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Lumped-Parameter and Finite Element Modeling of Heart Failure with Preserved Ejection Fraction
Published on: February 13, 2021
Advanced heart failure: guideline-directed medical therapy, diuretics, inotropes, and palliative care
Daniela Tomasoni1, Julie K K Vishram-Nielsen2, Matteo Pagnesi1
1Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
Insights
Advanced heart failure (HF) management is challenging. New treatments like omecamtiv mecarbil show promise in reducing cardiovascular events, especially in severe HF patients.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Heart failure (HF) is a significant cause of mortality and morbidity, with a growing number of patients progressing to advanced stages.
- Current treatment options for advanced HF, including heart transplantation and mechanical circulatory support, are limited.
- Effective medical management of advanced HF remains a critical challenge for healthcare systems.
Purpose of the Study:
- To review and summarize the current medical management strategies for patients with advanced heart failure.
- To highlight emerging therapeutic options and their potential impact on patient outcomes.
- To emphasize the importance of symptomatic relief and end-of-life care in advanced HF management.
Main Methods:
- Review of evidence-based oral treatments for advanced HF.
- Assessment of strategies for symptomatic burden reduction, including decongestion and hemodynamic improvement.
- Analysis of data from the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial regarding omecamtiv mecarbil.
Main Results:
- Evidence-based oral treatments for advanced HF are often poorly tolerated.
- Omecamtiv mecarbil demonstrated safety and efficacy in reducing cardiovascular death or HF events in the GALACTIC-HF trial.
- The benefits of omecamtiv mecarbil were more pronounced in patients with severe left ventricular dysfunction.
Conclusions:
- Medical management of advanced HF requires a comprehensive approach, including optimizing oral therapies and addressing symptomatic burden.
- Novel agents like omecamtiv mecarbil offer new therapeutic possibilities, particularly for severe HF.
- Multidisciplinary end-of-life care is essential for patients with advanced heart failure.
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.
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