Stable but Progressive Nature of Heart Failure: Considerations for Primary Care Physicians

Abstract

Primary care physicians play a significant role in managing heart failure (HF), with the goals of reducing mortality, avoiding hospitalization, and improving patients’ quality of life. Most HF-related hospitalizations and deaths occur in patients with New York Heart Association functional class II or III, many of whom are perceived to have stable disease, which often progresses without clinical symptoms due to underlying deleterious effects of neurohormonal imbalance and endothelial dysfunction. Management includes lifestyle changes and stepped pharmacological therapy directed at the four stages of HF, with aggressive uptitration of therapies, including beta-blockers and inhibitors of the renin-angiotensin-aldosterone system. Recently, two new HF treatments have become available in clinical practice. Ivabradine was approved to reduce the risk of hospitalization for HF in patients with stable, symptomatic HF. Additionally, the angiotensin receptor–neprilysin inhibitor (ARNI), sacubitril/valsartan, was found to be significantly superior to enalapril in reducing risks of cardiovascular death and HF-related hospitalization. The respective 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America clinical practice guideline updates recommend that patients taking angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy be switched to ARNI therapy to further reduce morbidity and mortality. For HF management to be maximally effective, physicians must be knowledgeable about the risks and benefits of treatments and stay engaged with patients to identify signs of disease progression. This article provides an overview of the progressive nature of HF in apparently stable patients and describes areas for treatment improvement that may help to optimize patient care.

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic heart failure in primary care (PREFER): a real-world study

“… 20 However, deterioration of cardiac structure and function is often subclinical and proceeds unrecognised, eventually increasing the patient’s risk of an adverse outcome. 32 In PREFER, despite the majority of patients being in NYHA class II and considered ‘stable’, nearly two-thirds had markedly elevated NT-pro-BNP levels of ≥600 pg/mL, about half needed inpatient care in the 12 months prior to entering the study, and in the relatively short follow-up time, about 15% of referred patients experienced an SAE (majority causally related to HFrEF). These observations emphasise the need to optimise GDMT, even in patients considered mildly symptomatic or clinically stable, with a better multidisciplinary approach involving PCPs, cardiologists, nurses and pharmacists.…”

Cardiac Regeneration: New Insights Into the Frontier of Ischemic Heart Failure Therapy

“…It has been argued that numerous pharmacological therapies including renin-angiotensin-aldosterone system inhibitors, dual angiotensin receptor/neprilysin inhibitors, and β-adrenergic receptor antagonists (β-blockers) are significantly underutilized in the HF patient population. Optimizing pharmacotherapy in this population could prevent tens of thousands of deaths per year in the United States alone (Anand, 2018 ). In contrast, some argue that the strength of β-blocker recommendations in particular should be reevaluated.…”

Rho‐kinase pathway activation and apoptosis in circulating leucocytes in patients with heart failure with reduced ejection fraction

“…These criteria are currently used to define clinical stability in HFrEF patients. 22 All patients were in sinus rhythm. patients, and its assessment in PMBCs could be useful to evaluate reverse remodelling and disease regression.…”