Strategies for Reverse Remodeling

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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 the concept of reverse remodeling in heart failure and review several pharmacologic and mechanical strategies for achieving this.

Dr. Schulze says reverse remodeling involves “regression of myocardial hypertrophy, changes in the substructure of the cells of the fibrosis in the myocardium, and also in regards to the size of the myocardium.” He says that patients with heart failure tend to do better if they can decrease the diameter of their left and right ventricles and are able to regress from their hypertrophic pictures.

“This is a positive sign of reverse remodeling” in heart failure, he says. “It has been associated with medications such as beta blockers, such as ACE inhibitors, but also with nonpharmacological treatment such as CRT, resynchronization therapies, but also the implantation of left ventricular assist devices.”

Dr. Schulze notes that he and others have observed that patients who received first-generation assist devices often have higher rates of recovery compared with patients who have received newer continuous flow devices. This is “particularly seen in young patients who have a more acute onset of their acute heart failure syndrome,” he says.

Dr. Felker agrees, saying that “this very desirable idea of reverse remodeling, sort of rewinding all these pathologic changes,” is quite complicated and involves “the neurohormonal milieu” of the heart. He goes on to say that “even all mechanical unloading is not potentially created equal because in some ways, the older, less sophisticated pulsatile devices seem to be more effective at contributing to myocardial recovery than some of the newer devices which are non-pulsatile in nature.”

Dr. Januzzi says the process of reverse remodeling “is different than just the opposite of forward remodeling.” In other words, you don’t see a reversal of “the molecular processes that led to ventricular remodeling, fibrosis, dilation, and weakness of LV function… frequently, when you see a recovered ventricle, if you look at it macroscopically or microscopically, it still looks very abnormal.”

Although the goal of aggressive heart failure care is to reverse remodel patients, Dr. Januzzi says clinicians treating these patients fear “the reversal of that reverse remodeling… the loss of reverse remodeling which often portends a poor prognosis for the patient.” He says that clinicians don’t have a very good grasp on how this occurs and how to identify it when it does, which is why it is so important to monitor patients even if they have a positive initial response to medical therapy.