ESC Rene Laennec Lecture on Clinical Cardiology: Prof. Carolyn SP Lam
Heart failure with preserved ejection fraction: past, present, future
26 Aug 2022
The presenter of this year’s ESC Rene Laennec Lecture in Clinical Cardiology is Professor Carolyn SP Lam (National Heart Centre Singapore and Duke-NUS Graduate Medical School Singapore - Singapore, Singapore) whose research into heart failure with preserved ejection fraction (HFpEF) has contributed to the first successful treatments.
What first made you interested in cardiology?
Actually, my first love was infectious disease – the investigative nature of hunting for the specific culprit to target effective treatment really appealed to me. I’m a maths geek, so what turned me around to cardiology was echocardiography, specifically the physical and haemodynamic principles involved. Once I also realised the breadth and depth of cardiology – from prevention to treatment to palliation, involving both drugs and devices – I was hooked. My first publication in cardiology was on the L wave, indicating diastolic dysfunction on Doppler echocardiography; all thanks to my first mentor, Lieng Hsi Ling in Singapore. I then headed for Rochester, MN, USA, so that I could work with the doyenne of HFpEF, Margaret Redfield. I never looked back and spent the next two decades studying a condition that was in search of a treatment and that, even now, attracts a great deal of controversy.
What are the key themes of your lecture?
I want to recount HFpEF’s rollercoaster journey. When I started working in this area, I saw a disease that occurs more commonly in women than men and for which we couldn’t improve patient outcomes. It is difficult to appreciate now how little was known about HFpEF. Even its name has changed several times over the years, reflecting increasing knowledge.
After a long time in the wilderness, we now – for the first time in history – have robustly positive outcomes trials in HFpEF, using SGLT2 inhibitor treatment. Last year saw the publication of results from the EMPEROR-Preserved trial,1 with empagliflozin, and results from the DELIVER trial, investigating dapagliflozin, will be presented in a Hot Line session tomorrow. This is undoubtedly a time for celebration. But it is also a time for taking stock. During the lecture, I will talk about how we got here, what we’ve learned not to do and where we are heading.
What are the current challenges in your field?
Now with effective treatment, it is critical that we identify patients early so that we can get the right treatment to the right patients, quickly. Most patients are elderly with multiple comorbidities and their symptoms may be missed by primary care practitioners. We need to educate both the medical profession and the general public so that they are alert to signs of HF, such as breathlessness and tiredness. We also have to better equip non-specialist practitioners with diagnostic tools, for example by highlighting the use of B-type natriuretic peptide testing or by increasing access to echocardiography.
Where do you think research in your field is heading in the future?
One of the key avenues of future research will be to understand patients with HF and higher ejection fraction (>60%) better – going back to haemodynamics and focusing on left ventricular volume in pressure-volume loop relationships will be important. Clinical experience tells us that the elderly lady with hypertension is very different from the young man with obesity – yet they can both present with HFpEF! We celebrate but mustn’t be complacent following the success of SGLT2 inhibitors. There is still a huge residual unmet need that will be addressed in future drug trials, such as with mineralocorticoid receptor antagonists, anti-obesity and anti-inflammatory approaches. We will also see novel device approaches to HFpEF, such as an inter-atrial shunt,2 along with methods to increase venous capacitance and so relieve the volume-overloaded heart, such as splanchnic nerve denervation. Of course, many have talked about personalised or precision approaches to HFpEF in the future – we would be wise to separate hype from hope here, and start by recognising the treatable mimickers of HFpEF right in front of us, such as cardiac amyloidosis, hypertrophic cardiomyopathy and constrictive pericarditis.
1. Anker SD, et al. N Engl J Med. 2021;385:1451–1461.
2. Sun W, et al. Circ Heart Fail. 2022;15:e008362.