Formulary Decisions Matter: 4 reasons to add SGLT2i to your inpatient formulary

Several advances in the pharmacologic treatment of heart failure with reduced ejection fraction (HFrEF) have been made in the past several years. Despite known benefits, use of guideline-directed medical therapy in these patients remains wildly suboptimal. There are several reasons for this, including increasing complexity of HF regimens as well therapeutic inertia. While we may not have control over all components of therapeutic inertia, we feel strongly as a pharmacist that we cannot let our inpatient formulary decisions be one of them. As such, here we discuss 4 reasons why you should add these agents to formulary.

Managing Septic Shock in Patients with a Broken Heart: Focus on Hemodynamic Management with Fluids and Vasoactive Agents

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Currently, national guidelines do not address sepsis management in patients with underlying heart failure with reduced ejection fraction (HFrEF). Several factors make the management of sepsis in patients with HFrEF uniquely challenging, including a heightened risk of volume overload and the need for alternative vasoactive regimens to maintain cardiac output. The purpose of this blog is to provide practical considerations in the hemodynamic management of septic patients with HFrEF using fluids and vasoactive agents.

Help or Hype: Vericiguat for Heart Failure with Reduced Ejection Fraction

The recently published VICTORIA study assessed the efficacy and safety of vericiguat, a soluble guanylate cyclase stimulator in patients with heart failure with reduced ejection fraction, and met its primary composite outcome of death from cardiovascular causes or first hospitalization for heart failure. This blog describes four reasons why despite a technically positive study, I’m not sure I see a significant role for vericiguat in this population.

TRED Lightly: Should Guideline-Directed Medical Therapy be Continued Indefinitely in Everyone?

The TRED-HF trial considerably narrowed the population deemed as being low risk for heart failure relapse following the withdrawal of guideline-directed medical therapy (GDMT). However, several key subgroups were underrepresented and some patients may still wish to attempt GDMT withdrawal, especially in the setting of adverse effects or excess costs. In this post, we explore three questions that can be used to guide a shared decision-making process regarding GDMT withdrawal.

SGLT2 Inhibitors, the next GDMT?

Questions regarding the role of sodium-glucose co-transporter-2 inhibitors (SGLT2i) in heart failure have been raised since the publications of EMPA-REG OUTCOME in 2015. The recent results of the Study to Evaluate the Effect of Dapagliflozin on the Incidence of Worsening Heart Failure or Cardiovascular Death in Patients With Chronic Heart Failure (DAPA-HF) shed some light on the potential for these medications in HFrEF. In this blog, we discuss the implications of DAPA-HF and the role of SGLT2i for heart failure, including perspectives from a cardiologist.

Aldosterone Receptor Antagonist Use in Heart Failure Patients with End Stage Renal Disease Undergoing Dialysis: Is it Safe?

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end stage renal disease (ESRD). A significant number of patients with ESRD undergoing dialysis have reduced left ventricular ejection fraction. Contemporary treatment of heart failure with reduced ejection fraction (HFrEF) includes multiple pharmacotherapeutic strategies such as renin-angiotensin-aldosterone system inhibitors to reduce mortality and slow disease progression. However, because of concerns about hyperkalemia, aldosterone receptor antagonists are not commonly used in patients with HFrEF and ESRD undergoing dialysis. This blog summarizes the current evidence for efficacy and safety of aldosterone receptor antagonists in patients with concomitant HFrEF and ESRD requiring dialysis.

3 Clinical Pearls For Acute Management of Atrial Fibrillation in Patients with Heart Failure with Reduced Ejection Fraction

Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) often occur concomitantly. Despite this, optimal treatment strategies remain unclear. Current rate and rhythm control pharmacotherapy options present challenges when used in patients with HFrEF. In this blog, we cover 3 clinical pearls to consider for acute management of AF in patients with HFrEF.

Hydralazine-nitrate combination for heart failure with a reduced ejection fraction – does formulation matter?

Teaser: Does the formulation of oral nitrate therapy matter when used for patients with heart failure with reduced ejection fraction (HFrEF)? Should fixed-dose hydralazine (HYD)/isosorbide dinitrate (ISDN) (BiDil®) be used in those with HFrEF or can the medications be prescribed separately? In clinical practice the individual components HYD and ISDN are often prescribed as a result of cost concerns with the brand name, fixed-dose combination product. Additionally, clinicians often substitute extended-release isosorbide mononitrate (ISMN) for ISDN given its less frequent administration schedule. In this post we will discuss whether these formulations can be used interchangeably in those with HFrEF.

Can beta-blockers be continued in patients requiring inotropic therapy?

Although beta blockers are considered a fundamental therapy for patients with heart failure (HF), questions remain on how to manage them these medications in patients presenting with decompensation requiring intravenous inotropic therapy. In this post, we will provide some insights on managing the chronic beta blockade and intravenous inotropic therapy when used concomitantly in a decompensated HF patient.