Heart Failure Progression

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The HCPLive Peer Exchange: Advances in Heart Failure Management features expert opinion and analysis from leading physician specialists on the latest developments in heart failure research, diagnosis, and management.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Michael Felker, MD, MHS, Professor of Medicine, Chief of the Heart Failure Section, Director of the Heart Center Clinical Research Unit, and Director of the Advanced Heart Failure Fellowship at Duke University School of Medicine
• Jim Januzzi, MD, Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at Massachusetts General Hospital and Hutter Professor of Medicine at Harvard Medical School
• Christian Schulze, MD, PhD, Associate Professor of Medicine, Division of Cardiology at Columbia University Medical Center, and Director of Research for the Center of Advanced Cardiac Care at Columbia University Medical Center

In this segment of the Peer Exchange, the panelists discuss heart failure stages and functional classification and the clinical effects and characteristics associated with worsening disease. They also discuss measures that can reverse some of the cardiovascular effects of the disease while also improving patients’ quality of life.

Michael Felker, MD, says that although heart failure starts out as a heart disease, it progresses to “a total body disease because one thing we see very frequently is not just the cardiovascular manifestations but also the effects on renal function, liver function, and skeletal muscle, which is very under appreciated.”

In patients with advanced disease, even if their physician can intervene to reverse some of the cardiovascular changes that have occurred, “it’s still very much an open question whether some of these extra cardiac manifestations are actually reversible. This comes up a lot in LVAD patients. A patient has end-stage heart failure and we put a ventricular assist device in. Their ventricle is now unloaded. Their cardiac output is now normal, but not all the organ dysfunction that’s developed over time is potentially reversible. That’s a big challenge,” says Dr. Felker.

Treatment goals have evolved from focusing on symptom reduction to placing greater emphasis on patient-oriented treatment and things like reducing the number of hospitalizations, making quality of life better, and targeting associated comorbidities, says Christian Schulze, MD, PhD. For example, he notes that several guidelines focus on “frailty syndrome” and improving quality of life. “Ultimately, it comes down to slowing the disease progression to make sure that patients are appropriately and adequately treated. An ACE inhibitor and beta blocker at a certain dose is not the same treatment for patient A versus patient B,” he says.

According to Jim Jannuzi, MD, in studies that have shown a reduced risk of mortality or hospitalization due to heart failure in patients treated with therapies such as beta blockade, ACE or ARB inhibitors, RAS inhibitors, or mineralocorticoid receptor blockade, the central finding is reverse remodeling.

Although reverse remodeling is the biologic process that we’re trying to foster, “we have to keep the whole patient in mind while improving the remodeling status of the patient,” and recognize that “quality of life and extra cardiac dysfunction are also very important to focus on in order to improve the overall outcome of the patient,” he says.

Januzzi points to cardiac resynchronization therapy (CRT) as an approach that has been good for treating heart failure while also improving quality of life. “There’s a profound reverse remodeling effect, and among the therapies that we do for our patients, CRT really does improve quality of life.”