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A Focus On: Heart Failure

Fig. 57.1 Chest radiograph of patient with a defibrillator implanted on the left and a vagal stimulator on the right. The device on the right-hand side of the patient uses an intracardiac lead for detection and a cuff wrapped around the vagus nerve in the neck to deliver appropriately timed vagal stimulation. Reproduced from Chapter 57: The Future. In Oxford Textbook of Heart Failure. Edited by Theresa A. McDonagh, Roy S. Gardner, Andrew L. Clark, and Henry Dargie. © 2011 Oxford University Press. DOI: 10.1093/med/9780199577729.001.0001

Heart failure (HF) has come a long way since diuretics and digitalis were largely the ceiling of therapy, and an imminent departure was assured.

Although often described as ‘an epidemic’, we are fortunate that outputs from HF research have been hugely rewarding over the last twenty years. As a result, we are far better informed about the diagnosis, assigning of prognosis, and treatment of HF1. We also now benefit from what is perhaps the most comprehensive evidence base in medicine. This now means that, in many countries, HF is a recognised subspecialty in its own right2.  

The treatment of heart failure in 2014 now includes disease-modifying pharmacological therapy (ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists). For selected patients who continue to have severely impaired hearts, other options such as device therapy (CRT and ICDs), cardiac transplantation3, and mechanical circulatory support can be considered.  

However, we are about to witness a changing of the guard. ACE inhibitors – a cornerstone HF therapy – have beaten into second place for the first time.  The PARADIGM-HF study was stopped early because LCZ-696 (an angiotensin receptor neprilysin inhibitor, or ARNI) has been shown to be superior to enalapril4,5.  The future remains bright too, with ongoing research in stem cell and gene therapy, vagal nerve stimulation, extra-aortic balloon counter-pulsation, to name but a few.  

The blossoming interest in HF management has grown in leaps and bounds across the last decade. The diagnosis, pharmacological treatment, monitoring, and rehabilitation aspects involved in the comprehensive care of HF patients will only continue to develop. It is a rapidly evolving and exciting field that features constant improvement in evidence-based advice on the care and treatment of people with chronic heart failure.


References

  1. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 33: 1787-847 (2012).
  2. McDonagh TA, Gardner RS, Lainscak M, et al. Heart Failure Association of the ESC Specialist Heart Failure Curriculum.  Eur J Heart Fail 2014;16: 151-162 .
  3. UK Guidelines for referral and assessment of adults for heart transplantation. Banner NR, Bonser RS, Clark AL, Clark S, Cowburn PJ, Gardner RS, Kalra P, McDonagh TA, Rogers CA, Swan L, Parameshwar J, Thomas H, Williams SG. Heart 2011;97(18): 1520-7.
  4. McMurray JJ, Packer M, Desai AS, et al. Baseline characteristics and treatment of patients in Prospective comparison of ARNI and ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM-HF). Eur J Heart Fail. 2014a; 16(7): 817-25.
  5. McMurray JJV et al. Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure. NEJM. Published online 30 August, 2014. DOI: 10.1056/NEJMoa1409077. 

Dr Roy S Gardner, MBChB, MD, MRCP, FESC is Consultant Cardiologist, Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Scotland, UK


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