approach for lower-risk individuals. The discussion also touches on the role of phenotyping in tailoring treatment decisions, with GLP-1 receptor agonists being particularly relevant for patients with obesity and ARNi potentially benefiting those with mildly reduced ejection fraction. Looking ahead, the hosts preview upcoming trials, including CONFIDENCE and CONFIRMATION, which will evaluate combination therapy strategies in chronic kidney disease and HFpEF populations. They also discuss the potential of fixed-dose combination therapies to simplify implementation and improve adherence. The episode closes with both experts agreeing on the need for a structured, evidence-based approach to HFpEF treatment while emphasizing the importance of translating trial data into real-world practice. Relevant disclosures for Vaduganathan include Amgen, AstraZeneca, Bayer AG, Boehringer Ingelheim Pharmaceuticals, Cytokinetics, Lexicon, and others. Relevant disclosures for Greene include Amgen, AstraZeneca, Bayer Healthcare Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals, Cytokinetics, and others. Chapters 00:00-Intro 02:30-Argument for Rapid Sequencing 05:32-Argument Against Rapid Sequencing 10:00-Argument for Risk-Based Sequencing 14:25-Pillars of GDMT in HFpEF

In this episode, Dr. Valentin Fuster discusses a study from the ISCHEMIA trial, showing that achieving multiple guideline-directed medical therapy (GDMT) goals—especially blood pressure control—reduces cardiovascular events in chronic coronary artery disease patients. The study highlights the importance of early goal attainment and adherence, with the POLYPILL offering a potential solution to improve patient compliance.

With Henrique Arfsten, Medical University of Vienna, Vienna - Austria and Alexandre Mebazza, Hospital Lariboisiere, Paris - France.  In this episode of HFA CardioTalk, Henrike Arfsten and  Alexandre Mebazaa discuss the importance of rapid initiation and titration of guideline-directed medical heart failure therapy. A focus will be on data from the STRONG-HF trial, which demonstrated safety and efficacy of rapid up-titration following an acute heart failure event. The trial was even stopped early as the benefits of the intensive treatment strategy were overwhelming. Moreover, specific questions are raised, such as the right time to start therapy and how to deal with possible side effects. Mebazaa A, et al. Lancet 2022 Dec 3;400(10367):1938-52 Biegus J, et al. Heart Fail Rev 2024 Sep;29(5):1065-1077 McDonagh TA, et al. Eur J Heart Fail 2022 Jan;24(1):4-131 McDonagh TA, et al. Eur J Heart Fail 2024 Jan;26(1):5-17 This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:https://www.mycme.com/courses/managing-the-burden-of-hyperkalemia-9952SummaryIn this concise CME/CE podcast, a cardiologist and a family physician discuss risks associated with hyperkalemia in patients being treated for heart failure or chronic kidney disease (CKD)—including the risks that accompany down-titration or discontinuation of RAASi therapy.Drs. Javed Butler and Neil Skolnik provide guidance on which patients are most at risk and review the use of potassium binders that can manage hyperkalemia without compromising the crucial use of guideline-directed medical therapy (GDMT). By the end of this podcast episode, listeners will feel much more confident in their ability to safely and effectively address hyperkalemia in patients with heart failure or CKD.Learning ObjectivesAt the conclusion of this activity, participants should be better able to:Describe the disparities and clinical implications of hyperkalemia in patients with HF and CKD in terms of optimizing guideline-directed medical therapy (GDMT) and outcomesDiscuss the safety and effectiveness of potassium binders in reducing potassium and optimizing GDMT in patients with HF and CKDThis activity is accredited for CME/CE CreditThe National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The National Association for Continuing Education designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.The National Association for Continuing Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 121222. This activity is approved for 0.25 contact hours (which includes 0 hours of pharmacology).For additional information about the accreditation of this program, please contact NACE at info@naceonline.com.Summary of Individual DisclosuresPlease review faculty and planner disclosures here.Disclosure of Commercial SupportThis educational activity is supported by an educational grant from AstraZeneca Pharmaceuticals.Send us a text about this episode. Please visit http://naceonline.com to engage in more live and on demand CME/CE content.

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:https://www.mycme.com/courses/using-newer-agents-in-chronic-hyperkalemia-management-9953SummaryIn this concise CME/CE podcast, a cardiologist and primary care physician review hyperkalemia management options that safely allow continuing GDMT for patients with heart failure or CKD. Using case examples, the clinicians provide education on individualizing treatment and addressing disparities in care.Learning ObjectiveAt the conclusion of this activity, participants should be better able to:Identify practical aspects of using potassium binders for treating hyperkalemia and optimizing GDMT to achieve equitable care for patients with HF and CKDThis activity is accredited for CME/CE CreditThe National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The National Association for Continuing Education designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.The National Association for Continuing Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 121222. This activity is approved for 0.25 contact hours (which includes 0.25 hours of pharmacology).For additional information about the accreditation of this program, please contact NACE at info@naceonline.com.Summary of Individual DisclosuresPlease review faculty and planner disclosures here.Disclosure of Commercial SupportThis educational activity is supported by an educational grant from AstraZeneca Pharmaceuticals.Send us a text about this episode. Please visit http://naceonline.com to engage in more live and on demand CME/CE content.

The following question refers to Sections 7.4 and 7.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by the Director of the CardioNerds Internship Dr. Akiva Rosenzveig, answered first by Vanderbilt AHFT cardiology fellow Dr. Jenna Skowronski, and then by expert faculty Dr. Randall Starling.Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling's sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. American Heart Association's Scientific Sessions 2024As heard in this episode, the American Heart Association's Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It's a special year you won't want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!When registering, use code NERDS and if you're among the first 20 to sign up, you'll receive a free 1-year AHA Professional Membership! Question #38 Mrs. M is a 65-year-old woman with non-ischemic dilated cardiomyopathy (LVEF 40%) and moderate to severe mitral regurgitation (MR) presenting for outpatient follow-up. Despite improvement overall, she continues to experience dyspnea on exertion with two flights of stairs and occasional PND. She reports adherence with her medication regimen of sacubitril-valsartan 97-103mg twice daily, metoprolol succinate 200mg daily, spironolactone 25mg daily, empagliflozin 10mg daily, and furosemide 80mg daily. A transthoracic echocardiogram today shows an LVEF of 35%, an LVESD of 60 mm, severe MR with a regurgitant fraction of 60%, and an estimated right ventricular systolic pressure of 40 mmHg. Her EKG shows normal sinus rhythm at 65 bpm and a QRS complex width of 100 ms. What is the most appropriate recommendation for management of her heart failure?AContinue maximally tolerated GDMT; no other changesBRefer for cardiac resynchronization therapy (CRT)CRefer for transcatheter mitral valve intervention Answer #38 ExplanationChoice C is correct. The 2020 ACC/AHA Guidelines for the management of patients with valvular heart disease outline specific recommendations.In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF

The following question refers to Section 7.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by the Director of the CardioNerds Internship Dr. Akiva Rosenzveig, answered first by Vanderbilt AHFT cardiology fellow Dr. Jenna Skowronski, and then by expert faculty Dr. Clyde Yancy.Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the ACC/AHA Joint Committee on Clinical Practice Guidelines.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. American Heart Association's Scientific Sessions 2024As heard in this episode, the American Heart Association's Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It's a special year you won't want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!When registering, use code NERDS and if you're among the first 20 to sign up, you'll receive a free 1-year AHA Professional Membership! Question #37 Mr. S is an 80-year-old man with a history of hypertension, type II diabetes mellitus, and hypothyroidism who had an anterior myocardial infarction (MI) treated with a drug-eluting stent to the left anterior descending artery (LAD) 45 days ago. His course was complicated by a new LVEF reduction to 30%, and left bundle branch block (LBBB) with QRS duration of 152 ms in normal sinus rhythm. He reports he is feeling well and is able to enjoy gardening without symptoms, though he experiences dyspnea while walking to his bedroom on the second floor of his house. Repeat TTE shows persistent LVEF of 30% despite initiation of goal-directed medical therapy (GDMT). What is the best next step in his management?AMonitor for LVEF improvement for a total of 60 days prior to further interventionBImplantation of a dual-chamber ICDCImplantation of a CRT-DDContinue current management as device implantation is contraindicated given his advanced age Answer #37 Explanation Choice C is correct. Implantation of a CRT-D is the best next step. In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for >1 year,ICD therapy is recommended for primary prevention of SCD to reduce total mortality (Class 1, LOE A). A transvenous ICD provides high economic value in this setting, particularly when a patient's risk of death from ventricular arrhythmia is deemed high and the risk of nonarrhythmic death is deemed low. In addition, for patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II, III, orambulatory IV symptoms on GDMT, cardiac resynchronization therapy (CRT) is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. Cardiac resynchronization provides high economic value in this setting. Mr.

When treating heart failure, how do we distinguish between the expanding list of medications recommended for “Guideline Directed Medical Therapy” (GDMT) and what might be considered runaway polypharmacy? In this week's podcast, we'll tackle this crucial question, thanks to a fantastic suggestion from GeriPal listener Matthew Shuster, who will join us as a guest host. We've also invited two amazing cardiologists, Parag Goyal and Nicole Superville, to join us about GDMT in heart failure with reduced ejection fraction (HFrEF) and in Heart Failure with preserved EF (HFpEF).  We talk about what is heart failure, particularly HFpEF, how we treat it (including the use of sodium–glucose cotransporter-2 inhibitors (SGLT2's), and how we should apply guidelines to individual patients, especially those with multimorbidity who are taking a lot of other medications. I'd also like to give a shout out to a recent ACP article on HFpEF with an outstanding contribution from Ariela Orkaby, geriatrician extraordinaire (we also just did a podcast with her on frailty).  

Surgical clearance, NICM assessment, dueling perspectives on PCI as first-line therapy for angina, GDMT in HFrEF are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. New ACC Peri-operative Guidelines Released ACC Guideline document https://www.jacc.org/doi/10.1016/j.jacc.2024.06.013 J Vasc Surg https://www.jvascsurg.org/article/S0741-5214(21)00335-9/fulltext McFalls and colleagues; CARP https://www.nejm.org/doi/full/10.1056/NEJMoa041905 II. NICM – We may be doing it wrong in Selecting ICDs JAMA Meta-analysis https://jamanetwork.com/journals/jama/fullarticle/2823869/ German CMR ICD Trial https://www.clinicaltrials.gov/study/NCT04558723 BRITISH CMR trial https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/britishusing-cmr-scar-as-risk-indication-tool-in-nicm-and-severe-lvsd/ III. When Should PCI be Used in Chronic Stable CAD?   Rajkumar and Al-Lamee; PCI First https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.124.011201   Boden and De Caterina; Meds First https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.124.011268 ORBITA 10.1016/S0140-6736(17)32714-9 ORBITA 2 trial https://www.nejm.org/doi/full/10.1056/NEJMoa2310610 IV. GDMT Underuse in HFrEF Greene and colleagues https://doi.org/10.1016/j.jchf.2024.08.002 DAPA HF https://www.nejm.org/doi/full/10.1056/NEJMoa1911303 RALES https://www.nejm.org/doi/full/10.1056/NEJM199909023411001 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

The following question refers to Section 2.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by University of Colorado internal medicine resident Dr. Hirsh Elhence, answered first by University of Chicago advanced heart failure cardiologist and Co-Chair for the CardioNerds Critical Care Cardiology Series Dr. Mark Belkin, and then by expert faculty Dr. Mark Drazner.Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the President of the Heart Failure Society of America.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.  Question #35 A 50-year-old woman with a history of congestive heart failure, hypertension, type 2 diabetes mellitus, and obstructive sleep apnea presents to the outpatient clinic to follow up on her heart failure management. One year prior, echocardiogram showed an ejection fraction of 30% with an elevated BNP, for which she was started on appropriate GDMT. Repeat echocardiogram today showed an EF of 50%. Which of the following best describes her heart failure status? A HFrEF (HF with reduced EF) B HFimpEF (HF with improved EF) C HFmrEF (HF with mildly reduced EF) D HFpEF (HF with preserved EF) Answer #35 Explanation The correct answer is B – HFimpEF, or heart failure with improved ejection fraction, best describes her current heart failure status. Left ventricular ejection fraction is an important factor in classifying heart failure given differences in prognosis, response to treatment, and use in clinical trial enrollment criteria. The classification of heart failure by EF (adopted from the Universal Definition of HF): –        HFrEF (HF with reduced EF): LVEF ≤40% –        HFimpEF (HF with improved EF): previous LVEF ≤40%, a ≥10% increase from baseline LVEF, and a second measurement of LVEF >40%. –        HFmrEF (HF with mildly reduced EF): LVEF 41%–49%, andevidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement) –        HFpEF (HF with preserved EF): LVEF ≥50%, and evidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement) Patients with HFmrEF are usually in a dynamic state of improving from HFrEF or deteriorating towards HFrEF. Therefore, patients with HFmrEF may benefit from follow-up evaluation of systolic function and etiology of sub-normal EF. Improvements in EF are associated with better outcomes but do not indicate full myocardial recovery or normalization of LV function. Indeed, structural and functional abnormalities such as LV dilation and systolic or diastolic dysfunction often persist. Moreover, EF may remain dynamic with fluctuations in either direction depending on factors such as GDMT adherence and re-exposure to cardiotoxic agents. As such, the term heart failure with “improved EF” was deliberately chosen over “recovered EF” and “preserved EF”. Importantly, in patients with HFimpEF while on GDMT, the EF may decrease after withdrawal of GDMT. Main Takeaway

With David Duncker, Hannover Heart Rhythm Center, Hannover - Germany, and Giuseppe Boriani, Modena Polyclinic Modena University Hospital, Modena - Italy. This episode will tackle GDMT in patients with cardiac implantable electronic devices: Heart failure medication optimization, ICD indications, remote monitoring.  

CardioNerds Dr. Rick Ferraro, Dr. Gurleen Kaur, and Dr. Maryam Barkhordarian discuss the evidence and data supporting SGLT inhibition for cardiovascular and kidney health outcomes with expert faculty Dr. Muthu Vaduganathan. They discuss the role of SGLT inhibitors in different populations, including those with diabetes mellitus, heart failure, CKD, and myocardial infarction. Show notes and audio editing by CardioNerds Academy Fellow Dr. Maryam Barkhordarian. This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals. CardioNerds Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - The Data Supporting SGLT Inhibition with Dr. Muthiah Vaduganathan The benefit of SGLT inhibition extends beyond diabetes, and improves cardiovascular and kidney health outcomes independent of diabetes in appropriate patient populations. SGLT inhibition decreases cardiovascular mortality and heart failure hospitalization independent of left ventricular ejection fraction. SGLT inhibitors reduce clinically relevant events such as dialysis and transplantation in CKD patients irrespective of etiology and are now a cornerstone for the prevention of CKD progression. The introduction of polypills in heart failure can simplify GDMT implementation. Show notes - The Data Supporting SGLT Inhibition with Dr. Muthiah Vaduganathan How did SGLT inhibitors transition from “diabetes medication” to guideline-directed cardiovascular medicine? Most therapies in cardiology were developed for a particular purpose and ended up being indicated for a vastly different reason. The SGLT-2 inhibitors are no different. Cardiovascular safety concerns about diabetes medications led to a mandate to conduct cardiovascular outcomes trials for all novel diabetes medications. This federal requirement shed light on the cardiovascular benefits of SGLT inhibitors in patients with diabetes. These initial trials showed that not only are these medications safe but also, surprisingly, proved their role in preventing heart failure and delaying progression of chronic kidney disease. What are the mechanisms of action of SGLT-2 and SGLT-1/2 inhibitors? The central mechanism(s) of how these medications confer health outcomes benefits patients is/are not well understood. The main organ involved in the action of SGLT-2 inhibitors is the kidney at the level of the proximal tubule, impacting the cardiovascular system by handling salt and water and improving kidney efficiency. Conversely, SGLT-1/2 inhibitors also act at the level of the gut, the predominant location of the SGLT-1 cotransporter. Their effects on the cardiovascular system are secondary, given there is no SGLT-1 or -2 cotransporters in the myocardium. These secondary effects can be impacted through blood pressure reduction, volume regulation, improved glycemic control, etc. to overall improve cardiovascular status. Whatever the underlying mechanisms, the empirical data for their use is strong and growing. What is the role of SGLT inhibitors in preventing CKD progression? RAAS inhibitors (ACE inhibitors and ARBs) have been the cornerstone of CKD management for the past two to three decades. SGLT inhibitors have been the first add-on to this background therapy. Four trials, DAPA-CKD, EMPA-CKD, CREDENCE, and the SCORED, investigated the effects of SGLT-2 and SGLT-1/2 inhibitors in patients with CKD with or without diabetes. The outcomes of these trials include modifying the course of CKD and reducing events such as dialysis initiation and transplantation. These effects were regardless of participants' diabetic status, CKD etiology, or individual patient profile.

In this enlightening episode of Parallax, which focuses on guideline directed medical therapy (GDMT), Dr Ankur Kalra is joined by two guests, Dr Georges Chahoud, a Heart Failure Cardiologist at St. Louis Cardiology Consultants in the US, and Dr Carsten Israel, Chief of Cardiology at Bethel-Clinic in Germany. Building on their expertise, they share insights on how they would personally consult colleagues on how to manage patients with new onset acute decompensated heart failure (ADHF) and how to optimise this management in the hospital setting. They cover key topics such as why early initiation of GDMT even before hospital discharge is important, what other imaging modalities can help in better stratifying patients at risk of sudden cardiac death and they address the management and assessment of the risk for sudden cardiac death in patients on quadruple backbone GDMT. This episode is a must-listen for all healthcare professionals dedicated to advancing their understanding and treatment of heart failure. This series is supported by ZOLL and is intended for Health Care Professionals.

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As healthcare continues to evolve, the need for efficient management of chronic diseases becomes more pressing. Remote patient monitoring (RPM) emerges as a crucial innovation in this landscape, offering a solution to the rising number of chronic disease cases and the subsequent strain on healthcare systems. A 2023 study found that 60% of American adults have at least one chronic condition, highlighting the urgency for effective management solutions.Can remote patient monitoring revolutionize chronic disease management, and what are the tangible benefits for patients and healthcare providers?In the latest episode of I Don't Care with Dr. Kevin Stevenson, host Dr. Kevin Stevenson engages in a timely discussion with Dr. Ted Feldman, Chief Medical Officer of Cadence. The episode delves into the capabilities and impact of Cadence's RPM technology, which partners with hospitals and health systems to enhance patient outcomes and alleviate clinician workload through advanced practice provider-led clinical care teams.Key Points of Discussion:Seamless Integration: Cadence's cellular-enabled RPM technology simplifies patient enrollment and data collection without the need for additional devices or applications.Effective Communication: Integration with major electronic medical records (EMRs) ensures that patient data is accessible to healthcare providers, enhancing treatment continuity and decision-making.Care Delivery Teams: Cadence attaches care delivery teams to RPM data, ensuring that patients receive guideline-directed medical therapy (GDMT) and ongoing monitoring, ultimately reducing hospital readmissions and improving clinical outcomes.Dr. Ted Feldman has over 37 years of experience in interventional cardiology. His career includes pioneering work in percutaneous coronary interventions and significant contributions to clinical trials for chronic disease treatments. As the Chief Medical Officer of Cadence, Dr. Feldman leverages his extensive background to advance the use of technology in chronic disease management.

CardioNerds Co-Founder Dr. Daniel Ambinder, Episode Chair Dr. Dinu Balanescu, and FIT Lead Dr. Natalie Tapaskar discuss advanced heart failure in CardioOncology with expert Dr. Richard Cheng. Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig. In this episode, we discuss the spectrum of advanced heart failure in patients with a history of cancer. We dissect cancer therapy-related cardiac dysfunction (CTRCD) cases and the imaging and biomarker tools available for risk stratification and disease monitoring. We delve into the data on the use of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy (CRT) in these patients. We discuss the risk of prior radiation and chemotherapy during cardiac surgery. Finally, we learn about the post-transplant risk of rejection, recurrent malignancy, and de-novo malignancies, as well as treatment strategies we can employ for these patients. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.  CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Advanced Heart Failure in CardioOncology Use the HFA-ICOS risk tool to understand the baseline risk of developing cancer therapy-related cardiac dysfunction (CTRCD). Key factors are type of cancer therapy, baseline CV risk factors, and age. A relative change in global longitudinal strain of more than 15% from baseline is a marker of early cardiac dysfunction and predicts the subsequent risk for systolic dysfunction in patients undergoing cardiotoxic chemotherapy. Statins may be useful in prevention of cardiovascular dysfunction in patients receiving anthracycline chemotherapy. There is limited data on the 4 pillars of GDMT in prevention of CTRCD, but should be started early once CRTCD is suspected or diagnosed! Mediastinal radiation causes adhesions and scarring which increase the risk of bleeding during cardiac surgery, lead to longer operative times, and can lead to RV failure and poor wound healing. Patients with a pre-transplant history of malignancy have a higher risk of mortality due to post-transplant malignancy. And patients with active cancer should not be considered for heart transplant. Post-transplant malignancy risk can be mitigated by utilizing an mTOR based, CNI free immunosuppression regimen. Show notes - Advanced Heart Failure in CardioOncology How do cardio-oncology and advanced heart failure intersect? There are 3 basic populations of patients to consider:Patients with advanced heart failure who develop cancer.Patients with pre-existing chemotherapy and radiation exposure for cancer treatment who later develop advanced heart failureHeart transplant recipients who, in the long term are at very high risk of developing cancer Cardio-oncologists must consider risk assessment and mitigation, long-term prognosis, and treatment strategies for each of these unique populations. How can we assess the risk of developing cardiovascular disease during cancer treatment (CTRCD)? There are many proposed risk tools. However, the majority are not well-validated. One of the most used tools is the HFA-ICOS risk tool.1You can select the planned cancer therapy for the patient (anthracyclines, HER-2, VEGF, RAF/MEK inhibitors, Kinase inhibitors, multiple myeloma therapies) and then calculate their risk of developing CV disease during cancer treatment based on baseline variables:1) previous history of CV disease,2) biomarkers – troponin and NT-proBNP3)age,4) CV risk factors -HTN, DM,

TRIO Score and Choosing Patients Most Likely to Benefit From Tricuspid Valve Intervention Guest: Sorin V. Pislaru, M.D., Ph.D. Hosts: Sharonne N. Hayes, M.D. Tricuspid Regurgitation (TR) is an extraordinarily heterogeneous, highly prevalent valvular heart disease. Given the tremendous variability, individualizing risk in patients with TR to guide appropriate therapy will be explored. Other topics discussed will be the use of TRIO scores, GDMT as a first line in therapy, as well as when to consider surgery or percutaneous interventions.   Topics Discussed: Is TR a relevant valvular heart disease? Why the need for a risk score? So what is the TRIO score What else did you learn from the score? The future?   Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. LinkedIn: Mayo Clinic Cardiovascular Services Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.

Drs Michelle Kittleson and Ronald Oudiz dive into everything cardiologists need to know about the diagnosis and treatment of pulmonary hypertension. Relevant disclosures can be found with the episode show notes on Medscape (https://www.medscape.com/viewarticle/997320). The topics and discussions are planned, produced, and reviewed independently of advertisers. This podcast is intended only for US healthcare professionals. Resources Heart Failure https://emedicine.medscape.com/article/163062-overview Pulmonary Arterial Hypertension https://emedicine.medscape.com/article/303098-overview Cardiac Catheterization in Pulmonary Hypertension: Doing It Right, With a Catheter on the Left https://pubmed.ncbi.nlm.nih.gov/33224785/ How to Initiate and Uptitrate GDMT in Heart Failure: Practical Stepwise Approach to Optimization of GDMT https://pubmed.ncbi.nlm.nih.gov/36456074/ Phosphodiesterase Inhibitors https://www.ncbi.nlm.nih.gov/books/NBK559276/ Cardiovascular Biology of Prostanoids and Drug Discovery https://pubmed.ncbi.nlm.nih.gov/32295420/ Soluble Guanylate Cyclase as an Emerging Therapeutic Target in Cardiopulmonary Disease https://pubmed.ncbi.nlm.nih.gov/21606405/ Pulmonary Hypertension Association https://phassociation.org/

In this episode of Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives hosts are joined by Brendon Neuen, MBBS, PhD, nephrologist and director of the Kidney Trials Unit at Royal North Shore Hospital and senior research fellow at The George Institute for Global Health. During the episode, Neuen talks about the FLOW trial, topline results, how the rapid advancement in pharmacotherapies has altered conversations around management, the concept of 4 pillars of GDMT for CKD in type 2 diabetes, and how to approach sequencing of these therapies. Video Version: https://www.hcplive.com/view/diabetes-dialogue-flow-trial-and-chronic-kidney-disease-updates-with-brendon-neuen-mbbs-phd Episode Highlights 00:32 - Neuen Introduction 01:55 - FLOW Trial 05:15 - Pillars of CKD Therapy 16:15 - Need for New Guidelines 21:15 - Barriers to Uptake 24:50 - Need for Screening

Javed Butler, MD, MPH, MBA - Practical Perspectives and Straightforward Strategies for Optimising GDMT in HFrEF: The Role of ARNI as a Fundamental Building Block

Javed Butler, MD, MPH, MBA - Practical Perspectives and Straightforward Strategies for Optimising GDMT in HFrEF: The Role of ARNI as a Fundamental Building Block

Javed Butler, MD, MPH, MBA - Practical Perspectives and Straightforward Strategies for Optimising GDMT in HFrEF: The Role of ARNI as a Fundamental Building Block

Javed Butler, MD, MPH, MBA - Practical Perspectives and Straightforward Strategies for Optimising GDMT in HFrEF: The Role of ARNI as a Fundamental Building Block

In the sequel to last week's episode, we are back with Dr. Jonathan Davis, Director of the Heart Failure program from San Francisco General. We continue our tour of GDMT for HF, by covering SGLT2-i, MRAs, as well as some AKI and outpatient considerations. This is part 1 of 2 parts which will cover an overview of GDMT medications, and dive into Beta-blockers and ARNIs. Part 2 to come out next week! | 00.33 - Previously on Booster Shots | | 01.31 - Chapter 3: SGLT2-i | The now famous EMPA-REG OUTCOME trial [NEJM 2015] Empagliflozin in HFpEF (not discussed in this episode [NEJM 2021] | 04.24 - Chapter 4: MRAs | RALES trial demonstrating benefit in Morbidity/Mortality [NEJM 1999] | 10.04 - Organizing follow up | | 11.51 - Issues with AKI | | 15.10 - Some fun questions about Fun questions | | 16.54 - Summary of All The Things! | [The appearance of external hyperlinks does not constitute endorsements by UCSF of the linked websites, or the information, products, or services contained therein. UCSF does not exercise any editorial control over the information found therein, nor does UCSF make any representation of their accuracy or completeness. All information contained in this episode are the opinions of the respective speakers and not necessarily the views their respective institutions or UCSF, and is only provided for information purposes, not to diagnose or treat.] Music by Amit Apte. Medical Heart Vectors by Vecteezy

We talk to Cardiologist Dr. Jonathan Davis, Director of the Heart Failure program from San Francisco General about goal directed medical therapy in heart failure with reduced ejection fraction (HFrEF). This is part 1 of 2 parts which will cover an overview of GDMT medications, and dive into Beta-blockers and ARNIs. Part 2 to come out next week! | 00.34 - Introduction | | 01.55 - Consult Q: GDMT for HF | Heart failure outcomes | 05.20 - GDMT medication summary and overview | | 07.17 - Effect on blood pressure and relative risk reduction for each drug | | 10.59 - What order to start in | Hint: ALL AT ONCE… if you can | 11.53 - Beta-blockers | When not to start (new HF in VOL), and when to re/start (almost all other times) Tartrate vs Succinate: duration of action | 15.40 - ARNI (Sacubitril-Valsartan) | Potent natriuresis effect Balancing the orthostatics | 20.37 - Outro | [The appearance of external hyperlinks does not constitute endorsements by UCSF of the linked websites, or the information, products, or services contained therein. UCSF does not exercise any editorial control over the information found therein, nor does UCSF make any representation of their accuracy or completeness. All information contained in this episode are the opinions of the respective speakers and not necessarily the views their respective institutions or UCSF, and is only provided for information purposes, not to diagnose or treat.] Music by Amit Apte. Medical Heart Vectors by Vecteezy

CME credits: 0.25 Valid until: 26-01-2025 Claim your CME credit at https://reachmd.com/programs/cme/the-beat-goes-on-new-data-on-improving-symptoms-in-hfref-patients-using-novel-device-therapy/14474/ Even with guideline-directed medical therapy, or GDMT, many patients with heart failure are limited in their daily activities, due to increasing symptoms and reduced functionality. However, new data from BeAT-HF, a clinical trial that examines the long-term effects of baroreflex activation therapy, or BAT, shows that BAT may provide patients with sustained and durable benefits in exercise capacity, functional status, and quality of life.=

Watch as CMHC faculty Juan Frías, MD and Shivani Agarwal, MD discuss important pearls in the management of type 2 diabetes, including screening for social determinants of health (SDOH), the impact of SDOH on treatment, culturally-sensitive care, as well as the importance of early glycemic control, screening, and GDMT optimization (recorded October 20, 2023).

In this episode, Our guest host Avromi talks about pushing GDMT via the STRONG-HF trial. We also start our MHP2023 recap series with some pearls from Dr. Zier's cardiology update session. | 00.33 - TOC | | 01.19 - MHP2023 Afib updates | AFFIRM 2002 (rate and rhythm non-inferior) EAST-AFNET 4 - using dofetilide CABANA - using ablation and evaluating HF patients ESC commentary - impact of AFFIRM and changes in management to today | 03.04 - Guest host Avromi and STRONG-HF [Lancet 2022]. Click here for a slide deck overview of the study. | | 08.49 - MHP2023 high-sensitivity Troponin and AMI management | COMPASS-MI - using hs-cTnT for early rule out PLATO (lower primary outcome w/ ticagrelor v clopidogrel, equivalent bleeding), TRITON-TIMI 38 (lower primary outcome w/ prasugrel v clopidogrel, equivalent bleeding), ISAR-REACT 5 (lower mortality w/prasugrel v ticagrelor w/ similar bleeding risks) RAPID CABG (NOT PEER REVIEWED YET)- similar rates of bleeding waiting off ticagrelor 2-3d vs 5-7d REVERSE-IT - bentracimab for reversal of ticagrelor 2023 ESC Guidelines for ACS | 11.17 - Closing | [The appearance of external hyperlinks does not constitute endorsements by UCSF of the linked websites, or the information, products, or services contained therein. UCSF does not exercise any editorial control over the information found therein, nor does UCSF make any representation of their accuracy or completeness. All information contained in this episode are the opinions of the respective speakers and not necessarily the views their respective institutions or UCSF, and is only provided for information purposes, not to diagnose or treat.] png image from pngtree.com

Episode 154: Heart Failure and GDMTDr. Malave explains the four main medications that are part of the guideline-directed medical therapy of heart failure with reduced ejection fraction. Dr. Arreaza added comments and questions.  Written by Maria Fernanda Malave, MD. Edits by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Brief introduction: Heart failure (HF) is a common condition that affects about 23 million people in the world, and it is estimated that 50% of cases are due to heart failure with reduced ejection fraction (HFrEF). It is a major public health concern because of the high morbidity and mortality with a 5-year survival rate of 25% after hospitalization due to HFrEF.In recent years, the management of HFrEF has evolved due to increased evidence in favor of certain medications. Guideline-directed medical therapy (GDMT) is the foundation of medical therapy for these patients, and it is the result of multiple randomized controlled trials and reviews favoring four main drug classes: 1. renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors -ACEi- and angiotensin receptor blockers -ARB), 2. evidence-based β-blockers, 3. mineralocorticoid inhibitors, and 4. sodium-glucose cotransporter 2 inhibitors -SGLT-2i-. The benefit of this therapy is mostly seen when these four groups of medications are used in conjunction. During this episode, we will provide some key elements about the prescription of these medications, but this is only an overview, and you are invited to continue learning from reputable sources.Definitions: HF is defined as the impairment of the heart to meet the metabolic demands of the body. It can be caused by multiple conditions that interfere with the filling up of the heart or conditions that prevent an effective ejection of blood out of the heart. Classification of HFrEF: Based on the EF by echocardiogram, heart failure can be classified as:Heart failure with preserved ejection fraction (HFpEF) when the EF is 50% or more.Heart failure with mildly reduced ejection fraction when EF ranges between 41-49%.Heart failure with reduced ejection fraction (HFrEF) when EF is 40% or less.GDMT: Once we make the diagnosis of HF, it is key to educate our patients and re-educate them every single visit about the importance of guideline-directed medical therapy (GDMT) and lifestyle modifications, because this can change the prognosis and exacerbation rates. Many patients think that since they are feeling well after starting GDMT they can stop it, but that's going to increase exacerbations, hospitalizations, and decrease quality of life. Key points to discuss with patients.First, discuss that GDMT are disease-modifying drugs that regulate the neurohormonal system to stop the progression of the disease. We should explain to our patients that medications should be taken despite feeling well. Also, patients should be educated about regular follow-ups and medication titration. We can even instruct our patients about increasing their furosemide dose if they observe signs of overload, such as a weight increase of 2-3 kgs in 3-4 days, tight rings, socks or bracelets, also Paroxysmal nocturnal dyspnea, dyspnea on exertion, and more.  Second, lifestyle modifications such as: quit smoking and alcohol. Additionally, in general, water restriction between 1.2-1.5L daily, salt restriction (there is no official recommendation about how many grams, but in general we recommend less than 2g daily). Third, it is highly recommended to do aerobic exercise that produces mild dyspnea since this improves cardiovascular capacity and decreases hospitalization risk. Patients should be encouraged to have their annual influenza vaccine and pneumococcal vaccine according to their own immunization schedule. According to the AFP journal, in September 2022, researchers found a clinically and statistically significant reduction in all-cause mortality for patients who received an influenza vaccine right after an MI, with a number needed to treat of 50, the effectivity of the vaccine may vary by season.GDMT, groups of medications:What are the basic medications any patient with HF should be on? At least, patients should be on angiotensin receptor blockers ARBs/ACEIs and Beta-blockers. Let's keep in mind that beta-blockers should be given cautiously in cases of exacerbation, but in general low doses are safe. We also have the angiotensin receptor/neprilysin inhibitors (ARNIs), a group of medications whose representative is the combination of sacubitril/valsartan, aka Entresto®. This medication should be the target once ARBs/ACEIs are tolerated. ARBs/ACEIs/ARNIs should be discontinued in the setting of advanced CKD, with a GFR of 30 or less. This applies to other medications used in HF such as SGLT-2 and mineralocorticoid receptor antagonist (MRA, such as spironolactone/eplerenone). Remember that SGLT-2 inhibitors should be started regardless diabetes status, and BB are safe in the setting of CKD. We also have other groups that are considered safe in patients with advanced CKD such as hydralazine/isosorbide dinitrate (combined or not), which are used in African Americans whose BP and HF symptoms do not improve with maximally tolerated dose of ARBs/ACEIs + BB.Ivabradine: Let's not forget about ivabradine, which is an SA node inhibitor like BB. Patients need to meet criteria such as a maximally tolerated dose of beta-blocker, heart rate of a least 70 or more and being on normal sinus rhythm to be started on this medication. Ivabradine does not improve survival as BB do, so even though they are not contraindicated in HF exacerbation, BB are still preferred since ivabradine does not decrease mortality.Titration and follow-ups in the HF management:-ARBs/ACEIs/ARNIs should be titrated approx. Q2 weeks until the maximally tolerated dose is achieved, ARNI should be titrated up Q2-4weeks. With these medications, we should monitor BP, potassium levels and Glomerular Filtration Rate (GFR). -BB can also be titrated up Q2weeks until the maximally tolerated dose is achieved. HR, BP and signs of congestion should be observed in patients on BB. Same for hydralazine/isosorbide, with BP follow-up. -MRA, such as spironolactone/eplerenone, these meds can be added in patients who remain symptomatic despite maximally tolerated doses of “ARBs or ACEIs or ARNIs” plus Beta-blockers. For MRA, potassium level, and GFR should be monitored every 2-3 days after initiation, 7 days after titration, monthly for 3 months, and then Q3 months. To start a patient on MRA, K+ must be lower than 5.Patients with HF should be followed up at least in a 2-week interval either via telephone, telemedicine, or clinic visit to assess symptoms, vital signs, bloodwork and to perform a physical exam. Monitoring EF: After 3-6 months of the patient´s stabilization, we should reorder an echo, EKG, BNP and Basic Metabolic Panel. The ejection fraction improves in all patients after GDMT initiation and compliance, and in some patients, this improvement is very significant, so we need to reassess EF after stabilization. Comorbidities: Also, let´s keep in mind that most of the patients have associated comorbidities such as Afib, diabetes, valve disease, or anemia. These comorbidities must be addressed either by starting anticoagulation, adjusting anti-diabetes medications, starting iron, or referring to cardiology if a valve replacement is needed.When to refer to Cardiology? Some patients will qualify for device therapy (ICD) as a primary prevention for ventricular arrhythmias that can degenerate either into torsades or ventricular fibrillation. These patients must be symptomatic, at least in 3 months of maximally tolerated GDMT, and EF between 30-35%. Symptomatic

The following question refers to Section 8.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by University of Southern California cardiology fellow and CardioNerds FIT Trialist Dr. Michael Francke, and then by expert faculty Dr. Shashank Sinha. Dr. Sinha is an Assistant Professor of Medical Education at the University of Virginia School of Medicine and an advanced heart failure, MCS, and transplant cardiologist at Inova Fairfax Medical Campus. He currently serves as both the Director of the Cardiac Intensive Care Unit and Cardiovascular Critical Care Research Program at Inova Fairfax. He is also a Steering Committee member for the multicenter Cardiogenic Shock Working Group and Critical Care Cardiology Trials Network and an Associate Editor for the Journal of Cardiac Failure, the official Journal of the Heart Failure Society of America. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #30 Ms. V. Tea is a 55-year-old woman with a history of cardiac sarcoidosis, heart failure with mildly reduced ejection fraction (HFmrEF – EF 40%), and ventricular tachycardia with CRT-D who presents with recurrent VT. She has undergone several attempts at catheter ablation of VT in the past and previously had been trialed on amiodarone which was discontinued due to hepatotoxicity. She now continues to have episodic VT requiring anti-tachycardia pacing and ICD shocks despite medical therapy with mexiletine, metoprolol, and sotalol. Her most recent PET scan showed no active areas of inflammation. Currently, her vital signs are stable, and labs are unremarkable. What is the best next step for this patient? A Evaluation for heart transplant B Evaluation for LVAD C Dobutamine D Prednisone E None of the above Answer #30 Explanation The correct answer is A – evaluation for heart transplant. For selected patients with advanced heart failure despite GDMT, cardiac transplantation is indicated to improve survival and quality of life (Class 1, LOE C-LD). Heart transplantation, in this context, provides intermediate economic value. Clinical indicators include refractory or recurrent ventricular arrhythmias with frequent ICD shocks. Patient selection for heart transplant includes assessment of comorbidities, goals of care, and various other factors. The United Network of Organ Sharing Heart Transplant Allocation Policy was revised in 2018 with a 6-tiered system to better prioritize unstable patients and minimize waitlist mortality. VT puts the patient as a Status 2 on the transplant list. There was a contemporary analysis of patients with end-stage cardiomyopathy due to cardiac sarcoidosis, published in Journal of Cardiac Failure, in 2018 that demonstrated similar 1-year and 5-year survival after heart transplant between patients with and without cardiac sarcoidosis. Choice B (evaluation for LVAD) is incorrect. While bridge to transplant with LVAD is definitely a potential next step in patients with cardiac sarcoidosis, it is not recommended in patients presenting primarily with refractory ventricular arrhythmias due to granuloma-induced scarring. In this situation, patients benefit from direct heart transplant rather than bridge to transplant LVAD approa...

The following question refers to Section 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Palisades Medical Center medicine resident & CardioNerds Academy Fellow Dr. Maryam Barkhordarian, answered first by Hopkins Bayview medicine resident & CardioNerds Academy Faculty Dr. Ty Sweeny, and then by expert faculty Dr. Gregg Fonarow. Dr. Fonarow is the Professor of Medicine and Interim Chief of UCLA's Division of Cardiology, Director of the Ahmanson-UCLA Cardiomyopathy Center, and Co-director of UCLA's Preventative Cardiology Program. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #28 Mr. Gene D'aMeTi, a 53-year-old African American man with ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 30-35%), is recently admitted with acutely decompensated heart failure and acute kidney injury on chronic kidney disease stage III. His outpatient regiment includes sacubitril-valsartan 97-103mg BID, carvedilol 25mg BID, and hydralazine 50mg TID. Sacubitril-valsartan was held because of worsening renal function. Despite symptomatic improvement with diuresis, his renal function continues to decline. He is otherwise well perfused & with preservation of other end organ function.   Throughout this hospitalization, he has steadily become more hypertensive with blood pressures persisting in the 170s/90s mmHg. What would be an appropriate adjustment to his medication regimen at this time? A Resume Losartan only B Start Amlodipine C Increase current Hydralazine dose D Start Isosorbide dinitrate therapy E Both C & D Answer #28 ExplanationThe correct answer is E – both increasing the current hydralazine dose (C) and starting isosorbide dinitrate therapy (D). Although ACEI/ARB therapy (choice A) has shown a mortality and morbidity benefit in HFrEF, caution should be used in patients with renal insufficiency. In this patient with ongoing decline in renal function, RAAS-inhibiting therapies (ACEi, ARB, ARNI, MRA) should be avoided. In this case, as his RAAS-I has been stopped, it would be reasonable to increase current therapies to target doses (or nearest dose tolerated), as these demonstrated both safety and efficacy in trials (Class 1, LOE A). Considering that his high dose ARNI was stopped, it is unlikely that either hydralazine or isosorbide dinitrate alone, even at maximal doses, would be sufficient to control his blood pressure (Options C and D, respectively). Interestingly, in the original study by Massie et. Al (1977), the decision was made to combine these therapies as the result was thought to be superior to either medication alone. ISDN would provide preload reduction, while Hydralazine would decrease afterload. Consequently, we do not have data looking at the individual benefit of either medication in isolation. In self-identified African Americans with NYHA class III or IV HFrEF already on optimal GDMT, the addition of hydralazine & isosorbide dinitrate is recommended to improve symptoms and reduce mortality and morbidity (Class 1, LOE A). In this case, as the patient has evidence of progressive renal disfunction, we are limited in using traditional RAAS-I, such as ACEI, ARB, or ARNI.

The following question refers to Section 7.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Cleveland Clinic internal medicine resident and CardioNerds Intern Akiva Rosenzveig, answered first by UPMC Harrisburg cardiology fellow and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Randall Starling. Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling's sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.  The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #27 Which of the following sentences regarding diuretics in the management of heart failure is correct? A In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes. B Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates. C The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms. D The maximum daily dose of furosemide is 300 mg. Answer #27 Explanation Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF. Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival. Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class...

The following question refers to Sections 10.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy House Faculty Leader Dr. Dinu Balanescu, and then by expert faculty Dr. Ileana Pina. Dr. Pina is Professor of Medicine and Quality Officer for the Cardiovascular Line at Thomas Jefferson University, Clinical Professor at Central Michigan University, and Adjunct Professor of Biostats and Epidemiology at Case Western University. She serves as Senior Fellow and Medical Officer at the Food and Drug Administration's Center for Devices and Radiological Health. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #24 Mr. E. Regular is a 61-year-old man with a history of HFrEF due to non-ischemic cardiomyopathy (latest LVEF 40% after >3 months of optimized GDMT) and persistent atrial fibrillation. He has no other medical history. He has been on metoprolol and apixaban and has also undergone multiple electrical cardioversions and catheter ablations for atrial fibrillation but remains symptomatic with poorly controlled rates. His blood pressure is 105/65 mm Hg. HbA1c is 5.4%. Which of the following is a reasonable next step in the management of his atrial fibrillation? A Anti-arrhythmic drug therapy with amiodarone. Stop apixaban. B Repeat catheter ablation for atrial fibrillation. Stop apixaban. C AV nodal ablation and RV pacing. Shared decision-making regarding anticoagulation. D AV nodal ablation and CRT device. Shared decision-making regarding anticoagulation. Answer #24 Explanation The correct answer is D – AV nodal ablation and CRT device along with shared decision-making regarding anticoagulation.” Maintaining sinus rhythm and atrial-ventricular synchrony is helpful in patients with heart failure given the hemodynamic benefits of atrial systole for diastolic filling and having a regularized rhythm. Recent randomized controlled trials suggest that catheter-based rhythm control strategies are superior to rate control and chemical rhythm control strategies with regards to outcomes in atrial fibrillation. For patients with heart failure and symptoms caused by atrial fibrillation, ablation is reasonable to improve symptoms and quality of life (Class 2a, LOE B-R). However, Mr. Regular has already had multiple failed attempts at ablations (option B). For patients with AF and LVEF ≤50%, if a rhythm control strategy fails or is not desired, and ventricular rates remain rapid despite medical therapy, atrioventricular nodal ablation with implantation of a CRT device is reasonable (Class 2a, LOE B-R). The PAVE and BLOCK-HF trials suggested improved outcomes with CRT devices in these patients. RV pacing following AV nodal ablation has also been shown to improve outcomes in patients with atrial fibrillation refractory to other rhythm control strategies. In patients with EF >50%, there is no evidence to suggest that CRT is more beneficial compared to RV-only pacing. However, RV pacing may produce ventricular dyssynchrony and when compared to CRT in those with reduced EF (≤ 50%),

Visit pointofcaremedicine.com to see the templates, pearls, literature, and other resources discussed in this episode. Our mission is to create accessible and easy-to-use digital resources that help healthcare professionals tackle common clinical presentations at the point of care, without getting bogged down by unnecessary details or trivia. Show Notes: 00:00:15 - Introduction and Terminology 00:01:51 - Beta Blockers 00:02:47 - ACE/ARB/ARNI 00:04:30 - MRA's 00:05:28 - SGLT2i's 00:06:12 - Nitrates and Hydralazine 00:08:41 - Loop Diuretics 00:09:25 - Initiating and Titrating GDMT 00:11:18 - Barriers and Other Considerations 00:13:44 - Resources for Use at the Point of Care Other Resources and References: GDMT for Everyone – https://www.gdmt.org/HFrEF.php Table of all the Sacubitril/Valsartan Trials Published to Date (2023) - https://twitter.com/jaycvance/status/1660732176999108623 An elegant graphic showing how the hazard ratios with confidence intervals for all-cause mortality improve based on adding on each extra GDMT medication; brought to my attention by a tweet from Dr. Scott Cameron - ⁠https://twitter.com/2Scottish/status/1556798319996932096⁠ Heart Failure with Reduced Ejection Fraction: A Review (JAMA, 2020) - https://pubmed.ncbi.nlm.nih.gov/32749493/ A Systematic Review and Network Meta-Analysis of Pharmacological Treatment of Heart Failure With Reduced Ejection Fraction (JACC, 2022) - ⁠https://www.jacc.org/doi/full/10.1016/j.jchf.2021.09.004

AF screening, BNP, a new SGLT2 inhibitor, a sky-is-blue study, and the UK Mini Mitral surgical trial are discussed in this week's podcast This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I AF Screening - Effects of Atrial Fibrillation Screening According to N-Terminal Pro-B-Type Natriuretic Peptide: A Secondary Analysis of the Randomized LOOP Study https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.064361 - Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial https://doi.org/10.1016/S0140-6736(21)01698-6 - Natural History of Subclinical Atrial Fibrillation Detected by Implanted Loop Recorders https://www.jacc.org/doi/full/10.1016/j.jacc.2019.09.050 - Prevalence and Prognostic Significance of Bradyarrhythmias in Patients Screened for Atrial Fibrillation vs Usual Care https://jamanetwork.com/journals/jamacardiology/fullarticle/2801362 - Stepwise mass screening for atrial fibrillation using N-terminal pro b-type natriuretic peptide: the STROKESTOP II study design https://doi.org/10.1093/europace/euw319 - Current misconception 3: that subgroup-specific trial mortality results often provide a good basis for individualising patient care https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068511/ II Frailty and GDMT of HFrEF Frailty Linked to Lower Use of Guideline Treatments in HFrEF https://www.medscape.com/viewarticle/993218 - Physical Frailty and Use of Guideline‐Recommended Drugs in Patients With Heart Failure and Reduced Ejection Fraction https://www.ahajournals.org/doi/10.1161/JAHA.122.026844 III Sotagliflozin FDA Approves New Drug, Sotagliflozin, for Heart Failure https://www.medscape.com/viewarticle/992518 - Sotagliflozin in Patients with Diabetes and Chronic Kidney Disease https://www.nejm.org/doi/full/10.1056/NEJMoa2030186 - Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure https://www.nejm.org/doi/full/10.1056/NEJMoa2030183 IV Mini-Mitral Support for Minimally Invasive Mitral Valve Repair: Mini Mitral Published https://www.medscape.com/viewarticle/993191 - Minithoracotomy vs Conventional Sternotomy for Mitral Valve Repair https://jamanetwork.com/journals/jama/article-abstract/2805908 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact: news@medscape.net

The following question refers to Section 8.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by University of Southern California cardiology fellow and CardioNerds FIT Trialist Dr. Michael Francke, and then by expert faculty Dr. Prateeti Khazanie. Dr. Khazanie is an associate professor and advanced heart failure and transplant Cardiologist at the University of Colorado. Dr. Khazanie is an author on the 2022 ACC/AHA/HFSA HF Guidelines, the 2021 HFSA Universal Definition of Heart Failure, and multiple scientific statements. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Clinical Trials Talks Question #22 You are taking care of a 34-year-old man with chronic systolic heart failure from NICM with LVEF 20% s/p CRT-D. The patient was admitted 1 week prior with acute decompensated heart failure. Despite intravenous diuretics the patient developed acute kidney injury, and ultimately placed on intravenous inotropes on which he now seems dependent. He has been following up with an advanced heart failure specialist as an outpatient and has been undergoing evaluation for heart transplantation, which was subsequently completed in the hospital.   His exam is notable for an elevated JVP, a III/VI holosystolic murmur, and warm extremities with bilateral 1+ edema. His most recent TTE shows LVEF 20%, moderate MR, moderate-severe TR and estimated RVSP 34 mmHg. His most recent laboratory data shows Na 131 mmol/L, Cr 1.2 mg/dL, and lactate 1.6 mmol/L. Pulmonary artery catheter shows RA 7 mmHg, PA 36/15 mmHg, PCWP 12 mmHg, CI 2.4 L/min/m2 and SVR 1150 dynes*sec/cm5.   The patient was presented at transplant selection committee and approved for listing for orthotopic heart transplant. What is the most appropriate next step in the management of this patient? A Refer patient for transcatheter edge-to-edge repair for MR B Continue IV inotropes as a bridge-to-transplant C Refer patient for tricuspid valve replacement D Initiate 1.5L fluid restriction Answer #22 Explanation The correct answer is B – continue IV inotropes as a bridge-to-transplant. Positive inotropic agents may improve hemodynamic status, but have not been shown to improve survival in patients with HF. These agents may help HF patients who are refractory to other therapies and are suffering consequences from end-organ-hypoperfusion. Our patient is admitted with worsening advanced heart failure requiring intravenous inotropic support. He has been appropriately evaluated and approved for heart transplant. He has demonstrated the requirement of continuous inotropic support to maintain perfusion. In patients such as this with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as “bridge therapy” (Class 2a, LOE B-NR). Continuous IV inotropes also have a Class 2b indication (LOE B-NR) in select patients with stage D HF despite optimal GDMT and device therapy who are ineligible for either MCS or cardiac transplantation, as palliative therapy for symptom control and improvement in functio...

The following question refers to Section 7.6 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by premedical student and CardioNerds Intern Pacey Wetstein, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy Chief Dr. Teodora Donisan, and then by expert faculty Dr. Nancy Sweitzer.Dr. Sweitzer is Professor of Medicine, Vice Chair of Clinical Research for the Department of Medicine, and Director of Clinical Research for the Division of Cardiology at Washington University School of Medicine. She is the editor-in-chief of Circulation: Heart Failure. Dr. Sweitzer is a faculty mentor for this Decipher the HF Guidelines series.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. /*! elementor - v3.13.3 - 28-05-2023 */ .elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}Clinical Trials Talks Question #21 Ms. Betty Blocker is a 60-year-old woman with a history of alcohol-related dilated cardiomyopathy who presents for follow up. She has been working hard to improve her health and is glad to report that she has just reached her 5-year sobriety milestone. Her current medications include metoprolol succinate 100mg daily, sacubitril-valsartan 97-103mg BID, spironolactone 25mg daily, and empagliflozin 10mg daily. She is asymptomatic at rest and up to moderate exercise, including chasing her grandchildren around the yard. A recent transthoracic echocardiogram shows recovered LVEF from previously 35% now to 60%. Ms. Blocker does not love taking so many medications and asks about discontinuing her metoprolol. Which of the following is the most appropriate response to Ms. Blocker's request? A Since the patient is asymptomatic, metoprolol can be stopped without risk B Stopping metoprolol increases this patient's risk of worsening cardiomyopathy regardless of current LVEF or symptoms C Because the LVEF is now >50%, the patient is now classified as having HFpEF and beta-blockade is no longer indicated; metoprolol can be safely discontinued D Metoprolol should be continued, but it is safe to discontinue either ARNi or spironolactone Answer #21 Explanation The correct answer is D – continue current therapy. The patient described above was initially diagnosed with HFrEF and experienced significant symptomatic improvement with GDMT, so she now has heart failure with improved ejection fraction (HFimpEF). In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic (Class 1, LOE B-R). Although symptoms, functional capacity, LVEF and reverse remodeling can improve with GDMT,

The following question refers to Sections 7.3.2, 7.3.8, and 7.6.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Palisades Medical Center medicine resident & CardioNerds Intern Dr. Maryam Barkhordarian, answered first by Hopkins Bayview medicine resident & CardioNerds Academy Fellow Dr. Ty Sweeny, and then by expert faculty Dr. Robert Mentz. Dr. Mentz is associate professor of medicine and section chief for Heart Failure at Duke University, a clinical researcher at the Duke Clinical Research Institute, and editor-in-chief of the Journal of Cardiac Failure. Dr. Mentz is a mentor for the CardioNerds Clinical Trials Network as lead principal investigator for PARAGLIDE-HF and is a series mentor for this very Decipher the Guidelines Series. For these reasons and many more, he was awarded the Master CardioNerd Award during ACC22. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #20 Ms. Betty Blocker is a 60-year-old woman with a history of alcohol-related dilated cardiomyopathy who presents for follow up. She has been working hard to improve her health and is glad to report that she has just reached her 5-year sobriety milestone. Her current medications include metoprolol succinate 100mg daily, sacubitril-valsartan 97-103mg BID, spironolactone 25mg daily, and empagliflozin 10mg daily. She is asymptomatic at rest and up to moderate exercise, including chasing her grandchildren around the yard. A recent transthoracic echocardiogram shows recovered LVEF from previously 35% now to 60%. Ms. Blocker does not love taking so many medications and asks about discontinuing her metoprolol. Which of the following is the most appropriate response to Ms. Blocker's request? A Since the patient is asymptomatic, metoprolol can be stopped without risk B Stopping metoprolol increases this patient's risk of worsening cardiomyopathy regardless of current LVEF or symptoms C Because the LVEF is now >50%, the patient is now classified as having HFpEF and beta-blockade is no longer indicated; metoprolol can be safely discontinued D Metoprolol should be continued, but it is safe to discontinue either ARNi or spironolactone Answer #20 Explanation The correct answer is B – stopping metoprolol would increase her risk of worsening cardiomyopathy. Heart failure tends to be a chronically sympathetic state. The use of beta-blockers (specifically bisoprolol, metoprolol succinate, and carvedilol) targets this excess adrenergic output and has been shown to reduce the risk of death in patients with HFrEF. Beyond their mortality benefit, beta-blockers can improve LVEF, lessen the symptoms of HF, and improve clinical status. Therefore, in patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations (Class 1, LOE A). Beta-blockers in this setting provide a high economic value. Table 14 of the guidelines provides recommendations for target doses for GDMT medications. Specifically for beta blockers, those targets are 25-50mg twice daily for carvedilol (or 80mg once daily for the continuous release formulation), 200mg once daily for metoprolol succinate,

In this episode of the podcast, Andrew Perry discusses with Dr. Albert the barriers to implementing guideline-directed medical therapy in heart failure with reduced ejection fraction and how to improve matters. If you enjoy the show, please leave us a podcast review at https://itunes.apple.com/gb/podcast/heart-podcast/id445358212?mt=2

In this episode of the podcast, Andrew Perry discusses with Dr. Albert the barriers to implementing guideline-directed medical therapy in heart failure with reduced ejection fraction and how to improve matters. If you enjoy the show, please leave us a podcast review at https://itunes.apple.com/gb/podcast/heart-podcast/id445358212?mt=2

Michael Dickinson, MD, FACC, FHFSA - board-certified Cardiologist and Heart Failure Specialist answers questions on initiating GDMT-4 and reducing HF hospitalizations.

The following question refers to Section 10.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Boston University cardiology fellow and CardioNerds Ambassador Dr. Alex Pipilas, and then by expert faculty Dr. Ileana Pina.Dr. Pina is Professor of Medicine and Quality Officer for the Cardiovascular Line at Thomas Jefferson University, Clinical Professor at Central Michigan University, and Adjunct Professor of Biostats and Epidemiology at Case Western University. She serves as Senior Fellow and Medical Officer at the Food and Drug Administration's Center for Devices and Radiological Health.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #15 Mrs. Framingham is a 65-year-old woman who presents to her cardiologist's office for stable angina and worsening dyspnea on minimal exertion. She has a history of non-insulin dependent type 2 diabetes mellitus and hypertension. She is taking metformin, linagliptin, lisinopril, and amlodipine. Blood pressure is 119/70 mmHg. Labs are notable for a hemoglobin of 14.2 mg/dL, iron of 18 mcg/dL, ferritin 150 ug/L, transferrin saturation 15%, and normal creatine kinase. An echocardiogram shows reduced left ventricular ejection fraction of 25%. Coronary angiography shows obstructive lesions involving the proximal left anterior descending, left circumflex, and right coronary arteries. In addition to optimizing GDMT, which of the following are recommendations for changes in management? A Anticoagulation, percutaneous revascularization, and IV iron B A change in her diabetic regimen, percutaneous revascularization, and PO iron C A change in her diabetic regimen, surgical revascularization, and IV iron D A change in her diabetic regimen, medical treatment alone for CAD, and PO iron E Anticoagulation and surgical revascularization Answer #15 Explanation The correct answer is C – a change in her diabetic regimen, surgical treatment and IV iron. Multimorbidity is common in patients with heart failure. More than 85% of patients with HF also have at least 2 additional chronic conditions, of which the most common are hypertension, ischemic heart disease, diabetes, anemia, chronic kidney disease, morbid obesity, frailty, and malnutrition. These conditions can markedly impact patients' tolerance to GDMT and can inform prognosis. Not only was Mrs. F found with HFrEF (most likely due to ischemic cardiomyopathy), but she also suffers from severe multi-vessel coronary artery disease, hypertension, and non-insulin dependent type 2 diabetes mellitus. In addition to starting optimized GDMT for HF, specific comorbidities in the heart failure patient warrant specific treatment strategies. Mrs. Framingham would benefit from a change in her diabetic regimen, namely switching from linagliptin to an SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin). In patients with HF and type 2 diabetes, the use of SGLT2i is recommended for the management of hyperglycemia and to reduce HF related morbidity and mortality (Class 1, LOE A). Furthermore, as she has diabetes, symptomatic severe multi-vessel CAD, and LVEF≤35%,

The following question refers to Section 4.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by medicine resident Dr. Ahmed Ghoneem, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #21 Ms. J is a 57-year-old woman with a past medical history of myocardial infarction resulting in ischemic cardiomyopathy, heart failure with reduced ejection fraction, and major depressive disorder who presents today for follow-up. She reports feeling extremely overwhelmed lately due to multiple life stressors. She is on appropriate cardiovascular GDMT agents and is not prescribed any medications for her mood disorder. True or false: in addition to psychotherapy for stress management, it is appropriate to consider Ms. J for anti-depressant SSRI pharmacotherapy at this time to improve cardiovascular outcomes. A True B False Answer #21 Explanation The correct answer is FALSE. An ESC class 3 recommendation states that SSRIs, SNRIs, and tricyclic antidepressants are not recommended in patients with heart failure and major depression; this is based on data suggesting potential lack of SSRI efficacy for reducing depression or cardiovascular events, as well as safety data indicating an association between SSRI use and increased risk of CV events and all-cause as well as cardiovascular mortality among HF patients. Mental health disorders are associated with worse outcomes in patients with ASCVD and appropriate treatment effectively reduces stress symptoms and improves quality of life. Nonpharmacologic modalities of treatment (exercise therapy, psychotherapy, collaborative care) should be considered before pharmacotherapy to improve cardiovascular outcomes in patients with heart failure. Of note, the ESC suggests SSRI treatment be considered for patients with coronary heart disease (without HF) and moderate-to-severe major depression based on data that SSRI treatment is associated with lower rates of CHD readmission (RR 0.63), all-cause mortality (RR 0.56), and the composite endpoint of all-cause mortality/MI/PCI (HR 0.69) vs. no treatment. This is a class 2a recommendation. ESC also gives a class 2a recommendation to consider referral to psychotherapeutic stress management for individuals with stress and ASCVD to improve CV outcomes and reduce stress symptoms. The ACC/AHA guidelines do not provide focused recommendations regarding mental health considerations in patients with elevated cardiovascular risk. Main Takeaway It is important to consider mental health treatment in patients with ASCVD as mental disorders are associated with increased CVD risk and poor patient prognosis, and data support that mental health interventions can improve overall and CVD outcomes, as well as improve quality of life. Guideline Loc. Section 4.4 CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!

Drs Michelle Kittleson and Jennifer Ho discuss the vital clues to help diagnose and precisely treat heart failure with preserved ejection fraction. Relevant disclosures can be found with the episode show notes on Medscape (https://www.medscape.com/viewarticle/982159). The topics and discussions are planned, produced, and reviewed independently of advertisers. This podcast is intended only for US healthcare professionals. Resources 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 Heart Failure With Preserved Ejection Fraction: A Kidney Disorder? https://www.ahajournals.org/doi/full/10.1161/circulationaha.116.022249 Optimal Pharmacologic Treatment of Heart Failure With Preserved and Mildly Reduced Ejection Fraction: A Meta-analysis https://pubmed.ncbi.nlm.nih.gov/36125813/

It's another session of CardioNerds Rounds! In these rounds, Dr. Jenna Skowronski (Chief FIT at University of Pittsburgh) and Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) join transformational leader, educator and researcher, Dr. Mary Norine Walsh (Director of Heart Failure and Transplantation at Ascension St. Vincent Heart Center and Program Director of AHFT at St. Vincent) to discuss cardio-obstetrics and heart failure cases. Amongst her many accomplishments, Dr. Walsh is past president of the American College of Cardiology, Deputy Editor of JACC Case Reports, and a preeminent voice and thought leader in women's cardiovascular health. Audio editing by CardioNerds academy intern, Pace Wetstein. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Cardio-Obstetrics and Heart Failure Case 1 Synopsis: A woman in her earlier 30s, G1P1, with a history significant for peripartum cardiomyopathy presents to clinic for pre-conception counseling.  Her prior pregnancy was in her late 20s with an uneventful pre-natal course and a spontaneous vaginal delivery at 37w2d.  Two weeks after delivery, she experienced symptoms of heart failure and was found to have a new diagnosis of HFrEF. At that time TTE showed LVEF 30-35%, LVIDd 5.1cm (top normal size), diffuse hypokinesis. At that time, she was diuresed and discharged on metoprolol succinate 25mg po daily and furosemide 20mg po daily.  She had one follow up visit 6 months postpartum and the furosemide was discontinued.  Today in your office, she has NYHA Class I symptoms with no signs of symptoms of congestion. She walks daily and does vigorous exercise 1-2 times per week, while remaining on metoprolol.  Repeat TTE with LVEF 45-50% and similar LV size. She would like to have another child and was referred to you for counseling. Case 1 Rounding Pearls: Dr. Walsh discussed extensively the importance of full GDMT in this patient who was initially undertreated with only a beta blocker.  If patients are breastfeeding, clinicians should consider the addition of ACE-Inhibitor and Spironolactone. Otherwise, if not breastfeeding, they should receive maximally tolerated doses of full GDMT. For more details on medical therapy for Heart Failure during pregnancy and after, refer to this previous CardioNerds Episode with Dr. Julie Damp. Patients with peripartum cardiomyopathy are at highest risk of worsening LV systolic function when they have persistent LV systolic dysfunction from their initial diagnosis. In this circumstance, shared decision making is paramount.  These patients should receive counseling on contraception and risk of pregnancy on worsening LV function, death, & fetal demise. In addition, counseling includes discussing with patients limited options in some states for complete, comprehensive reproductive care, including pregnancy termination. If patients with prior peripartum cardiomyopathy do become pregnant, a team-based approach including cardiologists, maternal fetal medicine, and obstetrics (amongst other team members) is essential to determine care & delivery timing/method.  These patients should also be examined for signs of decompensation throughout the pregnancy, including rales, S3 or a reported history of PND.

The following question refers to Section 8.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.  The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by Brigham & Women's medicine resident and Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Prateeti Khazanie. Dr. Khazanie is an Associate Professor and Advanced Heart Failure and Transplant Cardiologist at the University of Colorado. She was an undergraduate at Duke University as a B.N. Duke Scholar. She spent two years at the NIH in the lab of Dr. Anthony Fauci and completed a dual MD-MPH program at Duke Medical School. When she started residency, she thought she was going to be an ID doctor, but she fell in love with cardiology at Stanford where she was an intern, resident, and then chief resident. She went back to Duke for her general cardiology and advanced heart failure/transplant fellowships as well as research training at the DCRI. Dr. Khazanie joined the University of Colorado in 2015 as a health services clinician researcher with a focus on improving health equity and bioethics in advanced heart failure care. She mentors medical students, residents, and fellows and is a faculty mentor for the University of Colorado Cardiology Fellows “House of Cards” mentoring group. She has research funding from the NIH/NHLBI K23, NIH Ethics Grant, and Ludeman Center for Women's Health Research. Dr. Khazanie is an author on the 2022 ACC/AHA/HFSA HF Guidelines, the 2021 HFSA Universal Definition of Heart Failure, and multiple scientific statements. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #11 A 64-year-old woman with a history of chronic systolic heart failure secondary to NICM (LVEF 15-20%) s/p dual chamber ICD presents for routine follow-up. She reports several months of progressive fatigue, dyspnea, and peripheral edema. She has been hospitalized twice in the past year with acute decompensated heart failure. Efforts to optimize guideline directed medical therapy have been tempered by episodes of lightheadedness and hypotension. Her exam is notable for an elevated JVP, an S3 heart sound, and a III/VI holosystolic murmur best heard at the apex with radiation to the axilla. Labs show Na 130 mmol/L, Cr 1.8 mg/dL (from 1.1 mg/dL 6 months prior), and NT-proBNP 1,200 pg/mL. ECG in clinic shows sinus rhythm and a nonspecific IVCD with QRS 116 ms. Her most recent TTE shows biventricular dilation with LVEF 15-20%, moderate functional MR, moderate functional TR and estimated RVSP of 40mmHg. What is the most appropriate next step in management? A Refer to electrophysiology for upgrade to CRT-D B Increase sacubitril-valsartan dose C Refer for advanced therapies evaluation D Start treatment with milrinone infusion Answer #11 Explanation The correct answer is C – refer for advanced therapies evaluation. Our patient has multiple signs and symptoms of advanced heart failure including NYHA Class III-IV functional status, persistently elevated natriuretic peptides, severely reduced LVEF, evidence of end organ dysfunction, multiple hospitalizations for ADHF, edema despite escalating doses of diuretics, and progressive intolerance to GDMT. Importantly, the 2018 European Society of Cardiology revised definition of advanced HF focuses...

Recently Dr. Charlie Porter published a landmark article in JACC Cardio-Oncology titled "Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology" You can read the article here Our hosts Dr. Stephen Caselli and co-host Dr. Arjun K Ghosh are interviewing Dr. Charlers Porter to discuss the following topic “Permissive Cardiotoxicity”. Dr. Caselli is the executive director of ICOS, and Dr. Ghosh is a consultant cardiologist at University College London Hospitals and Barts Heart Centre. Dr. Porter is the founding Medical Director of cardio-oncology at the University of Kansas Medical Center. Dr. Porter has been actively involved in heart failure and cardiac transplantation for over thirty years in Kansas City. He worked with Dr. William Reed to help launch the third heart transplant program in Missouri and the first in Kansas City in 1985. He was a co-author of the research paper that introduced and validated the Kansas City Cardiomyopathy Questionnaire which has subsequently become one of the leading patient-centered quality-of-life surveys in the world. He had a recent review article published at JACC Cardio-oncology with the following title “Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology”.1 Episode Pearls   1. Permissive Cardiotoxicity is a novel term that represents an essential concept in the field of cardio-oncology and among practicing cardio-oncology specialists. It emphasizes a proactive rather than reactive approach to the continuation of lifesaving cancer therapies to achieve the best oncologic outcome while mitigating associated and potential cardiotoxicities. 2. Permissive cardiotoxicity–based treatment strategies often start with the recognition of this urgent need to commence anticancer therapy and for cardiology evaluation of CV risk factors without delaying important cancer treatment. Such patients may require a cardioprotective strategy implemented without the luxury of a few weeks of escalating GDMT for patients with HFrEF or the scheduling of several diagnostic studies over a period of days or weeks before the patient is deemed ready for cancer therapy. 3. A common example eluding how permissive cardiotoxicity as a concept is important, is trastuzumab interruption (about 62% in the study by Sardesai et. Al) in HER2-positive breast cancer demonstrated worse disease-free (adjusted HR: 4.4) and overall survival (adjusted HR: 4.8) after adjusting for age, stage, grade, estrogen receptor status, node status, and trastuzumab-associated cardiotoxicity.2 4. Another example is that developing severe hypertension as a side effect of VEGF inhibitors is associated with improved cancer outcomes in some tumors sensitive to VEGF inhibitors.3 5. Mindset needs to be changed from treating cardiotoxicity to screening and early detection of cardiotoxicity and from “Should this therapy be discontinued?” to “How can this therapy be continued?” 6. Implementing permissive cardiotoxicity needs collaboration and clinical care needs to be delivered in a multidisciplinary fashion involving the patient, oncologist, pharmacist, and cardio-oncology specialist.   References   1. Porter C, Azam TU, Mohananey D, et al. Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology. JACC CardioOncol. 2022;4(3):302-312. Published 2022 Sep 20. 2. Sardesai S, Sukumar J, Kassem M, et al. Clinical impact of interruption in adjuvant Trastuzumab therapy in patients with operable HER-2 positive breast cancer. Cardiooncology. 2020;6(1):26. Published 2020 Nov 5. 3. Cai J, Ma H, Huang F, et al. Correlation of bevacizumab-induced hypertension and outcomes of metastatic colorectal cancer patients treated with bevacizumab: a systematic review and meta-analysis. World J Surg Oncol. 2013;11:306. Published 2013 Nov 28. Thank you to our show notes writers for this episode: Abdelrahman Ali, MDCardio-Oncology FellowMD Anderson Cancer Center Department of Cardiology Alana Quadros

Don't Miss a Beat hosts are joined by Alexandre Mebazaa, MD, PhD, lead investigator of the STRONG-HF trial, to discuss the inspiration for the trial, its design, and important takeaways for those looking to implement a similar strategy of rapid, in-hospital uptitration of GDMT in heart failure at their own practice. Video Version

The following question refers to Section 7.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Cornell cardiology fellow and CardioNerds Ambassador Dr. Jaya Kanduri, and then by expert faculty Dr. Clyde Yancy.Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the AHA/ACC/HFSA Heart Failure Guideline Writing Committee.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #5 Ms. L is a 65-year-old woman with nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 35%, hypertension, and type 2 diabetes mellitus. She has been admitted to the hospital with decompensated heart failure (HF) twice in the last six months and admits that she struggles to understand how to take her medications and adjust her sodium intake to prevent this.  Which of the following interventions has the potential to decrease the risk of rehospitalization and/or improve mortality? A Access to a multidisciplinary team (physicians, nurses, pharmacists, social workers, care managers, etc) to assist with management of her HF   B Engaging in a mobile app aimed at improving HF self-care   C Vaccination against respiratory illnesses   D A & C   Answer #5   The correct answer is D – both A (access to a multidisciplinary team) and C (vaccination against respiratory illness).   Choice A is correct. Multidisciplinary teams involving physicians, nurses, pharmacists, social workers, care managers, dieticians, and others, have been shown in multiple RCTs, metanalyses, and Cochrane reviews to both reduce hospital admissions and all-cause mortality. As such, it is a class I recommendation (LOE A) that patients with HF should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival. Choice B is incorrect.  Self-care in HF comprises treatment adherence and health maintenance behaviors. Patients with HF should learn to take medications as prescribed, restrict sodium intake, stay physically active, and get vaccinations. They also should understand how to monitor for signs and symptoms of worsening HF, and what to do in response to symptoms when they occur. Interventions focused on improving the self-care of HF patients significantly reduce hospitalizations and all-cause mortality as well as improve quality of life. Therefore, patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner (Class I, LOE B-R). However, the method of delivery and education matters. Reinforcement with structured telephone support has been shown to be effective. In contrast the efficacy of mobile health-delivered educational interventions in improve self-care in patients with HF remains uncertain. Choice C is correct. In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality (Class 2a, LOE B-NR). For example, administration of the influenza vaccine in HF patients has been shown to reduce...

The following question refers to Section 7.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Cornell cardiology fellow and CardioNerds Ambassador Dr. Jaya Kanduri, and then by expert faculty Dr. Randall Starling.Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling's sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #6 Mr. D is a 50-year-old man who presented two months ago with palpations and new onset bilateral lower extremity swelling. Review of systems was negative for prior syncope. On transthoracic echocardiogram, he had an LVEF of 40% with moderate RV dilation and dysfunction. EKG showed inverted T-waves and low-amplitude signals just after the QRS in leads V1-V3. Ambulatory monitor revealed several episodes non-sustained ventricular tachycardia with a LBBB morphology. He was initiated on GDMT and underwent genetic testing that revealed 2 desmosomal gene variants associated with arrhythmogenic right ventricular cardiomyopathy (ARVC). Is the following statement true or false? “ICD implantation is inappropriate at this time because his LVEF is >35%” True   False   Answer #6 Explanation This statement is False. ICD implantation is reasonable to decrease sudden death in patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death who have an LVEF ≤45% (Class 2a, LOE B-NR). While the HF guidelines do not define high-risk features of sudden death, the 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy identify major and minor risk factors for ventricular arrhythmias as follows: Major criteria: NSVT, inducibility of VT during EPS, LVEF ≤ 49%. Minor criteria: male sex, >1000 premature ventricular contractions (PVCs)/24 hours, RV dysfunction, proband status, 2 or more desmosomal variants. According to the HRS statement, high risk is defined as having either three major, two major and two minor, or one major and four minor risk factors for a class 2a recommendation for primary prevention ICD in this population (LOE B-NR). Based on these criteria, our patient has 2 major risk factors (NSVT & LVEF ≤ 49%), and 3 minor risk factors (male sex, RV dysfunction, and 2 desmosomal variants) for ventricular arrhythmias. Therefore, ICD implantation for primary prevention of sudden cardiac death is reasonable. Decisions around ICD implantation for primary prevention remain challenging and depend on estimated risk for SCD, co-morbidities, and patient preferences, and so should be guided by shared decision making weighing the possible benefits against the risks,

Join CardioNerds (Dr. Mark Belkin and Dr. Natalie Tapaskar) as they discuss the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure with Writing Committee Chair Dr. Paul Heidenreich. They discuss how one gets involved with a guideline writing committee, the nuts and bolts of the guideline writing process, pitfalls and utility of the term “GDMT,” background behind inclusion of “Value Statements,” potential omissions from the document, clinical uptake of recommendations, and anticipated changes for the next iteration. Audio editing by CardioNerds academy intern, Pace Wetstein. This discussion is a prelude to the CardioNerds Decipher The Guidelines Series designed to enhance understanding and uptake of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. We will be using high-impact, board-style, clinical vignette-based questions to highlight core concepts relevant to your practice. We will do so by releasing several short bite-sized Pods with one question per episode. Note that the cases used are hypothetical and created solely to illustrate core concepts. This series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CME credits: 0.25 Valid until: 18-11-2023 Claim your CME credit at https://reachmd.com/programs/cme/direct-from-the-heart-failure-clinic-novel-device-therapy-for-patients-with-hfref/14473/ Despite the use of guideline-directed medical therapy (GDMT), many heart failure (HF) patients may experience worsening symptoms and disease progression. There is now an FDA-approved device that works with GDMT and uses the baroreflex to improve HF-related physiological effects and clinical consequences. Tune in to keep up with baroreflex activation therapy, its mechanism of action, and the associated improved patient outcomes.

CME credits: 0.25 Valid until: 07-10-2023 Claim your CME credit at https://reachmd.com/programs/cme/what-you-should-know-when-addressing-gdmt-for-id-in-heart-failure/13509/ Despite being an important and common comorbid condition in patients with heart failure, iron deficiency remains underdiagnosed and undertreated. Join Dr. Piotr Ponikowski, Dr. Andrew Sindone, and Dr. Adrian Hernandez as they discuss using guideline-directed medical therapy to overcome the morbidity, mortality, and very poor quality of life experienced by patients with heart failure and iron deficiency.

It's another session of CardioNerds Rounds! In these rounds, Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) and Dr. Karan Desai (formerly FIT at University of Maryland and now General Cardiology faculty at Johns Hopkins) join Dr. Rick Nishimura (Professor of Medicine at Mayo Clinic) to discuss the nuances of managing mitral regurgitation through real cases. Dr. Nishimura has been an author or Chair of the ACC/AHA valve guidelines going back 20 years and has been recognized internationally as one of the world's best educators, so you don't want to miss the #NishFactor on these #CardsRounds! Audio editing by CardioNerds academy intern, Pace Wetstein. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Speaker disclosures: None Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Mitral Regurgitation with Dr. Rick Nishimura Case #1 Synopsis: A man in his 70s with a history of non-ischemic cardiomyopathy (last known LVEF 15-20%) and atrial fibrillation, presented with decompensated heart failure in the setting of moderate to severe mitral regurgitation. He was diuresed, transitioned to GDMT, and referred to cardiac rehabilitation. Over the next 6 months, he continued to have debilitating dyspnea (NHYA Class IIIa) and his outpatient physicians were limited on titrating GDMT further due to hypotension. A TEE was done which demonstrated EF 15%, severe MR by color and quantitation (EROA of 0.5 cm2; Regurgitant Volume of 65 mL), systolic flow reversal in the pulmonary vein and severe tricuspid regurgitation. We were asked how we would approach this case Case #1Takeaways In attempting to keep the evaluation of chronic mitral regurgitation relatively simple, we should ask ourselves three primary questions: (1) What is causing the MR; (2) How much MR is there; and (3) What is the hemodynamic consequence of the MR.To the first question of what is the etiology of the MR – a simple framework is to think of the etiology as an issue of the valve (primary) or an issue of the ventricle/atria (secondary). There is further classification that can be made based on the Carpentier Classification which speaks to the valve leaflet movement and position (normal leaflet motion, excessive leaflet motion [e.g., prolapse], or restricted in systole and/or diastole [e.g., rheumatic heart disease]).During rounds, Dr. Nishimura provided some historical context in that the original valve guidelines had recommendations for intervention on primary mitral regurgitation and not secondary – given that it is considered a disease of the ventricle. Trials like the COAPT trial have greatly shifted our practice in treating secondary mitral regurgitation. Though, we have to be familiar with which patients with secondary MR would truly derive benefit from mitral valve interventionIn regards to the COAPT trial, patients with moderate to severe (3+) or severe (4+) mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were included. Dr. Nishimura makes the point that about one-third of patients intended to be enrolled in the trial were not included because they improved so much on GDMT. And thus, when evaluating patients for consideration of mitral valve intervention in secondary MR – a...

Connecting the Dots Between Cardio-Oncology & Door-to-GDMT Time for Heart Failure

This month, Daniel R. Goldstein, MD, Editor-in-Chief of JHLT, and the JHLT Digital Media Editors are discussing two impactful studies—in pediatric heart transplantation and MCS—from the August issue of The Journal of Heart and Lung Transplantation. You'll hear more about each of these studies, as well as the authors themselves. First, the editors speak with Craig Laurence, MD (pictured), a consultant in Pediatric Cardiology and Heart Failure & Transplantation at Great Ormond Street Hospital in London, UK. He's the first author on a paper entitled “Pediatric heart transplantation following donation after circulatory death, distant procurement, and ex-situ perfusion.” Dr. Goldstein, David Schibilsky, MD, and Erika Lease, MD, interview Dr. Laurence about the study, which compares how patients fare after transplantation with DBD vs DCD hearts. They also discuss his multi-national and multi-faceted background, including training and practicing in four different countries, as well as in clinical care, research, and training the next generation.   Next, we hear from Ravi Karra, MD, Associate Professor in the Departments of Medicine and Pathology at Duke University, senior author of the study, “Recovery of left ventricular function is associated with improved outcomes in LVAD recipients.” Van-Khue Ton, MD, and Marty Tam, MD, discuss the study with Dr. Karra, including questions on the mechanisms by which LVEF may impact improved outcomes, optimal doses of GDMT, and how gender influences LV recovery. They also discuss how Dr. Karra's lab balances translational research and epidemiological research, and how Dr. Karra splits his time between all his different responsibilities.   Follow along in the August issue at www.jhltonline.org/current, or, if you're an ISHLT member, log in at ishlt.org/journal-of-heart-lung-transplantation.  Don't already get the Journal and want to read along? Join the International Society of Heart and Lung Transplantation at www.ishlt.org for a free subscription, or subscribe today at www.jhltonline.org. This episode of JHLT: The Podcast, but not the studies within, is sponsored by Bayer Pharmaceuticals.

CME credits: 0.25 Valid until: 10-06-2023 Claim your CME credit at https://reachmd.com/programs/cme/how-do-i-optimize-gdmt-with-new-therapies-in-my-patients-following-a-worsening-hf-event/13610/ Recent clinical trial data and subsequent approval of novel therapies have expanded the treatment armamentarium. These advances have the potential to improve long-term patient outcomes, but also make the choice of therapy more complex. This activity aims to educate clinicians managing patients with HFrEF already on guideline-directed medical therapy (GDMT) who continue to be at high risk of rehospitalization to recognize the clinical characteristics of worsening heart failure and to select appropriate HF treatment strategies including novel classes of agents in heart failure.

CME credits: 0.25 Valid until: 10-06-2023 Claim your CME credit at https://reachmd.com/programs/cme/how-do-i-optimize-gdmt-with-new-therapies-in-my-patients-following-a-worsening-hf-event/13610/ Recent clinical trial data and subsequent approval of novel therapies have expanded the treatment armamentarium. These advances have the potential to improve long-term patient outcomes, but also make the choice of therapy more complex. This activity aims to educate clinicians managing patients with HFrEF already on guideline-directed medical therapy (GDMT) who continue to be at high risk of rehospitalization to recognize the clinical characteristics of worsening heart failure and to select appropriate HF treatment strategies including novel classes of agents in heart failure.

Host: Javed Butler, MD, MBA, MPH Guest: Tariq Ahmad, MD, MPH The Pragmatic Trial of Messaging to Providers About Treatment in Heart Failure (PROMPT-HF) was designed to test the hypothesis that tailored and targeted electronic health record alerts recommending guideline-directed medical therapy (GDMT) for patients with heart failure (HF) would result in greater adherence to medication use. Explore the trial's findings with Dr. Javed Butler and Dr. Tariq Ahmad, Director of the Heart Transplant and Mechanical Circulatory Support Program and Chief of Heart Failure at the Yale University School of Medicine.

It's another session of CardioNerds Rounds! In these rounds, Co-Chairs, Dr. Karan Desai and Dr. Natalie Stokes and Dr. Tiffany Dong (FIT at Cleveland Clinic) joins Dr. Randall Starling (Professor of Medicine and Director of Heart Transplant and Mechanical Circulatory Support at Cleveland Clinic) to discuss the nuances of guideline directed medical therapy (GDMT) through real cases. As a past president of the Heart Failure Society of America (HFSA) and author on several guidelines, Dr. Starling gives us man pearls on GDMT. Come round with us today by listening to the episodes and joining future sessions of #CardsRounds! This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Speaker disclosures: None Cases discussed and Show Notes • References • Production Team CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - CardioNerds Rounds: Challenging Cases - Modern Guideline Directed Therapy in Heart Failure with Dr. Randall Starling Case #1 Synopsis: A man in his 60s with known genetic MYPBC3 cardiomyopathy and heart failure with a reduced ejection fraction of 30% presents with worsening dyspnea on exertion over the past 6 months. His past medical history also included atrial fibrillation with prior ablation and sick sinus syndrome with pacemaker implantation. Medications are listed below. He underwent an elective right heart catheterization prior to defibrillator upgrade for primary prevention. At the time of right heart catheterization, his blood pressure was 153/99 with a heart rate of 60. His RHC demonstrated a RA pressure of 15mmHg, RV 52/16, PA 59/32 (mean 41), and PCWP 28 with Fick CO/CI of 2.8 L/min and index of 1.2 L/min/m2. His SVR  was 1900 dynes/s/cm-5. He was admitted to the cardiac ICU and started on nitroprusside that was transitioned to a regimen of Sacubitril-Valsartan and Eplerenone. His final RHC numbers were RA 7, PA 46/18/29, PCWP 16 and Fick CO/CI 6.1/2.6. His discharge medications are shown below. Takeaways from Case #1 Unless there are contraindications (cardiogenic shock or AV block), continue a patient's home beta blocker to maintain the neurohormonal blockade benefits. A low cardiac index should be interpreted in the full context of the patient, including their symptoms, other markers of perfusion (e.g., urine output, mentation, serum lactate), and mean arterial pressure before holding or stopping beta blockade. Carvedilol, metoprolol succinate and bisoprolol are all evidence-based options for beta blockers in heart failure with reduced ejection fraction.If there is concern of lowering blood pressure too much with Sacubitril/Valsartan, one method is to trial low dose of valsartan first and then transition to Sac/Val. Note, in the PARADIGM-HF trial, the initial exclusion criteria for starting Sac/Val included no symptomatic hypotension and SBP ≥ 100. At subsequent up-titration visits, the blood pressure criteria was decreased to SBP ≥ 95.In multiple studies, protocol-driven titration of GDMT has shown to improve clinical outcomes, yet titration remains poor. The following image from Greene et al. in JACC shows that in contemporary US outpatient practices that GDMT titration is poor with few patients reaching target dosing. Case #2 Synopsis: A 43 year-old male with a past medical history of familial dilated cardiomyopathy requiring HVAD placement two years prior now comes in with low flow alarms.

How do you counsel patients on beta blockers? Is one beta-blocker better than the other? What is preferred: ACEi, ARBs or ARNIs? What are the pros and cons of each? How does spironolactone compare to eplerenone? When do you stop mineralocorticoid receptor antagonist? What are risks with SGLT2 inhibitors? How do you initiate GDMT? Which meds do you start first and in what order?Show notes, Transcript and References:  https://www.coreimpodcast.com/2022/05/11/5-pearls-on-guideline-directed-medical-therapy/Sponsor: https://go.amboss.com/GDMTGet CME-MOC credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im Time stamps:03:13 Pearl 112:14 Pearl 220:36 Pearl 326:42 Pearl 432:16 Pearl 5Tags: IM Core, CoreIM, heart failure with reduced ejection fraction, GDMT, treatment, cardiology

CardioNerds  (Amit Goyal, Daniel Ambinder) and special co-host Dr. Mark Belkin, join the Journal of Cardiac Failure Family to discuss the 2022 ACC/AHA/HFSA Guideline for The Management of Heart Failure. The JCF Editor-In-Chief Dr. Robert Mentz, Deputy Editor Dr. Anu Lala, and FIT editors -- Dr. Vanessa Bluemer, Dr. Ashish Corrhea, and Dr. Quinton Youmans -- share their hot takes and practical takeaways from the guidelines. At JCF, we're privileged to share this important document that will support improved care for those living with heart failure,” stated Editor-in Chief Dr. Robert J. Mentz and Deputy Editor Anu Lala. “The 2022 guidelines convey patient-centered updates regarding the language we use to communicate disease considerations (e.g., stages of HF) and practice-changing guidance around the diagnosis and management of HF including newer therapeutics (e.g., SGLT2i). There is an emphasis not only on managing HF but also on how to treat important comorbidities as part of the holistic care for patients living with HF." 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure Executive Summary A Clinician's Guide to the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure by Dr. Michelle Kittleson CardioNerds Heart Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Guideline Top 10 Take-Home Messages - Guideline for The Management of Heart Failure 1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i). 2. SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population. 3. New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARBs (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit). 4. Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment. 5.Value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published. 6. Amyloid heart disease has new recommendations for treatment including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation. 7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%. Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement). 8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies, and uses palliative care including palliative inotropes where consistent with the patient's goals of care. 9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B. 10.Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders,

Today, Dr. James Fang, Chief of Cardiovascular Medicine at the University of Utah, and AHA/ACC/HFSA Heart Failure Guideline Committee Member, joins us to talk about the new heart failure guidelines, published in April 2022.  We talk about the new classifications, including HF with improved EF and HF with mildly reduced EF, and new recommendations for medical therapy for all the heart failure types. How do you start someone on GDMT? Who should get SGLT-2 inhibitors? How can we get more people on ARNIs? Dr. Fang provides lots of clinical pearls and practical wisdom for applying these new recommendations. Check it out! 2022 Heart Failure GuidelinesMusic from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R

Brian, Awais, and Adnan welcome Mo back this episode to discuss the in's and out's (see what we did there?) of systolic heart failure exacerbations. Highlights include diuresis titration, GDMT, and strategies to prevent readmission.

This activity will review how social determinants of health have led to inequities and disparate outcomes in HF. Attendees will take part in an expert-led exploration of current treatment guidelines, with an emphasis on HFrEF, and a review of emerging novel therapeutics. Learners will review real-world cases, empowering them to effectively interpolate novel agents into established guideline-directed medical therapy (GDMT) protocols and promote the closure of outcomes chasms driven by disparities in care.Supported by an independent educational grant from Merck.

Washington was calm, cold, and rainy in the first days of Ramadan but it was totally worth it because the American college of cardiology ACC meeting was back in person after two years of virtual attendance.In this episode of cardio buzz, we are bringing you, what we think are, the best late-breaking trials announced in the ACC meeting last week. More than 20 trials were announced as late-breaking as well as another bunch of featured clinical research. I decided to choose only 5 trials to present here. Choosing the top 5 articles was challenging. I chose the ones that I felt will have a bigger impact on your practice, bring in newer concepts, or change our views on medicine in general.Let's start the count downNumber 5; PROMPT-HFElectronic medical records changed the way we practice medicine. They have obvious advantages but I can't hide the fact that it makes us spend more time with screens than with patients. However, these electronic systems can prove useful in other aspects. By nudging the doctors, we might improve our prescription habits and overcome our inertia in prescribing medications or up titrating them. And one of the domains in which inertia is clear is heart failure. GDMT is under-prescribed in patients with heart failure. We usually don't prescribe the 4 essential medications and we rarely up titrate them to the maximum tolerable dose. And the PROMPT-HF trial was not a study on patients, it was a study on doctors. 100 healthcare providers, caring for patients with HFrEF in the outpatient were randomized to either an alert or usual care. one-third of them were not physicians. The alert started working at the moment of prescribing medications. It highlighted the patients' creatinine, potassium, blood pressure, eGFR, heart rate, and EF. The system notified providers of missing medications and the need to build up the dose. The electronic alerts increased GDMT prescription by >40% and were highly significant for beta clockers. 79% of alerted doctors agreed that the alert was effective at enabling improved prescription of medical therapy for HF. This low-cost intervention can be rapidly integrated into clinical care and accelerate the adoption of high-value therapies for heart failure. So next time, don't be angry when the system alerts you to the need of increasing the beta-blocker dose.Number 4 CHAP trial Treating mild chronic hypertension during pregnancy.We know that treating hypertension does prevent strokes, MI, and heart failure but the situation in pregnancy is more complicated. Unless hypertension is severe and complicated by eclampsia, we did not have evidence that treating hypertension can improve pregnancy outcomes given the potential hazards of the drugs on the fetus. The CHAP trial enrolled 2,408 women with mild chronic hypertension (

Hear a discussion on GDMT and the gaps between the evidence and the practicality of implementation. They discuss the gap between trial-proven evidence-based heart failure therapies and implementation of these medications to our most vulnerable patients.

In this episode presented by the Canadian Heart Failure Society (CHFS) entitled “Newly Diagnosed HF: Initiation of GDMT”, presented by Dr. Graham Wong, you will learn which drug to start first, whether there is a preferred sequence to start with, whether one drug should be fully titrated before starting the next one, what to do if the patient has hypotension and Heart Failure and more! An on-demand version of the 30-minute episode presented on the same topic is available right now at www.imedicus.ca/hf21. To learn more about the Canadian Heart Failure Society and find out more about upcoming programs and initiatives, visit www.heartfailure.ca. We hope you enjoy this episode! This program was made possible through grants from Novartis and BI-Lilly Alliance.

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Loie Farina (Northwestern University CardioNerds Ambassador), Dr. Josh Cheema, and Dr. Graham Peigh from Northwestern University for drinks along the shores of Lake Michigan at North Avenue Beach. They discuss a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presents with progressive symptoms of heart failure and is found to have a severe, non-ischemic cardiomyopathy. The etiology of her cardiomyopathy is not clear until her untimely death. She is ultimately diagnosed with cardiac AL amyloidosis with isolated vascular involvement a real occam's razor or hickam's dictum conundrum. We discuss the work-up and management of her condition including a detailed discussion of the differential diagnosis, the underlying features of systemic sclerosis with cardiac involvement as well as cardiac amyloidosis, the role of a shock team in managing cardiogenic shock, and how to identify those with advanced or stage D heart failure. Advanced heart failure expert Dr. Yasmin Raza (Northwestern University) provides the ECPR segment.  Episode introduction by CardioNerds Clinical Trialist Dr. Liane Arcinas. Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Summary - Occam's Razor or Hickam's Dictum? This is a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presented with progressive dyspnea on exertion and weight loss over the course of 1 year. Her initial work-up was notable for abnormal PFTs and finding of interstitial pneumonia on high-resolution CT, an ECG with frequent PVCs and normal voltage, a transthoracic echocardiogram with a mildly reduced ejection fraction of 40%, and a right/left heart catheterization with normal coronary arteries, filling pressures, and cardiac output. Scleroderma-related cardiac involvement is suspected. She is placed on GDMT, but her condition worsens over the next several months, and repeat echocardiogram shows severely reduced biventricular function, reduced LV global longitudinal strain (GLS) with apical preservation of strain, severely reduced mitral annular tissue Doppler velocities, and a normal left ventricular wall thickness. Scleroderma-related cardiac involvement remains highest on the differential, but because of some findings on the echo that are concerning for cardiac amyloidosis, an endomyocardial biopsy was obtained. It showed vascular amyloid deposition without interstitial involvement. The diagnosis of cardiac amyloid was discussed but deemed unlikely due to lack of interstitial involvement. However, a serologic work-up soon revealed a monoclonal serum lambda light chain and a follow-up bone marrow biopsy showed 20% plasma cells. She was discharged with very near-term follow-up in oncology clinic with a presumptive diagnosis of AL amyloidosis, but she unfortunately returned in shock and suffered a cardiac arrest. She initially survived and underwent emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation with subsequent left ventricular assist device placement (LVAD). However, she passed away due to post-operative hemorrhage. Autopsy was consistent with a final diagnosis of cardiac AL amyloidosis with isolated vascular involvement.  Case Media - Occam's Razor or Hickam's Dictum? EKG CXR TTE Pathology CMR Episode Teaching -Occam's Razor or Hickam's Dictum? Pearls Scleroderma causes repeated focal ischemia-reperfusion injuries which result in patchy myocardial fibrosis. Cardiac involvement in scleroderma is frequent but often not clinically evident; when symptomatic, it is associated with a poor prognosis.

Management of heart failure (HF) has evolved over the past few years, prompting the American College of Cardiology (ACC) to release a 2021 Update to Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment to provide guidance and recommendations on clinical care of HF patients with a reduced ejection fraction (HFrEF). New therapies for HFrEF have emerged that expand the arsenal for this patient population, particularly angiotensin receptor-neprilysin inhibitors (ARNI) and sodium glucose cotransporter-2 (SGLT2) inhibitors. However, use of guideline directed medical therapy (GDMT) is still suboptimal, and there is a need for pharmacists to assist in improving medication adherence. This podcast episode provides general practitioners an update on new evidence for pharmacotherapy and provides guidance on how to initiate GDMT in patients with HFrEF successfully in both inpatient and outpatient settings.      The information presented during the podcast reflects solely the opinions of the presenter. The information and materials are not, and are not intended as, a comprehensive source of drug information on this topic. The contents of the podcast have not been reviewed by ASHP, and should neither be interpreted as the official policies of ASHP, nor an endorsement of any product(s), nor should they be considered as a substitute for the professional judgment of the pharmacist or physician.

CME credits: 0.50 Valid until: 15-12-2022 Claim your CME credit at https://reachmd.com/programs/cme/synergy-of-guideline-directed-medical-therapies-in-heart-failure-to-optimize-patient-outcomes/13115/ Renin-angiotensin-aldosterone system inhibition (RAASi) is the foundation of guideline-directed medical therapy (GDMT) for heart failure patients. However, due to practice gaps, a significant proportion of the population requiring its use do not experience the benefits of RAASi therapy, which is especially true for patients with comorbid conditions. Hyperkalemia is a common adverse effect of RAASi therapy that needs to be anticipated and mediated so that the optimal dosing of necessary medications can occur. Maximizing GDMT in the face of hyperkalemia remains a key clinical challenge that, if not handled properly, can result in increased morbidity and mortality. In this activity, Drs. Javed Butler, Mikhail Kosiborod, and Matthew Weir review a patient case and discuss different treatment approaches to optimize GDMT while managing hyperkalemia. Tune in to make sure you're doing all you can to improve outcomes for your patients with heart failure and comorbid conditions.

CME credits: 0.50 Valid until: 15-12-2022 Claim your CME credit at https://reachmd.com/programs/cme/synergy-of-guideline-directed-medical-therapies-in-heart-failure-to-optimize-patient-outcomes/13115/ Renin-angiotensin-aldosterone system inhibition (RAASi) is the foundation of guideline-directed medical therapy (GDMT) for heart failure patients. However, due to practice gaps, a significant proportion of the population requiring its use do not experience the benefits of RAASi therapy, which is especially true for patients with comorbid conditions. Hyperkalemia is a common adverse effect of RAASi therapy that needs to be anticipated and mediated so that the optimal dosing of necessary medications can occur. Maximizing GDMT in the face of hyperkalemia remains a key clinical challenge that, if not handled properly, can result in increased morbidity and mortality. In this activity, Drs. Javed Butler, Mikhail Kosiborod, and Matthew Weir review a patient case and discuss different treatment approaches to optimize GDMT while managing hyperkalemia. Tune in to make sure you're doing all you can to improve outcomes for your patients with heart failure and comorbid conditions.

Door-to-Guideline Directed Medical Therapy Time & Door to Max Dose GDMT Time for Heart Failure

CME credits: 0.25 Valid until: 15-10-2022 Claim your CME credit at https://reachmd.com/programs/cme/guidelines-practice-key-updates-2021-hfsa/12927/ Rapid initiation and up-titration of guideline-directed medical therapy (GDMT) is critical to achieve optimal patient outcomes in heart failure. This is particularly important in patients with multiple comorbidities and in pivotal situations to avoid stopping or lowering the dose of any of the four critical medicines that these patients must receive. Drs. Javed Butler, Ileana Piña, and Giuseppe Rosano will recap the data and the views that were presented at a symposium held in conjunction with the Heart Failure Society of America's 2021 annual scientific meeting.

CME credits: 0.25 Valid until: 15-10-2022 Claim your CME credit at https://reachmd.com/programs/cme/guidelines-practice-key-updates-2021-hfsa/12927/ Rapid initiation and up-titration of guideline-directed medical therapy (GDMT) is critical to achieve optimal patient outcomes in heart failure. This is particularly important in patients with multiple comorbidities and in pivotal situations to avoid stopping or lowering the dose of any of the four critical medicines that these patients must receive. Drs. Javed Butler, Ileana Piña, and Giuseppe Rosano will recap the data and the views that were presented at a symposium held in conjunction with the Heart Failure Society of America's 2021 annual scientific meeting.

CME credits: 1.50 Valid until: 28-09-2022 Claim your CME credit at https://reachmd.com/programs/cme/demystifying-continued-pharmacologic-therapy-hfref-pivotal-opportunities-improve-patient-outcomes/12902/ Recent guideline updates and publications are leading to changes in care in patients with heart failure with reduced ejection fraction (HFrEF). What clinical evidence is driving recent changes to guideline directed medical therapy (GDMT) in HFrEF, and what real-world data exists that may impact the landscape of care and patient outcomes? Join Drs. Piña, Butler, Fonarow, and Rosano for a lively discussion on the evolving role of precision medicine in HFrEF, including key pivotal situations of care that surround GDMT initiation, management, optimal dosing, and common morbidities.

CME credits: 1.50 Valid until: 28-09-2022 Claim your CME credit at https://reachmd.com/programs/cme/demystifying-continued-pharmacologic-therapy-hfref-pivotal-opportunities-improve-patient-outcomes/12902/ Recent guideline updates and publications are leading to changes in care in patients with heart failure with reduced ejection fraction (HFrEF). What clinical evidence is driving recent changes to guideline directed medical therapy (GDMT) in HFrEF, and what real-world data exists that may impact the landscape of care and patient outcomes? Join Drs. Piña, Butler, Fonarow, and Rosano for a lively discussion on the evolving role of precision medicine in HFrEF, including key pivotal situations of care that surround GDMT initiation, management, optimal dosing, and common morbidities.

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:Advances in HFrEF: Slowing a Poor Hospital Prognosis, Part 2 - Evidence-Based Management PodcastFeaturing James L. Januzzi Jr., MD, FACC, FESC as faculty, moderated by Alanna Morris, MD, MSc, FHFSA, FACC, FAHA.SummaryIn this 2-part educational podcast series, Dr. James Januzzi and Dr. Alanna Morris discuss new therapies and treatment strategies for management of patients with heart failure and reduced ejection fraction (HFrEF). In part 2, the faculty review new developments in the management of and guideline-directed medical therapy for patients with HFrEF.Heart failure (HF) accounts for around one million hospitalizations in the United States every year, and approximately 50% of these are caused by HF with reduced ejection fraction (HFrEF). Optimal care for patients with HFrEF continues to be refined with the recent advancements in drug and device therapies that can reduce the incidence of cardiovascular (CV) death or hospitalization and improve the prognosis of patients with HFrEF. Clinicians need updated information regarding these recent advancements, when and how to use them, and recommendations for adhering to guideline-directed medical therapies (GDMT) for HF.This podcast was recorded and is being used with the permission of the presenters.Learning ObjectivesUpon completion of this activity, learners should be able to:Apply evidence-based GDMT when treating patients with chronic heart failure, including up-titration of medications to meet recommended target levelsIdentify patient populations with symptomatic, chronic HFrEF who would benefit from newer agents, based on safety and efficacy data and individual patient characteristicsThis activity is accredited for CME/CE credit. For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:Advances in HFrEF: Slowing a Poor Hospital Prognosis, Part 2 - Evidence-Based Management PodcastThe National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The National Association for Continuing Education designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.National Association for Continuing Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 121222. This activity is approved for 0.25 contact hours (which includes 0.25 hours of pharmacology).This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:Advances in HFrEF: Slowing a Poor Hospital Prognosis, Part 1- Stratifying Risk PodcastFeaturing James L. Januzzi Jr., MD, FACC, FESC as faculty, moderated by Alanna Morris, MD, MSc, FHFSA, FACC, FAHA.SummaryIn this 2-part educational podcast series, Dr. James Januzzi and Dr. Alanna Morris discuss new therapies and treatment strategies for management of patients with HF and reduced ejection fraction (HFrEF). In part 1, the faculty review aspects of risk stratification in patients with HFrEF and why stratifying risk for these patients is so important.Heart failure (HF) accounts for around one million hospitalizations in the United States every year, and approximately 50% of these are caused by HF with reduced ejection fraction (HFrEF). Optimal care for patients with HFrEF continues to be refined with the recent advancements in drug and device therapies that can reduce the incidence of cardiovascular (CV) death or hospitalization and improve the prognosis of patients with HFrEF. Clinicians need updated information regarding these recent advancements, when and how to use them, and recommendations for adhering to guideline-directed medical therapies (GDMT) for HF.This podcast was recorded and is being used with the permission of the presenters.Learning ObjectiveUpon completion of this activity, learners should be able to:Identify disease and patient characteristics that increase the risk of re-hospitalization or CV death in people with heart failureThis activity is accredited for CME/CE credit. For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:Advances in HFrEF: Slowing a Poor Hospital Prognosis, Part 1- Stratifying Risk PodcastThe National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The National Association for Continuing Education designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.National Association for Continuing Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 121222. This activity is approved for 0.25 contact hours (which includes 0 hours of pharmacology).This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

In this episode, we will review the beta-blocker drug class. We discuss their pharmacology, pharmacokinetic/pharmacodynamic parameters, evidence-based use, efficacy, and safety considerations. Key Concepts Various beta-blockers are divided into four main subtypes: non-selective, B1-selective, beta-blockers with alpha 1 antagonistic activity, and beta-blockers with intrinsic sympathomimetic activity (ISA). These subtypes govern their place in therapy, efficacy, and adverse effects. With regards to dosing, “start low and go slow”. The antihypertensive effect is dose-specific, but heart failure therapy requires a GDMT dosing approach to initiate and reach a certain target dose. Do not initiate as a new agent in acutely decompensated heart failure and definitely do not abruptly stop the therapy -- a taper over 1-2 weeks is required. Beta blockers are not first-line antihypertensives; however, they should be used in patients with compelling indications, such as systolic heart failure and post-MI. Other uses include angina, atrial fibrillation, migraine, tremors, and more. Beta blockers are associated with a number of adverse effects including bradycardia, bronchoconstriction, weight gain, dyslipidemia, hyperkalemia, and masking of hypoglycemia. More severe adverse effects include heart block, exacerbation of heart failure, and morbidity/mortality from acute withdrawal.

On today's episode we discuss: · Smoking Is Associated With COVID-19 Progression: A Meta-analysis: Authors affiliated with University of California, San Francisco and Mahidol University conducted a meta-analysis (n= 19 studies between January 1 and April 28, 2020 from China, U.S., and Korea) of 11,590 total patients with COVID-19 and found that 731 of these patients reported a history of smoking. · Household Composition May Explain COVID-19 Racial/Ethnic Disparities: A summary of a study by the Agency for Healthcare Research and Quality (U.S.), written by JAMA scientific news writer Rita Rubin, MA, explains that the higher observed death rates from COVID-19 in Black and Hispanic patients compared to White patients may be due to differences in exposure to the virus from work. A simple analysis of risk factors (e.g. age and preexisting conditions) does not explain the ethnic/racial disparities in COVID-19 death rates, but it may be explained by the fact that Black and Hispanic individuals are more frequently employed in a job where in-person essential work is required compared to White individuals. — Management: Marked factor V activity elevation in severe COVID-19 is associated with venous thromboembolism: Pathologists from the Massachusetts General Hospital conducted a prospective cohort study of 102 patients with severe COVID-19 in March through April 2020, showing elevated Factor V activity at unprecedented levels in the hospital's history (median 150 IU/dL with 16% of values above 200 IU/dL), which was associated with thromboembolitic complications. The authors suggest Factor V levels may serve as an important diagnostic and prognostic marker for COVID-19, and recommend further investigation of increased anticoagulation doses for prophylaxis in patients with severe COVID-19 and markedly elevated Factor V activity. · Heart Failure In Covid-19 Patients: Prevalence, Incidence And Prognostic Implications: Researchers within the departments of cardiology, clinical analytics, and pharmacy at the Hospital Universitario La Paz, Spain performed a single-center, retrospective study on 3,080 COVID-19-positive patients (with a 30-day or more follow-up) and heart failure. Based on this study's findings (illustrated below), the authors suggest maintaining heart failure guideline directed medical therapy (GDMT) when possible or re-instituting these regimens at discharge. —Adjusting Practice During COVID-19: A Novel Non-contact Self-Injection-Locked Radar for Vital Sign Sensing and Body Movement Monitoring in COVID-19 Isolation Ward: A case series of two patients with COVID-19 in hospital isolation, conducted at Kaohsiung Medical University Hospital in Taiwan, investigated the accuracy of patient vitals collected by a novel contactless device, a non-contact self-injection-locked radar (Figure 1), compared to a nurse's vital sign testing. Over the course of patient isolation (13 days and 5 days), the patients' temperatures and heart rates were insignificantly different between the device's and nurse's measurements. —R&D: Diagnosis & Treatments: Hydroxychloroquine for treatment of non-severe COVID-19 patients; systematic review and meta-analysis of controlled clinical trials. --- Support this podcast: https://anchor.fm/covid19lst/support

With progressing CKD & HFrEF, what GDMT medications can you start, continue or stop? What does the data on hydralazine/isosorbide tell us and what does it NOT tell us? What are the pros and cons of starting GDMT inpatient versus outpatient? Do you still keep patients on GDMT once their EF recovers? Sponsors: Hellofresh | Pranay's Effective Living Formula CoursePranay's Free Masterclass (Sept 20 and 27th at 5pm PST)CME : http://bit.ly/CIMCME || Show Notes & TranscriptTimestamps01:54 Pearl 1 – Recap of GDMT and CKD09:15 Pearl 2 – Hydralazine and Isosorbide Dinitrate 20:59 Pearl 3 – Ivabradine 25:47 Pearl 4 – Inpatient vs Outpatient Initiation of GDMT30:55 Pearl 5 – Ejection Fraction Recovery  Tags: IMCore, CoreIM, hydralazine, heart failure reduced ejection fraction, HFmrEF, HFimpEF, chronic kidney disease, cardiologyFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Use code 50COREIM for HelloFresh, America's #1 Meal: http://hellofresh.com/50COREIMAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

How do you manage GDMT in a frail older adult? When is a guardian needed and what is the process for obtaining guardianship?Sponsor: Echonous, the maker of Kosmos, is redefining point-of-care ultrasound at half the price (or less) of comparable carts. Mention Core IM at the Demo to get a free A.I application of choice!Youtube Interviews: When to consider a guardian?Guardianship ProcessLimitation and value of individualismShow Notes & TranscriptTimestamp04:03 Deep Dive 1: How do you approach guideline-directed medical therapy of heart failure with reduced ejection fraction in a frail older adult?11:55 Deep Dive 2: When is a guardian needed and what is the process for obtaining guardianship?28:30 Deep Dive 3: How do you re-evaluate GDMT in a frail older adult once an adverse event has occurred?33:27 Reflections37:06 RecapTags: IMCore, CoreIM, nursing home, primary care, cardiology, palliative care hospital medicine, interprofessional education, social work, case managementFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Go to https://www.factormeals.com/coreim50 For a great deal: Use the code coreim50Advertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy