Discover and read the best of Twitter Threads about #GDMTWorks
Most recents (10)
Day 5 on service at @MGHHeartHealth. No better time than now to think about the favorite drug of @AndrewJSauer...spironolactone.
The story of how the drug was discovered is interesting, and gave a hint as to the fact the drug would eventually become a pillar of HF care.
The story of how the drug was discovered is interesting, and gave a hint as to the fact the drug would eventually become a pillar of HF care.
The first mineralocorticoid synthesized was deoxycorticosterone (DOC). Simultaneously, aldosterone was discovered. Both exerted powerful sodium retention effects. This was in the early 1950s.
Simultaneously, people began to recognize that pts with HF retained salt and water...
Simultaneously, people began to recognize that pts with HF retained salt and water...
Recognizing that Na/water retention in HF resembled that of DOC/aldo treatment, efforts began on the synthesis of ways to block their effects with a family of compounds called 17-spironolactones.
one had potent anti-mineralocorticoid effects, and was dubbed "aldactone".
one had potent anti-mineralocorticoid effects, and was dubbed "aldactone".
Day 4 on service @MGHHeartHealth. 4 thoughts on beta blockers.
Don’t worry @AndrewJSauer, MRA are coming tomorrow.
@cardiojaydoc02 @AHajduczok
Don’t worry @AndrewJSauer, MRA are coming tomorrow.
@cardiojaydoc02 @AHajduczok
One: begin your target BB at the start. I don’t know how the culture of starting short acting metoprolol “for titration” came from but it’s not supported by any science, uses a drug that failed in the MDC trial, and may actually be harder to titrate due to on/off effects.
Two: if you use carvedilol, scan the med list for other alpha blockers and d/c them. Carvedilol has alpha blocking effects, so if you d/c the other it’s likely to “buy” more BP, and won’t be noticed. Remember—tamsulosin (used for BPH) is an alpha blocker…
Here's a question that you might not have considered: how did the dose for #sacubitril/valsartan in #HFrEF get chosen?
Out today is a paper in @JACCJournals led by @RezaMohebiMD that addresses some questions about sac/val dose in HFrEF.
a 🧵
jacc.org/doi/epdf/10.10…
Out today is a paper in @JACCJournals led by @RezaMohebiMD that addresses some questions about sac/val dose in HFrEF.
a 🧵
jacc.org/doi/epdf/10.10…
It's a little known fact that prior to the PH3 PARADIGM trial, a PH2 study in HFrEF was not performed--normally PH2 studies provide target doses for the pivotal outcomes trials.
So how was the dose of sacubitril/valsartan chosen??
So how was the dose of sacubitril/valsartan chosen??
The target dose of 97/103 mg twice daily was selected to achieve serum concentrations of valsartan = to those in Val-HeFT and VALIANT while simultaneously achieving 90% neprilysin inhibition in normal individuals.
Presented today as late-breaking data at #HFSA2022 and posted online @CircAHA, new data from PROVE-HF regarding impact of #sacubitril/valsartan on #mitralregurgitation in #HFrEF.
Thanks to @DukeHFDoc for presenting in my absence.
What did we find? A 🧵...
Thanks to @DukeHFDoc for presenting in my absence.
What did we find? A 🧵...
It is well-known that MR severity is an important determinant of symptoms and prognosis in those with HFrEF.
Thanks to work from @LindenfeldJoann and @GreggWStone in the COAPT trial, it is also known that repair of MR may improve outcome in HFrEF.
Thanks to work from @LindenfeldJoann and @GreggWStone in the COAPT trial, it is also known that repair of MR may improve outcome in HFrEF.
Medical Therapy for Functional #MR
#GDMT is the first step and prevails as the mainstay in the treatment of #FMR
This review addresses the medical Tx options for FMR Mx and highlight a targeted approach for each FMR category
#HeartFailure #VHDs ahajournals.org/doi/10.1161/CI… @CircHF
#GDMT is the first step and prevails as the mainstay in the treatment of #FMR
This review addresses the medical Tx options for FMR Mx and highlight a targeted approach for each FMR category
#HeartFailure #VHDs ahajournals.org/doi/10.1161/CI… @CircHF
#GDMT plays a pivotal role in LV reverse remodeling (LVRR) in FMR and leads to reduction in severity and improved outcomes for both atrial and ventricular #FMR
#GDMTWorks #VHDs #HeartFailure
#GDMTWorks #VHDs #HeartFailure
Studies report 28% to 50% reduction in grade of #FMR from baseline in patients receiving optimal or maximally tolerated doses of #GDMT (including diuretics) in both ischemic #cardiomyopathy and non-ischemic CMP
#GDMTWorks #VHDs #MR
#GDMTWorks #VHDs #MR
What happens to BNP when a person is started on #sacubitrilvalsartan?
#BNP should go up, right?
Thanks to work by @pmyhre in our group, we have some new and interesting data.
A 🧵, read on! 👇
#BNP should go up, right?
Thanks to work by @pmyhre in our group, we have some new and interesting data.
A 🧵, read on! 👇
When the #PARADIGM-HF study was published, one of the things immediately noticed was the increase in BNP that occurred after being started on sacubitril/valsartan.
This is because through effect of sacubitril, neprilysin is inhibited. Why might this lead to an increase in BNP?
This is because through effect of sacubitril, neprilysin is inhibited. Why might this lead to an increase in BNP?
#Neprilysin is a ubiquitous metalloproteinase that assaults BNP (among other targets including ANP and CNP) and cleaves it in numerous places as shown.
Note that in BNP, there are cleavage sites that involve numerous places where immunoassays for measurement of BNP may bind.
Note that in BNP, there are cleavage sites that involve numerous places where immunoassays for measurement of BNP may bind.
In one month, I've diagnosed more cases of ATTR cardiomyopathy than I did in 10 years. If you don't look for it, you won't find it.
A micro-tweetorial...
What should you look for?
@HannaGaggin @frederickruberg
A micro-tweetorial...
What should you look for?
@HannaGaggin @frederickruberg
--unexplained mild "LVH"
--PAF that has little explanation
--spinal stenosis
--carpal tunnel
--orthostatic hypotension
--bruising
--lack of EF response to #GDMTworks
--Diuretic sensitivity
--Higher biomarkers "than they should be"
--PAF that has little explanation
--spinal stenosis
--carpal tunnel
--orthostatic hypotension
--bruising
--lack of EF response to #GDMTworks
--Diuretic sensitivity
--Higher biomarkers "than they should be"
Why are biomarkers higher in amyloid? It has mainly to do with direct myocardial toxicity of the amyloid protein, and NOT congestion/ischemia in most cases.
hs-cTn is almost universally elevated.
Both NPs and hs-cTn are prognostic, regardless of their 'decoupling' from HF/MI.
hs-cTn is almost universally elevated.
Both NPs and hs-cTn are prognostic, regardless of their 'decoupling' from HF/MI.
❤️Enjoyed watching the #HeartFailure: Looking Back and Moving Forward webinar.
❤️Dr. Braunwald summarized his 70 years of experience in ~20 minutes.
❤️So much has happened before I was even born!
❤️Yet, so much more to look forward to! Thank you for a tour back in time!
❤️Dr. Braunwald summarized his 70 years of experience in ~20 minutes.
❤️So much has happened before I was even born!
❤️Yet, so much more to look forward to! Thank you for a tour back in time!
❤️I thoroughly enjoyed Dr. John McMurray’s overview of “the five alive” & his emphasis on moving away from vertical integration approach.
❤️Up-titrating each medication should not interfere w/ adding meds w/ complimentary benefits.
❤️No excuses, because #GDMTworks.
❤️Up-titrating each medication should not interfere w/ adding meds w/ complimentary benefits.
❤️No excuses, because #GDMTworks.
❤️Loved how Dr. Milton Packer went back in time to highlight the origin of LVEF cut-offs & the confusion that followed.
❤️He then advised using strain & myocardial contraction fraction, compared & contrasted common diseases using the same.
❤️HFpEF:disease of something else!
❤️He then advised using strain & myocardial contraction fraction, compared & contrasted common diseases using the same.
❤️HFpEF:disease of something else!
1/ Remember : the vast majority of patients in PARADIGM-HF reported NYHA Class II symptoms, tolerating background GDMT and virtually all had SBP > 100 mmHg at randomization. So basically “the patient is stable” is the IDEAL patient for ARNI.
According to @propublica my profile of prescription behavior (CMS data 2016) reflects my number one Rx is spironolactone. I ❤️ spiro. #GDMTWorks. @gcfmd @IAmDrIbrahim @ShashankSinhaMD @yaleHFdoc @SJGreene_md @MKIttlesonMD @JonathanDavisHF @MichaelNassifMD @ajaysmd @JJheart_doc
projects.propublica.org/checkup/ if you want to check out your prescribing behavior.
I generally love #GDMTWorks and it pretty much tops my action list when seeing patients. Descending order of Rx below.
