Advanced heart failure: guideline‐directed medical therapy, diuretics, inotropes, and palliative care

Abstract

Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence‐based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86–0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.

Heart failure: an update from the last years and a look at the near future

“…321 The efficacy and tolerability of GDMT in patients with the most advanced stages of HFrEF often remain unsettled. 150,322,323…”

“…The HFA‐ESC advanced HF definition was associated with a higher risk of all‐cause mortality or first HF hospitalization (adjusted HR 1.98; 95% CI 1.57–2.50; P < 0.001) 321 . The efficacy and tolerability of GDMT in patients with the most advanced stages of HFrEF often remain unsettled 150,322,323 …”

The efficacy and safety of sarcomeric contractile activators in patients with reduced ejection fraction in heart failure: a network meta-analysis

“…Levosimendan plays a vasodilator and cardioprotective role and has been shown to be effective in improving cardiac function, relieving symptoms, and reducing mortality and hospitalization rates in patients with heart failure [28][29][30] . As for Omecamtiv mecarbil 31,32 , the completed phase II and phase III trials COSMIC-HF trial 33 , GALACTIC-HF trial 34 , and ATOMIC-AHF trial 35 have all shown a bene t of Omecamtiv mecarbil on heart failure improvement in patients with HFrEF, and for patients with LVEF < 40%. When LVEF < 28%, patients treated with Omecamtiv Mecarbil showed greater improvement in the primary end point event, and the bene t may be greater.…”

Updates in heart failure: sodium glucose co-transporter 2 inhibitors and beyond – major changes are coming

“…Medical management of patients with advanced HF remains a largely unmet clinical need 55,68–70 . Current guidelines report that long-term mechanical circulatory support (MCS) and heart transplantation have to be considered also in patients with NYHA class II at high risk for HF progression.…”