Heart failure is a condition where the heart muscle cannot pump enough blood to meet the body’s needs. It develops over time as the heart’s pumping action weakens. While a serious condition, recent progress in treatment has significantly improved the prognosis and quality of life for many patients. These advancements have transformed heart failure management from focusing on symptom control to targeting the disease’s underlying mechanisms.
The Evolving Landscape of Heart Failure Care
There are two primary forms of heart failure. The first is Heart Failure with reduced Ejection Fraction (HFrEF), where the left ventricle does not contract effectively, creating a “pumping” or “systolic” problem. The heart muscle is too weak to push enough blood into circulation.
The second type is Heart Failure with preserved Ejection Fraction (HFpEF). In HFpEF, the heart muscle contracts normally, but the ventricle is stiff and does not relax properly. This creates a “filling” or “diastolic” issue, as the chamber cannot adequately fill with blood before it pumps. This distinction is important because treatments are specialized for each type.
Historically, treatments were more generalized, but care now involves personalized strategies. Medical professionals tailor therapies based on the specific type of heart failure, its cause, and the patient’s health profile. This customized approach has led to more effective management and better outcomes.
Breakthroughs in Medication
SGLT2 Inhibitors
A development in heart failure medication is a class of drugs originally for diabetes management. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, like dapagliflozin and empagliflozin, are now a foundational treatment for both HFrEF and HFpEF. These medications prompt the kidneys to excrete more glucose, salt, and water. This reduces the total fluid volume in the circulatory system, which lessens the strain on the heart. Clinical trials demonstrated a reduction in cardiovascular mortality and hospitalizations for patients with HFrEF.
Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)
Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), such as sacubitril/valsartan, are another advancement. This medication combines two active components. The valsartan component is an angiotensin receptor blocker that relaxes blood vessels and lowers blood pressure, reducing the effort the heart must exert to pump blood.
The sacubitril component works by inhibiting an enzyme called neprilysin. This allows beneficial substances produced by the body, known as natriuretic peptides, to remain active longer. These peptides help protect the heart by promoting the removal of sodium and water and further relaxing blood vessels.
Vericiguat
For patients with worsening symptoms despite other therapies, vericiguat offers an alternative. Vericiguat is a soluble guanylate cyclase stimulator that targets the nitric oxide signaling pathway. By stimulating this pathway, it helps relax blood vessels and improve blood flow. This can help manage symptoms and reduce the risk of hospitalization in certain high-risk patients.
Advanced Device-Based Therapies
Cardiac Contractility Modulation (CCM)
Cardiac Contractility Modulation (CCM) is a device-based treatment that improves the heart’s pumping ability. Unlike a pacemaker, a CCM device delivers precisely timed electrical pulses to the heart muscle during a specific phase of the heartbeat. These signals are not intended to trigger a heartbeat but to enhance the strength of the heart’s contraction. This helps the heart pump blood more efficiently without increasing its oxygen consumption. The device is considered for patients with moderate to severe symptoms who are not candidates for other device therapies.
Left Ventricular Assist Devices (LVADs)
For severe heart failure, Left Ventricular Assist Devices (LVADs) are mechanical pumps that take over the work of a failing left ventricle. Surgically implanted, an LVAD helps circulate blood from the weakened ventricle to the body. These devices can be a “bridge to transplant,” supporting a patient awaiting a donor heart.
LVADs are also used as “destination therapy,” a long-term solution for patients not eligible for a heart transplant. Continuous improvements have made these devices smaller and more durable. This has improved survival and quality of life for those with end-stage heart failure.
Modern Pacemakers and Defibrillators
Advancements have been made in pacemakers and implantable cardioverter-defibrillators (ICDs). Traditional devices use wires, or “leads,” threaded through veins into the heart, which can cause complications. Newer technologies include leadless pacemakers, which are small devices implanted directly inside the heart chamber. Another innovation is the subcutaneous ICD, placed under the chest skin with a lead that runs near the heart, avoiding wires inside the heart and blood vessels.
Innovations in Minimally Invasive Interventions
Transcatheter Valve Repair
Heart failure can cause problems with the heart’s valves, particularly the mitral valve. An enlarged heart can stretch the valve opening, causing it to leak in a condition called mitral regurgitation. This backward blood flow forces the heart to work harder, but the minimally invasive MitraClip procedure offers a solution without open-heart surgery.
In this transcatheter procedure, a catheter is guided through a leg vein to the heart. The MitraClip is delivered through the catheter and used to clip the leaky mitral valve’s leaflets together. This reduces regurgitation, decreases the heart’s workload, and improves symptoms. The COAPT trial showed this procedure can reduce hospitalizations and improve survival for certain patients.
Other Transcatheter Options
The success of minimally invasive valve repair has spurred similar techniques for other valve problems that contribute to heart failure. Transcatheter aortic valve replacement (TAVR) is a procedure to replace a narrowed aortic valve. Instead of surgically removing the old valve, a new one is delivered via a catheter and expanded into place. Initially for patients at high risk for surgery, TAVR is now an option for a wider range of individuals. These catheter-based interventions allow for treating complex structural heart issues with lower risk and faster recovery times compared to traditional surgery.