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Published on: March 29, 2024
Risk of heart failure progression in patients with reduced ejection fraction: mechanisms and therapeutic options
Edoardo Gronda1, Emilio Vanoli2,3, Stefania Sacchi2,4
1Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico di Milano Dipartimento Di Medicina e Specialità Mediche Milan, Milan, Italy. edoardo.gronda@multimedica.it.
Insights
Identifying high-risk heart failure (HF) patients and managing sympathetic nervous system (SNS) overdrive are crucial for preventing end-stage disease. New therapies targeting SNS activation and fluid overload offer improved congestion management in advanced HF.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- Progression from stage C to D in heart failure (HF) signifies irreversible end-stage disease.
- Identifying high-risk patients and prompt management are vital to intervene in HF progression.
- Established markers for poor prognosis include recurrent decompensation, treatment intolerance, and diuretic resistance.
Purpose of the Study:
- To highlight the significance of sympathetic nervous system (SNS) overdrive and NT-proBNP as predictors of adverse outcomes in HF.
- To explore novel therapeutic strategies for counteracting SNS activation, including combined neprilysin/angiotensin receptor inhibition and baroreceptor stimulation therapy (BAT).
- To emphasize the importance of understanding fluid retention and redistribution mechanisms in acute HF decompensation and the role of peritoneal ultrafiltration.
Main Methods:
- Review of established prognostic markers in heart failure.
- Discussion of novel therapeutic agents and interventions targeting SNS activation.
- Analysis of mechanisms driving sodium and water retention and fluid redistribution in HF.
Main Results:
- NT-proBNP and SNS overdrive are strong predictors of adverse clinical outcomes, identifying high-risk HF patients.
- New strategies like combined neprilysin/angiotensin receptor inhibition and BAT aim to mitigate SNS effects.
- Understanding fluid overload mechanisms informs the use of options like peritoneal ultrafiltration for congestion management.
Conclusions:
- Effective management of high-risk HF patients requires early identification and intervention, particularly addressing SNS overdrive.
- Novel therapeutic approaches offer potential to improve outcomes by targeting SNS activation and fluid overload.
- Peritoneal ultrafiltration represents an underutilized option for managing congestion in advanced heart failure.
Abstract:
Transition from stage C to stage D of heart failure (HF) represents an irreversible process toward end-stage disease. Crucial interventions to be adopted in the attempt to interfere with this process are represented by the identification of patients at high risk to develop HF progression and by an effective and prompt management. Markers of worse prognosis and disease progression are well established and include recurrence of HF decompensation, intolerance to the neurohormonal standard pharmacological treatment, and resistance to loop diuretics. In addition, both NT-proBNP and sympathetic nervous system (SNS) overdrive are strong predictors of adverse clinical outcome and allow to identify high-risk HF patients even in the presence of mild symptoms. To counteract the deleterious effects of the SNS activation, new strategies such as a new drug combining angiotensin receptor and neprilysin inhibition and baroreceptor stimulation therapy (BAT) have been investigated. Inability to properly counteract the SNS overdrive leads to acute HF decompensation by different mechanisms. The leading ones are represented by the progressive sodium and water retention with fluid overload and by the blood volume redistribution between splanchnic and non-splanchnic regions. The correct understanding of these mechanisms, together with the availability of new therapeutic options such as peritoneal ultrafiltration, represent the rationale but not infrequently overlooked therapeutic options to improve congestion management in HF patients.
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