Updates in the Management of Heart Failure and the Pharmacist’s Role in Patient Education

Updates in heart failure (HF) was a topic of interest during the 2020 virtual Directions in Pharmacy® conference. Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPSAQ Cardiology, CACP, presented a comprehensive overview of new and emerging agents for HF management and the role of the pharmacist.

Dr Beavers began his discussion with a summary of the burden of HF, including a projected increase of 46% by the year 2030. There are approximately 1000 admissions annually and there were 80,480 deaths in 2017. HF is classified as HF with preserved ejection fraction (HFpEF), HF with mid-range ejection fraction (HFmEF), and HF with reduced ejection fraction (HFrEF).

Dr Beavers then went on to review guideline-directed medical therapy for HFrEF based on the stage of HF. Traditional therapies include angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and β-blockers for all patients. Additional adjunct therapies include nitrates, non-dihydropyridine calcium channel blockers, aldosterone antagonists, and vasodilators, depending on individual patient circumstances.

Ivabradine is a newer agent that blocks the hyperpolarizationactivated- cycline-nucleotide-gated channel responsible for the cardiac pacemaker If current, which regulates heart rate. Ivabradine selectively lowers heart rate without impacting cardiac conductivity and repolarization. It also improves left ventricular diastolic filling, reduces myocardial oxygen consumption, and increases coronary perfusion time. Patients should be monitored for phosphenes typically occurring within the first 2 months.

Sacubitril/valsartan, the orally-active, first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) in a 1:1 ratio, was also discussed. Sacubitril/valsartan’s efficacy was established in the PARADIGM-HF phase 3 trial. The trial was discontinued early due to overwhelming evidence of efficacy. It is indicated to reduce the risk of cardiovascular death and hospitalization for HF in patients with chronic HF and reduced ejection fraction. Sacubitril/valsartan is contraindicated with concomitant use of ACEI or ARB therapy (within 36 hours) and any history of angioedema.

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are emerging agents for the treatment of HFrEF with or without diabetes with initially promising results from the DAPA-HF trial. Other agents include vericiguat and omecamtiv mecarbil via the VICTORIA and GALACTIC-HF trials, respectively.

Dr Beavers also discussed the treatment of HFpEF, which includes β-blockers, verapamil/diltiazem, ivabradine, digoxin, nitrates, phosphodiesterase-5 inhibitors, ACEIs/ARBs, ARNIs, and aldosterone antagonists. In contrast to HFrEF, further research still needs to be conducted to conclude benefit for HFpEF therapies. SGLT2is are also under investigation for their utility in HFpEF.

Dr Beavers also discussed the pharmacist’s role in the management of HF, including medication reconciliation, identifying and following up on drug-related problems, addressing adherence, patient and caregiver education, and collaboration with community and ambulatory care pharmacists. End-of-life care (including palliative care) is essential to the quality of life in patients with refractory HF and pharmacists play an important role in this as well.

CRAIG BEAVERS, PharmD, FACC, FAHA, FCCP, BCCP, BCPS-AQ CARDIOLOGY, CACP, graduated in 2009 from the University of Kentucky (UK) College of Pharmacy and completed a PGY1 pharmacy practice residency and a PGY2 cardiology pharmacy residency at UK Albert B. Chandler Hospital in Lexington, Kentucky. Dr Beavers is the current director of Cardiovascular Services at Baptist Health Paducah. He recently served as the cardiovascular (CV) clinical pharmacy coordinator at UK Healthcare and with the UK Gill Heart Institute, as the director of Cardiovascular Services for the Hospital Corporation of America, and a CV clinical pharmacy specialist with TriStar Centennial Medical Center. Previously he was adjunct faculty for Lipscomb University College of Pharmacy, University of Tennessee College of Pharmacy, and served as the PGY2 cardiology pharmacy residency program director at TriStar Centennial Medical Center in Nashville, Tennessee.Dr Beavers is an assistant adjunct professor with the UK College of Pharmacy. He serves as the chair of the American College of Cardiology’s (ACC’s) Cardiovascular Team Council and was the co-chair of the ACC’s Clinical Pharmacist Workgroup. He served on the Surviving Acute Myocardial Infarction Steering Committee with the ACC. He is the first pharmacist to be a Cardiovascular Professional for the Society for Cardiovascular Angiography and Interventions (SCAI) and serves on SCAI’s Quality Committee. He has served as the vice chair and chair of the American College of Clinical Pharmacy’s (ACCP’s) Cardiology Practice and Research Network Student and Resident Committee as well as served as ACCP’s Cardiology Practice and Research secretary/treasurer and chair. He is an active member of the American Heart Association, American Society of Health-System Pharmacists, American Pharmacists Association, and Kentucky Society of Health-System Pharmacists. He has published numerous papers, abstracts, and textbook chapters and presented internationally on topics focused on CV pharmacotherapy and CV quality improvement. He is board certified in pharmacotherapy with added qualifications in cardiology and a boardcertified cardiology pharmacist from the Board of Pharmacy Specialties. Dr Beavers is also a board-certified anticoagulation care provider. He is a fellow of the American Heart Association and an associate of the American College of Cardiology.