“Turning Points” for Heart Failure

For decades, doctors rarely provide patients with heart failure, where emission rates are preserved, a rise in global health problems with severe mortality rates five years after diagnosis, rarely providing patients with patients with heart failure. . But that began to change in 2021 when drug trials showed benefits in preventing hospitalization and death.

Since then, new clinical trials have been conducted each year to demonstrate the value of yet another drug in HFPEF.

“So amazing,” says Dr. Michelle Kittleson, Maryland, Professor of Cardiology at the Smit Heart Institute in Cedars Sinai, Los Angeles and chairman of the latest American Faculty of Cardiology Writing Committee (ACC). said. Update the HFPEF management route.

Talking to a patient with HFPEF was extremely difficult because there was nothing else I could do other than manage my expectations. You should say, “I'm sorry, but there are no medicines that will affect the natural history of your illness.” It had to be,” she said.

“It's comforting to have arrived at the age of HFPEF where you can say, 'I have the tools to improve your quality of life,'” she added.

Five new drugs in four years

“This is a turning point in the history of HFPEF treatment,” said Dr. Marco Metra, Maryland, of Assto Superior Private Heart Disease Research Institute in Brescia, Italy. He co-discussed the European Society of Cardiology (ESC) Heart Failure Task Force, which updated the guidelines in 2023.

The rapidly changing landscape means that, according to experts, the focus is on diagnosis and treatment decisions for cardiologists and primary care clinicians navigating new terrain.

Diagnosis of HFPEF is even more important as there are evidence-based treatments that can significantly alter the course of the disease. This forced a committee considering updating the guidelines for heart failure.

Previously published in 2021 ESC Heart Failure Guidelines did not include recommendations regarding HFPEF.

“30 minutes after we presented the ESC guidelines in 2021, The Emperor's Preservation“- The first trial of the sodium glucose cotransporter 2 (SGLT2) inhibitor of HFPEF, according to Metra.

Enter SGLT2 inhibitors

Following this in 2022 We offer trials of dapagliflozin, another SGLT2 inhibitor of HFPEF. Both trials showed significant improvements in key outcomes. Hospitalization for cardiovascular death or heart failure. The results of the delivery also included emergency medical visits.

Most of the benefits of these trials were reduced hospitalizations, Metra said, but meta-analysis later showed that cardiovascular death also decreased. He explained that because these trials had fewer deaths, it was difficult to show the impact on death.

SGLT2 inhibitors represent “the most Hugest Advence in HFPEF in the last decade.”

In 2023, the ESC guidelines and the ACC management route were published. Both contained SGLT2 inhibitors. But there has been more development since then.

Glucagon-like peptide 1 (GLP-1) and heart failure

2023 Step HFPEF Trial We demonstrated the value of semaglutide, a well-known GLP-1 agonist used in patients with diabetes and obesity. In this study, patients with HFPEF and obese who received semaglutide had significantly reduced symptoms and physical limitations and improved motor function than patients who received placebo.

2024, Summit Trial Another GLP-1 agonist, tilzepatide, showed that HFPEF and obese patients had a lower risk of cardiovascular death or worsening heart failure, resulting in improved health status.

These two trials were limited by a small number of cardiovascular events and deaths in each, Metra said. While clear conclusions about cardiovascular events may be premature, “We can certainly say that GLP-1 agonists are likely to improve quality of life and reduce major events,” says HFPEF. and obese patients.

It is unclear how GLP-1 agonists function in HFPEF, according to Kittleson. “I think there are special sources of these drugs. They have essential cardiac benefits to the natural progression of HFPEF.” However, HFPEF has not yet been shown by regulatory authorities.

Even in 2024 Finearts Trial Recently approved drugs for finrenone, a chronic kidney disease, reduce the rate of heart failure or cardiovascular mortality compared to placebo in patients with mildly reduced or reduced conserved elimination rates or preserved. It showed that. Finrenone, like spironolactone, which has been used for a long time in heart failure, is a steroid-type mineralocorticoid receptor antagonist.

international Studies of spironolactone in HFPEF Ten years ago there was no improvement in cardiovascular death, cardiac arrest or hospitalization for heart failure. But the trial saw significant differences in outcomes between different parts of the world, leading to concerns about how it was implemented, Kittleson said.

And now there are treatments for specific causes of HFPEF, Metra says it contains myocardial inhibitors for hypertrophic cardiomyopathy. The drugs are located in the heart amyloidosis pipeline.

Effective medications are good news, but they lead to clinical questions.

Clinical treatment will catch up

Dr. Neil Skolnick, professor of family and community medicine at Thomas Jefferson University Sydney Kimmel Medical College in Philadelphia, says that a variety of drugs “work through a variety of mechanisms.” The challenge is to identify people who can benefit from these treatments that have emerged over the past five years and decide which medications to use and the multiple medications to benefit from.

Current standard care should include mineralocorticoid antagonists and SGLT2 inhibitors. GLP-1 inhibitors can be added to obese or diabetic patients. These drugs are not yet shown in HFPEF, but they actually say “If the patient has another sign of these drugs, it's safe if the patient has HFPEF” You might get it, Kittleson said.

Angiotensin Receptors – Neprilysin inhibitors and angiotensin receptor blockers may be added if indicated. Treatment of comorbidities is also important.

The increased prevalence of HFPEF is linked to population aging. “Aging is the greatest risk factor, so HFPEF increases as patients live longer,” Kittleson said.

In addition to age, she explained, “there are many comorbidities that contribute to HFPEF, which are more common with age.” Management pathways explain complex interactions with hypertension, diabetes and obesity, causing coronary artery disease, atrial fibrillation, sleep apnea and chronic renal disease. The latter two conditions exacerbate hypertension, and all comorbidities affect outcomes in patients with HFPEF.

“It's the perfect storm,” Kittleson said.

The increasing prevalence means primary care physicians must be aware of the possibility of HFPEF, Skolnik said.

For example, HFPEF is found in 20% to 25% of diabetic patients, and the American Diabetes Association recommends annual screening of heart failure in these patients.

Without screening, you can miss HFPEF. “This presentation can be very subtle compared to heart failure, where the rate of elimination is reduced. People are burdened with illness,” he explained. “In HFPEF, symptoms often overlap with experiences in people over 50 to 60 who do not exercise actively. Fatigue, shortness of exercise, peripheral edema, etc. are also overweight.”

The most important thing in primary care is the high-suspecting index and low screening thresholds, Skolnik said.

“Primary care physicians should be aware of these drugs.

“We hope that our primary care physicians, the heroes of our health care system — feel empowered to prescribe these treatments,” Kittleson said.