poly pharmacy in cardiac failure is it justified
TRANSCRIPT
![Page 1: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/1.jpg)
Poly pharmacy in cardiac failure Is it justified ?
Dr.S.Venkatesan, MD,DM. Cardiologist.
Madras medical college.Chennai.India
![Page 2: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/2.jpg)
Use of a number of different drugs, possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several health problems.
Saunders medical dictionary
Dispensation of unnecessarily numerous or complex medicines.
Dorland‘s
Mosby medical Dictionary,
Administration of many drugs together. Administration of excessive medication
www.drsvenkatesan.com
![Page 3: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/3.jpg)
Poly-pharmacy is an universal issue
Ethical Geography
Elderly
(Up to 17 -50 % is admission are due to poly-pharmacy)
www.drsvenkatesan.com
![Page 4: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/4.jpg)
Polypharmacy
Physician
Patient
HospitalIndustry
AdministrativeErrors
www.drsvenkatesan.com
![Page 5: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/5.jpg)
Drug Interactions
Drug –Drug
Drug –Disease
Drug –Host
www.drsvenkatesan.com
![Page 6: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/6.jpg)
“All medicines which are not clinically indicated is referred to poly-pharmacy”
Fulton MM, Allen ER (2005) Polypharmacy in the elderly: a literature review. Journal of the American Academy of Nurse Practitioners, 17, 123–132.
www.drsvenkatesan.com
![Page 7: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/7.jpg)
www.drsvenkatesan.com
![Page 8: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/8.jpg)
Poly-pharmacy in cardiac failure
• Avoidable
• Acceptable (Appropriate)
• Essential
www.drsvenkatesan.com
![Page 9: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/9.jpg)
ACC/AHA Guidelines for CHF
www.drsvenkatesan.com
![Page 10: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/10.jpg)
www.drsvenkatesan.com
![Page 11: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/11.jpg)
DiabetesArthritis DepressionDyspepsia
Non cardiac poly-pharmacy -Appropriate
Inappropriate (Antacids/Sedatives/Vitamins)
www.drsvenkatesan.com
![Page 12: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/12.jpg)
Appropriate
In acute heart failure
Advanced CHF
Atrial fibrillation
Co-existing illness
www.drsvenkatesan.com
![Page 13: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/13.jpg)
What is the need for poly-pharmacy in CHF ?
Cardiac failure will overtake CAD soon
Shifting concepts , Multiple targets
Still . . . Limited success
Drugs has to catch up with Interventional techniques
More research . . . More drugs
www.drsvenkatesan.com
![Page 14: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/14.jpg)
Changing concepts in CHF
Hemodynamic model
to
Neuroendocrine model
www.drsvenkatesan.com
![Page 15: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/15.jpg)
“CHF can be thought of as a state of
neurohormonal imbalance, in which the activity of
potentially harmful pathways outweighs that of
favorable ones”
Current definition of cardiac failure
www.drsvenkatesan.com
![Page 16: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/16.jpg)
Going back to the fight/flight model
www.drsvenkatesan.com
![Page 17: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/17.jpg)
www.drsvenkatesan.com
![Page 18: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/18.jpg)
How to stimulate only the favorable factors
and block the unfavorable responses ?
CHF is a condition where both favorable and
unfavorable responses occur simultaneously
The Crux of the issue : Balancing
the NEM responses
www.drsvenkatesan.com
![Page 19: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/19.jpg)
Principles of Prescribing in CHF
www.drsvenkatesan.com
![Page 20: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/20.jpg)
Not more than 4 drugs
www.drsvenkatesan.com
![Page 21: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/21.jpg)
General principles
Always review the drugs
Listen to the patient
Discourage multiple physician contact
Habitual hospital hoppers ?
www.drsvenkatesan.com
![Page 22: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/22.jpg)
Class 1 drugs
Beta blockers
ACEI & ARB
Aldosterone antagonists
Essential
Diuretics and Digoxin
www.drsvenkatesan.com
![Page 23: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/23.jpg)
ACEI Inhibitor
ARBs
Never both
ELITE 2 / VALIANT
www.drsvenkatesan.com
![Page 24: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/24.jpg)
Beta blockers in CHF
Metoprolol succinate
Carvidilol
Bisoprolol
www.drsvenkatesan.com
![Page 25: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/25.jpg)
A word about Aldosterone antoagonist
Aldactone ? Routine
Eplerenone ? ( VIP CHFs)
Extreme caution is require d diabetic nephropathy
( ACEI /ARB/ALD) Triple RASS blockade is forbidden
With due respects to RALES /EPHESES
www.drsvenkatesan.com
![Page 26: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/26.jpg)
Aldosterone antagonist
www.drsvenkatesan.com
![Page 27: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/27.jpg)
Diuretics
www.drsvenkatesan.com
![Page 28: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/28.jpg)
www.drsvenkatesan.com
![Page 29: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/29.jpg)
Don’t underestimate the value of Digoxin
But , recognise it low safety margin
www.drsvenkatesan.com
![Page 30: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/30.jpg)
It is known that digitalis can exert sympathoinhibitory,
sympathoexcitatory, and direct vasoconstricting
effects. The relative predominance these differing effects in response
to digitalis may depend on the degree of activation of the
neuroendocrine
www.drsvenkatesan.com
![Page 31: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/31.jpg)
Diastolic Failure
www.drsvenkatesan.com
![Page 32: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/32.jpg)
www.drsvenkatesan.com
![Page 33: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/33.jpg)
www.drsvenkatesan.com
![Page 34: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/34.jpg)
The enigma of diastolic dysfunction in cardiac failure
• We know the problem is real
• We know it often coexist with systolic dysfunction
• We do not still have specific treatment
www.drsvenkatesan.com
![Page 35: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/35.jpg)
Diastolic Failure
No pharmacy ?
www.drsvenkatesan.com
![Page 36: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/36.jpg)
CHARM-Preserved -Candesartan
PEP-CHF – Perindopril
Beta blocker
Primarily HR, BP reduction
(Longitudinal function )
Drugs for Diastolic dysfunction
ACEI
www.drsvenkatesan.com
![Page 37: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/37.jpg)
Arrhythmia Management in cardiac failure (AF and VPDs)
Beta blocker will take care
Don’t get tempted by Amiodarone.
Pro-arrhythmic potential can easily exceed benefits
ICD - Always consider (But don’t get mad about MADIT )
(Don’t panic with few VPDs or transient in CHF as long as LV function is good )
www.drsvenkatesan.com
![Page 38: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/38.jpg)
Handling diabetic heart failure
Very common , Unique situation
Polypharmacy becomes essential
Avoid thioglitazones
Statin ?
www.drsvenkatesan.com
![Page 39: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/39.jpg)
Combined cardiac and renal failure ?
Aim should be to reduce the burden
Drug dosage to be reduced
(Except diurteics )
www.drsvenkatesan.com
![Page 40: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/40.jpg)
Is polypill an Answer ?
www.drsvenkatesan.com
![Page 41: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/41.jpg)
Polypill in cardiac failure
Yusuf S, Pais P, Afzal The Indian Polycap Study (TIPS). Effects of a polypill (Polycap) on risk factorsin middle-aged individuals without cardiovascular disease (TIPS): a phase II, double-blind,randomized trial. Lancet. 2009;373:1341–1351.
ACEI + + Betablocker(Carvidilol) +Diuretic + Digoxin
ABCD
Polypill as a concept CVD prevention . . . not yet for CHF
www.drsvenkatesan.com
![Page 42: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/42.jpg)
Drugs with Glamour
L carnitine
Trimetazidine
Ranalozine
Cardio-vitamins
Co-enzyme Q 10
www.drsvenkatesan.com
![Page 43: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/43.jpg)
Watch out : Many are waiting on the pipe line
TNF blocker
Endothelin antagonist
NEP antogonist
Vasopressin antagonist
Nesiritide
www.drsvenkatesan.com
![Page 44: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/44.jpg)
www.drsvenkatesan.com
![Page 45: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/45.jpg)
Treating chronic heart failure with 4 drugs . Is it possible ?
ACEI
Beta blocker
Diuretic +
Aldosterone anatogonist
Antiplatelet + Anticoagulants
How many class 1 A drugs ?
www.drsvenkatesan.com
![Page 46: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/46.jpg)
Do not deny state of the art strategies if eligible and affordable
Revacularisation
Valve surgery
CRT , ICD
Cardiac transplantation
www.drsvenkatesan.com
![Page 47: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/47.jpg)
Drug interactions in CHF
1 . Statins
2 . Aspirin
www.drsvenkatesan.com
![Page 48: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/48.jpg)
Statin and worsening of CHF
Cholesterol levels and in-hospital mortality in patients with acute decompensatedheart failure. AU Horwich TB Am Heart J. 2008;156(6):1170.
Low serum total cholesterol is associated with marked increase in mortality in
advanced heart failure. AU Horwich Card Fail. 2002;8(4):216.
Stain rules the world of coronary syndrome
Dubious role in CHF
www.drsvenkatesan.com
![Page 49: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/49.jpg)
www.drsvenkatesan.com
![Page 50: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/50.jpg)
A total of 5011 patients > 60 years
Ischemic cardiac failure
36 month follow up
10 mg of Rosuvastatin
CORONA Group / Norway *
Controlled Rosuvastatin Multinational Trial in Heart Failure(CORONA)
November 2007
www.drsvenkatesan.com
![Page 51: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/51.jpg)
InterpretationRosuvastatin 10 mg daily did not affect clinical outcomes in patients with chronic heart failure of any cause, in whom the drug was safe
GISSI -HF
www.drsvenkatesan.com
![Page 52: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/52.jpg)
Statin in heart failure –Summary
No benefit
High dose may be detrimental
Need not withhold it ?
Reduce the dose .
www.drsvenkatesan.com
![Page 53: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/53.jpg)
If NSAIDs are notorious for worsening cardiac failure
Aspirin is the mother of all NSAID
Caution is warranted.www.drsvenkatesan.com
![Page 54: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/54.jpg)
www.drsvenkatesan.com
![Page 55: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/55.jpg)
In spite of all these CHF mortality is prohibitive ( 5 year 60 %)
www.drsvenkatesan.com
![Page 56: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/56.jpg)
www.drsvenkatesan.com
![Page 57: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/57.jpg)
Holistic approach to cardiac failure
Only solution ?
www.drsvenkatesan.com
![Page 58: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/58.jpg)
Comes free
www.drsvenkatesan.com
![Page 59: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/59.jpg)
Drug less pharmacotherapy
www.drsvenkatesan.com
![Page 60: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/60.jpg)
In cardiac failure
Skeletal muscle mitochondrial
Dysfunction due to sustained
Muscle sympathetic activity
Functional capacity directly related to skeletal muscle
function www.drsvenkatesan.com
![Page 61: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/61.jpg)
www.drsvenkatesan.com
![Page 62: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/62.jpg)
Is exercise training increase stress to heart ?
• Isometric exercise > 3 minutes was shown to increase after load and transient reduction in EF %
• Leg press exercise at 70 % of max capacity
Increases muscle power without VO2 increase
www.drsvenkatesan.com
![Page 63: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/63.jpg)
www.drsvenkatesan.com
![Page 64: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/64.jpg)
CRT vs Skeletal muscle training
Simple exercise can achieve the same result
(Miracle 28 meter extra in 6 minute walk )
www.drsvenkatesan.com
![Page 65: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/65.jpg)
www.drsvenkatesan.com
![Page 66: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/66.jpg)
Self empowered patients !
Patient guided dose adjustments
www.drsvenkatesan.com
![Page 67: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/67.jpg)
Role of Family , Spouse , community
CHF : A behavioral disorder www.drsvenkatesan.com
![Page 68: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/68.jpg)
(visiting death’s door)
Social isolation
Living in fear
Losing a sense of control
Knowledge anxiety
(Addressing these issues can drastically reduce drug burden )
Emotional support and Ejection fraction !
www.drsvenkatesan.com
![Page 69: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/69.jpg)
Make the life simple slow .
Dobutamine
Beta blocker
www.drsvenkatesan.com
![Page 70: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/70.jpg)
Summary
Cardiac failure is like management of cancer
Optimal drugs ,constant vigil ,Resist temptation
Do not banish polypharmacy . Use it judiciously.
Use non pharmacological methods liberally
Consider ICD/CRT/Surgical option whenever possible
Aim for peace in patient mind
www.drsvenkatesan.com
![Page 71: Poly pharmacy in cardiac failure Is it justified](https://reader030.vdocument.in/reader030/viewer/2022012601/61980489a04f230b2921925c/html5/thumbnails/71.jpg)
Future looks bright A drug less world ?
Thank you
www.drsvenkatesan.com