1. Heart Failure Medications Zachary Cox, PharmD Associate Professor Lipscomb University College of Pharmacy Clinical Pharmacist, Vanderbilt University Medical Center

2. Medications in HF ACE Inhibitors (ACEIs) Angiotensin Receptor Blockers (ARBs) Beta BlockersAldosterone Antagonists Captopril Benazepril Enalapril Fosinopril Lisinopril Perindopril Quinapril Ramipril Trandolapril Candesartan Losartan Valsartan Bisoprolol Carvedilol Carvedilol CR Metoprolol XL Spironolactone Eplerenone

3. Medication Differences by Ejection Fraction Systolic HF (HF r EF) Diastolic HF (HF p EF) Medication StudiesMany Studies Positive Results Fewer Studies Frustrating Results Medication OutcomesIncreased Length of Life Less Hospitals Visits Less Hospital Visits Medication GoalsSpecific DosesSymptom Control Blood Pressure Control Medications that improve HF outcomes ACEI, ARB, Valsartan/Sacubitril, Beta Blocker, Aldosterone Antagonist, Hydralazine/Nitrate, Ivadrabine, Digoxin ARBs Spironolactone

4. Symptom Control Hospital Avoidance Increased length of life ACE Inhibitors -OR- ARBs -OR- Sacubitril/ Valsartan -OR- Hydralazine + Nitrates ACE Inhibitors -OR- ARBs -OR- Sacubitril/ Valsartan -OR- Hydralazine + Nitrates Beta Blockers Carvedilol -OR- Metoprolol XL -OR- Bisoprolol Beta Blockers Carvedilol -OR- Metoprolol XL -OR- Bisoprolol Aldosterone Antagonists Spironolactone -OR- Eplerenone Aldosterone Antagonists Spironolactone -OR- Eplerenone

5. Additional Symptom Control Loop Diuretics Bumetanide Furosemide Torsemide Ethacrynic Acid HF Medications Digoxin Ivabradine Nitrates Tolvaptan Disease States Heart Rhythm Heart Arteries Heart Valves Diabetes Cholesterol Blood Pressure Sleep Apnea Kidney Disease Lung Diseases

6. Loop Diuretics Threshold EffectDuration of Effect 0 1 2 3 4 5 6 7 Hours 0 1 2 3 4 5 6 7 Hours DIURETIC

7. Multiple Providers & Conflicting Advice HF patients with Medicare see an average of 15 providers a year and have 8 different prescribers 17% report conflicting advice from doctors 22% of HF patients taking wrong medications received conflicting medication instructions 2/3 HF patients have 2-3 different diets State of the Science: Promoting Self-Care in Persons with Heart Failure. Circulation 2009;120:1141-63.

8. Medications to Avoid in HF Diltiazem/Verapamil Itraconazole Cilostazol Flecanide Propafenone Pioglitazone/Rosiglitazon e Minoxidil Dronedarone ADHD Medications NSAIDs – Ibuprofen – Naproxen – Celecoxib – Meloxicam – Diclofenac TNF Alpha Inhibitors – Infliximab (Remicade) – Etanercept (Enbrel) – Adalimumab (Humira)

9. Medication Adherence 1.Forgetful or Busy 2.Access to Pharmacy 3.Perception Benefit Risks 4.Organization Administration times Refill dates 1.Reminder Alerts 2.Home Delivery 3.Initiate Conversation Real outcomes Odds of adverse event Individualized risk BarriersSolutions

10. Medication Organization Levothyroxine Furosemide Enalapril Carvedilol Hydralazine Isosorbide Dinitrate Hydralazine Isosorbide Dinitrate Furosemide Carvedilol Hydralazine Isosorbide Dinitrate Enalapril Atorvastatin Furosemide Enalapril Carvedilol Hydralazine Isosorbide Dinitrate Furosemide Hydralazine Isosorbide Dinitrate Atorvastatin Enalapril Carvedilol Hydralazine Isosorbide Dinitrate Levothyroxine 6 AM7 AMNoon3 PM6 PM10 PM 7 AM3 PM10 PM