Guideline-recommended treatment, timely referral keys to improving HF outcomes
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Recognizing the signs and symptoms of HF at any stage, as outlined in the updated universal definition of HF, is crucial to the timely application of optimal guideline-recommended medical therapy, a speaker reported.
During a presentation at the Cardiometabolic Health Congress, Alanna A. Morris, MD, MSc, FHFSA, assistant professor of medicine at the Emory University Clinical Cardiovascular Research Institute, and a Cardiology Today Next Gen Innovator, reviewed the updated definitions of HF and highlighted the importance of guideline-recommended treatment and timely referral in more advanced stages of disease.
“We’ve spent a lot of time talking about heart failure or at least ways to reduce heart failure in patients that are at risk for heart failure, from the perspective of both diabetes as well as their [chronic kidney disease],” Morris said during the presentation. “I tend to see these patients on the other end, when they already have manifest heart failure. The risks related to hospitalization is the reason why many of us are talking about heart failure so much. There’s a high prevalence and burden of heart failure in our country in particular, but heart failure has a very high global prevalence as well.”
According to the American Heart Association Heart Disease and Stroke Statistics – 2020 Update, approximately 6.2 million Americans aged 20 years or older had HF from 2013 to 2016.
Adults with HF experience a 5-year mortality rate of about 42%, regardless of ejection fraction, Morris said.
As Healio previously reported, in March in the Journal of Cardiac Failure, Morris and colleagues provided a new universal definition and classification for HF designed to standardize language and practices. The update was endorsed by the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology and the Japanese Heart Failure Society.
“In that document, we wanted to address the definition of heart failure and address some of the unmet needs that maybe weren’t in some of the past definitions of heart failure. They include that some of the prior definitions of heart failure included hemodynamic characterization of heart failure. Although that was useful for us as heart failure clinicians ... in primary care and hospitalist spaces, and for clinicians who are taking care of these patients, there’s probably not a lot of use for hemodynamic data.”
The new universal definition redefined the labeling of the HF stages: stage A is now “at risk for HF”; stage B is now “pre-HF”; stage C is now “HF”; and stage D is now “advanced HF.”
According to Morris, patients at risk for HF or who have pre-HF represent the largest group.
Patients who are stage A or at risk may not exhibit symptoms of HF, but may have a history of hypertension, CVD, diabetes, obesity or cardiotoxic exposure or have a family history of cardiomyopathy.
Patients with pre-HF, or stage B, also may not present as symptomatic, but may have structural heart disease, abnormal cardiac function or elevated natriuretic peptides and troponin in the setting of cardiotoxic exposure.
Patients who are at risk or have pre-HF should receive guideline-directed medical therapy and risk factor modification for the primary prevention of HF, Morris said. In addition, patients who are pre-HF will likely need referral to a cardiologist for further diagnostic and treatment strategies to prevent the progression of HF.
Patients with HF, or stage C, will present with current or prior signs and symptoms of HF caused by structural or functional abnormalities.
“Certainly, if a patient has stage C or actual manifest heart failure, we know that we want to put them on guideline-directed medical therapy, which is now quadruple therapy ... to make sure that we reduce their risk for morbidity and mortality.”
Patients can receive a timely diagnosis using natriuretic peptide levels or with the recognition of evidence of systemic or pulmonary congestion or elevated filling pressures, Morris said.
Patients with advanced HF will present with NYHA class III to IV symptoms; two or more HF hospitalizations in a year; a high-risk biomarker profile; an inability to up-titrate guideline-directed medical therapies due to hypotension, dizziness and worsening renal function; onset of arrhythmias; increasing diuretic dosing; and a need for IV inotropes, Morris said.
Patients with advanced HF should be referred to an HF specialist according to their goals of care, such as heart transplantation, mechanical circulatory support or palliative care.
“When we think about who needs to be referred to an advanced heart failure cardiologist, we want to see them before they have persistent worsening renal function or persistent multiorgan failure that we can’t turn around with the addition of inotropes or the addition of mechanical circulatory support,” Morris said. “We want them to be referred to us before their renal function is too adversely affected.
“The bulk of the [HF population] are patients at risk for heart failure or have pre-heart failure,” Morris said. "There are so many good therapies out there. We also now have a ton of therapies for patients with stage C heart failure, and we want to use those therapies to reduce morbidity and mortality for these patients. Even for patients with stage D, heart failure who receive [left ventricular assist device] or transplant, we have incredible outcomes for those patients as well, but we want to see those patients before they have irreversible end-organ dysfunction.”
References:
- Bozkurt B, et al. J Card Fail. 2021;doi:10.1016/j.cardfail.2021.01.022.
- Virani SS, et al. Circulation. 2020;doi:10.1161/CIR.0000000000000757.
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Morris AA. The Changing Spectrum of Heart Failure: From HFrEF to HFmrEF to HFpEF. Presented at: Cardiometabolic Health Congress; Oct. 14-17, 2021; National Harbor, Md. (hybrid meeting).
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