I would like to thank the Heart Failure Society of America for allowing me to present this and as we talk about heart failure medications and the challenges that come with those medications. So we're going to sort of back up and initially sort of talk about what is this concept of ejection fraction, the term that we throw around a lot in heart failure and if you look there at the picture of the heart, on that right side where it's blue, that's where the non-oxygenated blood then goes to the lungs and gets its oxygen and then drops down into the left side. The left side, that left ventricle that's circled there, that is the workhorse of the heart. So when we're talking about it via ejection fraction, that's what we're talking about is how well does that left ventricle squeeze and then the blood shoots out into the aorta, that is what carries the blood to the body. The heart's job is to transport oxygen and nutrients to all the organs in the body parts. I like to tell my patients it goes from the, it's supposed to go from the tip of your head to the bottom of your toes, that's its job. The ejection fraction is an indicator of how well is the heart doing its job, how well is it squeezing and pumping the blood to the rest of the body. How do we figure out what this ejection fraction is? Well what we do is we actually look at the amount of blood that is filled in the ventricle when it's relaxed, this is called diastole and then how much of the blood is actually shot out into the body when the heart contracts known as systole. A normal ejection fraction is greater than 50%. If you think about it, it's about like having a five to six cylinder engine in your chest. If you have a pumping function less than 40%, then it's not working quite as well. And also like an example, a math example of how this blood is calculated, if your heart filled with 100 milliliters of blood, it would need to actually push out at least 50 milliliters to have a normal pumping function. So let's talk about how do we categorize heart failure? We have two definitions, it's half breath or half path. And patients that have a less than normal ejection fraction, less than 40% so like working out of four out of six cylinders or less is called heart failure with reduced ejection fraction. It's also known as systolic heart failure is the old term. And then on the flip side, we have patients that have a normal pumping function, but they also have heart failure. That means the squeeze of their heart works perfectly fine. It just doesn't like to relax that heart muscle is a little stiff. That's called heart failure with preserved ejection fraction, or the old term was called diastolic heart failure. So we're going to talk about medications, that's the majority of what this talk is about. And we are going to talk about how we differentiate these differences between whether you have a reduced pumping function, or if you have a preserved pumping function. When we look at the evidence, people that have a reduced pumping function, we have multiple studies with very positive results on there. And we have these medicines, there's all these medicines, like five lines of medication that we have studied. And we know that they improve outcomes and heart failure, they prolong your life, they reduce hospital visits, and they improve your symptoms. They improve you dying from heart failure. Later on with HF-PF, we have many studies, but those studies have had very neutral results in regards to improving outcomes, been very frustrating for researchers and heart failure specialists. We do know there are a few medicines that are listed here that can help improve heart failure symptoms, and can reduce some hospital visits. Our goals for our medications are very different depending on what type of heart failure you have. With our ones that have a reduced ejection fraction, we're looking at optimizing these medicines to either the target dose that we saw a benefit in the clinical studies, or to the dose that you can tolerate without having significant side effects or feeling bad. And we know that that is what is going to be the target to try to get that heart to pump more effectively, to gain some cylinders in your car engine. Where our medication goals with a preserved ejection fraction is much different. It's much more built around symptom control, sort of trying to improve shortness of breath, trying to control your swelling or that fluid retention you get in your legs or your belly, and also making sure that that blood pressure is very well controlled, as that is important in trying to make that stiff heart work a little bit more effectively. So we're going to sort of talk about medications and heart failure. This slide is mainly just showing you we have different classes for our heart failure medications. We have what we call our ARNs, our ACEs, our ARBs, our beta blockers, and our aldosterone antagonists, and there's drugs in each of these classes, depending on how they target the body. There's different hormones in heart failure that get activated, and they cause a more rapid progression of the disease. That's why it's very important to make sure that we have you on the right drugs, and we're going to talk a little bit more of what this exactly means. So we're going to look at these hormones. I like to call them the bad guys in heart failure. We have some good guys in heart failure, but we really have a lot more bad guys in heart failure that are causing these circulating hormones. We know from 50 years of research that these hormones, the adrenaline or epinephrine, angiotensin 2, aldosterone, all are responsible for harmful effects on the body's organs over time. We know that the adrenaline increases the workload on that very tired, not well-pumping heart. We know that angiotensin 2 causes constriction of the blood vessels, so that big aorta gets tightened down, so blood cannot get out of the heart as well. It poses great resistance to the heart pumping. It also causes fluid retention, so the kidneys want to hold on to that fluid in water. Then the aldosterone causes actually scarring inside of the blood vessels in the heart and the kidney. Also, it's not on this slide, but it also makes the kidney want to hold on to sodium in water. So all in very different ways, they cause problems to the organs long-term. We know from research and from studies in humans that these hormones, when they get so activated, they make your heart failure worse. I'd like to explain it on a teeter-totter. You have to think that your heart is in the middle of the teeter-totter, and on one side you've got good guys in heart failure, and on the other side of the teeter-totter you have these bad guys. What happens is that more of the bad guys keep coming and jumping on that side of the teeter-totter, and the good guys can't keep up. What happens is the teeter-totter then does what? It tips, and it can't upright itself. That's where our medicines work. They are the one that's going to come and knock some of those bad guys off that end of the teeter-totter by blocking some of those bad effects. Our beta blockers work on blocking epinephrine or adrenaline so that poor, tired heart doesn't have to work so hard. Our hydrolyzine and our isosorbide work directly on the constriction of the blood vessels. I like to explain that it makes the vessels more loosey-goosey, and it takes a longer time for them to tighten up. Our ACEs and our ARBs and our Secubitril or Entrusto drugs actually do two things. They not only work on the constriction of those vessels, but they also work on that fluid retention part that the kidneys play. And then aldosterone, it gets blocked by aldosterone antagonists, and we're going to talk a little bit more on the exact drugs so that way you may know, oh, yeah, I'm on this drug. This is why I'm taking that. But it works on trying to make the kidney get rid of the sodium and water and works on that microvascular, that small inside of the scarring of the blood vessels. We know that our studies have shown that people on these drugs with heart failure have improved outcomes. Your symptoms improve. You live longer. We know that you should be on one of these classes of drugs. So I call it the three buckets of bad guys. We need to make sure that all three buckets are blocked. We do know that African Americans also benefit from the additional blockade of hydrolazine and Iserdil. They actually do better if they have that additional benefit of relaxing those constricted blood vessels in that heart. So this is a building blocks of heart failure. This is where we work on blocking those bad guys of heart failure. So our beta blockers, that is the drugs that are called Corvatalol or Coreg. Maybe the Metoprolol, Sexonate or Toprol or Bisproprolol. So you should be on one of those beta blocker drugs unless there are certain times we cannot put these patients on drugs that your provider should explain to you why you're not on those medications. The second bucket is where we're trying to block the constriction of the vessels. We're trying to work on that fluid retention take up in the kidney. This is your ACE inhibitors. So these are the drugs that end in pril, that P-R-I-L, like Lisinopril or Enalapril. Or you may be on what we call an ARB, which would be a Sartan drug, Losartan, Valsartan or Candisartan. Or the third drug is Secubitril or Valsartan or better known as Entresto. It's one of our newer heart failure drugs. And the nice thing about this drug is it's the only drug we have that can increase those good guys, those nutritic peptides in heart failure that better try to help balance out that teeter-totter. And then we may or may not have the addition of the hydrolazine and the isorbsorbide. The third bucket is this aldosterone antagonist. So this is what helps the kidney not hold on to the sodium and water. It helps the blood vessels inside the heart and the kidney not get scarred down. And those medicines would either be Spiralactone or Apirilum. And now some of you may be thinking, well, I'm also on a fluid pill, where does that fall in? Well, these three classes, those are our blocks. And then we have what we call some additional medicines that we use to help improve your symptoms, maybe try to keep you out of the hospital, but they're not going to necessarily prolong your life. This is our diuretics. So this is what is going to help us control the amount of fluid that you may have in your abdomen or your legs. These medicines cause the kidney to release more sodium and water. I call them the big guns, because when you take them, it doesn't take very long and you don't have to go in the bathroom. You're going to urinate more frequently. Our three big ones we use is Furosemide or Lasix, Immunodide or Bumex, Torsemide or Demodex. These last two are what we call booster diuretics. They're like super duper diuretics that make those first three more effective. We use those very cautiously, more towards our end-stage heart failure patients, because they can worsen the kidney function, so we want to be very cautious when we use that. In the other drug options, we have three medicines there. Digoxin is used, is really one of the very old heart failure drugs. We use it mainly now for people that are in this rhythm called atrial fibrillation to try to control the heart rate and try to keep them out of the hospital, because you don't tolerate being in this rhythm when you have heart failure. The next drug is called Ivaberdine or Colinor is the brand name. It's for people that we can't go up on their beta blockers, on their Coreg, on their Metoprolol any further because of lower blood pressure, or maybe they're at the maximum dose. We need their heart rate down lower. Heart rates in the 90s to 100s for a regular person is not an issue. Someone with heart failure, that's too much. It's making that poor, tired heart work a lot harder, and it's going to get weak over time. We have this medication to put on so we can pull that heart rate down more into the 50s or 60s, which will allow that workload of the heart to be much more effective. And then our nitrates. This is people that we use that maybe have blockages in their arteries. They have what we call ischemic cardiomyopathy, which is an enlarged heart due to either a heart attack or blockages in your heart arteries, and we need those heart arteries to be a little bigger to help prevent chest pain or maybe shortness of breath. So this is your nitroglycerin, your patches, your Imdur, your Iserdil, those type of medications on there. So diseases that impact heart failure. We know there are a lot of things that impact heart failure. It's not a disease process that stands by itself. There are a lot of things that can make heart failure the cause of the heart failure, or it can make heart failure worse. Those are things like that heart rhythm, people in atrial fib, atrial flutter, or more concerning rhythms such as ventricular fibrillation or ventricular tachycardia, people that have blockages in their heart arteries on there. If you have a leaky or real narrow valve, usually either the mitral or the aortic are the two biggest ones that we see. Diabetes and heart failure go hand in hand. People that are diabetic are much more prone to develop heart failure down the road. People that have high cholesterol, high blood pressure, and the high blood pressure, I like to explain it to if you think, and I'm going to go back here to this heart picture, this aorta there, if you see, if that, if you think of it as a milkshake, if that's like a normal size straw, you can drink that milkshake without a whole lot of problem. But if you would take this and shrink that aorta down into what taking the straw out and putting a coffee stirrer in there, you're going to have to work really hard to drink the milkshake. The heart has to work really, really hard to get the blood out of the body. And that weakened heart can't handle it and will just get weaker and weaker. Sleep apnea, very important that if you have heart failure and you have not been, had a sleep study to assess for sleep apnea, that you talk with your heart failure provider about that. We know that significant amount of heart failure patients have sleep apnea. And if it is not treated, it can make treating your heart failure much more difficult on there. Kidney disease, it is not unusual that you don't have normal filtering kidneys when you have heart failure. But if you already have diabetes and you have worsening renal function coming in, that makes it a bigger difference or a bigger problem of trying to manage your heart failure. People that are anemic, people that have thyroid, so they have a very hypo or hyperthyroidism. People that have lung diseases such as COPD, pulmonary hypertension, which is high blood pressure in the lungs. This all makes it very much more difficult to treat your heart failure. And it's why it is good that you are going to see a heart failure specialist, because we are very used to 10 spinning plates. And we know how these diseases affect your heart failure and what medications you would need to be on. The other question that we get is, what are these drugs going to do to me? Yes, there are some possible side effects. The first one, the allergies, that is really a true medication adverse effect. So, sometimes you can get facial swelling with usually your ACE inhibitors like your lisinopril or your nalopril. We can see it with like losartan, candesartan, those, but not usually. Any drug can cause a rash on there, a cough. These next ones are more of a side effect of the drug. And if you have any of these, talk to your provider because they will help us try to ascertain, you know, is this a true side effect of the medication? Is it related to the dose? What do we need to do with that? Cough is usually seen with the ACE inhibitors, lisinopril, those pril drugs. It's usually dry, sort of hacky on there. Lightheadedness and fatigue, we see these with our heart failure medication. And that is because we are dropping the blood pressure to help the heart work a little more effectively. But usually, this will get better after you've been on the dose for several days. When I am adjusting doses, I always tell my patients, if you have a little more dizziness or lightheadedness or a little more tiredness, and it lasts more than a few three to four days, then call me on there. We do see a little bit more fatigue with the beta blockers in some patients. They can cause in men some sexual dysfunction. We do not recommend that you stop your medications if that happens. Call us. Let's discuss it. Let's see if there's another option of a medication we can use. In also speaking about abnormal blood tests, with any of those angiotensin drugs or your aldosterone drugs, those pril drugs, the sartin drugs, spiral lactone, apirilone, intresto, because of the way they work, they can cause abnormal higher potassium levels. They could potentially worsen kidney function. So that's why it is of utmost importance when we start these medications and we change any doses that we are getting lab work. So when we ask you to get lab work the next week, it is very important that you do because that's where the problem is. It's not in the drug. It's that we're not getting the monitoring lab work to make sure that we can catch when things start to go a little sideways and we can make adjustments and medications. And I cannot impress enough to not stop your medication. Talk to your provider and let us help figure that out. So now we're going to talk about common challenges with medical medications. You may sort of feel a little bit like my patients with this, that you feel like you're just one giant multiple medications because unfortunately with heart failure we don't have just one medication that we have to take. So some of the issues that we have is we have multiple providers that you're seeing and they can sometimes give conflicting advice. Communication with your providers are very vital, whether it's your heart failure doctor, your general cardiologist, your primary care doctor, your diabetes doctor, communication. Some patients who have heart failure, most of them you're seeing multiple providers. It says this heart failure patient with Medicare patients sees an average of 15 providers per year and eight of those are describing different medicine. Wow, no wonder we can get confused of what we're supposed to do and we get conflicting advice from our providers on their with diet and medications. And some of it could be a misunderstanding that maybe they don't realize you have heart failure or maybe it's a non-heart failure specialist that doesn't realize maybe certain medications, how that affects your heart failure. And sometimes we need to change dietary things based on other things going on. An example of this could be that your heart failure doctor, you've gone, you're on Lasix, so that's furosemide, 80 milligrams twice a day. So you get the flu, three months later you go to your primary care doctor, they tell you stop your diuretic, drink lots of fluids. Now that's correct, however, then there needs to be discussion about once I get better, what do I do? And maybe when you feel like the flu, that's not the time you feel like taking that conversation. But then when you get to feeling better, calling your doctor, whether it's your heart failure doctor or your primary care doctor, say hey I'm feeling great, do I need to restart my diuretics? And because then we do need to do that, we need to start curtailing how much fluid we're taking in with that. So then we don't have the reverse or the opposite problem where you're now holding on to much fluid because you're not taking your diuretics. And if you're ever unsure, call us. That's what I tell my patients. If you ever have any questions, if you're not sure what medication or should I stop this, should I be restarting this, call us. Let us help you figure out. Also 22 percent of heart failure patients, also what we talked about, sorry about that, both the medication instructions, but about two-thirds of the heart failure patients have two to three different diets. This makes it extremely challenging. It's very easy for us to say okay I want you to do a low salt diet. Then you go to your kidney doctor and he says okay your phosphorus level is too high, I need you to do a diet low in phosphorus. And then you go to see your diabetes doctor and he says I need you to follow carbohydrates and sugars, reduce that in your diet. Now you have three different diets which pretty much has left you that you cannot hardly eat squat. You're not happy with us, which I get. It's important that then you contact each of us, say hey I have very little to eat because I have to watch my phosphorus, I have to watch my sugars, I have to watch my salt, I need help with that. And allow us to compromise and work with you to try to get maybe not quite as of a restrictive plan to give you more options so we can achieve the goal to make sure that your diabetes, your kidney function, and your heart failure are all well treated with that. I utilize the dieticians a lot in our offices. Also the Hy-Vee grocery stores, I don't know if you have those in your area, but some grocery stores have dieticians there that you can talk to to help you with some of these issues of trying to figure out what can I eat. Now let's talk about the other problem that we have is medication adherence. And medication adherence is basically a fancy term for saying your ability to take your medication as prescribed without forgetting doses. On the left side of this slide there are some barriers to that. Sometimes we're forgetful, we get busy. The solution to that is to set alerts. We all have smartphones, most of us. Set a daily alert to remind you to take your medication or download an app that will give you an alert to say, hey, it's time to take your Coreg or it's time to take your diuretic with that. If you miss doses because you're dependent on others to pick up your medications for you, that's the other thing that we have issues with. Access to pharmacy. Maybe you can't drive, you have to rely on somebody. Look into where you get your medications, especially if it's a home pharmacy. Do they deliver? I know that like Walgreens chain does do home delivery. A lot of the three-month prescriptions like Express Scripts, Selmer Scripts, those are all mail orders. So looking at mail order pharmacies, that way you can get your medications delivered to your home on there. Also, the cost of drugs. We get it. If they, you know, you have lots of medications you're taking, some of these drugs can be fairly on the expensive side. Talk to us. When we put you on a drug, if you get to the drugstore and you're like, I can't afford that co-pay, call us back. Let us work with you. We might be able to use samples while we try to get you some assistance from the assistance from the pharmaceutical company, find patient's assistance with you. We're there to help you with that cost on there. Perception of the medication. Sometimes you may not understand exactly why am I taking this medication on there. Talk with your healthcare provider. Talk with your pharmacist if you go to a local pharmacy because they can talk about benefits and risk on there. We can tell you the reason we want you on this drug. This is the outcome. The studies have shown, like I'm just going to use Entrusto for example. Studies have shown that by being on this drug, we can decrease your chance of dying from heart failure by 20%. And then you can have that dialogue. What are the odds of you having an adverse event? That would mean, what are my chances of me developing really high potassium in my blood? What is the chance of having worsening kidney function? What is the chance of me getting dizzy, lightheaded? And we can explain what the risk that would be for you on there. The other thing is organization. When are we going to try to take our medications? We're going to talk here on the next slide about sort of administrative times and how to figure that out. Yes, we know multiple drugs. We're going to talk with that on the next slide. Refill dates. I think this is one that gets us sometimes in trouble we don't think about. And especially as providers, we don't necessarily think about because we're putting you on medicines or changing medicine. Talk to us. Remind us when you come to our visit or calling our nurses. Say, hey, can you please get me every three months refill? So you're not having to go to the pharmacy every single week or every few days to pick up medications. If you can get all your refills on a schedule where you're only needed getting once a month or every three months, that's going to be able to entail you're going to have all your medications with you when you need them on there. Sometimes you need to work with your pharmacy on there to try to coordinate that refill schedule. Other common medications that our heart failure patients take. Unfortunately, this is what we see. It's not just the heart failure medications. Those four or five you may be on the heart failure. It's that you also have high blood pressure. Now, fortunately, some of those medications we have on for your heart failure work on lowering your blood pressure. So sometimes we can eliminate some of those other blood pressure pills you may not need. But a lot of times you're on a pill to lower your cholesterol. If you have had clotting issues, either in your legs or your lungs, or you have atrial fibrillation or atrial flutter, then you're also on a blood thinner on there. If you've had a recent stent put in your heart artery, then you're on one of those other platelet agents along with aspirin. If you've got diabetes, you have injections or pills, arthritis, allergy, if you have chronic pain, you pretty soon that's why all of a sudden you have I'm on 15 pills on there. Because it's not just one sided. Taking multiple pills is what we call polypharmacy. And when you have polypharmacy and you're taking multiple medications, there's a higher chance of you having a medication problem. If you take more than five drugs, our heart failure drugs, those are four drugs if you just do the building blocks, your beta blocker, that angiotensin blocker, your aldosterone blocker, and then your diuretic. There's four right there. Not to mention if you're on an aspirin or diabetes or other things. If you take drugs for more than three health problems, if you get prescriptions from more than one provider. And then the other thing we see is you've gotten put in the hospital for heart failure. Maybe it's for completely different reasons. Maybe you had a hernia surgery and you get discharged and your prescriptions have changed or you've added new prescriptions to what you already have. Can be very complicated. I cannot stress enough to talk with your health care provider. Allow us to help try to help you manage this problem of this polypharmacy. Some of how you can help with this is knowing the name and the person or the purpose for the medication that has been prescribed with this. I am a full believer that it is very important for you to know not only the dose of the medicine, but why are you taking it? Carry a list of your medications with you. And I don't know what your clinic does. Our clinic, when you leave, the clinic visit after care visit has the new list of medications. I tell my patients, use that. Take that with you to your appointments, not just your heart failure appointment, but your other appointments. That way changes can be written on there. If another provider makes changes that will also help you when you go to fill your medication bottles or your trays for the week, you have that list on there. Understanding the purpose of your medication. Yes, several of your heart failure medications will lower blood pressure, but that's not why you're on them. You're on there to either make your heart pump more effectively or to make your blood vessels not so tight. It's not for blood pressure. Knowing how to take your medication. Talk with us about that, you know, so that you know, is it a once a day a drug? Is it a twice a day drug? Sometimes if you're having dizziness and lightheadedness and you're on lisinopril and metoprolol, those are usually both one day of drugs. We may need to have you take one of those in the morning and one in the evening. Let us know any non-prescription medicines you're taking because there are certain ones we're going to talk about here in a minute that are a big problem if you take them if you're heart failure. Many of your medications are going to have more than one effect. We sort of get two things for the price of one. Also knowing there are two names for each drug. There's a brand name and a generic name. I always put on my paperwork I send home with my patients both names because we may talk in the office about Coreg because it's easier to say but when you get home and you look at the bottle and it says Cervetolol and you're like I don't have a drug called Coreg. Well knowing that Coreg and Cervetolol are the same drug with that because your medication bottles are going to come with a generic name on there. How should you schedule your medicine throughout the day? Taking too many medicines at once can cause fatigue, dizziness, upset stomach. Let us know because like I just said in the previous slide we may need to adjust the timing of doses. Knowing that you may need to be taking that medication on an empty stomach or maybe with food your pill bottle should tell you that. Some medications last 24 hours that's why you can take them once a day. Some only last for 12 hours so that's why we have to take them twice a day. Once a day medicines you can take them at any time but you need to take them at the same time every day. That is going to help prevent some of those side effects you can have from dizziness or lightheadedness or tiredness with that. The best way to make sure medicines are taken care of you can bring your pills with you to your appointments or bring your pill list so we can make sure that we know exactly what medications you're on. Pill boxes I think are the best thing on there to make sure that you know you've taken your medicine versus taking them out of the pill bottle. Get ones that have three or four slots so they have a morning afternoon night or maybe a morning lunch afternoon night slot so you can make sure you have those pills done in there correctly. Some people that want to take them out of the bottle turn it upside down after taking. What I tell my patients is when they're filling their trays you fill one medicine at a time when you're done turn it upside down so that way you know oh I've got that medicine all in my pill box. Using pill reminder apps on your mobile phone your ipad sit or if you don't have the apps just there's alarms on your phone set those with those and using medication tracking sheets like this so you can write down your medication the doses when do I take them and what are they for so it sort of has everything in one spot you can sort of check that off with their sometimes your clinics have these available sometimes you can find them online and print them off with that. What should you do if you're having difficult affording your medication there's a reason that first one is in all caps because we cannot help you if you don't let us know you can't afford your medicine the medicine is not going to do you any good if you can't afford to take it and we definitely don't want you sacrificing on paying your bills or on what food you can buy to afford your medication, so talk to us. We may have a lesser expensive drug on there. We may be able to help you with samples. Now, that's not a long-term solution, but if we're looking into assistance programs, whether it's with the drug company or whether it's with different patient assistants or the clinic, we can use samples to sort of tie you over. Sometimes we do have to stop the drug and choose another option, but most of the times we can find a alternative if you let us know that ahead of time. Sometimes you may be on the medicines, not been a problem, then your insurance company changes pharmacy providers on there, and now all of a sudden the medicine that cost you $10 for three months supply now is costing you 100. Let us know so we can work on that. Sometimes we can put an appeal into the insurance company. Now let's talk about medications you should avoid if you are in heart failure, because as we said, you have multiple different providers that you're seeing. Sometimes they're not aware that there are medications that can worsen your heart failure, so sometimes you have to be an informed patient to say, hey, I'm not sure this is a medicine that I should be on, or if you're not for sure, call us. I tell my patients that if they have a medication that's prescribed by another provider and they're unsure whether they should take that, or if they're unsure if that's gonna affect my heart failure, to call my nurses and we can double check on that. Medications, Diltiazem, Cardizem, is a well-known medication for high blood pressure, for heart rate control, not good for someone that has a pumping function that's reduced, that actually can worsen your heart failure. On there, certain rhythm drugs can cause an issue. The big one that we see is this Keoglitazone and the Rosita Glitazone, those are diabetes medicines that actually we know will have very bad effects. It increases risk of death if you have heart failure. So those are things that a diabetes specialist could prescribe, not thinking maybe how that affects the heart failure. Sometimes psychiatrists can prescribe medicines such as Ritalin, Adderall, if you have ADHD. Rheumatology will prescribe these TNF-alpha inhibitors or GI for ulcerative colitis. Those are all things that can exacerbate, worsen heart failure. On there, the one thing that we want you to know is look on that top sort of right side of there, NSAIDs. That's the biggest one that we need your help with, knowing I should not take. Because a lot of you, we have arthritic conditions or maybe we have, you know, a backache or we pulled a muscle and, you know, our primary care doctor or us, we said, oh, I'll go and I'll take some Motrin. Anything with ibuprofen, the naproxen, those are non-steroidal anti-inflammatory drugs. That's what that NSAID stands for. They actually interfere with some of the heart failure medications like your lisinopril, urinalopril, your diuretics. They actually can cause worsening heart failure and worsening kidney function. So it's very important that we're not taking those non-steroidal medications. And if you're not sure if one of the other medicines like meloxicam or some other arthritic medication is an issue, call us before you take it on there. It's, remember, it is very important for you as the patient to keep an accurate list of your medicine and you bring it with you to every single visit, to every single provider. That way there's a less chance that we may inadvertently put you on a medication that can worsen your heart failure. And to make sure that you also ask, hey, is this medication safe to take with my heart failure? It's a shared responsibility. So in summary, there are numerous and excellent medical treatment options available for heart failure. It's a chronic condition now. There are about 6 million people in the United States that have heart failure. We have now done so well with medications and other treatments for heart failure that now people are living much longer with this disease process. And that's why we wanna make sure that you are taking these medications as we're prescribing them, as we're explaining them to you, doing the healthy lifestyle, exercising, watching that salt, staying within that 2000 milligrams sodium restriction, two liter fluid restriction. These are all things that are not only gonna help improve your symptoms, but also prolong your life with that. Also remember there are numerous perceived medication side effects, but also some of those symptoms, fatigue, shortness of breath, could also be signs of worsening heart failure. If you are having any of those symptoms, if they get worse or you start having them, call your heart failure provider. Let us help sort that out. Is that due to a medication or is your heart failure getting worse and we need to make some adjustments to medication? When you have questions or concerns about your treatment, reach out to us for advice. That's what we're here for. We have wonderful nurses that help us with that. And also the Heart Failure Society has done a fabulous job with going to their website. There's numerous resources for information and advice. And if you don't have this app downloaded, I highly recommend that you download the Heart Failure Health Storyline app. It is a patient tool that's available to you. It only has education resources, but it actually has apps on there where you can put your medications on there for medication reminders. What you can also help you with, tracking your water intake or your fluid intake, tracking any symptoms, your weight, you can put all that in. So when you come to your appointments, here it is. Has wonderful, lots of good information with that. And I'd like to thank our education partners with Amgen and Cytokinetics. They've given us an educational grant to allow us to be able to give this program to you. So that is the content of our program. And I am now open to any questions anybody may have. I don't see anything in the queue at the moment. Thank you, Lisa, for a very informative presentation today. If you have any questions, you can submit them now in the question tab, which is located on the left-hand side of your screen. And while we wait for some of those questions to come in, I just wanted to discuss a few other things regarding our patient resources that are available to you and other activities that are going on throughout this week. The week of February 10th through the 16th is actually Heart Failure Awareness Week. So we do have a variety of webinars in addition to this one, as well as some social media activities. If you're interested in learning more, you can find that information on our website at www.hfsa.org. Also wanted to let you all know that we do have some heart failure education modules. This is a series of modules that are designed to help patients learn to live successfully with heart failure. There are 11 in total, and those can also be found on our HFSA website. You will also be able to find additional webinars that we've recorded previously. If there's an interest in learning about some additional topics that are targeted towards the patient community, again, that information is also located on our website. See if we have any questions coming in. Just to make you all aware that HFSA will be sending out an evaluation following the webinar to get your feedback on today's presentation. And we would also like to encourage today's webinar listeners to take part in the Heart Failure Patient Journey Survey, which is also located on our website. Oh, we've got a question in. One, can you address the antidepressants and how they interact with heart failure medication? Okay, yes, I can do that. Actually, this is one of the things, one of the probably very few drugs that you not always, affect people with heart failure, mainly the SSRIs is what we see. Some of the other depression medicines can increase blood pressure, such like Infexor. With that, some of the tricyclics, like amitriptyline, can sometimes elevate, dizziness, elevate heart rate. So those SSRIs, those are more like Zoloft, Paxil. Those types of drugs are really pretty safe to take with heart failure patients. And in fact, that's what, if I have a patient, because it's very common, unfortunately, depression does go along with heart failure. And those are the type of medicines we normally prescribe on there. So it looks like we have a number, that's number one question. Number two is, how often does systolic dysfunction become diastolic dysfunction? And it's usually the other way around. Usually diastolic dysfunction, the stiffness of the heart can come first. And then over time, it potentially can become a reduced or systolic dysfunction, so reduced function. Now, there are times when you do have a weak heart pump, that if you have certain, like if you have a weak heart pump and maybe your blood pressure is not well controlled, that can also cause some stiffness in the heart. People that don't have sleep apnea, that's not well treated. But most of the time, the diastolic dysfunction is gonna come first on here. And see what common cold and flu meds are recommended for heart failure patients? Excellent, excellent question. So what I tell my patients is the Coracidin brand, it's the Coracidin HBP, so it's high blood pressure. They are specially formulated for patients that have heart disease, whether it's high blood pressure, heart failure, they are all okay. I think they have a cough, a cold, and a flu formula. Or allergies or cold. Any, I recommend, you can do like the Muconex DM. You can do any like the Allegra, Benadryl, Zyrtec, all those, but nothing with that D behind it. So I tell my patients, if you can pick the box off the shelf and put it in your cart, you can have it. If it tells you to go to the pharmacy and you have to sign it out and you're only allowed two boxes, you have to show your license, you can't have that. That has the ingredient that's gonna elevate your heart rate, that's gonna cause problems with that. Next question, is homopathic treatments to avoid? So, and I meant, actually that's a good question also, I meant to put that on the other slide with the over-the-counter things. Supplements, just check with us to see if that is something that is okay to take. There are some over-the-counter supplements that are okay to take. Any supplement that is for weight loss, you need to bring that in so we can look at the ingredients. A lot of those have an ingredient that's gonna elevate heart rate and blood pressure. For the most part, essential oils, as far as I know, I've not had an issue. Massage, absolutely, is great with that. It's not gonna have any effect. The relaxation part, actually, is probably a good thing. It can help with depression and other things with that on there. And then, Patrice, this webinar, it's recorded and it will be available on the website? Yes, this webinar has been recorded and it will be available on our website within the next week. Okay, that's what I thought on there. And then, Tiffany had put back in there that I guess her doctor and pharmacy had taken you off your SSRI because of the effect of metoprolol. That would just be a discussion I would have with them since I don't particularly know all of what's going on with you. There may be a multiple layer and maybe they were concerned about that. I have patients that are on metoprolol and SSRI, but like I said, this is more of a general thing. There are different specifics with patients with that. And then, let's scroll back. Had several questions pop in once. Are there alternative treatment options for heart failure patients who naturally low blood pressure? Not really, but what we do sometimes, you know, if you have really bad orthostasis where your blood pressure is a little low, but it really drops really far down when you try to stand up, sometimes we will add some thing called monitodrine to try to help boost the blood pressure. But that's a very specific thing you would need to discuss with your provider. Across the board, we really don't have any specific things for that. Unfortunately, sometimes that limits a lot of times of how we can put and how much medicine we can actually put you on. And then we have to, you know, if your heart failure gets significantly worse, then we would have to start discussing about what we call advanced heart failure therapy, such as pumps or transplants, because we just can't get you on the medication with that. And then there's one more question I'm gonna try to get here. So I'm a nursing researcher. One of my patients reported that his pharmacy didn't send him diuretics and he experienced fluid overload more than two weeks. Finally, they found this was a medication error. Can you give any advice of how patients can check whether their medications are correctly refilled? Well, the main thing that I would tell, you know, is they know that they were on diuretics before and they didn't get their refill. They need to call their pharmacy, one, and make sure that it is being refilled. But also they could go ahead and call their pharmacy now and make sure if they are, make sure are their medications on this automatically refill that when it gets, let's say diuretics, for example, okay, we know you're gonna get this amount of Lasix every three months sent out, then make sure that that two weeks before you would be out that you get that refilled on there. Checking also with your heart failure provider and making sure that you have medication refills sent in, that you have active medication refills. That's really about the best suggestions that I can have with that. And that's where that ownership of knowing what medicines you're taking and knowing that when you're starting to get down to that two weeks, making sure that you're being in touch with your pharmacy to make sure that refill is coming if you're not on an automatic refill with that. So I think that is all the questions. I don't think I missed anything in there. Well, it looks like we've captured all the questions today and thank you again, Lisa, for that very informative presentation and for all our participants that asked questions. As we're coming to an end of the webinar time, HFSA would again like to gratefully acknowledge AstraZeneca, CytoKinetics, and Novartis for their sponsorship of our overall Heart Failure Awareness Week activities, as well as Amgen and CytoKinetics for their continued support of our community education program. We'd also like to thank Mended Hearts and Needy Meds for their continued collaboration to help support our mission and informing patients on how to better manage their heart failure. Thank you to all of you for participating in today's webinar. Again, an evaluation will be sent to you following the presentation today and a recording of this webinar and others can be found on the HFSA website at www.hfsa.org. Thank you all again and have a wonderful day.

heart failure medications

ejection fraction

heart failure types

medication adherence

heart function

medication classes

communication with healthcare providers

organizing medications

symptom changes