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Medical management 

Medical management
Medical management

Dr Jamal Khan

, Dr Tania Pawade

, and John Cleland

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date: 17 June 2021

Heart failure is common and may afflict people at any age, but the great majority of patients in developed countries are aged >60 years. At least one in five people will develop heart failure at some time in their life, but this might be a serious under-estimate due to inadequate case ascertainment and frequent failure to identify heart failure as a complication of other cardiac problems. Many people with high blood pressure and most people who have a heart attack or develop atrial fibrillation will first develop heart failure before they die. Good treatment of predisposing conditions will delay the onset of heart failure but may not prevent it.

The life-time risk of developing heart failure may be high, but the prevalence is modest and probably at most 3% of adults or about 2% of the entire population. The disparity between incidence and prevalence reflects the high mortality, which ranges from about 5% per year in stable, well-treated patients with mild disease to more than 30% in patients who have new-onset heart failure or who have experienced a recent hospitalization for worsening symptoms. As survival rates for heart failure improve, its prevalence will rise. Heart failure is often a terminal process with prognosis measured in days, weeks, or months rather than years. However, expert care can restore many patients to a good quality of life for prolonged periods.

Effective management of hypertension and coronary artery and valve disease will delay the onset of heart failure and reduce its incidence in younger people. However, as life expectancy increases and the proportion of the population aged >70 years rises, the prevalence of heart failure will rise inexorably. Patients who previously would have died of a myocardial infarction will now survive longer, which may fuel a further increase in heart failure. Moreover, contemporary pharmacological therapy may have tripled life expectancy and, therefore, provided the patient can be stabilized on therapy, the prevalence of heart failure will rise.

Heart failure is a complex, multidimensional problem. The pathophysiology is diverse. Some treatments, such as diuretics, may be applied generically to all forms of heart failure, but most are directed at specific subgroups such as valve disease, electrical disturbances, or left ventricular systolic dysfunction. Although heart failure is common, only a small proportion may be suitable for a particular therapy. Moreover, some patients will respond very well to specific therapies, for instance valve repair, and may not need the full panoply of heart failure therapy. Other patients have disease or multiple cardiac and non-cardiac co-morbidities that are so severe that it renders palliative care the preferred management strategy rather than trying to prolong life. Good patient management requires in-depth knowledge of the disease and its treatment as well as a more holistic assessment of the patients’ needs.

The following section focuses on patients with chronic heart failure due primarily to left ventricular systolic or diastolic dysfunction. Several treatments have been shown to be highly effective at improving symptoms and prognosis in patients with left ventricular systolic function and, in some cases, this has been associated with an improvement in cardiac structure (reverse remodelling) and function suggesting modification of the underlying disease. The cumulative effect of these treatments may have reduced the annual mortality of patients with moderately severe disease from more than 30% to less than 10%. Few other cardiovascular conditions have yielded so much to innovations in treatment over the last 25 years. The impact is much larger than, for instance, coronary artery bypass surgery for three vessel coronary disease. The search for treatments for patients with primarily diastolic dysfunction has been less successful and there is no evidence that treatment has improved the outcome of patients with acute heart failure at all in the last 25 years. In other words, we have made a useful start to tackling the problem of heart failure but the war is not yet half won and, indeed, may turn out only to have been, so far, a successful rearguard action.

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