Medical treatment for heart failure

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Medical Treatment for Heart Failure

Introduction to Heart Failure Treatment

Heart failure (HF) is a prevalent cardiovascular condition, particularly among individuals over 60 years of age, and is a leading cause of hospital admissions1. Over the past three decades, significant advancements have been made in the treatment of chronic heart failure with reduced ejection fraction (HFrEF), although challenges remain in treating acutely decompensated heart failure and heart failure with preserved ejection fraction (HFpEF)1.

Pharmacological Therapies for Heart Failure

Neurohormonal Blockers

The cornerstone of HF treatment involves neurohormonal inhibition, particularly targeting the renin-angiotensin-aldosterone system (RAAS) and the adrenergic system. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers have been shown to significantly reduce morbidity and mortality in patients with HFrEF3 9. The introduction of combined angiotensin receptor-neprilysin inhibitors (ARNIs) has further improved patient outcomes3.

Mineralocorticoid Receptor Antagonists and SGLT2 Inhibitors

Mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter-2 (SGLT2) inhibitors are also recommended as part of the four-pillar therapy for HFrEF, providing additional benefits in reducing hospitalizations and improving survival7.

Diuretics and Digoxin

Diuretics and digoxin remain important for symptom management and reducing hospitalizations, although they do not significantly impact long-term survival9.

Implantable Devices in Heart Failure Management

Ventricular Resynchronization Therapy

Implantable devices, such as those used for ventricular resynchronization therapy (CRT), have shown promise in improving cardiac performance and quality of life in patients with chronic heart failure. The COMPANION trial demonstrated that CRT, with or without defibrillator capability, can reduce all-cause mortality and hospitalizations when combined with optimal pharmacological therapy2.

Defibrillators and Other Devices

Implantable cardioverter-defibrillators (ICDs) are well-established in preventing sudden cardiac death in HF patients. Emerging devices, such as those for baroreflex modulation and cardiac contractility modulation, are under investigation and may offer additional therapeutic options in the future3.

Personalized and Holistic Approaches

Patient Profiling and Tailored Therapy

Effective HF management requires a personalized approach, considering individual patient profiles, including heart rate, renal function, and the presence of comorbidities. Tailoring therapy to these profiles can optimize treatment outcomes and improve adherence4.

Precision Medicine

Advances in precision medicine are paving the way for more individualized HF treatments. By understanding the genetic and molecular underpinnings of HF, clinicians can better match therapies to patient-specific disease mechanisms, potentially improving outcomes10.

Challenges and Future Directions

Implementation and Adherence

Despite the availability of evidence-based treatments, implementation remains suboptimal, with many patients not receiving therapies at target doses due to issues such as low blood pressure, renal impairment, and hyperkalemia4. Ensuring adequate staffing and resources, such as heart failure nurse specialists and pharmacists, is crucial for overcoming these challenges6.

Novel Therapies

Ongoing research is exploring new pharmacological agents, including dual-acting neurohormonal modulators, vasoactive peptides, and myocardial protectants, which may further enhance the therapeutic arsenal for HF5.

Conclusion

The treatment landscape for heart failure has evolved significantly, particularly for HFrEF, with a combination of pharmacological therapies and implantable devices improving patient outcomes. Personalized and precision medicine approaches hold promise for further advancements, although challenges in implementation and adherence must be addressed to fully realize the benefits of these therapies.

Sources and full results

Most relevant research papers on this topic

Heart failure drug treatment

Heart failure drug treatment has progressed, but optimal implementation requires disease management programs to provide a multidisciplinary, holistic approach to optimal medical care.

Rigorous Journal

Highly Cited

2019·240citations·P. Rossignol et al.·The Lancet

The Lancet ··DOI

Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators.

Implantable devices for ventricular resynchronization may improve chronic heart failure management by reducing mortality, morbidity, and improving functional capacity and quality of life.

RCT

Highly Cited

2000·327citations·M. Bristow et al.·Journal of cardiac failure

Journal of cardiac failure ··DOI

The Treatment of Heart Failure with Reduced Ejection Fraction.

Chronic systolic heart failure treatment with drugs and implanted devices, as recommended in guidelines, can significantly improve clinical outcomes.

Systematic Review

2020·39citations·D. Berliner et al.·Deutsches Arzteblatt international

Deutsches Arzteblatt international ··DOI

Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology

A personalized approach, adjusting guideline-directed medical therapy to patient profile, may improve treatment implementation in heart failure patients with a reduced ejection fraction.

Highly Cited

2021·204citations·G. Rosano et al.·European Journal of Heart Failure

European Journal of Heart Failure ··DOI

New medical therapies for heart failure

Novel heart failure treatments, such as dual-acting neurohormonal modulators and contractility-enhancing agents, show potential for enhancing our current pharmacotherapy arsenal.

2015·49citations·T. Lueder et al.·Nature Reviews Cardiology

Nature Reviews Cardiology ··DOI

Sequencing of medical therapy in heart failure with a reduced ejection fraction

Accelerated initiation of heart failure drug therapies can improve symptoms and survival, but requires adequate staffing and a novel treatment score to ensure optimal care.

Literature Review

Rigorous Journal

2022·3citations·H. Savage et al.·Heart

Heart ··DOI

Holistic approach to drug therapy in a patient with heart failure

A holistic, tailored approach to drug therapy is crucial for patients with heart failure, considering shared decision-making, drug-related considerations, polypharmacy, and adherence.

2023·1citation·P. Forsyth et al.·Heart

Heart ··DOI

Treatment for chronic heart failure in the elderly: current practice and problems

Chronic heart failure treatment for elderly patients faces challenges, including underuse of first-choice drugs, poor adherence to therapy, and potential new treatments like stem cells and gene delivery.

Highly Cited

2013·79citations·P. Abete et al.·Heart Failure Reviews

Heart Failure Reviews ··DOI

Therapy of heart failure.

Spironolactone, an aldosterone antagonist, improves morbidity and mortality in heart failure patients.

2000·51citations·R. Schrier et al.·Kidney international

Kidney international ··DOI

Towards precision medicine in heart failure

The number of therapies for heart failure (HF) with reduced ejection fraction has nearly doubled in the past decade. In addition, new therapies for HF caused by hypertrophic and infiltrative disease are emerging rapidly. Indeed, we are on the verge of a new era in HF in which insights into the biology of myocardial disease can be matched to an understanding of the genetic predisposition in an individual patient to inform precision approaches to therapy. In this Review, we summarize the biology of HF, emphasizing the causal relationships between genetic contributors and traditional structure-based remodelling outcomes, and highlight the mechanisms of action of traditional and novel therapeutics. We discuss the latest advances in our understanding of both the Mendelian genetics of cardiomyopathy and the complex genetics of the clinical syndrome presenting as HF. In the phenotypic domain, we discuss applications of machine learning for the subcategorization of HF in ways that might inform rational prescribing of medications. We aim to bridge the gap between the biology of the failing heart, its diverse clinical presentations and the range of medications that we can now use to treat it. We present a roadmap for the future of precision medicine in HF. In this Review, Weldy and Ashley summarize the biology of heart failure (HF), the mechanisms of action of HF drugs, and both the Mendelian genetics of cardiomyopathies and the complex genetics of HF. Finally, they present a roadmap for the future of precision medicine in HF. The number of therapies for heart failure with reduced ejection fraction has nearly doubled in the past decade, with new therapies for hypertrophic and infiltrative disease emerging. We are on the verge of a new era in heart failure, in which basic biology can be matched to an understanding of genetic predisposition to inform precision therapy. The precision model of treatment for Mendelian disease is focused on treating the underlying mechanism, for which genetic therapy is increasingly in clinical development; genetic variants can also function as strong modifiers of complex disease, which might inform precision-based treatment of heart failure in the future. Important precision medicine approaches for the diagnosis and treatment of myocardial hypertrophy caused by hypertrophic cardiomyopathy, amyloidosis, Fabry disease or Noonan syndrome are available today but are underutilized. Machine learning tools to evaluate large clinical, biological and genetic data sets can be used to phenotypically group patients and improve prediction of response to therapy, providing an important mechanism to guide precision approaches to therapy. We aim to bridge the gap between the basic biology of the failing heart, its diverse clinical presentations and the range of medications we can now use to treat heart failure. The number of therapies for heart failure with reduced ejection fraction has nearly doubled in the past decade, with new therapies for hypertrophic and infiltrative disease emerging. We are on the verge of a new era in heart failure, in which basic biology can be matched to an understanding of genetic predisposition to inform precision therapy. The precision model of treatment for Mendelian disease is focused on treating the underlying mechanism, for which genetic therapy is increasingly in clinical development; genetic variants can also function as strong modifiers of complex disease, which might inform precision-based treatment of heart failure in the future. Important precision medicine approaches for the diagnosis and treatment of myocardial hypertrophy caused by hypertrophic cardiomyopathy, amyloidosis, Fabry disease or Noonan syndrome are available today but are underutilized. Machine learning tools to evaluate large clinical, biological and genetic data sets can be used to phenotypically group patients and improve prediction of response to therapy, providing an important mechanism to guide precision approaches to therapy. We aim to bridge the gap between the basic biology of the failing heart, its diverse clinical presentations and the range of medications we can now use to treat heart failure.

2021·42citations·Chad S. Weldy et al.·Nature Reviews Cardiology

Nature Reviews Cardiology ··DOI

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