Current drug therapy for heart failure with reduced ejection fraction

New Perspectives in the Treatment of Acute and Chronic Heart Failure with Reduced Ejection Fraction

Acute and chronic heart failure with reduced ejection fraction (HFrEF) is a major public health problem, studies showing a 25% survival rate at 5 years after hospitalization. If left untreated, it is a common and potentially fatal disease. In recent years, the medical and device therapies of patients with HFrEF have significantly improved. The aim of our review is to provide an evidence-based update on new therapeutic strategies in acute and chronic settings, to prevent hospitalization and death in patients with HFrEF. We performed a systematic literature search on PubMed, EMBASE, and the Cochrane Database of Systemic Reviews, and we included a number of 23 randomized controlled trials published in the last 30 years. The benefit of beta-blockers and renin-angiotensin-aldosterone system inhibitors in patients with HFrEF is well known. Recent developments, such as sodium-glucose cotransporter 2 inhibitors, vericiguat, transcatheter mitral valve repair, wireless pulmonary artery pressure monitor and cardiac contractility modulation, have also proven effective in improving prognosis. In addition, other new therapeutic agents showed encouraging results, but they are currently being studied. The implementation of personalized disease management programs that directly target the cause of HFrEF is crucial in order to improve prognosis and quality of life for these patients.

Perspectives of bilateral thoracic sympathectomy for treatment of heart failure

Surgical neuromodulation therapies are still considered a last resort when standard therapies have failed for patients with progressive heart failure (HF). Although a number of experimental studies have provided robust evidence of its effectiveness, the lack of strong clinical evidence discourages practitioners. Thoracic unilateral sympathectomy has been extensively studied and has failed to show significant clinical improvement in HF patients. Most recently, bilateral sympathectomy effect was associated with a high degree of success in HF models, opening the perspective to be investigated in randomized controlled clinical trials. In addition, a series of clinical trials showed that bilateral sympathectomy was associated with a decreased risk of sudden death, which is an important outcome in patients with HF. These aspects indicates that bilateral sympathectomy could be an important alternative in the treatment of HF wherein pharmacological treatment barely reaches the target dose.

New drugs: big changes in conservative heart failure therapy?

During the last 20 years, the prognosis for heart failure (HF) with reduced ejection fraction has steadily improved due to advances in drug treatment and the consistent implementation of guideline-recommended evidence-based drug therapy. Nevertheless, the morbidity and mortality rates of patients with HF can still be improved. The prevalence of HF is high and continues to increase steadily. Thus, timely and efficient drug treatment plays a central role in improving the quality of life and prognosis for patients with HF. Current therapeutic concepts combine inhibition of the renin–angiotensin–aldosterone system with blockage of the sympathetic system. New therapeutic approaches such as selective heart rate reduction, attenuation of the degradation of natriuretic peptides by neutral endopeptidase inhibition and treatment of comorbidities (e.g. iron deficiency, diabetes mellitus, hyperkalaemia) have led to a further improvement in the survival, time-out-of hospital and quality of life of affected patients. The goal of this article was to give an overview of the current standard drug therapy for HF and the value of new therapeutic approaches implemented in recent years.

[Quality of life in patients with heart failure with preserved ejection fraction and the bendopnea symptom]

PURPOSE

The study of quality of life (QOL) in patients with CHF with preserved LVEF (left ventricular ejection fraction) and a symptom of bendopnea with different levels of salt intake. Materials and methods. The study included 66 patients. The main symptoms of CHF were edema in 54.5% of cases, dyspnea in 77% of cases, ascites was detected in only 2 patients, an enlarged liver in 7 patients. Abdominal obesity was detected in 53 patients. Quality of life was assessed by the SF‑36 questionnaire, the level of salt intake was assessed by the Charlton: SaltScreener questionnaire. Results. On average, the time of occurrence of the bendopnea was 22.5±9.3 seconds, the minimum was 5 seconds. The absence of the effect of abdominal obesity on the risk of bendopnea (relative risk 1.18 [0.76; 1.83]) was revealed. According to the SF‑36 questionnaire, a decrease in physical health indicators (median 31.3 points [20.7; 42.3]) and psychological health (average score 43.2±21.7) was found. In patients with bendopnea, QOL was reduced due to both physical and mental health, unlike patients without bendopnea: physical functioning (Physical Functioning - PF) 24.8±16.1 against 47±28.9 points, p=0.001 ; role‑based functioning due to physical condition (Role‑Physical Functioning - RP), 0 [0; 25] vs. 37.5 [0; 100] points, p=0.008; general health (General Health - GH) 29.9±15.8 against 50±14.2 points, p=0.0005, social functioning (Social Functioning - SF) 56 ± 38 against 78.9 ± 17.8 points ; p = 0.004. Multidimensional regression analysis revealed the relationship between the time of occurrence of the symptom bendopnea and the level of salt intake, physical and psychological activity (r2=0.25; p<0.009). The time of onset of the symptom of bendopnea in patients with CHF decompensation was significantly longer (18.9±8.7 vs. 26.2±8.5 seconds, p=0.003). The presence of diseases such as hypertension, COPD, IHD, atrial fibrillation, cerebrovascular disease did not significantly affect QOL (p> 0.05), while the presence of bronchial asthma or chronic kidney disease significantly reduced QOL of patients (p<0.05). Conclusion. The presence of the symptom bendopnea significantly reduces the quality of life of patients with CHF with preserved LVEF (left ventricular ejection fraction).

Ultrafiltration for the Treatment of Acute Heart Failure

Ultrafiltration (UF) mechanically removes excess fluid volume through an extracorporeal circuit and has been applied to clinical situations in which volume removal is the mainstay of therapy. Because of this ability, UF serves as an enticing method to treat acute heart failure (AHF) in which most symptoms are driven by congestion due to excess volume. Additional physiologic properties of UF and the biochemical composition of the extracted fluid confer additional theoretic benefits in the treatment of AHF. Herein the concepts underlying UF, clinical evidence evaluating its efficacy, and ongoing challenges understanding the role of UF are reviewed.