Advances in science are making it possible for fewer and fewer people to die from heart attacks. The downside, however, is that coronary artery disease persists and is the most common cause of heart failure. Established and new therapeutic strategies address this issue.
Once diagnosed, therapy is based less on etiology and more on whether ejection fraction is preserved or reduced, as Andreas Flammer, MD, of Zurich, explained. Accordingly, a distinction is made between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Heart failure with mildly reduced ejection fraction is referred to as “mildly reduced” HFmrEF.
Therapy of HFrEF
Several therapeutic options are now available for HFrEF that significantly improve prognosis. “The main pillars are drugs that act on the renin-angiotensin-aldosterone system (RAAS), especially ACE inhibitors and aldosterone receptor antagonists, and the beta-blockers that inhibit sympathetic activity,” the expert said. Angiotensin receptor neprilisin inhibitor (ARNI), a combination of sacubitril and valsartan, offers a new option. Study results suggest that switching from an already effective ACE inhibitor to an ARNI may improve prognosis. “Diuretics are other important medications that particularly relieve the patient’s symptoms but should be routinely adjusted,” Flammer opined. If the impaired ejection fraction and symptoms persist, an implantable cardioverter defibrillator (ICD) may be prognostic.
Do not disregard comorbidities
In particular, diabetes mellitus and iron deficiency are two comorbidities that should be taken into account. In the treatment of diabetes, drugs were able to lower blood sugar but did not improve prognosis. “This is now different,” the expert rejoiced. “The new SGLT-2 inhibitors have been shown in trials to reduce cardiovascular events, especially in high-risk patients.” In addition, because a reduction in hospitalization frequency has been demonstrated, patients with HFrEF have been studied with the new group of agents – whether or not they had diabetes. The outcome of the study was a highly significant reduction in mortality and hospitalization frequency for heart failure in all patients.
Iron deficiency is also common in patients with HFrEF. Since iron is not only important for blood formation, but an equally important substrate in the cellular respiratory chain, it should definitely be balanced. This has been shown to improve quality of life and performance.
Heart failure with preserved ejection fraction (HFpEF)
The disease is somewhat as common as HFrEF. As a rule, however, older people and more women are affected. Often the disease is not even recognized as such. This is where new clarification schemes help. “The important thing is that patients are recognized,” Flammer said. “This is because the main symptom, effort dyspnea, can be treated well with diuretic therapy.” The underlying cause of HFpEF, arterial hypertension, should also be treated.
However, the treatment options in HFpEF do not look quite as rosy in contrast to those in HFrEF. This is because current therapies for HFrEF show no prognostic benefit in this setting. A subset of HFpEF is due to cardiac TTR amyloidosis-much more common than previously thought. “This is where a TTR stabilizer stirs up hope for the future,” the expert said.
Therapy options are advancing
Overall, a great deal has been achieved in recent years in the diagnosis and treatment of heart failure – life-saving assist device implantations and heart transplantation as ultima ratio have not even been mentioned in this context. “However, it is fascinating how large the arsenal of therapeutic options has become, especially in HFrEF. The challenge is to define the value and timing of each therapy,” Flammer concluded.
Source: “Heart failure: a challenge”, lecture/abstract at the 59th Medical Congress LUNGE ZÜRICH in Davos, February 6-8, 2020
CARDIOVASC 2020; 19(1): 22 (published 3/23/20, ahead of print).
