Role of Dapagliflozin in the Management of Heart Failure With Reduced Ejection Fraction Part 3
Optimal medical therapy and the same indication is with now with sglk2 ejection fraction lesson 40 class 2 class 4 administered in combination with the background of gdm so now the indication of adding warning and precaution was concerned i think for contract referencing supposed to be more safe in relative function as compared to just all i don’t think there
Is much difference between these three drugs so it is proposed that a conversations you can some management of heart failure with reduced ef es repeaters then you add mri then you add if the patient is not because so the sglt2 inhibitors has opened a new era in management of the heart area when added to standard therapy reduces the risk of worsening heart
Failure events and cardiovascular patients the relative and absolute risk reduction in depth and hospitalization were substantial clinically important and consistent in patients with their withdrawal data was well tolerated and the rate of treatment discontinuation was low both interacting and non-damaging offer a new approach to the treatment of heart
Failure with the reduced ear infection thank you very much thank you for that updating us on the role of htlt2 in heart failure as you said none of us updates with me possibly for the first time that even the fda said in may 2020 that a drug developed to treat diabetes can be used in heart failure with or without diabetes that is very interesting and as you
Have shown the moist data we are getting more and more areas the last but one slide again you showed where to put it the fantastic four beta blocker mra rna and cld2 how to sequence it these are areas where possibly we can have a interesting discussion we will have the second talk also to come and uh may have the pleasure of inviting uh dr banner project
Banerjee for his talk on the importance of heart rate i think every one of us are aware how important heart rate is in the in the uh eventualities what happens in heart failure both in the genesis of its mortality and otherwise so preserve energy please good evening everybody and welcome to the city of joy our president and all other respected dc members dear
Friends so my task is to discuss the role of beta blocker in the management of heart failure in reduced ejection fraction now you all know that this is age-old drug beta blocker and is being called as reverse remodeling drug so there is no controversy of using beta blocker in the management of heart failure with reduced ejection fraction but now the concept
Has come in whether you can combine a newer molecule evaporated with beta blocker in the management of heart failure where the patient cannot tolerate the recommended dose of vitamin k because of the various side effects of contraindication now we all know that the heart rate is one of the most ominous sign particularly the resting heart rate in the outcome
Of the heart failure with reduced ejection fraction so if you cannot achieve the basic heart rate in the rest below 70 you don’t get the outcome benefit and to achieve that beta blocker is definitely a major drug particularly the beta1 receptor blocker like metropolitan oil and the isopolar now the question is that many patients do not tolerate the target
Dose or when you try to upright the dose of beta blocker several side effects come in and obviously you have to restrict the dose and then you have to think of another molecule which is having a beta-blocker-like effect but doesn’t cause any compromise in the hemodynamics of the heart like the blood pressure cardiac output etc so therefore initially when the
Patient comes we first start with the beta blocker and other drugs already we discussed like mra sniper or rna and finally what dr john has already said about the issue to individual and even then the patient’s resting heart rate is going high then you think of using a new molecule you have ready you already know that being used for a quite long time which is
If channel individual acting on the ac node and not causing significant bradycardia and also does not have any effect on the cardiac thermodynamics now this is the energy lost because of the continuous beating of the heart almost 300 milligrams of atp part wheat and 30 kg of entropy per day so heart rate reduction by 10 bits saves 5 kg of atp per day so the
Main target is is to reduce the heart rate to below the 78 but not below the rate of 50 because that will be associated with other side effects now the prospective study has shows the primary composite endpoint as you going below the medicare side or lowering the heart rate and if you compare when the heart rate is more than 87 as opposed to when it is less
Than 70 or 72 the primary composite end point also progressively decreases so thereby lesser the heart rate less is the chance of what’s outcome from the heart failure we reduce ejection fraction now is it a risk factor or is a marker now the slide shows that it is more of a risk factor now as there is a increase in the heart rate that will lead to situation
Of chronic heart failure because of the tachycardia induced myopathy you all know that and there is increase in the oxygen demand there is a ventricular inefficiency because of the reduction in the filling time so automatically the stroke volume will reduce and thereby ultimately patient will go into the chronic heart failure because of persistent tachycardia
And there is also some comorbidity problem like micro aluminum that is remodeling of the heart that is a cardiac hypertrophy and because of the increased heart rate as you know there is a demand supply imbalance and there is chance of ischemia and reduced asthma lead to decrease in the coronary perfusion and finally there is increased rate of atherosclerosis
Because of the oxidative stress because of the flux the stability and because of the arterial stiffness so all these factors are considered as the risk factors for various uh numerous things what i already mentioned so thereby the idea is to reduce the heart rate and thereby you prevent chronic heart failure hormone remodeling ischemia and atherosclerosis now
When you are not being able to reduce the heart rate to the target level obviously then you have to choose another molecule and that is called hybrid which is if channel individual acting on the sa node and thereby reducing the heart rate and helps in tightening the nose of the beta blocker or also help in reducing the side effect of the beta blocker when being
Used in combination now we all know that beta blockers there are three mainly used and there is no much difference between the carbonyl or metropolis or isopolar all those have definitely the modality reduction and antenna modeling effect so thereby choice of beta blocker is your experience and you are comfortable with and these are the various beta blocker trials
Like many third failure series 2 and the copernicus using the metropole the vistopolo and carvalenton more or less they are having the similar results the relative risk reduction varying from 34 to 35 percent so there is no much difference in reduction of the modality now what is the difference between these three molecules all of them are beta 1 receptor blocker
But the carbohydrate has additional beta 2 blockage effect and it also causes alpha blocking effect and there are no effect on the isa or by all three of these beta blocker only ncl ancillary benefit by the carbon diode is that it has got antioxidant and endothelin and anti-polyphenol so that is the only difference with the other beta blockers so thereby when
Metropolis is compared with the carbonyl and in the comet study and as the days progresses the length of therapy increases and they have shown that there is divergence of the car as you continue to treat with this two molecule in terms of reduction in the mortality and that is definitely a beneficial in favor of this carbonyl as compared to the metropolitan
Similarly the onset of new diabetes also you can see as you continue treatment with these two molecules there is again the divergence of the car and incidence of diabetes has seen to be more with the metropolis as compared to the curvature now coming to the heart rate reduction when you achieve a heart rate of 70 or less than 70 and you can see the annual
Modality rate also progressively diminishes so thereby the bottom line of the fact is that the reduction of the heart rate that particularly the resting heart rate below 70 has to be achieved without any side effect of the dictating after treating those of the beta blocker but if you come across with that effect then you have to consider this new molecule
That is hyperbarine which is a if inhibitor and acting on the sinus node and thereby that there is a key determinant of the heart rate s node and hydrogen reduces the actual depolarization slope and the advantage of y variation is that it does not cause any effect on the cardiac hemodynamics like the systolic blood pressure or the cardiac output and mean heart
Rate reduction as you compare the placebo with the ivormatic then as you can see there is no much significant difference between the heart rate of different doses of hydrogen so thereby there is no fear of producing significant medicare here as you operate in the dose of anode coming to the effect of the composite input reduction again when it is compared with
The plasma and as you can find out that the cumulative frequency of the composite endpoint reduction was by 18 percent in favor of i’ve ever written when it is compared with the classical what can we achieve to target the heart rate the again it is the slide showing that greater the rate and more is the chance of chance of primary composited point so again
Showing the result that this is from the shift trial that if you can reduce the heart rate between the 60 to 70 the primary composite point also comes down and that has been shown from the day 28 onwards that progressively the patient heartache becomes stabilized to the tune of 60 to 70 the primary composite words comes down now as he gets the other outcome
Like the cardiovascular mortality hospitalization of the worsening heart failure death from heart failure all cause mortality all cause hospitalization and any cardiovascular hospitalization all are in favor of hyperbole and as when you achieve the target heart trend so the question is now is it possible to combine the ibrahim with the other bitter blocker
Particularly which is now recently been marketed with the curvature now if you consider the contraction and relaxation in a heart failure with a reduced ejection fraction as you can see that there is compared with the normal situation and the there is a reduction in the contraction and also there is a prolonged relaxation period so that will ultimately affect
The cardiogram and the pathophysiology is that in the heart rate reduction associated with increased performance so when the contraction is reduced the feeling is also less the stroke volume is also less but when you reduce the heart rate the phase diastole filling period is more and that there will be more cardiac output and the whole hemodynamics also changes
The short-term effect of i heard it on the lb function as it shows when you look at around eight four hours of therapy the heart rate is reduced by 27 percent stroke volume is increased by 51 percent and there is a neutral effect on the cardiac index and that is the advantage of hydrogen over the other beta blockers the short and long term hemodynamic effects
Of the beta blocker varies and you can see the left ventricular ejection fraction when the metabolol is compared with the standard therapy now initially there is no much increase in the ah ejection fraction now as you continue to ah follow the treatment with the guideline directed therapy look at the three-month result there is a significant improvement in
The left ventricular injection fraction as compared to the early therapy so longer that you
Transcribed from video
Role of Dapagliflozin in the Management of Heart Failure With Reduced Ejection Fraction Part 3 By CSI HQ