Recently, the American College of Cardiology, The American Heart Association, and the Heart Failure Society of America reported on their newest guidelines for the diagnosis and treatment of patients with heart failure.
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We (WF and JA) have really come a long way since our student and trainee years during the 1960s, when chronic symptomatic heart failure had a mortality rate comparable with that of untreated leukemia. Treatment of heart failure patients during that time included various digitalis preparations often given in toxic doses. Loop diuretics had just become available for clinical use in both oral and intravenous forms to reduce pulmonary congestion and peripheral edema. Acute pulmonary edema, a common emergency in heart failure patients, was treated with oxygen by mask, rotating tourniquets applied to the limbs and phlebotomy for relieving congestion, and parenteral morphine; vasodilator was also used to relieve agitation, but often caused apnea to occur with intubation. Ventricular size was assessed by chest roentgenography, measuring the ratio between heart size and thoracic wall size (C/T ratio); hemodynamic function was assessed by measurements of the circulation time using a stopwatch and peripheral venous pressures.
Over the past 50 years, there have been dramatic advances in heart failure prevention, diagnosis, and disease management. Echocardiography has helped to visualize anatomy and function of the heart (ejection fraction), identifying patients with systolic ventricular dysfunction (HFrEF) and diastolic ventricular dysfunction (HFpEF).
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A variable, HFimpEF, used to reflect improvement in ventricular function with treatment measurements of biomarkers such as b-type natriuretic peptide (BNP), is available to assess the degree of congestion with acute and chronic heart failure,3
and can complement the use of daily body weights.Many patients with systolic dysfunction and chronic heart failure have done well on oral therapies, with improvement in symptoms, ventricular functioning, and survival prognosis. These therapies include inhibitors of the renin-angiotensin system (angiotensin-converting enzyme inhibitors,
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angiotensin II receptor blockers,5
and combined angiotensin receptor, neprilysin inhibitors,6
beta-adrenergic blockers,7
mineralocorticoid receptor antagonists,8
and most recently, the use of sodium-glucose cotransporter-2 inhibitors.9
Adjunctive treatments include ivabradine, a sinus node inhibitor,10
and vericiguat, a soluble guanylate cyclase inhibitor.11
For the first time, there are now US Food and Drug Administration-approved drugs for the treatment of patients with diastolic dysfunction that include the sodium-glucose cotransporter-2 inhibitor, empagliflozin,12
and the sacubitril-valsartan combination.13
In those patients who show an improvement in ventricular function with chronic pharmacologic therapy, discontinuation of treatment will worsen symptoms and other clinical outcomes, strongly suggesting that treatment should be for life.14
There have been advances with the use of devices following maximal drug therapy
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that include the use of implantable cardioverter-defibrillators for preventing sudden death and cardiac resynchronization with pacemaker insertion to augment ventricular function. Other invasive surgical approaches include heart transplantation for refractory heart failure, coronary artery bypass for ischemic cardiomyopathy and valvular repair, and replacement. Recently, xenotransplantation utilizing a porcine donor has been utilized.With the major advances in heart failure management discussed in the guidelines, emphasis is also placed on prevention of heart failure with treatment of patients having systemic hypertension, hyperlipidemia, obesity, and diabetes, risk factors for ventricular dysfunction.
What a remarkable journey has taken place over the past 50 years in heart failure diagnosis and management, which we were both part of, as clinical investigators. These current guidelines
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provide a comprehensive and evidence-based approach for rescuing patients with heart failure from the jaws of death.References
- 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice guidelines.J Am Coll Cardiol. 2022; 79: e263-e421
- Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28: 1-39.e14
- Natriuretic peptide response and outcomes in chronic heart failure with reduced ejection fraction.J Am Coll Cardiol. 2019; 74: 1205-1217
- Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.N Engl J Med. 1991; 325: 293-302
- A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure.N Engl J Med. 2001; 345: 1667-1675
- The path to an angiotensin receptor antagonist—neprilysin inhibitor in the treatment of heart failure.J Am Coll Cardiol. 2015; 65: 1029-1041
- Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomized Intervention Trail in Congestive Heart Failure (MERIT-HF).Lancet. 1999; 353: 2001-2007
- Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med. 2003; 348: 1309-1321
- Cardiovascular and renal outcomes with empagliflozin in heart failure.N Engl J Med. 2020; 383: 1413-1424
- Ivabradine and outcomes in chronic heart failure (SHIFT): a randomized placebo-controlled study.Lancet. 2010; 376: 875-885
- Vericiguat in patients with heart failure and reduced ejection fraction.N Engl J Med. 2020; 382: 1883-1893
- Empagliflozin in heart failure with a preserved ejection fraction.N Engl J Med. 2021; 385: 1451-1461
- Sacubitril/valsartan across the spectrum of ejection fraction in heart failure.Circulation. 2020; 141: 352-361
- Heart failure with recovered left ventricular ejection fraction: JACC Scientific Expert Panel.J Am Coll Cardiol. 2020; 76: 719-734
Article Info
Publication History
Published online: May 12, 2022
Footnotes
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors have participated in the preparation of the manuscript.
Identification
Copyright
© 2022 Published by Elsevier Inc.
