Heart failure is a leading health care problem in Spain and other countries due to its rising incidence (population aging) and prevalence (higher survival rates among patients with heart disease). While improvements have been made in both diagnosis and treatment, prognosis is still poor and the high rehospitalization rates associated with this condition place an enormous burden on the health care system.
Conceptually speaking, the latest European guidelines for the diagnosis and treatment of acute and chronic heart failure distinguish between 3 groups of heart failure based on left ventricular ejection fraction (LVEF). This distinction has therapeutic implications, as most of the current evidence is based on the treatment of heart failure with reduced LVEF (< 40%). No treatments to date have been shown to be effective or to improve prognosis in patients with preserved LVEF (> 50%). The most novel concept in the European guidelines is the inclusion of heart failure with mid-range LVEF,1: a move aimed at promoting research and building scientific evidence to improve the management of patients with LVEF between 40% and 49%.
Natriuretic peptides are now recognized as key biochemical markers for early heart failure screening. They are mostly used in primary care and emergency departments as an adjunct to history and physical examination. They have also proven useful as a prognostic stratification tool, although approaches based on serial measurements are not perhaps the most valid option for guided therapy (GUIDE-IT study2).
None of the treatments applied to patients with acute heart failure to date have succeeded in improving prognosis. We have witnessed the failure of promising new treatments, such as recombinant serelaxin and ularitide (TRUE-AHF trial3). We are also learning that early treatment of acute heart failure, with shorter door-to-diuretic times, improves prognosis and is becoming a quality metric that should be implemented across hospitals (REALITY study4).
The most notable aspect of chronic heart failure treatment is the now widespread use of angiotensin receptor neprilysin inhibitors (ANRIs) to treat symptomatic disease in patients with systolic dysfunction. ANRIs have emerged as an alternative to traditional angiotensin-converting enzyme inhibitors II(ARA-II), and the latest US guidelines5 recommend their use at an earlier stage than that proposed by the European guidelines (where they are ranked at the same level as mineralocorticoid receptor antagonists).
Another interesting development is the increasing importance attached to the adequate management of comorbidities in a bid to improve quality of life, prevent disease progression, improve prognosis, and reduce heart failure hospitalizations. Intravenous iron therapy, for example, has been shown to improve functional capacity in patients with systolic dysfunction, although its effectiveness in reducing hospitalizations due to heart failure remains to be confirmed in clinical trials. Promising reductions in hospitalization rates have been reported in trials of sodium-glucose cotransporter 2 inhibitors (SLGT-2), where particularly good results have been observed for empagliflozin, although specific evidence is lacking for diabetic patients with heart failure. Finally, although sleep disorders are known to play a role in the pathophysiology and perpetuation of heart failure, no benefits have been observed for the use of specific systems to treat central sleep apnea in this setting.
Heart failure is the paradigmatic example of a chronic disease that requires new treatment approaches if there is to be a true impact on prognosis. Apart from specific therapeutic interventions, we need integrated care systems that bring together the different actors involved to form multidisciplinary teams, with carers and patients taking a leading role. Improved adherence to treatment guidelines has been found to have a favorable impact on prognosis and on heart failure hospitalizations in particular (QUALIFY study6). Health care managers, professionals, and society at large must all engage in fostering a coordinated multidisciplinary strategy aimed at improving outcomes in patients with heart failure and reducing associated health care costs.
