Five Years On Am Heart Hosp J.

2011;9(2):7880
I
t is interesting to look back at our predictions
1
to see
where we are relative to these forecasts. Five years is
not that long ago and so, hopefully, we will be close
to the targets we set.
Prevention
Prevention remains the ultimate approach to managing
heart failure (HF). Basically, we are talking about
eliminating the risks for left ventricle (LV) dysfunction for
the Stage A patient (who has risks for LV dysfunction, but
with a normal LV) and eliminating the threatening risks
for the Stage B patient (who has asymptomatic LV
dysfunction) with the intent of preventing, or at least
delaying, the progression of LV dysfunction
into symptomatic HF. Unfortunately, our preventive
interventions are still blunted by social and
economic roadblocks.
More physicians are aware of these risks, but how are we
doing? Hypertension awareness in the general public has
risen and the need to bring hypertension under control
has caught the attention of more practicing physicians.
The target blood pressure remains a moving target, but
certainly <140 mmHg systolic is a good place to start.
Patient compliance, largely related to the cost and
convenience of delivering the ideal antihypertensive
therapy, is a limiting factor for millions.
The risk of high blood lipids has also attracted public
awareness and the attention of practicing physicians.
Again, patient adherence to lipid management is often the
limiting factor, not only in taking the one or more
medications, but also in obtaining the follow-up lipids,
liver enzymes, and related studies. Having physicians test
for lipids in their adult and adolescent populations is a
good start.
Inpatient diabetic control has lightened up somewhat
(from strict diabetic management) and outpatient
management has benefited from the introduction of new
improved agents to provide a wider spectrum of choices
and overall better control.
There are data to show that tobacco abuse is slowly
dropping, but remains a major threat among many of our
young (who will most probably drag smoking into
adulthood). Other forms of substance abuse (e.g. alcohol
and drugs) remain unchanged in prevalence or, in some
circles, slowly growing in popularity.
Obesity is increasing in incidence and prevalence, as are its
consequences, hypertension, diabetes mellitus and
hyperlipidemia. Certain segments of our society have
adopted a more active lifestyle with regular physical
activity, but this group is relatively small compared with
the obese population. Obesity is becoming a major
problem of childhood and adolescence; fast foods, snacks,
soft drinks, television, and video games are relentless,
tough competitors.
The HF population is steadily growing, in part related to the
advancing age of our population and to our ability
to enhance the survival of the HF patient with
-blockade, angiotensin-converting enzyme (ACE)
inhibitors, angiotensin II (AII) antagonists, biventricular
pacemakers, and implantable cardioverter-defibrillators
A Look Back at The Management of Heart
Failure 5 Years Hence
Carl V Leier, MD
1
and Garrie J Haas, MD
2
78 A Look Back at The Management of Heart Failure 5 Years Hence Winter 2011
1. James W Overstreet Professor of Medicine and Pharmacology; 2. Professor of Medicine, The Ohio State University
Correspondence: Carl V Leier, MD, Division of Cardiovascular Medicine, Davis Heart-Lung Research Institute, The Ohio State University, 473 West 12th
Avenue, Columbus, OH 43210. E: carl.leier@osumc.edu
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The American Heart Hospital Journal Five Years On
(ICDs). Unfortunately, some of the expansion of the HF
population is also related to our inability to bring
the HF risks for the Stage A and B patients under better
control. As predicted, over the past five years we have
achieved very little with respect to reducing HF risks.
Physicians, the entire spectrum of healthcare providers, and
society in general have plenty of work remaining in the
common goal of preventing HF.
Diagnostic and Monitoring Modalities
More biomarkers are on the horizon for HF
prognostication. It remains to be seen whether any of them
are able to improve upon or unseat B-type natriuretic
peptide (BNP) as the dominant player in this area.
At this point, the contrast 64-slice computed tomography
(CT) scan has impacted the evaluation of peripheral vascular
disease more than it has coronary atherosclerosis. We have
learned over the past four to five years that the radiation
exposure of CT angiography is considerably higher than
anticipated, blunting the enthusiasm for the routine use of
this diagnostic tool. Magnetic resonance imaging (MRI) has
played a greater role in cardiovascular imaging. MRI is now
the preferred method for assessing myocardial scarring and
viability, ventricular volumes and systolic function,
complex congenital cardiac lesions, and peripheral vascular
disease. Myocardial evaluation by MRI now also provides
information on prognostication, based on the amount of
scarring, and information on inflammatory (myocarditis)
and infiltrative (amyloidosis) disease; the last feature has
reduced the need for myocardial biopsy to establish these
diagnoses. At the present time, MRI in the HF patient is
restricted to those without an indwelling metallic device
(e.g. pacemaker, cardioverter-defibrillator). MRI-compatible
devices are under development. Defining coronary anatomy
by MRI is still a shortcoming.
As predicted, the use of the flow-directed, Swan-Ganz,
pulmonary artery catheter has continued to decline, but
there is a tremendous amount of research and activity
occurring in the area of indwelling devices for
hemodynamic monitoring. Pulmonary artery and left atrial
pressures can now be recorded continuously to detect the
development of early HF decompensation; early
intervention can then be directed at averting symptoms and
hospitalization. Success will depend on the development of
an infrastructure within hospitals and practices to monitor
the hemodynamics from these devices and then institute
appropriate therapy. Whether these methods will thrive is
linked to their cost-effectiveness: basically, will they prevent
enough hospitalizations to offset the cost of the device?
Proper patient selection will probably be mandatory.
We have learned more about genetic testing for familial
cardiomyopathies. There are now more than 40 genetic
defects, alone or in combination, associated with these
conditions. This area will continue to attract research to
define additional genetic disorders, both in familial and
non-familial cardiomyopathy. To address the So what?
question, the hope is to eventually replace or manipulate the
genetic defect once the specific derangement is identified.
Pharmacotherapeutics
As predicted, digoxin utilization has fallen to <30 %, while
ACE inhibitors (or AII antagonists) and -blockade are
approaching >90 % of eligible HF patients. The use of
aldosterone antagonists is steadily increasing for New York
Heart Association functional class (FC) IIIV HF, with
hyperkalemia and renal dysfunction restraining some
of the enthusiasm for routine use. Administration of
aldosterone antagonists requires careful monitoring
of serum potassium. Vasopressin antagonists may be
helpful for the volume-overloaded hyponatremic patient.
To date, endothelin blockers and cytokine inhibitors have
not been found to play a major role in HF therapeutics.
We are waiting to see if pharmacogenomics will impact the
practice of HF therapeutics.
Other than judicious diuretic administration, and perhaps
some -blockade and an ACE inhibitor to block the
reninangiotensinaldosterone response to the diuretic,
the management of diastolic HF (HF with preserved
ejection fraction) remains a challenge, and there is little
hovering on the horizon.
Device Intervention
Biventricular pacing for resynchronization of ventricular
contraction has impacted HF management, but
distinguishing the 6570 % who will benefit from this
intervention from the 3035 % who will not (or worsen)
remains a challenge. We now know that left bundle branch
block with a QRS duration of >150 msec has the highest
incidence of improvement. However, some of the patients
with durations of 120150 msec will also benefit; but who?
Ultrafiltration provides the most efficient means of
removing fluid in a patient with marked volume overload;
a reasonable approach for the patient who has a sluggish
response to diuretics.
Surgery for Heart Failure
The Surgical treatment for ischemic heart failure (STICH)
trial was mired from the start with major difficulties (e.g.
recruitment, patient assignment), making the results
79 Winter 2011 A Look Back at The Management of Heart Failure 5 Years Hence
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Five Years On The American Heart Hospital Journal
virtually uninterpretable. Perhaps we learned that surgical
ventricular restoration (SVR) of an aneurysmal LV (with or
without concomitant mitral valve surgery) was not helpful
for the group randomized to SVR, but we all have individual
patients who benefited greatly from this procedure.
Whether coronary bypass surgery is of benefit to the patient
with LV dysfunction-HF (ejection fraction <30 %) secondary
to coronary artery disease remains largely unanswered
and this approach is now threatened by the continued
development of catheter-based coronary interventions.
Left ventricular assist devices (LVADs) are now in the third
generation of development. The changes brought about by
their continued improvement have greatly reduced the
complication rate (e.g. stroke, infection, bleeding) and
increased the longevity of the devices. LVAD use is on a
steady climb, particularly with the ongoing shortage of
donor hearts, the expanded criteria for LVAD candidacy,
and for patients awaiting transplantation. Research in this
area will continue at a steady pace with the goal set at no
embolization, little bleeding, and a self-contained, internal
energy source.
Survival following cardiac transplantation is gradually
improving to >90 % at one year and >80 % at five years. This
has occurred despite our liberalization of recipient criteria to
include more comorbidities (e.g. complicated diabetes,
peripheral vascular disease). The improved survival is
probably related to the increased experience of transplant
cardiologists, newer improved immunosuppressant agents
(e.g. tacrolimus, anti-thymocyte globulin, sirolimus) and
augmented strategies to counter cardiac allograft
vasculopathy. We are now expecting most of our transplant
patients to survive 10 years following transplant, with a goal
of over 20 years.
Stem cell therapy, a form of transplant in most instances,
is certainly an intervention of the future. Post-infarction
patients will be initially targeted. This area is moving fast,
with optimistic hope for the future.
Closing Comments
As noted, our improved therapies and the increasing age of
our population are expanding the HF base. While
theoretically solvable, the obesity epidemic (and
associated hypertension and diabetes mellitus) in
particular will greatly increase the HF population, by
initially adding patients with diastolic dysfunction HF, and
will bring this condition into a younger age group.
With respect to our predictions for HF care, made five years
ago, we were not too far offbut how could we miss? n
80 A Look Back at The Management of Heart Failure 5 Years Hence Winter 2011
1. Leier CV, Haas GJ, The management of
heart failure 5 years hence, Am Heart
Hospital J, 2006;4:20710.
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