Practical issues across the lifetime of heart failure

Abstract

Over the past 10–20 years there have been major changes in the management of heart failure, based on a robust evidence base from randomized clinical trials. This has led to improved outcome for patients but prognosis is still poor. Some of the challenges to provision of evidence-based care and new developments in heart failure therapy were discussed at the 2010 Annual Meeting of the British Society for Heart Failure. The conference theme was ‘Practical issues across the lifetime of heart failure’, with the 2-day conference covering a broad range of topics from diagnosis to end-of-life care.

Theresa McDonagh (Royal Brompton Hospital, London, UK) outlined data from the National Heart Failure Audit. This audit has been underway since 2007 and now includes data on over 50,000 hospital admissions, making the database larger than that of the US Optimise-HF study and the European Heart Failure Survey II. The audit covers England and Wales (UK), and focuses on the care and treatment of patients with an unscheduled admission to hospital with heart failure.

McDonagh reported that the promising results seen in clinical trials are not yet being achieved in clinical practice. The latest data, covering the period April 2009 to March 2010, show that prognosis remains poor, with 30% 1-year mortality and 9.6% in-patient mortality. One key point highlighted by the data is that outcome is improved if patients have access to specialist cardiology care. At present, approximately 50% of patients are treated on general medical wards rather than cardiology wards.

There has been an important change to the recommended diagnostic pathway for patients with suspected heart failure in the UK. New guidelines from NICE on the management of chronic heart failure were issued in August 2010.

Abdallah Al-Mohammad (Sheffield Teaching Hospitals, NHS Trust, UK) explained that the guidelines recommend that after taking a history and clinical examination, general practitioners should measure plasma natriuretic peptides (B-type or N-terminal pro-B-type natriuretic peptide). Decision on referral for echocardiography should then be based on the result of the natriuretic peptide test, with a normal level indicating that heart failure is unlikely and further testing not required. He said that the test has been shown to be more accurate than the ECG as a ‘rule-out’ test for heart failure.

Natriuretic peptide levels are raised in patients with heart failure in line with New York Heart Association (NYHA) class. Allan Struthers (Ninewells Hospital, Dundee, UK) explained that there is also interest in whether peptide levels are useful for monitoring heart failure therapy. He said that trials of natriuretic peptide-guided therapy have suggested that monitoring might be a good predictor of outcome in the short term and particularly in younger patients, but this is not yet established for routine practice.

In a presentation on the use of echocardiography in assessment of patients with suspected heart failure, Antoinette Kenny (Freeman Hospital, Newcastle, UK) said that new developments in echocardiography using tissue Doppler imaging have shown that patients with presumed diastolic heart failure do not have ‘pure’ diastolic dysfunction but in fact have occult or early left ventricular (LV) systolic dysfunction.

Kenny explained that ejection fraction measures radial contraction, which is an insensitive measure of overall LV systolic function. Measuring long-axis function by tissue Doppler imaging appears to be a more sensitive measure. Longitudinal fibers are believed to be more vulnerable to stresses from ischemia, fibrosis and other insults, and thus become abnormal earlier in the cascade of LV systolic impairment. There are as yet no longitudinal data to show progression of LV systolic dysfunction in these patients but studies to assess this are planned.

Kenny suggested that routine echocardiography in suspected heart failure should include measurement of long-axis function as well as ejection fraction.

Several important new clinical trials in heart failure were reported in 2010 and were presented to the conference by John Cleland (University of Hull, UK). These included the Systolic Heart Failure Treatment with the If Inhibitor Ivabradine (SHIFT) trial [1]. Cleland explained that the only cardiac action of ivabradine is to slow the rate of sinus node discharge, reducing heart rate. In SHIFT, reduction in heart rate was associated with an 18% reduction in risk of cardiovascular death or hospitalization for heart failure (the primary composite end point; p < 0.0001).

Another positive trial was the Eplerenone in Mild Patients Hospitalisation and Survival Study in Heart Failure (EMPHASIS-HF) trial [2], which showed that addition of the aldosterone receptor antagonist eplerenone in patients with NYHA class II heart failure and LV systolic dysfunction was associated with a 37% reduction in the primary composite end point of cardiovascular death or hospitalization for heart failure (p < 0.001).

Henry Dargie (University of Glasgow, UK) suggested that the overall trial experience with aldosterone antagonists indicated that these drugs should join ACE inhibitors and β-blockers as routine first-line therapy for patients with chronic and postmyocardial infarction heart failure.

Dargie said that over the past 20 years, large randomized clinical trials have produced a remarkably robust evidence base for the management of patients with chronic heart failure due to LV systolic dysfunction, exemplified by reduced ejection fraction. However, to date no drugs have been proven to be effective in acute heart failure and results have been disappointing in trials of treatment of heart failure with preserved ejection fraction.

When new drugs have failed because of adverse reactions, in some cases this is probably related to inadequate clinical trial design, Dargie suggested, with treatment being initiated at too high a dose instead of starting at a low dose and uptitrating (as is recommended for ACE inhibitors and β-blockers).

Discussing the increasing role of imaging in prognostic assessment of heart failure patients, Simon Woldman (Heart Hospital, London, UK) said that ejection fraction remains the most easily available prognostic marker. Ischemia testing is more controversial: the presence of ischemia has a strong effect on prognosis but there is as yet little evidence that intervention (revascularization) is effective. He emphasized that there is little point in testing for adverse prognosis if there is nothing that can be done about it.

Woldman said that sympathetic imaging is a new technique with potential value. The AdreView Myocardial Imaging for Risk Evaluation in Heart Failure (ADMIRE-HF) study showed that meta-iodobenzylguanidine (mIBG) imaging could predict risk of arrhythmia [3]. Since then, research has been published showing that mIBG predicts risk after ST-elevation myocardial infarction, being a better discriminator of prognosis than ejection fraction. Of particular interest, new data indicate that mIBG testing might identify patients who are at high risk of sudden cardiac death and would most benefit from an implantable cardioverter-defibrillator (ICD) [4]. Further studies are needed on this. It will be important to assess whether the negative-predictive value is good enough to allow clinicians to change their criteria for defibrillator insertion.

Renal failure is common in patients with heart failure and an important prognostic factor. One of the pathological features of the cardio–renal syndrome is tubular damage. Kevin Damman (University of Groningen, The Netherlands) described newly identified urinary markers of renal tubular damage that might be an early marker of renal damage, with potential use to help guide therapy to preserve renal function in patients with heart failure. The markers are N-acetyl-β-D-glucosaminidase, kidney injury molecule 1 and neutrophil gelatinase-associated lipocalin. Damman said that there was evidence that measuring urinary levels of these markers alongside glomerular filtration rate and albumin excretion adds to prognostic information in patients with heart failure [5]. The markers have not yet been tested in clinical practice.

Klaus Witte (University of Leeds, UK) suggested that cardiopulmonary exercise testing should be routine in the management of patients with chronic heart failure. This gave an objective measure of severity and could help with assessment of prognosis. He said it was important to carry out a functional test that reproduces patients’ symptoms rather than just ECG and echocardiography. Witte reported that peak oxygen consumption is better than LV function as a prognostic marker. He acknowledged that not all patients will be able to undergo a treadmill or bicycle stress test, and said that the 6-min walk test could also be useful, although this is less reproducible.

The conference also heard an update on the use of telemonitoring (remote monitoring) for patients with heart failure from Martin Cowie (Imperial College London, UK), who said that there is increasing evidence that remote monitoring can help improve the outcome and experience of care.

Remote monitoring initially meant telephone support from a healthcare professional, but it has been developed to include more sophisticated systems for patient-initiated monitoring using standalone equipment and, more recently, systems that allow data to be transmitted from an implanted device, often without the patient needing to do anything. It is now technically feasible to remotely monitor many physiological features. With the implanted systems, data can be collected from a therapeutic device (e.g., an ICD) or from standalone monitoring devices, such as devices that measure pulmonary artery pressure.

The aim is to detect early warning of heart failure decompensation so that care can be adjusted as necessary. A recent Cochrane meta-analysis of randomized trials of telemonitoring showed that structured telephone support was associated with a 23% reduction in heart failure hospitalization (p < 0.0001) and there was a suggestion of reduced mortality (p = 0.08) [6]. For formal telemonitoring with remote transmission of data to a healthcare professional, there was a 34% reduction in mortality (p < 0.0001) and 21% reduction in hospitalization (p = 0.008) compared with usual care. Data on use of implanted monitoring systems are still being collected.

Cowie said that, in his experience, telemonitoring is very acceptable to patients. However, the exact model to use is still unclear and there is a need to work out how best to deal with the large amounts of data that are generated. One approach under investigation is the development of algorithms that analyze the data and could identify patients at high risk of problems. Cost–effectiveness also needs to be assessed. However, given the expected doubling in number of heart failure patients in the UK over the next 10 years, telemonitoring is likely to become an important part of care for selected patients, allowing specialist input to more patients.

In a session on unmet needs for patients with heart failure, John Buckley (University of Chester, UK) highlighted the need for cardiac rehabilitation for patients with heart failure, and Simon Conroy (University of Leicester, UK) explained how advanced care planning is important to ascertain patients’ priorities on treatment preferences at the end of life. Jim Beattie (Birmingham Heartlands Hospital, UK) said that end-of-life care is now ‘mainstream’ and part of the process of heart failure care: palliative care is no longer seen as relating only to cancer patients. With heart failure there are particular challenges in view of the difficulty in diagnosing the dying phase and ensuring that treatment options are consistent with the changing goals of care.

Conclusion

Heart failure prevalence is increasing, in part because of the aging population. With recent developments in management, prognosis for patients has certainly improved but it is still poor. The 13th Annual Autumn Meeting of the British Society for Heart Failure presentations left delegates in no doubt as to the challenges and opportunities in delivering optimum care to all patients.

The 2011 BSH Annual Autumn Meeting will be held in London on 24–25 November (further details will be available at www.bsh.org.uk).

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

This report was written by Joanna Lumb on behalf of, and with funding from, the British Society for Heart Failure.