Today, acute heart failure represents the most common reason for hospitalisation in the over-65 population.
Although hospital care improves symptoms in the first 24 hours after admission in around 50% of these patients, acute heart failure events still remain associated with a more than 50% mortality and rehospitalisation rate at 6-12 months. "Indeed," says Professor Marco Metra from the Cardiology Department of the University of Brescia, Italy, "it is the very rapid onset of symptoms and the need for urgent therapy which characterise the condition."
Treatments in acute heart failure, he adds, have not undergone any great change in recent decades, despite the demand of heart failure's increasing prevalence and huge personal and public impact. Professor Metra said that treatments are still based on loop diuretics (furosemide), peripheral vasodilators (nitrates) and inotropic agents. Even the more recently approved treatments, he added, such as levosimendan in Europe and nesiritide in the USA, have been associated with uncertain effects on outcomes in randomised trials. "So hospitalisations for acute heart failure are still associated with high mortality and rehospitalisation rates," he says. "The burden is tremendous because of the large number of patients involved, their poor prognosis and the costs of the treatment."
In a presentation at Heart Failure Congress 2009 Professor Metra defined two major pathways along which this burden might be reduced and treatment improved:
- Better selection of treatments. To date, he said, therapy in acute heart failure has been administered with little attention to the clinical presentation of each patient. Guidelines on heart failure issued by the European Society of Cardiology in 2008 define heart failure as a heterogeneous condition and recommend that different therapies are used on the basis of clinical presentation; for example, patients with fluid overload should undergo fluid removal through diuretics or other means, patients with high blood pressure should receive mainly vasodilators, and patients with low cardiac output should be treated with inotropic agents to improve the force of the heart muscle's contraction.
- Improved therapies. Many new agents are currently under development, said Professor Metra, which include adenosine type 1 receptors antagonists to enhance the diuretic effects of furosemide and increase renal blood flow, new vasodilators with different mechanisms of action, and new inotropic agents.
"Better treatment selection and the development of new agents give us some hope that we will finally be able to improve the symptoms and prognosis of such a large patient population as that suffering from acute heart failure," says Professor Metra. However, he also emphasised that urgent therapy is one of the key recommendations of the latest European guidelines.