1b) .@HFpEF will be sharing the algorithm he uses to treat #HFpEF based on evidence we have thus far and his anecdotal experience treating patients over the past 16 years in the @NMCardioVasc HFpEF Clinic.#CardioTwitter #MedEd @MedTweetorials #HeartFailure
— cardio-met (@cardiomet_CE) June 1, 2023
3) This treatment algorithm was recently published in @JACCJournals with my friends and co-authors Barry Borlaug, @KSharmaMD, and @JenHoCardiology (who provided great feedback!). See https://t.co/TCWulWqmkH. pic.twitter.com/UogxtwHDDz
— cardio-met (@cardiomet_CE) June 1, 2023
5) Step 2: Once the diagnosis of #HFpEF is made based on elevated LV filling pressures at rest or with exercise in the setting of an #LVEF ≥50%, first evaluate for masqueraders… pic.twitter.com/PTNLcRcUOe
— cardio-met (@cardiomet_CE) June 1, 2023
7) Step 3: Start with an #SGLT2i in all pts but use with caution in pts with exercise-induced LA hypertension (#EILAH) because they have normal filling pressures at rest. See our recent paper on EILAH in @JACCJournals: https://t.co/pWszQizthk
— cardio-met (@cardiomet_CE) June 1, 2023
9) Step 5: Treat comorbidities… pic.twitter.com/2uwqPtYd6I
— cardio-met (@cardiomet_CE) June 1, 2023
11) Step 7: Ask 6 key questions in all patients:
— cardio-met (@cardiomet_CE) June 1, 2023
(1) Is the pt on an #SGLT2i? If not, why not?
(2) Is the pt on an #MRA? If not, why not?
(3) Is the pt on an #ARNI? If not, why not?
(4) Is the patient on K+? If yes, replace with (or up-titrate) MRA if possible
13) Step 8a: Implement #HF education in all patients (daily weights, BP, and HR; establish “dry weight” for volume overloaded pts to guide #diuretic dosing [esp loop diuretics])
— cardio-met (@cardiomet_CE) June 1, 2023
15) Step 9: For persistent symptoms and/or #HF hospitalizations ➡️ HF clinic referral, reevaluate for #HFpEF masqueraders, check for worsening comorbidities, if persistent fluid overload Rx HCTZ, use implantable PA monitoring, and evaluate for chronotropic incompetence
— cardio-met (@cardiomet_CE) June 1, 2023
17) Additional tip #1: In patients with persistent fluid overload on #SGLT2i, #MRA, and loop #diuretic, avoid #metolazone! Low-dose #HCTZ typically works because of the benefit of sequential nephron blockade…
— cardio-met (@cardiomet_CE) June 1, 2023
19) Additional tip #2: Which exercise training regimen do you prescribe? I try to mimic what’s been done in trials of exercise in HFpEF patients…
— cardio-met (@cardiomet_CE) June 1, 2023
🔓 https://t.co/BXydk9IvCR
21) Additional tip #4: When caring for #HFpEF pts, we often become the coordinator of care ➡️ need to treat the WHOLE patient in order to make them feel better. Provide a #multidisciplinary Rx plan.
— cardio-met (@cardiomet_CE) June 1, 2023
23) Finally… there are many patients with HFpEF that need our help. Please consider starting a dedicated HFpEF program at your institution if you don’t have one already. This paper explains how to do it 😊… https://t.co/5GGGvoLdzg
— cardio-met (@cardiomet_CE) June 1, 2023
25) Caveats (cont’d): Yeast infections are readily treatable, usually not a reason to permanently stop #SGLT2i. Instruct pts to hold SGLT2i therapy for a few days on “sick days” (GI illness, dehydration, active infections). High #HgbA1c is not a contraindication to SGLT2i.
— cardio-met (@cardiomet_CE) June 1, 2023
27) Caveats (cont’d): #ARNI most effective if EF <55-60% or frequent HF hosp (congested phenotype); avoid in pts with history of #angioedema, low BP, orthostatic hypotension, restrictive #cardiomyopathy, #PAH, constrictive pericarditis, cardiac #amyloidosis
— cardio-met (@cardiomet_CE) June 1, 2023
29a) So, let's review a couple "take-home" points. All BUT which of the following should be considered "foundational" therapy for #HFpEF?
— cardio-met (@cardiomet_CE) June 1, 2023
a. #SGLT2i
b. #MRA
c. #anticoagulant
d. loop #diuretics (until euvolemic)
30a) Which of the following drugs is best avoided in patients with #HFpEF?
— cardio-met (@cardiomet_CE) June 1, 2023
a. #betablockers
b. #metolazone
c. #nitrates
d. all of the above
31) And just like that—you’ve earned 0.5hr 🆓 CE/#CME! Claim your credit NOW at https://t.co/aWCpCy1BuQ. And then FOLLOW US for more #MedEd by expert authors, delivered wholly on Twitter. .@HFpEF & @cardiomet_ce thank you for joining us!
— cardio-met (@cardiomet_CE) June 1, 2023