442 - Heart Failure Mgt., “Kidney Health Checks,” Beyond “Resilience”
Take 3 – Practical Practice Pointers©
From the Guidelines and the ACC/AHA/HFSA
1) Updated Heart Failure (HF) Guidelines 2022
In the US, approximately 115 million people have hypertension, 100 million have obesity, 92 million have prediabetes, 26 million have diabetes, and 125 million have atherosclerotic CVD. These are known risk factors for development of HF, which places a large portion of the US population for at-risk or stage A HF.
Three cardiology professional societies recently published joint updated guidelines on the management of HF. The 2022 guideline replaces the 2013 guideline and 2017 focused update, and is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with HF.
Some notable highlights include:
· New classifications for HF include HF with preserved ejection fraction (HFpEF = EF >50%), HF with mildly reduced EF (HFmrEF = EF 41-49%), HF with reduced EF (HFrEF = EF <40%). An additional category, HF with improved EF (HFimpEF) refers to patients with previous HFrEF who now have an LVEF >40%.
· Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B), which is new terminology for these patients.
· For newly diagnosed HF, laboratory evaluation should include CBC, UA, serum electrolytes, BUN, serum creatinine, glucose, lipid profile, LFTs, iron studies (serum iron, ferritin, transferrin saturation), and TSH to optimize management.
· For suspected or new-onset HF, or those presenting with acute decompensated HF, a CXR should be performed to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. Additionally, a transthoracic echocardiography (TTE) should be performed to assess cardiac structure and function
· In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF. In patients with chronic HF, BNP or NT-proBNP levels are recommended for risk stratification.
· Guideline-directed medical therapy (GDMT) for HFrEF now includes 4 medication classes: a sodium-glucose cotransporter-2 inhibitors (SGLT2i), a beta-blocker, a mineralocorticoid receptor antagonist (MRA - spironolactone), and a renin-angiotensin system (RAS) inhibitor (ACEi, ARB, or ARNi - angiotensin receptor-neprilysin inhibitor: sacubitril and valsartan/Entresto).
· SGLT2i have a Class of Recommendation (COR) 2a in HFmrEF. Weaker recommendations (COR 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers. In patients with HFrEF, with current or previous symptoms, 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) should be used.
· For HFpEF, consider use of SGLT2i (COR 2a), MRAs (COR 2b), ARBs (COR 2b) and ARNi (COR 2b). Routine use of nitrates or phosphodiesterase-5 inhibitors should be avoided (COR 3: No Benefit).
· Patients with HFimpEF should continue their HFrEF treatment.
· In patients with HF who have fluid retention, a loop diuretic is recommended to relieve congestion, improve symptoms, and prevent worsening HF (COR 1).
· 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).
· In patients with HF, assessment and documentation of NYHA functional classification is recommended to determine eligibility for treatments.
· For patients self-identified as African American with NYHA class III-IV HFrEF who are receiving optimal medical therapy, the combination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality.
· In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible.
· Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF.
This is a dense guideline filled with much information and should be considered the definitive guide for treating HF patients. I reached out to Daniel Pauly, MD, PhD, who is the Medical Director of the Carilion Clinic Advanced Heart Failure Program, for his insights on the new guidelines. He provided these words of wisdom: “As a clinician, you may find yourself dose-reducing or stopping a patient’s heart failure medication(s) for reasons such as hypotension, kidney dysfunction, hyperkalemia, bradycardia, or dizziness. That is considered a heart failure exacerbation and is a good time to refer the patient for advanced care and/or Cardiology co-management.”
Heidenreich P, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the ACC/AHA Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. Apr 01, 2022. Epublished DOI: Full Guideline Executive Summary
A Question from a Colleague
2) Yearly “Kidney Health” Checks in Patients With Diabetes
A colleague asks, “We’d like to see the evidence that doing urine microalbumins on almost all diabetics going forward is useful and cost effective.”
In 2020, the National Committee on Quality Assurance proposed a new HEDIS measure called Kidney Health Evaluation for Patients with Diabetes. This measure requires both an estimated glomerular filtration rate (eGFR) from a serum electrolyte panel and a urine albumin/creatinine ratio (uACR), regardless of the patient’s current treatment with any angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) In this proposal, NCQA cited the recommendations of two major guidelines – the American Diabetes Association’s Standards for Diabetes Care and the National Kidney Foundation’s KDIGO guidelines – for annual testing.
The text of the NCQA proposal included the following justification (edited):
“Evaluation of kidney health is more accurate when both eGFR and uACR are completed, as eGFR assesses kidney function by testing for waste products (creatinine) in the blood and uACR assesses kidney damage by testing for proteins (albumin) in the urine. Having both results allows appropriate identification, staging, monitoring and treatment of diabetic kidney disease… kidney health evaluation is underperformed for patients with diabetes…the current HEDIS Medical Attention for Nephropathy indicator is not precise enough to meet the needs of kidney health evaluation as an aspect of diabetes management”.
The ADA guidelines, after recommending annual kidney health evaluation, has a set of recommendations for medication management (ACEIs, ARBs, SGLT-2 inhibitors and GLP-1 antagonists) and referral that are based on the stage of kidney disease as defined by the eGFR and uACR tests. (See Take 3 #435 for specifics).
There is no systematic review that I can find that examines whether or not patients have better outcomes with this annual testing. There ARE data from Cochrane and other systematic reviews that show definite mortality and morbidity reduction from ACEI/ARB treatment in patients with diabetes and (micro-)albuminuria. In the UK, a 2014 cost-effectiveness modeling paper found that annual albuminuria screening in patients with type 2 diabetes without regard to ACEI/ARB use, while leading to significant overdiagnosis, was still cost-effective. However, this review did not address eGFR testing or continuing to monitor albuminuria levels after treatment with ACEI/ARB.
The evidence supporting yearly eGFR and uACR screening regardless of treatment is indirect at best and relies on the evidence of improved outcomes with treatment. I doubt that there will be a future funded study of yearly screening given the strong recommendations for treatment of diabetic kidney disease that the screening detects. As an analogy, there used to be recommendations about when to start performing cholesterol testing in adults, but then recommendations started assuming testing occurred, and focused on when to start statins instead. This seems to be the same.
· Strippoli GF et al. ACEi and ARBs for preventing the progression of diabetic kidney disease. Cochrane Kidney and Transplant Group, ed. Cochrane Database of Systematic Reviews. Published online October 18, 2006. Link
· Fink H et al. CKD Stages 1–3: Screening, Monitoring, and Treatment. Comparative Effectiveness Review No. 37. AHRQ; 2012:1003. Link
· Farmer AJ et al. Modelling progression of kidney disease in T2D. In: Optimal Strategies for Identifying Kidney Disease in Diabetes: Properties of Screening Tests, Progression of Renal Dysfunction and Impact of Treatment – Systematic Review. NIHR Journals Library; 2014. Accessed April 6, 2022. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Resilience??!! What We Need is More Rē-Zilience!
“What’s your ‘word’? Mine is Zilience.” Me
We were gathered together for one final time – a bittersweet moment. The end of the in-person 2022 AAFP Physician Health and Well-being Conference had arrived and as conference chair and “head coach” for the event, it was time for my closing thoughts. What the attendees didn’t hear from me was “Go and be more resilient!” Instead, I sent them forth with the poem “Zilience,” my attempt to capture in words the experience of living in and from my highest state of well-being. I shared the final lines:
“(you are) Now Called … to enter into the I am Rē deemed, leased, plenished, vivied, juvenated … zilient! Pick one. It’s a New Day … You are … in Love … again ….”
Then we parted, with hugs, tears, laughter, and a renewed sense of hope ….
Over the past decade, “resilience” has been all the rage as a recommended response to the epidemic of distress and burnout. The dictionary defines resilience as: “the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched. The ability to recover readily.” Those of us in healthcare have been told we need more of, and a whole industry has been created around this aim.
For too long now, too many of us have been returning over and over again to “survival mode,” and in the process, in no way advancing our well-being, but rather reinforcing the status quo. While perhaps well-intended, our striving for greater resilience as an end in itself has become the emotional equivalent of “Groundhog Day,” where one continues to get compressed, deformed, and distressed, only to return to the same, often struggling state. Sound familiar?! Certainly, having resilience is necessary, but far from sufficient to achieve an optimal state of personal and professional well-being, whatever you would call it … unless ….
If one is going to recover in such a way, it would certainly be desirable for them to be at their highest functioning, so that this would be the state they would bounce back to. But there is no word “silience” in the English language to attach the prefix “rē” (again) to! So I created my own – “Zilience,” which I define as “The state of being one’s highest self, including having and living from a deep sense that your life is about something larger than you.” Zilience is a transformation of the word resilience. This is the higher state I aspire to return to when distressed, and doing so has literally transformed my life.
How about you? How might you find your way to “zilience,” or thriving, fulfillment, joy, flourishing or whatever word you would use to describe your highest, best self – and then spend more of your time in that state of being? While there are many paths to get there, all have some things in common: a vision, a plan, and a team. No one arrives there accidently, or alone. The time has arrived for you to name your word, and then define it, embrace it, embody it, share it, and repeat – to keep bouncing back to that state of being, again … and again. It’s time for each of us to live into our equivalent of rē-Zilience! Afterall, it’s a New Day … and none are guaranteed, so let’s continue to encourage and support each other to choose wisely ….
Mark and John
Carilion Clinic Department of Family and Community Medicine
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