Insights into current heart failure management

Piotr Ponikowski

Piotr Ponikowski (Centre for Heart Disease, Clinical Military Hospital, Wroclaw, Poland), chairperson of the 2016 European Society of Cardiology (ESC) Guidelines for the diagnosis and treatment of acute and chronic heart failure, discussed at the 5th Edition of The Future of Heart Failure meeting (30 September‒1 October, Barcelona, Spain) the current goal of heart failure management. In this interview with Cardiac Rhythm News he gives more insights into this subject, speaking about the current most effective methods of heart failure treatment and the relevance of a multidisciplinary approach.

From your perspective as a heart failure specialist, what is the goal of treating patients with heart failure?
In heart failure treatment there are three key goals: goal number one is to improve the outcome of patients by reducing morbidity and mortality; goal number two, which is equally important, is to improve quality of life. In many heart failure patients, shortness of breath and exercise intolerance constitute one of their major problems, this is why improving symptoms is also very important; and goal number three, which is now becoming very relevant, is to prevent heart failure development. We need to be able to slow down the progression of the condition as early as possible.

Currently, what do you consider to be the most effective method(s) of treatment for heart failure patients?
We need to clearly differentiate effective therapies according to the type of heart failure. A very clear division of these patients is based on left ventricular ejection fraction (LVEF). For the time being, we can only offer successful and effective treatment—with pharmacological and device-based therapies—to heart failure patients with reduced LVEF (<40%). These therapies have shown positive improvement in mortality, morbidity and symptoms. For heart failure patients with LVEF >40% we cannot offer anything to improve mortality and morbidity. The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure suggest that pharmacological therapy should include angiotensin converting enzyme (ACE) inhibitors, beta-blockers and mineralocorticoid receptor antagonists. If the combination of these three therapies is still not effective and patients remain symptomatic then it is suggested to replace ACE inhibitors with the new drug, sacubitril/valsartan from the new group – ARNI.

Regarding devices, cardiac resynchronisation therapy (CRT) is recommended in selected patients with QRS duration of ≥130msec, and implantable cardioverter defibrillators (ICDs) are suggested in patients with reduced ejection fraction to prevent sudden cardiac death.

LVAD therapy, for the time being, has been recommended for patients with very advanced heart failure. This therapy can be seen as a bridge to transplantation or destination therapy; however, this second approach is not yet very common in Europe.

How preventable is acute and chronic heart failure nowadays?
If you have patients with chronic heart failure you need to make sure that you will be able to prevent episodes of decompensation with optimal treatment. This is not easy because decompensation in patients who are admitted to hospital with acute heart failure may be due to several underlying factors. Among those are poor adherence to medical management, infection, fast atrial fibrillation and acute coronary syndrome. With this in mind, several cases may be preventable, but not all.

Optimised treatment management, including pharmacological therapy and device-based treatment has also an educational component. Talking to patients and their families on the importance of adherence to treatment may contribute to prevent decompensation and to reduce the risk of hospital readmissions.

We also need to work on the prevention of chronic disorders which may lead to heart failure. For example, it is important to prevent recurrent myocardial infarction with optimal therapy in patients with coronary artery disease, and if you have patients with arterial hypertension you need to work on controlling blood pressure to reduce the risk of developing heart failure.

How relevant is treating heart failure patients with a multidisciplinary approach? Who should be involved?
This is a major topic currently discussed in Europe; we want to make sure that heart failure patients are treated on a multidisciplinary basis. We need to find a well-defined model with a heart team including cardiologists, nurses, dieticians, psychologists, etc. This is a fundamental element for comprehensive heart failure management.