Heart failure

More optimism warranted in heart failure: Professor John Cleland

Out with the doom and gloom scenarios – the miserable picture that some paint about heart failure doesn’t tell the whole story.

Presenting the RT Hall Lecture at the opening ceremony of CSANZ 2018, Professor John Cleland said there should be more optimism. And we could ‘steal some ideas from oncology’ by celebrating remission when cure couldn’t be achieved.

In the context of heart failure, remission might include resolution of symptoms, restoration of cardiac function, withdrawal of diuretics and no cardiac events.

A cure on the other hand might entail withdrawal of all treatment for heart failure without recurrence of cardiac dysfunction and normalisation of life expectancy.

Professor Cleland, director of the University of Glasgow’s Robertson Centre for Biostatistics, said in under 70-year-olds with stable heart failure with reduced ejection fraction (HFrEF) about 55% of patients would stabilise and 15% would recover; 15% would progress and 15% would experience a sudden death.

He presented a number of case studies of patients with dilated cardiomyopathies that initially looked grim, but resulted in recovery which was sometime rapid and spontaneous, sometimes lengthy.

“And there are a lot of anecdotes out there,” he quipped.

Professor Cleland told the limbic we need to be much clearer about how many wins we have with dilated cardiomyopathy in particular.

“With beta-blockers and heart rate lowering medications, myocardial recovery is really a quite common phenomenon. I would say 20, 30, 40% of dilated cardiomyopathies really get normalisation of ventricular function.”

“With those patients with ventricular dyssynchrony, again we can get dramatic turn-arounds with cardiac resynchronisation.”

“We should also remember there are many causes of heart failure with one of the key ones being valve disease. And with new techniques such as TAVI and MitraClip, we can do so much more to fix the valve problems and that can have a dramatic effect on the heart failure syndrome.”

He said diuretics may be the ‘unsung heroes of medicine’.

“We’ve been doing some work on diuretics and it’s remarkable. Within a matter of hours after a dose of diuretic you can really shrink the cardiac chambers. You can see substantial changes in left atrial volume within two hours of giving a dose of frusemide. And we know that if we shrink dilated hearts, the patients have less arrhythmia, their natriuretic peptides go down and that’s associated with a better outcome.”

“So we’ve long thought about ventricular remodelling as an important mechanism for myocardial recovery but you can induce something that looks very much like ventricular remodelling just with a diuretic.”

Looking forward

 Picking up again on the parallel with oncology, Professor Cleland said the future for heart failure would also involve deep dives into molecular diagnoses and finding very specific treatments that are highly effective for a small number of patients

“We are going to see more and more of that in heart failure. I think the next big one will be TTR amyloid where the treatments look devastatingly effective. It may be a small group of patients but in a sense if you can cure them one at a time, you will get them in the end.”

Professor Cleland told the meeting some of the other ways to improve patient outcomes were greater diagnostic precision, use of natriuretic peptides for risk stratification and earlier intervention.

He said harnessing telemedicine also had the potential to improve patient compliance with medications – a likely cause of relapsing disease.

New therapeutic strategies include improving cardiac efficiency with agent such as cardiac myosin activators.

Addressing mitochondrial function via cardiolipin repair, CoQ10, intravenous iron or carnitine palmitoyltransferase (CPT) 1 inhibitors were also on the table.

“The heart has the capacity to regenerate and recover,” he said. “The caveat is of course that this is an ageing population and age itself may become a barrier to progress.”

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