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2 decades of HF
A Cardiology Today Editorial Board Member discusses the shifts in management and treatment of patients with HF.
Editor’s Note: Cardiology Today is celebrating its 20th anniversary in 2017. We are reaching out to experts in cardiology for their take on changes in CV medicine since the publication launched in 1997. In this issue, James B. Young, MD, focuses on HF.
In the past 20 to 25 years, there has been a complete paradigm shift in the way that we are approaching the syndrome of HF. This has led to a different approach to diagnosis of HF, treatment of HF, and on the front end, prevention of HF.
All of this is linked to a change in philosophy. What people thought HF was about 30 to 40 years ago was congestion. It was considered a pump disorder, a problem with the heart itself. The first paradigm shift was an understanding that HF is a circulatory disorder, not just a pump disorder and not just a cardiac disorder.
And then, over the last 2 decades, we have obtained greater insight into the pathophysiology of HF, including the molecular link and its relationship to the overall syndrome, particularly as it relates to systolic dysfunction and diastolic dysfunction, and an understanding that contractility is components of both systole and diastole. That was the second paradigm shift.
The third major paradigm shift was that congestion had been the sine qua non of HF in the past, and this completely changed with guideline development and the creation of stage A through D HF that first appeared in the American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines. This moved us to a better understanding of the presentation of HF, and how it should be diagnosed.
Our diagnostic tools have improved. Imaging over the last 20 years has dramatically improved due to advances in CT, MRI and echocardiography. We now have better prognostication data and are better equipped to make difficult diagnoses such as amyloidosis and infiltrative cardiomyopathy.
Twenty years ago, we were staging patients with HF differently. We came to the realization that there is HF with reduced ejection fraction and HF with preserved ejection fraction. The development of guidelines has enabled us to employ good guideline therapy, which we did not have 2 decades ago. We did not have codified recommendations that were based on a good deal of evidence. Unfortunately, we still don’t have enough evidence, and many guideline recommendations are based on expert opinion.
Changes in treatments
The fourth big paradigm shift that occurred over this period was a movement from an inotropic treatment paradigm, where we were giving drugs like digoxin to improve contractility, but shifted to using vasodilators and neurohormonal modulating agents. For example, 20 years ago, it was still an anathema to use a beta-blocker, which is a perfect example of how the neuromodulation hypothesis came to form. During the past 2 decades, that has been established as a cornerstone of HF management. They have gone from being contraindicated to being mandated. We have seen the development of a variety of neurohormonal modulating agents, including ACE inhibitors, angiotensin receptor blocking agents, aldosterone antagonists, and most recently, the combination of sacubitril and valsartan (Entresto, Novartis), an angiotensin receptor-neprilysin inhibitor. Another drug we now use is ivabradine (Corlanor, Amgen).
There has also been a huge focus on devices during this time. The concepts regarding cardiac resynchronization therapy emerged. The concepts of utilizing implantable defibrillators to attenuate sudden cardiac death in patients with HF emerged. More recently, implantable monitoring systems have been developed. These can give more precise information about how much congestion is present and how patients are doing with their diuretic therapy.
We have also learned when surgical intervention is helpful, especially for the amelioration of ischemic heart disease and valvular heart disease. And we learned about some procedures we should not be doing, such as the so-called Batista procedure and cardiomyoplasty; and that mitral valve repair is better than mitral valve replacement.
The fifth paradigm shift was a movement away from focusing on the heart to focusing on the neurohormones that create the adverse effects.
Another example of a significant paradigm shift relates to mechanical circulatory support. We have moved from utilizing big, bulky, pulsatile pneumatic and electrically driven devices that were placed in the abdomen to much smaller, continuous-flow ventricular assist devices. We just do not see the big pulsatile VADs that were put in 20 years ago being used anymore. Of note, we are coming up on the 50th anniversary of the first successful heart transplant, but only in the last 2 decades have we seen dramatic improvement in outcomes in both transplantation and mechanical circulatory support devices.
Evolution of a specialty
I would summarize the last 2 decades as giving us better clarification on what we do, particularly with respect to the evolution of the specialty. One of the major developments that happened in the HF world over the past 20 years has been the codification, perhaps even the creation, of the specialty of advanced HF and cardiac transplant medicine. This was the newest American Board of Medicine exam to be developed and the newest subspecialty certified. We now have a whole cadre of individuals who are training with a formal curriculum to become advanced HF and transplant specialists.
There is no question that it means something very different to be diagnosed with HF today vs. 20 years ago. For example, a recent article in The New England Journal of Medicine made the argument that over the last 2 decades, there has been a reduction in sudden cardiac death as we’ve learned how to better diagnose stages of HF and implement new therapies. But we have got a lot more work to do.
– James B. Young, MD
Cardiology Today HF and Transplantation Section Editor
Cleveland Clinic
- Reference:
- Shen L, et al. N Engl J Med. 2017;doi:10.1056/NEJMoa/609758.
Disclosure: Young reports no relevant financial disclosures.