Reflecting on the advancements of HFrEF therapies over the last two decades and predicting what is yet to come. (19th December 2022)

• Record Type: Journal Article
• Authors: Piña, Ileana L; Gibson, Gregory T; Zieroth, Shelley; Kataria, Rachna
• Is Part Of: European heart journal supplements. Volume 24(2022)Supplement L
• Page Start: L2
• Page End: L9
• Publication Date: 2022-12-19
• Subjects: Heart failure with reduced ejection fraction -- Guideline-directed medical therapy -- Cardiogenic shock -- Mechanical circulatory support -- Remote monitoring -- Artificial intelligence; Cardiology -- Periodicals; Cardiology -- Europe -- Periodicals; 616.12005
• DOI: 10.1093/eurheartjsupp/suac112
• Languages: English
• ISSNs: 1520-765X

Abstract

Abstract: What was once considered a topic best avoided, managing heart failure with reduced ejection fraction (HFrEF) has become the focus of many drug and device therapies. While the four pillars of guideline-directed medical therapies have successfully reduced heart failure hospitalizations, and some have even impacted cardiovascular mortality in randomized controlled trials (RCTs), patient-reported outcomes have emerged as important endpoints that merit greater emphasis in future studies. The prospect of an oral inotrope seems more probable now as targets for drug therapies have moved from neurohormonal modulation to intracellular mechanisms and direct cardiac myosin stimulation. While we have come a long way in safely providing durable mechanical circulatory support to patients with advanced HFrEF, several percutaneous device therapies have emerged, and many are under investigation. Biomarkers have shown promise in not only improving our ability to diagnose incident heart failure but also our potential to implicate specific pathophysiological pathways. The once-forgotten concept of discordance between pressure and volume, the forgotten splanchnic venous and lymphatic compartments, have all emerged as promising targets for diagnosing and treating heart failure in the not-so-distant future. The increase in heart failure-related cardiogenic shock (CS) has revived interest in defining optimal perfusion targets and designing RCTs in CS. Rapid developments in remote monitoring, telemedicine, and artificial intelligence promise to change the face of heart failure care. In this state-of-the-art review, we reminisce about the past, highlight the present, and predict what might be the future of HFrEF therapies. Graphical Abstract: Graphical Abstract HFrEF: heart failure with reduced ejection fraction; ICD: implantable cardioverter-defibrillator; CRT: cardiac resynchronization therapy; RAS: renin-angiotensin system; ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker; ARNi: angiotensin receptor neprilysin inhibitor; SGLT2is: sodium-glucose cotransporter-2 inhibitors; MRAs: mineralocorticoid receptor antagonists; sGC: soluble guanylate cyclase; RCTs: randomized controlled trials; CS: cardiogenic shock.