Case Study Waleed AlHabeeb, MD, MHA Consultant Heart Failure Cardiologist President of the Saudi Heart Failure Group
Case Study
Waleed AlHabeeb, MD, MHA Consultant Heart Failure Cardiologist President of the Saudi Heart Failure
Group
• 52 Y/O gentleman
• Familial dilated cardiomyopathy
• Severe LV dysfunction EF 25%
• NYHA class II
• No orthopnea or PND
• BP 100/60 HR 80
• JVP 10cm
• On Valsartan 40mg BID, Bisoprolol 10mg, lasix80mg BID
• Cr 120 K 4.8
• Valsartan increased to 80mg BID K 5.2
• Symptoms and exam the same
Next step in managing this patient would be
A) Reduce valsartan back to 40mg BID
B) Add an aldosterone antagonist
C) Switch Valsartan to Sacubitril/Vasartan
D) Add Ivabradine
E) Refer for advanced therapies (VAD/TX)
F) Do nothing, just observe
A) Reduce valsartan back to 40mg BID
B) Add an aldosterone antagonist
C) Switch Valsartan to Sacubitril/Valsartan
D) Add Ivabradine
E) Refer for advanced therapies (VAD/TX)
F) Do nothing, just observe
Am Heart J 2006;151:444- 50
0
16
32
40
24
8
Enalapril(n=4212)
360 720 10800 180 540 900 1260
Days After Randomization
4187
4212
3922
3883
3663
3579
3018
2922
2257
2123
1544
1488
896
853
249
236
LCZ696
Enalapril
Patients at Risk
1117
Kap
lan
-Meie
r E
sti
mate
of
Cu
mu
lati
ve
Rate
s (
%)
914
LCZ696(n=4187)
HR = 0.80 (0.73-0.87)
P = 0.0000002
Number needed to treat = 21
PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)
N Engl J Med 2014;371:993–1004
*Enalapril 10 mg 2x daily as comparator vs ENTRESTO® 200 mg 2x daily in the PARADIGM-HF study (in addition of standard therapy). ‡Elevated serum creatinine ≥2,5 mg/dL. §Elevated serum potassium >5,5 mmol/l. ¶Angioedema with no treatment or use of antihistamines only.
McMurray et al. N Engl J Med 2014;371:993–1004
20
Pro
po
rtio
n o
f ad
vers
e ev
ents
(%
)
10
5
0Renal impairment‡
11.3
p<0.001
Sacubitril/valsartan (N=4,187)
Enalapril* (N=4,212)
15
Cough Hyperkalemia§ Angioedema¶ Symptomatichypotension
14.3
3.34.5
16.117.3
0.2 0.1
14.0
9.2
p=0.07
p=0.15
p=0.19
p<0.001
FollowupParameter Value
NYHA I
Blood Pressure102/68
Heart Rate72 Bpm
JVP8
Cr96
K4.5
NT-ProBnp1530
MedicationSacubitril/Valsartan 200mg BID
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