Heart Failure 2020: What Mattered Most?

Five University Hospitals Harrington Heart & Vascular Institute specialists offer their perspectives

Innovations in Cardiovascular Medicine & Surgery | Fall 2020

Among the important developments in the heart failure (HF) literature during 2020, which are the most significant in terms of patient care? Within the Section of Advanced Heart Failure at UH Harrington Heart & Vascular Institute, several different answers emerge.

Eiran Gorodeski, MD, MPH, the section’s director, points to the analysis of a theoretical 55-year-old patient with chronic HFrEF, published in The Lancet. This effort compared outcomes with lifetime use of comprehensive therapy (ARNI + BB + MRA + SGLT2i) versus limited conventional therapy (ACEi/ARB + BB). The results were what Dr. Gorodeski calls “astounding.”

“The difference was eight additional years free from cardiovascular death or heart failure hospitalization, or six additional years of overall survival,” he says.

This analysis made him even more committed to provide fellow cardiologists with the latest, best guidance on how best to manage these often-complex patients.

“Guideline-directed medical therapy for HFrEF has become increasingly more complex for providers and patients,” he says. “Our team of advanced heart failure clinicians is available to help with this endeavor.”

For UH heart failure specialist Monique Robinson, MD, PhD, the most significant development in the literature during 2020 was a study of ambulatory hemodynamic monitoring with an implantable pulmonary artery (PA) sensor, also known as CardioMEMS. The heart failure specialists at UH Harrington Heart & Vascular Institute were early adopters of the technology, and Dr. Robinson now leads the program at UH.

“Ambulatory hemodynamic monitoring with an implantable PA sensor is approved for patients with New York Heart Association Class III heart failure and a prior HF hospitalization within 12 months,” she says. “In a study published in Circulation: Heart Failure in August 2020, investigators assessed the efficacy and safety of PA pressure-guided therapy in routine clinical practice, involving 1,200 patients from 104 centers in the U.S. They found that PA pressure-guided therapy for HF was associated with lower PA pressures, lower rates of heart failure hospitalization (0.54 versus 1.25 events/patient-years) and all-cause hospitalization (1.67 versus 2.28 events/patient-years), and low rates of adverse events across a broad range of patients with symptomatic HF and prior HF hospitalization.

Research on SGLT2 inhibitors was deemed the most significant development by UH heart failure specialist Michael Zacharias, DO.

“SGLT2 inhibitors were initially considered a diabetes medication,” he says. “However, this new class of medications have recently demonstrated a profound impact on cardiovascular disease outcomes, in particular those patients with heart failure. Two major clinical trials (DAPA-HF Trial 2019, and EMPEROR-Reduced Trial 2020) demonstrated that adding Dapagliflozin 5mg daily or Empagliflozin 10mg daily resulted in improved outcomes in patients with heart failure, regardless of diabetes status.”

“At UH, our team of HF clinicians can help optimize these medications in this population,” Dr. Zacharias adds. “For diabetics, the new UH Center for Integrated and Novel Approaches in Vascular-Metabolic Disease (CINEMA), led by Sanjay Rajagopalan, MD, Division Chief of Cardiovascular Medicine, is also available for education and optimization.”

For Heather Blume, CNP, a study published in JACC: Heart Failure in February 2020 had the most impact this year. The authors examined race- and sex-based variation in the associations between modifiable risk factors and incident HF. They found that in a high-risk, low-income cohort, contributions of risk factors to HF varied, particularly by race.

“The researchers concluded that to reduce the population burden of HF, interventions tailored for specific racial and sex groups may be warranted,” Blume says. “This article had an impact on me because I feel fortunate to work with a diverse patient population and this highlights some of the challenges I face as a provider to identify their unique differences and adapt my care to better serve them. It is a reminder that as providers, we might be the most modifiable risk factor for our patients.”

Still, there are many things the provider can’t control, especially when dealing with patients who are seriously ill. Along these same lines, UH heart failure specialist Chantal ElAmm, MD, found perspective in a poem published in JAMA, dramatizing the challenges associated with the specialty.

“We have to be kind to ourselves and also accept the grief that comes with being an advanced heart failure provider,” she says. “It is important to celebrate our successes.”

For more information on the Section of Advanced Heart Failure at UH Harrington Heart & Vascular Institute or to refer a patient, please call 216-844-3800.