Defining Heart Failure

James Januzzi, MD: Hello and welcome to this Practical Cardiology Viewpoints discussion titled, “Optimizing Heart Failure Management.” I’m Jim Januzzi the Hutter Family Professor of Medicine at Harvard Medical School. Also, I’m a cardiologist at the Massachusetts General Hospital in Boston, Massachusetts. Joining me today in this virtual discussion are my valued colleagues, Dr Javed Butler, professor and chairman of the Department of Medicine at the University of Mississippi Medical Center in Jackson, Mississippi; Dr Gregg Fonarow, the interim chief of UCLA’s Division of Cardiology, director of the Ahmanson UCLA Cardiomyopathy Center, and co-director of UCLA’s preventive cardiology program in Los Angeles, California. And joining us also is Dr Nasrien Ibrahim, the director of heart failure clinical research at Inova Heart and Vascular Institute in Washington DC. Today, we’re going to discuss a number of topics pertaining to the optimization of management for both heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, including detecting heart failure in its early stages, strategies for approaching treatment, current and emerging therapies, as well as implementation challenges. This is a really great program with a lot to talk about. Let’s get started, shall we?

The first section will be focused on providing an overview of heart failure treatment and prevention. Let’s start off with a simple question because I think it helps to frame everything else that we’re going to talk about, which is defining heart failure and why the proper definition of heart failure is so important for treatment. I’m going to start off by asking Dr Fonarow if he might be able to speak on this. Gregg, there’s been a recent universal definition of heart failure, and that sort of sets a framework for what heart failure is. Can you fill us in a little bit on how we define what heart failure is?

Gregg C. Fonarow, MD: Sure. Heart failure has always been recognized as a clinical syndrome with classic signs and symptoms, and then there’d be further classification based on ejection fraction. But we know that the common signs and symptoms of heart failure can overlap in a broad differential. Fortunately with the new universal definition, there’s really been further effort to define the clinical syndrome, involving the signs and symptoms of heart failure, but together with structural or functional abnormalities, whether that is reduced systolic function, evidence of hypertrophy of the ventricle, evidence of elevated left ventricular filling pressures, or biomarkers in the case of elevation and natriuretic peptides. There’s further classification of heart failure based on ejection fraction; there’s been improved terminology whereas previously we would often refer to patients as stable heart failure that would belie the fact that these patients remained at significant risk. Now, terms like persistent heart failure are favored there. There’s also a category based on some of the remarkable medications we now have that can improve ventricular function of patients who started off with heart failure with reduced ejection fraction [EF], where their EF is now improved. Thus, we have through the universal definition, a way of really characterizing these patients, defining those who have heart failure, and then setting the stage for all of our evidence-based treatments and diagnostic approaches in further categorizing these patients.

James Januzzi, MD: That’s really helpful Gregg, and I have an important question that really sort of hinges around your role with respect to prevention as well. Like all diagnoses, heart failure starts at a certain point. I think we’ve come to recognize that the journey of heart failure often starts quite a few years before symptoms may be really advanced and where the treatment may be more challenging. Earlier recognition of heart failure might be able to allow for earlier intervention, maybe even prevention of the diagnosis. If you were talking to a primary care physician or even a general cardiologist about recognizing heart failure earlier, what might you tell them?

Gregg C. Fonarow, MD: What I really emphasize is this prevention message. There is actually refined staging that recognizes in the universal definition, there are risk factors and structural prerequisites before even developing symptomatic heart failure. For the vast majority of patients who present with heart failure, it could have been prevented. In the United States, those major modifiable risk factors are things like hypertension, diabetes, coronary artery disease. Thus, by recognizing that there are individuals who have known risk factors and by applying appropriate preventive therapies, we can prevent the vast majority of cases. There are remarkable benefits of blood pressure control in reducing the risk of heart failure and more intensively trying to get that systolic blood pressure in high-risk individuals below 130 mm Hg. For patients with type 2 diabetes, we have specific therapies now that go beyond just glucose control that can dramatically reduce the risk of new-onset heart failure. There is that message that these patients who develop heart failure, if we went back in time when they were being cared for by their primary care physician and things had been done differently, that heart failure would have been prevented.

James Januzzi, MD: That’s critically important because ultimately prevention is the way to beat heart failure.

This transcript has been edited for clarity.