The researchers of a recent British Medical Journal paper reviewed heart failure diagnosis and management data.
Heart failure has led to considerable health and financial burdens globally, especially among older individuals. Recent scientific discoveries have resulted in novel medicines and an improved prognosis for heart failure patients. These include novel medications, technologies, and diagnostic approaches. Although clinical standards incorporate these improvements, their treatment and diagnostic suggestions are frequently outdated.
Clinical Review: Advances in management of heart failure. Image Credit: santoelia / Shutterstock
About the review
In the present review, researchers present updated aspects of heart failure management.
The researchers searched the Cochrane and PubMed databases for randomized clinical trials (RCTs), epidemiological studies, and cohort studies concerning heart failure diagnosis and treatment published from January 2015 to July 7, 2023. They included studies excluded from the 2021–2022 Heart Failure Society of America/American College of Cardiology/American Heart Association (HFSA/ACC/AHA) and European Society of Cardiology (ESC) guidelines, excluding case reports and case series.
Heart failure epidemiology and diagnosis
The Global Burden of Disease (GBD) study reported heart failure events among 57 million individuals in 2019, with age-standardized rates reducing from 7.70 per 1,000 to 7.10 per 1,000 from 2010 to 2019. However, the rates are non-linear, with initial decreases followed by a 0.6% annual growth from 2016 to 2019. In the United States, young individuals are being admitted to hospitals for heart failure at an increased rate. Survival after diagnosis is poor and heavily determined by age. Changes in heart failure care include increased usage of basic medication classes, sodium-glucose cotransporter-2 (SGL-2) inhibitors, and life-prolonging medicines.
Cardiac dysfunction, diminished systolic function of the left ventricle (≤40%), or elevated filling pressures characterize heart failure. The condition is classified according to the left ventricular ejection fraction (LVEF): heart failures with decreased ejection fractions (HFrEF), heart failures with minimally reduced ejection fractions (HFmrEF), and those with preserved ejection fractions (HFpEF).
The difficulty in identifying increased filling pressure makes HFpEF challenging to diagnose. Although invasive methods are the gold standard for identifying increased filling pressures in the left ventricle, clinical scores such as HFA-PEFF and H2FPEF indicate non-invasive diagnosis. Identifying the etiology of heart failure is critical since some illnesses require particular therapy. Cardiac magnetic resonance (CMR) scans can benefit individuals with dilated cardiomyopathies and considerably hypertrophic vessels on echocardiography.
Advances in heart failure management
Individuals with HFrEF are prescribed SGLT2 inhibitors, renin-angiotensin system (RAS) inhibitors, angiotensin receptor blocking agents (ARBs), angiotensin receptor/neprilysin inhibitor molecules (ARNI), β blockers, mineralocorticoid receptor antagonist drugs (MRAs). Combining these four HFrEF drug pillars can reduce the relative risk of mortality by 73% and also the number needed to treat (NNT) to avoid death as compared to no treatment.
Combined treatment with ARB and ARNI is a primary component of managing heart failures. The SGL-2 inhibitor family, developed to enhance glycemic control in diabetes, can improve cardiac outcomes, including heart failure prevention. Today, this class, which includes dapagliflozin and empagliflozin, is considered one of the four primary preventive medications for heart failure and diabetes. During follow-up, around 15% of individuals with heart failure will observe their left ventricular function (LVEF) increase from below 40% to over 40%. SGLT2 inhibitors are the first line of treatment for individuals with modestly decreased or maintained LVEF. Other treatments for HFrEF include ARNI, ACE inhibitors, ARBs, and MRAs, which are considered second-line therapy due to little evidence of effectiveness.
The African-American Heart Failure Trial suggests a mix of drugs for black individuals with NYHA class III or IV heart failure. Ivabradine, an inhibitor of the cardiac pacemaker current, reduced cardiovascular mortality and hospital admission for heart failure by 18% in individuals with sinus rhythm and a heart rate ≥70 bpm. In the VICTORIA study, Vericiguat, a novel heart failure medicine that increases vasodilation and reduces cardiac remodeling, lowers the risk of cardiovascular mortality or hospital admission by 10%.
Heart failure resynchronization treatment (HFrEF) comprises implanted cardiac defibrillators (ICDs) and cardiac resynchronization therapy (CRT). Healthcare professionals must consider individual patient preferences and potential advantages when making shared decisions about ICD placement. Transcatheter edge-to-edge repair (TEER) is a viable treatment option for people with chronic, severe mitral regurgitation.
Based on the review findings, heart failure patient care has changed dramatically with the advent of four life-prolonging medication classes for individuals with low LVEF and SGLT2 inhibitors for mildly decreased and maintained LVEF. However, a correct diagnosis is still a difficulty. Further research is needed to understand the optimum starting technique and the causes of variations in heart failure prevalence. Furthermore, research should investigate the advantages of drugs for maintaining LVEF and whether patients should discontinue medication if their symptoms improve and their left ventricular function returns to normal.