Heart Failure: The Complexities of Treating a Complicated Condition

Gregg Fonarow, MD, professor of cardiovascular medicine at the University of California at Los Angeles, sat down with MD Magazine® to talk about some of the front-of-mind issues facing heart failure (HF) specialists. As a chronic and complicated condition, HF is often a challenge to manage and comes with multiple comorbidities and complexities.

The cardiology community is always concerned with rehospitalizations among patients with HF, Fonarow said, and staying abreast of the steps physicians and patients can take to prevent HF in the first place. Of course, there are always questions surrounding new therapies and strategies that affect HF practitioners and their patient populations.

HOSPITALIZATION

Hospitalization is essentially a guarantee for patients with HF, and once they are hospitalized, their risk of being readmitted within 30 days of discharge is incredibly high, as is their risk of mortality, Fonarow said. This has caused many researchers to focus on developing therapies that can reduce the risk of being rehospitalized.

“Short-term approaches using intravenous therapies in patients hospitalized with acute heart failure have been uniformly unsuccessful,” Fonarow said. “[With] trial after trial testing a variety of novel agents, despite their promise, their physiologic rationale—despite even phase 2 data taken to phase 3 trials—at best we’ve gotten safe but not effective [therapies], and at worse we’ve had therapies that have increased mortality.”

Fonarow noted that the current approach to reducing symptoms, length of stay, and risk of readmission related to HF has been disappointing. When it comes to intravenous treatment in the short-term, another answer is needed.

Hope is not lost, though. Real-world observational data, as well as several trials, have shown promise for chronic medications for HF. These therapies, according to Fonarow, could be the solution.

“Our chronic medications for heart failure—the guideline-directed medical therapies for heart failure with reduced ejection fraction—when initiated in hospitalized patients can have marked benefit not just in the long term but even in the short and intermediate terms,” he said. “So in-hospital initiation and strategy of angiotensin-converting enzyme [ACE] inhibitors, aortic regurgitation beta-blocker therapy, and aldosterone antagonist therapy is accepted now as the standard of care. It helps stabilize patients and improve short-term hospitalization risk as well as intermediate and long-term mortality risks.”

Fonarow pointed out that a therapy that seems to be underused by health care providers in the HF space is the angiotensin receptor neprilysin inhibitor combination therapy sacubitril/valsartan. This is surprising, he said, because the treatment is a class 1 recommended therapy in the guidelines set by the American Heart Association, Heart Failure Society of America, and American College of Cardiology.

“This, to me, is the most promising strategy, and in fact, data from PARADIGM-HF showed that when patients were discharged from the hospital after heart failure hospitalization, while on sacubitril/valsartan added to background therapy versus the ACE inhibitor enalapril, there’s actually a 38% lower risk of 30-day rehospitalization,” Fonarow said. “So we really see that this type of approach is critically important.”

Of course, patients with HF with preserved ejection fraction remain a population in desperate need of treatment, and Fonarow stressed the need to identify therapies for those patients. However, he said, there seems to be a “search for a magical acute heart failure drug,” that could lead in a frustrating dead-end.Patient hospitalization stays should serve as a moment to teach and learn about HF, he added. It should be an opportunity to optimize the current guideline-directed medical therapies for chronic conditions. Taking these hospitalizations as opportunities to learn how to prevent them is critical.

PREVENTION

“Of course, we need an increased focus on preventing heart failure in the first place,” Fonarow said. “It’s phenomenal to have the advances…for the sickest patients with advanced heart failure, and we need to apply those therapies that can truly be lifesaving, which is great, but our broader approach toward really benefiting the population health of those with heart failure by applying our guideline-recommended therapies is so critically important. It should be a major focus for anybody with an interest in heart failure. So prevention of heart failure is certainly critical.”

Calling the topic of prevention a critical step in HF treatment, Fonarow discussed the important role that managing other conditions plays in the prevention of HF. There are numerous risk factors for HF—often its comorbidities play a role in its development—and prevention starts with addressing them.

“Behavioral change is among the most difficult things to achieve, but we have some things that can readily be done,” Fonarow said. “Hypertension is a major risk factor for developing heart failure at every age, so more aggressive, appropriate, and intensive management of systolic blood pressure can play a phenomenal role. Atherosclerotic cardiovascular disease plays a major role. There’s still underutilization of statin therapy and high-intensity statin therapy for those with atherosclerotic cardiovascular disease, as well as those at risk, despite being widely available and well tolerated, and having benefits that greatly outweigh the risks and being available generically for $40 a year.”

Although changing behavior is, as Fonarow noted, difficult, lifestyle changes are among some of the most positive preventive measures that patients can take. The Heart Failure Society of America has taken a step toward promoting exercise from a civil engineering standpoint, and Fonarow agreed with the sentiment. Promoting a lifestyle with more walking, biking, and running can aid in the prevention of HF.

Diabetes is one of the biggest risk factors for HF, and its management is becoming more and more important as its prevalence in the United States increases. Fonarow noted that, as with sacubitril/valsartan, some of the most promising therapies for diabetes, like sodium glucose cotransporters inhibitors, are underutilized.

“Diabetes is a major risk factor for heart failure, and there’s now a remarkable therapy that doesn’t lower just hemoglobin A1C for better glucose control but actually dramatically lowers the risk of heart failure,” Fonarow said. “But most endocrinologists don’t use the therapy, and most patients with diabetes are not yet on this therapy even though it distinguishes itself from most diabetes medications in that this one can truly prevent heart failure: the sodium glucose cotransporter inhibitors.”

“There have been a number of therapeutic advances in the prevention of heart failure,” Fonarow added, “but getting that translated into population health benefits is a critical challenge that I think everybody who is involved in the care of heart failure should be involved with because they can see the [effects] of a real concerted effort to try to prevent heart failure.”

Watch GREGG FONAROW discuss heart failure at mdmag.com/link/1743.