Top 5:The battle against heart failure

Dr. Barry Greenberg, President of the Heart Failure Society of America, answers EHM’s top five questions about heart failure treatment.

1. What is the status of the battle against heart failure?

There is good news and bad news. The good news is that there have been substantial gains in our understanding of the mechanisms involved in progression of cardiac dysfunction and how to treat patients with this condition. In particular, the addition of beta blockers and, more recently, devices such as biventricular (BiV) pacemakers and internal cardiac defibrillators (ICDS) have led to a marked improvement in the clinical course including reductions in mortality and hospitalizations.

The bad news is that heart failure prevalence and incidence continue to increase, pointing out the need for increased attention to prevention and early initiation of treatment that will inhibit progression. Other areas in which advances have been less extensive than we would have wanted include the treatment of patients with acutely decompensated heart failure and management of patients with heart failure and preserved ejection fraction.

2. What are the most innovative diagnostic methods available today?

Although heart failure can be caused by numerous different conditions, it turns out that hypertension, diabetes and/or coronary artery disease accounts for about 90 percent of population-attributable risk for heart failure. Having said that, new imaging techniques for detecting myocardial ischemia and/or viable myocardium have been shown to be quite valuable in assessing and managing heart failure patients. One of the most innovative trends that will likely increase in importance over the next several years is the use of genotyping patients to detect mutations or polymorphisms that predispose to the development of heart failure or to a more severe clinical course.

3. What have been recent major advances in heart failure treatment?

The use of beta blockers is probably the most important advance in this area in decades. The use of evidence based beta blockers have resulted in 30 to 40 percent reduction in mortality in selected populations. Devices such as ICDs and BiV pacemakers, when given on top of optimal medical therapy, also have been shown to improve outcomes. In fact, these devices have now moved into the main stream of treatment for heart failure and they are considered in patients who fulfil criteria as outlined in the recent American College of Cardiology/American Heart Association (ACC/AHA) and Heart Failure Society of America (HFSA) heart failure guidelines.

4. What treatment options do you take special interest in?

I take special interest in drugs and devices that target the remodeling process. Much of my research work over the years in both the clinical and basic arenas has been in this general area. I find the remodeling process to be remarkably complicated in that there are numerous factors and pathways involved. On the other hand, once remodeling is initiated, the processes involved tend to be similar so that the response to injury, which starts the remodeling process, is prototypic in nature. Teasing out the pathways and trying to identify ways of altering remodeling is important since the changes brought about by remodeling are strongly associated with deterioration in cardiac function and with poor outcomes in heart failure patients.

5. What are the major challenges in the battle against heart failure?

We need to do a much better job in identifying patients at risk for heart failure and patients with early evidence of cardiac dysfunction since aggressive treatment can markedly alter outcomes. Effective therapies for treating patients with heart failure with preserved ejection fraction are also needed. Before we can make advances in this form of heart failure, though, we will need to better understand the causes and to appreciate the heterogeneity in etiologies in the population of patients with this condition. Finally, we need to develop better systems for managing patients particularly during the time immediately following hospital discharge since patients have been shown to be at high risk for both morbidity and mortality during this period.