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Challenges in the management of advanced heart failure, ESC and the Brazilian Society of Cardiology

ESC Congress Report

  • Current evidence for fluid and salt restriction in HF patients shows mixed results.
  • The PARAMOUNT trial may show promise for LCZ696 in the treatment of HF with preserved ejection fraction (HFpEF).
  • The impact of Chagas disease-induced cardiomyopathy.
  • Ventricular assist devices (VAD) : how to choose the best option for your patient and the best time to implant them.
Heart Failure (HF)

Advanced heart failure management is challenging and rapidly evolving. Despite recent advances, the prognosis for these patients is still ominous and therefore better strategies to manage heart failure are needed. This interesting session provided a nice overview on the topic. All the speakers agreed on the importance of multidisciplinary teams both for decisions about the best treatment and for patient care.

The first speaker was Dr. Marisa Crespo-Leiro (La Coruña, ES) who gave an update on the pharmacological treatment of heart failure. She started with an overview of the stages of HF, highlighting the importance of therapy from early stages to delay progression. Afterwards, she discussed the basic flowchart of drug treatment from the ESC 2012 guidelines with ACE/ARA, and using beta-blockers as pillars. She also mentioned the results from the EMPHASIS and SHIFT trials that catapulted MRAs and ivabradine into the HF arsenal of weapons.
Discussion cantered on Guideline-directed Medical Therapy (GDMT) and the importance of closely monitoring vital signs and drug dose titration to maximize chances of survival and quality of life. Glitazone oral anti-diabetics, calcium channel blockers and NSAID's are currently assigned a class III recommendation in HF patients. HF with preserved ejection fraction (HFpEF) patients still do not have any drug effective beyond symptomatic relief at their disposal, according to trial results. However, the recently initiated PARAMOUNT trial may show promise for LCZ696 after the immense success achieved in patients with reduced ejection fraction in the PARADIGM trial.
New drugs emerging in the treatment of acutely decompensated HF include serelaxin, which ameliorated symptoms, biomarker profile and late, but not immediate survival in the RELAX-HF trial, and omecamtiv, which unfortunately did not prove effective on the primary outcome of the ATOMIC-HF trial of dyspnoea at 48 hours. Finally, the standard of care in advanced HF still lies in the balance between the imposition of diuresis and inotropic support, though the latter is reserved for the setting of impending shock.

Dr. Luís Beck da Silva (Porto Alegre, Brazil) summarised current evidence for fluid and salt restriction in HF patients, which is, unfortunately, limited. Still, restriction is recommended widely in guidelines and as a standard of practice in acute HF despite no clear data supporting this. Three available randomised clinical trials were neutral, with no significant difference in body weight, signs of congestion, renal function, hydroelectrolytic parameters and hospitalisation rates.
On the other hand, when aggressive restriction is imposed, alarming thirst reported by patients limits quality of life. Furthermore, there is evidence for the emergence of an unfavourable neurohumoral profile in the face of sodium restriction and data suggesting a marginal benefit from instillation of a hypertonic saline solution in conjunction with low doses of furosemide.

Dr. Maria Consolação Moreira (Belo Horizonte, Brazil) focused her analysis of heart transplantation in special populations on the impact of Chagas disease-induced cardiomyopathy. Though mainly a problem in South America, immigration has led to increased world-wide incidence, especially in North America and Europe.
Active Trypanosoma cruzi infection in this growing subset of heart transplant candidates represents a major problem due to the difficulty it imposes in juggling the immunosuppressant load in order to overcome rejection while keeping the parasitic infection at bay. Prospective, multi-centre studies are needed to establish stronger recommendations and reach a worldwide standard of care and decision in this patient population.

Dr. Frank Ruschitzka (Zürich, CH) finished the session by focusing on advanced heart failure, the role of ventricular assist devices (VAD) and criteria for their selection and timely implantation. He reaffirmed VADs as bridges to decision, transplant or recovery in a case/problem centred discussion. Current generation continuous flow devices are still the best choice for patients awaiting transplant (recommendation I B) or facing the possibility of being symptom-free for at least one year (recommendation IIb A). In end-stage cases with acute or imminent RV decompensation, a biventricular VAD may be the best choice.

Nevertheless, one must be wary of potential complications such as, wear, valve dysfunction or thromboembolic disorders. He promised further insights to this topic at dedicated sessions taking place at the Heart Failure Association Congress in May 2015 in Seville, Spain he is chairing with Dr. Crespo-Leiro.




Challenges in the management of advanced heart failure, ESC and the Brazilian Society of Cardiology

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.