Economic burden of HF climbing, preventive guidance lacking, but tools available
HF is a growing economic burden in the U.S., with 1 million new cases projected to surface in 2021; however, there is a paucity of guidance on HF prevention, a speaker reported.
At the American Society for Preventive Cardiology Congress on CVD Prevention, Cardiology Today Editorial Board Member Javed Butler, MD, MPH, MBA, the Patrick H. Lehan Chair in Cardiovascular Research, and professor and chairman of the department of medicine at the University of Mississippi Medical Center, discussed the rising burden of HF in the U.S. and reviewed the existing evidence-based therapies for the prevention of HF hospitalization and death.
“The economic burden of heart failure is substantial and continues to grow. Lots of people develop heart failure. Once they develop heart failure, the prognosis is poor and that's the bad news. But the good news is that heart failure is preventable,” Butler said during the presentation. “Early risk factor modification and appropriate comorbidity treatment can substantially reduce the risk, and we have to think about heart failure prevention similar to how we think about prevention of other diseases like myocardial infarction and cancer.
“Now, I do not want to sound juvenile, comparing one disease to another, saying that my disease is more important than your disease,” Butler said. “But the bottom line is that there are diseases like myocardial infarction, stroke or many forms of cancer, where the medical community is attuned to be very sensitive, and very appropriately so. These conditions are serious, and they do lead to very adverse outcomes, but somehow we do not share the same risk profile in our mindset when it comes to heart failure.”
According to Butler’s presentation, the economic burden of HF continues to grow and is one of the most expensive health care problems.
In a study published in Circulation: Heart Failure, researchers found that after accounting for hospitalization, nursing homes, drugs or other medical durables, home health care, lost productivity and visits to physicians, the total cost of HF in the U.S. in 2013 was $39.2 billion. Assuming all costs of cardiac care for HF patients are attributable to HF and not comorbid conditions, the projected cost of treating HF will be approximately $160 billion by 2030, the researchers wrote.
Butler said that in 2021 there will be more than 1 million new cases of HF in the U.S. Moreover, HF, defined as HF hospitalization, confers 10 to 15 years of life lost among hospitalized patients compared with the general population.
However, Butler continued, HF is preventable but neglected.
HF prevention is rarely looked at in research, grants or publications, according to the presentation. It is left out of the Framingham Risk Score and American College of Cardiology/American Heart Association Pooled Cohort Equations. HF is largely not included in primary composite endpoints or is relegated to a secondary endpoint in most randomized clinical trials. It is also not included as one of the primary endpoints in FDA guidance on evaluating the CV safety of diabetes medications.
According to the presentation, HF is more often viewed as a less important endpoint compared with major adverse CV events: Even when HF is reduced in randomized trials, the study is viewed as neutral or negative unless major adverse CV events are reduced.
Additionally, there are no specific ACC/AHA, Heart Failure Society of America, European Society of Cardiology or American College of Physicians guidelines targeted on HF prevention, Butler said.
Butler stated that early modification of risk factors such as CAD, hypertension and diabetes can lower risk for HF. The recommendation of appropriate medical therapies to individuals with risk factors may represent an early opportunity to reduce the impact of HF on public and individual health.
In the PEACE trial, published in the New England Journal of Medicine, researchers found that patients with stable CAD and normal left ventricular function randomly assigned to the ACE inhibitor trandolapril (Mavik, Abbott) experienced lower risk for HF as a primary cause of hospitalization or death compared with placebo (HR = 0.75; 95% CI, 0.59-0.95; P = .02).
Two meta-analyses, published in the Archive of Internal Medicine and the Journal of the American College of Cardiology, respectively, evaluated 12 randomized trials of antihypertensive medication therapy for BP reduction. The researchers observed an approximately 52% reduction in incident HF and a 35% reduction in LV hypertrophy associated with antihypertensive medication therapy.
According to the presentation, patients with diabetes may have up to a fourfold greater risk for new-onset HF compared with those without diabetes.
In the EMPA-REG OUTCOME randomized trial of empagliflozin (Jardiance, Boehringer Ingelheim/Eli Lilly) compared with placebo in patients with diabetes, researchers found that the SGLT2 inhibitor reduced risk for HF hospitalization or CV death, regardless of baseline HF status, Butler said, noting that subsequent meta-analyses confirmed the results.
There are many ways to lower risk for HF, Butler said.
“For instance, people who age with the least amount of cardiovascular risk factors would reduce the risk for developing heart failure. The AHA Life's Simple 7, healthy diet and healthy exercise habits definitely reduce the risk for heart failure,” he said. “A low-salt diet reduces the risk for heart failure, presumably by reducing the risk for developing hypertension. Smoking cessation and lipid control in high-risk patients are also associated with risk reduction. ACE inhibitors in high-risk patients reduces the risk. Bariatric surgery can do miracles in terms of reducing the risk for heart failure.
“If I were to leave you with two messages, it would be that blood pressure control in all hypertensive patients and SGLT2 inhibitors in patients with diabetes substantially reduce the risk for development of heart failure,” Butler said. “We are not impotent against the risk of developing heart failure. There are a lot of things we can do.”
References:
- Braunwald E, et al. N Engl J Med. 2004;doi:10.1056/nejmoa042739.
- Heidenreich PA, et al. Circ Heart Fail. 2013;doi:10.1161/HHF.0b013e318291329a.
- Herbert PR, et al. Arch Intern Med. 1993;doi:10.1001/archinte.1993.00410050018004.
- Moser M, et al. J Am Coll Cardiol. 1996;doi:10.1016/0735-1097(95)00606-0.
- Zelniker TA, et al. Lancet. 2019;doi:10.1016/S0140-6736(18)32590-X.
- Zinman B, et al. N Engl J Med. 2015;doi:10.1056/nejmoa1504720.
Collapse
Butler J. Working in Prevention. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 23-25, 2021 (virtual meeting).