2 days Ago By Dr Ray O'Connor
Dr Ray O’Connor takes a look at the latest clinical articles on the subject of heart failure Heart failure (HF) is a complex and rapidly increasing syndrome, with an estimated prevalence of 1.1–5.5 per cent, accounting for 30 to 64 million people worldwide.
In European countries, the median incidence of HF is 3.20 cases per 1000 person-years, and the median HF prevalence is 1.7 per cent.
In the USA, the lifetime risk of heart failure is now estimated at 20–30 per cent. Although the incidence of HF slightly declined over time, its prevalence is increasing due to improved HF treatments and longer life expectancy in the population. Dr Ray O’Connor Hypertension represents one of the main and most common risk factors leading to the development of HF across the entire spectrum of left ventricular ejection fraction (LVEF), but with a fundamental role in HF with preserved EF (HFpEF, LVEF ≥ 50 per cent).
The age-standardized prevalence rate of hypertensive heart disease has been estimated at 217.9 per 100,000 people, with the individual and global disease burden increasing with patient and population aging. This review paper 1 considers the role of hypertension in the pathophysiology of HF.
A large body of evidence has demonstrated that adequate blood pressure (BP) control can reduce cardiovascular events, including the development of HF. The paper states that although the pathophysiological and epidemiological role of hypertension in the development of HF is well and largely known, some critical issues still deserve to be clarified, including BP targets, particularly in HF patients. Indeed, the management of hypertension in HF relies on the extrapolation of findings from high-risk hypertensive patients in the general population and not from specifically designed studies in HF populations.
The authors recommend that in patients with hypertension and HF with reduced ejection fraction (HFrEF), one should combine drugs with documented outcome benefits and BP-lowering effects. They also recommend that in patients with HFpEF, a therapeutic strategy with all major antihypertensive drug classes is adopted. Besides commonly used antihypertensive drugs, they state that type 2 sodium glucose transporter inhibitors (SGLT2i) have been shown to induce BP-lowering actions that favourably affect cardiac afterload, ventricular arterial coupling, cardiac efficiency, and cardiac reverse remodelling.
More recently, it has been demonstrated that finerenone, a non-steroidal mineralocorticoid receptor antagonist (MRA), reduces new onset HF and improves other HF outcomes in patients with chronic kidney disease and type 2 diabetes, irrespective of a history of HF. HF is characterized by a severe prognosis. Despite the efforts made over the last decades to improve its treatment, five-year mortality of HF patients is ≈20 per cent, and symptomatic HF has a one-year mortality ranging from 53 per cent to 67 per cent.
The purpose of this review paper 2 was to outline the principal pathogenic mechanisms that are involved in the development of HF in obese people, to summarize the recent progresses in CV imaging for diagnosis of HF in obese individuals, and to consider pathogenetic mechanism-based therapeutic strategies to improve prognosis in obese patients with HF . Obesity causes morphological and functional alterations involving the cardiovascular system. These can increase the risk of different cardiovascular diseases, such as atrial fibrillation, coronary artery disease, sudden cardiac death, and HF with both preserved EF and reduced EF.
Different pathogenetic mechanisms may help to explain the association between obesity and HF including left ventricular remodelling and epicardial fat accumulation, endothelial dysfunction, and coronary microvascular dysfunction. Multi-imaging modalities are required for appropriate recognition of subclinical systolic dysfunction typically associated with obesity, with echocardiography being the most cost-effective technique. Therapeutic approach in patients with obesity and HF is challenging, particularly regarding patients with preserved EF in which few strategies with high level of evidence are available .
Weight loss is of extreme importance in patients with obesity and HF. The depressing conclusion is that currently there are no clearly defined strategies for the diagnosis and treatment of obesity-induced HF. This issue is an unmet clinical need that should be promptly and adequately addressed.
The next review paper 3 highlights global trends in the burden of HF. Although the incidence of HF has stabilized or declined in high-income countries over the past decade, its prevalence continues to increase, driven by an ageing population, an increase in risk factors, the effectiveness of novel therapies and improved survival. This rise in prevalence is increasingly noted among younger adults and is accompanied by a shift towards HFpEF.
However, disparities exist in the epidemiological understanding of HF burden and progression in low-income and middle-income countries owing to the lack of comprehensive data in these regions. Therefore, the current epidemiological landscape of HF highlights the need for periodic surveillance and resource allocation tailored to geographically vulnerable areas. The European Society of Cardiology (ESC) has recently published an updated guideline on HF 4 .
They recommend SGLT2 inhibitors and finerenone for the prevention of HF in patients with diabetic chronic kidney disease (CKD). They also recommend SGLT2 inhibitors for the treatment of HF across the entire left ventricular ejection fraction spectrum. They state that the benefits of quadruple therapy in patients with HFrEF are well established.
Quadruple therapy adds Beta blockers and Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB) to SGLT2 inhibitors and MRAs like Finerenone. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. This drug is in a class of medications called soluble guanylate cyclase (sGC) stimulators.
It works by relaxing the blood vessels in the lungs to allow blood to flow easily. Also, in some trials, semaglutide 2.4 mg once weekly administered for one year decreased body weight and significantly improved quality of life and the six-minute walk distance in obese patients with HFpEF with or without a history of diabetes.
Some trial evidence supports the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e.
, mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, are also reviewed in this article. The American College of Cardiology (ACC) has also recently published heart failure guidelines, 5 though the ESC guideline is more recent and probably more relevant for European doctors. This paper focuses on the definition of heart failure, the medical treatments specific to left ventricular ejection fraction, use of devices for treatment and diagnosis, diagnosis and treatment of amyloidosis, treatment of iron deficiency, screening for asymptomatic left ventricular dysfunction, use of patient reported outcomes, and tools for implementation.
My personal conclusion is that heart failure is a complex condition that is difficult to understand for the generalist. However, the preventable nature of the condition, as well as the increasing availability of community based cardiac services and additions drugs for resistant to treat cases gives us some hope to be able to better manage the condition in the future. References:.
