Definition
Heart failure (HF) represents the end stage of various heart diseases, including specific and ill-defined cardiomyopathies, ischaemic heart disease and heart valve disease. According to the 2021 guidelines of the European Society of Cardiology (ESC), HF consists of cardinal symptoms (breathlessness, ankle swelling, fatigue) as well as elevated jugular venous pressure, pulmonary crackles and peripheral oedema. It is due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output.
Burden of the disease
Heart failure (HF) is a global pandemic, affecting around 26 million people worldwide, with increasing prevalence that mirrors the ageing of the population. Worldwide, 5-year mortality rates in patients with chronic HF are greater than 50%, and the economic burden of HF is estimated at $108 billion per annum.
Management
The modern management of heart failure (HF) is predominantly guided by objective assessments of left ventricular ejection fraction (LVEF), which has been shown to be predictive of adverse outcomes even in the absence of symptomatic HF. Management strategies recommended by international guidelines include pharmacological and non-pharmacological approaches. As both old and new drugs have proved beneficial and can be combined, a new era is starting for a more personalised medical treatment of patients with both HFpEF (heart failure with preserved ejection fraction) and HFrEF (heart failure with reduced ejection fraction). A multidisciplinary and inter-professional management team must be implemented. There are three main goals of treatment: reduction in mortality, prevention of hospitalizations and improvements in clinical status, functional capacity and quality of life.
Guidelines
The most recent guidelines to diagnose and treat heart failure (HF) are:
- Click on the slides below for a comparison of both guidelines’ treatment algorithms
DIAGNOSIS
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- Seferović PM, Vardas P, Jankowska EA, et al. The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics 2019. Eur J Heart Fail 2021;23:906-914.
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Personalised treatment for HF:
The majority of heart failure (HF) patients are not prescribed the correct medication/medication combinations due to the current ‘one size fits all’ approach to treatment. HF is a heterogeneous condition, with no single biomarker to characterise its phenotype, presenting itself differently in individuals in regards to congestion, haemodynamic status, blood pressure and kidney function. Generally, drugs presented to HF patients to improve prognosis impact their blood pressure, heart rate, renal function and potassium levels, but due to the heterogeneity of the HF phenotypes, a personalised approach to treatment is necessary. Side effects and comorbidities (both cardiovascular, such as hypertension, and non-cardiovascular, such as obesity) are necessary to consider in this approach.
Table 1 & 2: Rosano et al (2021)
It is suggested that 10 patient profiles are used, overlapping or being combined as necessary by clinicians to suit patient needs, to allow for clearer designations of treatments and their up-titration regulations. Click the slide below to view the types of patient profiles.
- Seferović P, Vardas P, Jankowska E et al (2019). The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics, Eur J Heart Fail 23:906-914
- Rosano et al (2021). Heart Failure Association of the European Society of Cardiology, Eur J Heart Fail 23:872–881
- McDonagh T, Metra M, Adamo M et al (2021). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, European Heart Journal 42:3599-3726