Abstract
The 12th Annual Meeting of the British Society of Heart Failure was held in London (UK). As heart failure has evolved into an accredited subspecialty in its own right, the conference has become increasingly well attended. This year there were over 400 delegates from around the world. As per clinical practice, there were large numbers of multidisciplinary members including a strong representation from the heart failure specialist nurse division.
Epidemiology
The conference opened with an overview of the current state of heart failure care within the UK. Primary and secondary care were both excellently represented. Overall, heart failure care has progressed and the uptake of therapies has increased. However, the mortality rate in the limited national audit carried out thus far remains obdurately high with in-hospital mortality within England and Wales remaining at 15%. With the increasing prevalence of the disease, more advanced treatment options were also discussed. This highlighted the problem with the reduction in number of cardiac transplants performed within the UK along with the growing need. One suggested solution would be the increased usage of Left Ventricular Assist Devices (LVADs) in appropriate populations. This is under scrutiny currently and is the subject of some future trials.
Excellent models of care were highlighted as well as the need for further integration between primary, secondary and tertiary care. A potential futuristic model that was highlighted and explored in a further session was that of telemonitoring. This may well revolutionize standards of care and is also the subject of much focus currently within the heart failure community.
The Philip Poole-Wilson inaugural lecture
Philip Poole-Wilson was one of the modern giants in cardiology. His untimely and sad death earlier in the year was a great shock to all concerned, and especially to this society to whom he had given so much. A thoroughly well-liked and respected individual, he was viewed as one of the pioneers of his time. His life’s work had been devoted to the study of the failing ventricle with its various implications. The creation of the society had been his idea and he had been the original chairman.
A touching tribute was paid by Henry Dargie, (Golden Jubilee National Hospital, Glasgow, UK), who has also nurtured many of the heart failure community. Dargie is also viewed as a leading contributor to the field of heart failure. In the inaugural memorial lecture, he gave a wonderful overview of heart failure and its connections with Poole-Wilson. He summated that there was a need for heart failure within the hospital to be looked after by specialists. This was best served, in his view, by the creation of acute heart failure units, which could become a focus of resources, knowledge and staff. It would be analogous to other combined multidisciplinary units in modern practice, for example, the coronary care unit (CCU) and the acute stroke unit.
Future therapies
This session was concentrated on current and imminent therapies. First, an overview of some of the postulated therapies was given by John McMurray (Western Infirmary, Glasgow, Glasgow, UK). He documented the multiple therapeutic failures that have been illustrated along the way. The recent Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist KW for Patients Hospitalized with Acute HF and Volume Overload to Assess Treatment Effect on Congestion and Renal Function Trial (PROTECT) trial was highlighted as an example Citation[1]. Here the adenosine antagonist, rolofylline had been proved to be no better than placebo. It was another of the litany of unsuccessful medications in the arena of heart failure.
Another area receiving increasing attention is that of iron deficiency and anemia in heart failure. A large multicenter trial had been recently conducted and was published the week of the conference. Ferinject Assessment in Patients with Iron Deficiency and Chronic Heart Failure (FAIR-HF) demonstrated some subjective end point evidence of the potential benefit of intravenous iron replacement therapy Citation[2]. One critique was that the study employed relatively clinical end points including symptoms and the 6-min walk distance. Nonetheless, this is becoming an intensive field of research and many suggest that FAIR-HF may become a pilot for future larger multicenter trials. Several future trials were highlighted with a strong degree of interest in the cohort with Heart Failure with Normal Ejection Fraction (HEFNEF). HEFNEF is a topic that is associated with little evidence. Perindropril, digoxin and candesartan have all been studied in this context and have been demonstrated to have no clinical benefit. We await the outcome of spironolactone within the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study.
Cardiac resynchronization therapy (CRT) has rapidly become an established therapy for advanced heart failure. The increasing implantation of CRT has led to further studies to refine the indications. One such major trial published earlier in the year was the Multicenter Automatic Defibrillator Implantation with Cardiac Resynchronization Therapy (MADIT-CRT) trial, whereby CRT was found to be beneficial on a composite end point of reduced heart failure hospitalization Citation[3]. This was executed in a population with less advanced disease than previous CRT trial populations. The suggestion that CRT may retard disease progression is the source of much interest and may lead to further device implantation.
Implantable cardioverting defibrillators (ICDs) were also highlighted with the results of the Early Defibrillator Implantation Post Myocardial Infarction (IRIS) trial Citation[4]. In an ischemic population, ICDs were deliberately implanted early. Once again, similar to previous studies, early implantation rates did not result in improved outcomes. In an as yet unexplained mechanism, the early implantation of an ICD actually worsens outcome.
Another exciting area of development is that of percutaneous valve therapy in heart failure populations. As heart failure becomes more prevalent within aging Western populations, one of the more common etiologies will be valvar disease. Transcutaneous valve implants for aortic valve disease have now become engrained within the cardiology community. Novel applications of this technology were demonstrated in prosthetic valve regurgitation. One particularly exciting use of percutaneous valve therapy is to combat mitral regurgitation. Functional mitral regurgitation is commonly encountered in dilated failing left ventricles. It is due to annular dilatation and a failure of leaflet coaptation. New percutaneous technologies to combat functional mitral regurgitation were discussed, with the summary that this will be a further future area of investigative focus.
Brain natriuretic peptide (BNP) has long been established as a biomarker in this field. Originally described over a decade ago, it has now become established within the guidelines as a potential screen for heart failure. Hence within the UK, it is now becoming increasingly offered to primary care physicians. BNP, however is still associated with a high degree of interindividual variability and is also prone to confounding variables including renal dysfunction. Therefore natriuretic peptides have been revisited and are being more intensively studied. The mid-regional atrial natriuretic peptide (MR-ANP) is the subject of the most intensive study. Biomarkers in Acute Heart Failure (BACH) published recently suggested that MR-ANP had a predictive value and the most powerful usage of this would be in combination of natriuretic peptides Citation[5]. This hypothesis was further explored by the illustration that a package of biomarkers may have a strong predictive value. Cystatin C, which is a marker of renal dysfunction when combined with N-terminal pro-BNP, was a powerful predictor of adverse outcomes Citation[6]. One further potential avenue of interest is biomarkers that allude to the immune activation that predisposes to myocardial fibrosis. One such cytokine identified in the hypothesis is IL-33 binds to the ST2 receptor. The ST2 assay also shows some initial promise.
Monitoring & disease surveillance
With an ever-increasing burden of disease, the need for careful monitoring of patients has become a prerequisite for high standards of care. A session was devoted to this and explored novel concepts including telemonitoring, device monitoring and monitoring with biomarkers. Traditional care is proving increasingly difficult with a more advanced elderly population. Therefore, one such way to monitor patients and optimize concordance with medication, prevent hospitalization and hopefully improve outcomes is with telemonitoring. This is the remote monitoring of physiological variables (e.g., blood pressure and highlighting trends). This is due to the findings that patients, prior to a decompensatory episode, would have increased weight gain and increased symptomatology. The original study was the Trans-European Network–Home-Care Management System (TENS-HMS) trial conducted by John Cleland’s group (Hull and East Riding NHS Hospitals Trust, Hull, UK) Citation[7]. Similar findings were established in a group chaired by Martin Cowie (Royal Brompton Hospital, London, UK) Citation[8]. This would enable better resource allocation and looks set to become a 21st Century method of patient follow-up.
Another futuristic method of follow-up proposed within this session was that of device-related follow-up. Patients with imbedded CRT or ICDs are starting to have a series of biological parameters transmitted wirelessly to a remote hub. Here the data is encoded and then fed back to a central server and can be relayed to an appropriate work terminal. This may enable the community to identify when a patient has entered into atrial fibrillation and is beginning to enter into a decompensatory phase. Each major device manufacturer has an integrated system for transmission of these data and again this looks to be the route of device development over the next few years.
Finally, despite any modern technology, the need for multidisciplinary care was highlighted. This involved tried and tested links of specialist heart failure nurse management allied with good primary care links.
Imaging & complexities of heart failure
Sessions were also devoted to imaging within heart failure and the complexities of heart failure. Imaging within heart failure covered cardiac magnetic resonance imaging, advanced echocardiography, nuclear imaging and PET scanning. Advanced echocardiography covered speckle tracking and intracavitary blood flow; further evaluation needs to take place. Nuclear imaging has been long held as the workhorse, and to some, unexciting side of cardiac imaging. A novel revelation allied to nuclear imaging is the recent application of meta-iodobenzylguanidine (MIBG) scanning. This has been incorporated into a risk model for sudden cardiac death in heart failure Citation[9]. 123-mIBG is a marker of the sympathetic activity and appears to be promising as a further tool for risk stratification. PET scanning has been a research technique for the last two decades, again this may be undergoing a transformation to become an established clinical tool. Again utilizing a MIBG tracer, there may be an indication for risk stratification for the development of left ventricular systolic dysfunction (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure; ADMIRE-HF) Citation[10].
In terms of the complexities of heart failure this was split into unusual etiologies, treatment conundrums and associated comorbidities. Unusual etiologies had several interesting and stimulating discussions including William McKenna (The Heart Hospital, London, UK) giving a brief overview of familial dilated cardiomyopathy. One potential etiology, which seems poised to become an increasing problem, is that of post-cancer survivors. Much of the chemotherapy and some of the other allied treatments (e.g., radiotherapy) are cardiotoxic. With increasing numbers of cancer survivors and especially childhood survivors of hematological malignancies, there will be an increased prevalence of disease in this cohort. Tellingly, up to 50% of childhood survivors will go on to develop left ventricular dysfunction after their initial exposure. Particular attention was paid to trastuzumab (Herceptin®), which also seems to have cardiotoxic effects. Martin Denvir (Western General Hospital, Edinburgh, UK) suggested that the evidence thus far should encourage closer working links between cardiology and oncology. The take-home message from this presentation was that ongoing cardiovascular vigilance is necessary and may lead ultimately to the creation of formal cardiovascular surveillance in these populations as compared with the current ad hoc practices.
Treatment difficulties addressed the old problems of diuretic resistance and hyponatremia. These are two well-recognized entities in heart failure but little progress has been made in either. Two cohorts, in which traditionally there are little evidence, was that of congenital heart disease and pulmonary hypertension. Pulmonary hypertension recently has seen a raft of new therapies tailored towards vasodilatation but remains a difficult condition to treat. Adult congenital heart disease remains another difficult heterogeneous population. The subject was illustrated with several cases by Lorna Swan (Royal Brompton Hospital, London, UK), which revealed the difficulty with identifying the underlying etiology and pathophysiology. It also suggests that this area is severely lacking evidence and is in desperate need of well-conducted trials.
Heart failure populations are generally aging populations. They also develop or can develop a plethora of comorbidities. Sleep-disordered breathing was presented by Anita Simmonds (Royal Brompton Hospital, London, UK), and the recognition that both obstructive sleep apnea and central sleep disorders were prevalent and underdiagnosed in heart failure populations. Arthritis was also covered and again more evidence seems to be emerging into inflammatory arthritis. Rheumatoid arthritis, we know already, carries an added degree of cardiovascular risk for ischemic heart disease, but the audience was also informed of a higher risk of left ventricular systolic dysfunction. This translated into an increasing degree of mortality. Diabetes mellitus was also briefly covered with emphasis placed on patients with persistently poor outcomes despite good uptake of modern therapies.
Conclusion
The British Society of Heart Failure Annual Meeting was a considerable success. It enabled an intelligent, involved audience to gain further understanding from true experts in the field. Although the presentation style is plenary, this leads to an informal atmosphere that is conducive for all concerned. It serves as a good overview of the entire specialty and therefore should be considered for not just those within the field, but any of those who have any contact with the care of patients with heart failure or who wish to gain further understanding of the subject.
Financial & competing interests disclosure
The authors have 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.
No writing assistance was utilized in the production of this manuscript.
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