The epidemic of heart failure: a lucid approach to stemming the rising tide

At least 1 in 5 Canadians will experience heart failure (HF) during their lifetimes, with an average 1-year mortality rate of 23.4%. Hospitalizations for HF are projected to increase 3-fold from 1996 to 2050. HF can be associated with either reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF), with the latter becoming increasingly common. The prognosis of both groups is equally concerning, but clinical trials testing pharmacologic therapies for HFpEF have been disappointing. We briefly discuss established therapies for HF and then focus on emerging therapies, challenges, and opportunities. Areas covered include practical pathophysiology; health care organization; monitoring and new technologies; pharmacogenomics, biomarkers, and personalized therapy; novel pharmacologic approaches; special considerations in acutely decompensated HF; revascularization; managing valve dysfunction; refining cardiac resynchronization therapy and device therapies; and cell therapy for cardiac repair. Among the novel pharmacologic directions we address are approaches to reducing oxidative stress, improving myocardial metabolism, new mineralocorticoid receptor antagonists, restoring vasoconstrictor-vasodilator balance, increasing cyclic guanosine monophosphate levels, and positive inotropic agents. Modifications in the organization of health care are particularly important, with an emerging hub-and-spokes model involving engaged patients cared for by primary care teams, with ready access to specialized HF clinics. Biomarkers have contributed to better understanding of the pathophysiology of HFrEF as well as HFpEF and will eventually allow much more effective and personalized management. Considering the vast array of areas in development, we can look forward to continuing improvements in the care and outcomes of patients with HF in the future.