Article Reviews Latest Knowledge of Heart Failure

In the inaugural issue of the Journal of American College of Cardiology: Heart Failure published on Feb. 4, Eugene Braunwald, MD, MACC, reviewed the latest scientific knowledge of the epidemiology, pathophysiology, management and future direction for the prevention and treatment of heart failure in the U.S.

Braunwald described the so-called heart-failure paradox: the disparity between the growing prevalence of heart failure and striking improvements in the prognosis of individual cardiac conditions, including acute coronary syndromes, severe hypertension, and valvular and congenital heart diseases. He explains that although the mortality risks associated with these other cardiac conditions has been reduced, survivors still have coronary artery disease and are at risk of further myocardial damage and possibly heart failure.

Additional Resources
A number of biomarkers have been identified for the diagnosis of heart failure, the most widely used being the b-type natriuretic peptide and the N-terminal pro b-type natriuretic peptide. Natriuretic peptides have been shown to be of clinical value in diagnosing heart failure in patients without clinical manifestations of heart failure, in those with dyspnea of unknown origin and in apparently healthy patients who are at high risk for heart failure. In the last quarter of the 20th century, the availability of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists, β-adrenergic blockers, internal cardioverter defibrillation and cardiac resynchronization therapy has substantially improved the treatment of heart failure patients with reduced ejection fraction, but Braunwald notes that these therapies have not been as successful for heart failure patients with a preserved ejection fraction.

Drugs under investigation for heart failure patients with a preserved ejection fraction include the phosphodiesterase-5 inhibitor sildenafil and an angiotensin receptor neprilysin inhibitor (LCZ696) that combines the angiotensin II receptor blocker valsartan with an endopeptidase inhibitor that blocks the metabolism of natriuretic peptides. Novel drug therapies for chronic heart failure include the selective sinus-node inhibitor ivabradine, which the 2012 European Society of Cardiology guidelines gave an IIa/B indication for the treatment of heart failure, and sildenafil for heart failure patients with reduced ejection fraction.

He adds that other new therapies under study for heart failure include autologous cardiac stem/progenitor cell therapy and gene therapy. In addition, new developments in continuous-flow left-ventricular assist devices, such as the HeartMate II, have advanced the treatment of heart failure.

"Substantial improvements in the prevention and management of HF present formidable challenges, but these challenges may be met because much of the necessary groundwork has already been carried out," concluded Braunwald. "The pages of JACC HF are expected to report the important skirmishes and victories of this last great battle in the war on cardiovascular disease. In so doing, JACC HF will accelerate the translation of scientific discoveries and technical developments to clinical care, will help to educate health care professionals, and will thereby make an important contribution to improving quality and duration of life in patients worldwide."

Keywords: Coronary Artery Disease, Stem Cells, Heart-Assist Devices, Purines, Receptors, Angiotensin, Mineralocorticoid Receptor Antagonists, Protease Inhibitors, Adrenergic Antagonists, Neprilysin, Benzazepines, Cardiac Resynchronization Therapy, Survivors, Genetic Therapy, Hypertension, United States, Natriuretic Peptide, Brain, Angiotensin Receptor Antagonists, Acute Coronary Syndrome, Piperazines, Valine, Sulfones, Dyspnea, Tetrazoles, Heart Failure, Peptide Fragments, Cyclic Nucleotide Phosphodiesterases, Type 5

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