By Abbas Bitar, MD, as told to Stephanie Watson
Our understanding of heart failure has evolved tremendously over the last couple of decades. In the past, we treated heart failure with medicines only, and we were limited in what we could do for people with this condition. Now we can offer patients more advanced therapies that help them live longer with a better quality of life.
New Heart Failure Medicines
One of the main ways we treat heart failure is with medicines, which include drugs that lower blood pressure, improve the heart's ability to pump blood, slow the heart rate, and prevent scarring of the heart muscles.
Over the last few years, we've had two new drugs approved: ivabradine (Corlanor) and sacubitril/valsartan (Entresto). I think the biggest addition to our resources is Entresto, which studies have shown reduces hospital visits and deaths from heart failure.
A few other drugs are in the pipeline. Omecamtiv mecarbil helps the heart pump blood more efficiently. One study showed that it lowered the risk of dying for people who have heart failure with reduced ejection fraction, meaning the left side of their heart doesn't pump blood as well as it should. In May 2020, the FDA fast-tracked this drug to speed its approval.
The FDA is also prioritizing the review of another new drug, vericiguat. It's part of a class of heart failure drugs called soluble guanylate cyclase (sGC) inhibitors. In studies, vericiguat lowered the risk of being hospitalized or dying from heart failure.
A group of drugs called sodium-glucose cotransporter-2 (SGLT2) inhibitors is also showing promise. These medicines, which were first developed to treat diabetes, appear to lower the risk of dying or having to go to the hospital because of heart failure. They’re an option for people with or without diabetes.
When someone comes into my clinic with heart failure, first I adjust their medicines to try to improve their symptoms. I try to increase their dose as much as I can. If the person does well, I'll keep them on medication. But some people don't do well, or they get worse to the point that their heart failure seriously limits their activity or starts to affect other organs. When that happens, we assess them to see if they’re a good candidate for a heart transplant or left ventricular assist device (LVAD).
Left ventricular assist devices help the heart’s main pumping chamber push blood out to the body. A heart transplant replaces the damaged heart with a healthy one from a donor. The technology for these procedures has improved, and doctors have become more skilled at performing them. In the short term, the results from a pump or a transplant are pretty similar. But in the long run, a heart transplant helps people live longer.
Challenges and What’s Next for Treatment
I think the biggest challenge we face in our day-to-day practice is knowing who is going to get better with medicine and who isn’t. We do know there are certain medications that can cut the risk of dying from heart failure or of going to the hospital for it. So we put people on those medications and follow them closely.
I think the future of treatment is personalized medicine, where we prescribe the medicine that we know will work best for each person. It’ll probably be many years before we get there.
LVAD technology has come a long way. The heart pump has become much more reliable, and the chances of bleeding, strokes, and other problems as a result of getting the device are lower. However, getting one still requires the risk of open-heart surgery. The device also needs power from outside the body, so a cord needs to come out through the skin, which is a common source of infection. In the future, the idea is to have a totally implantable heart pump where nothing comes through the skin. People will be able to swim and do pretty much anything they want to do, which will improve their quality of life.
For people who get heart transplants, we now have better medications to keep the immune system from attacking the new organ. We’re also able to closely watch for signs of rejection and cardiac allograft vasculopathy, a condition in which the arteries supplying the transplanted heart narrow relatively quickly. That’s led to increased life expectancy and a lower risk of complications after the transplant. We also know now that heart transplants from donors with hepatitis C are a safe option for people who need a new heart, which will help to ease the nationwide organ shortage.
In the meantime, the key to managing heart failure is to get diagnosed and start treatment early. That allows you to make informed decisions about your treatment before your heart failure becomes too severe.
Abbas Bitar, MD, clinical assistant professor, Frankel Cardiovascular Center, University of Michigan, Ann Arbor.
AJMC: "Merck Gets Priority Review in NDA for Vericiguat."
American Heart Association: "Heart failure projected to increase dramatically, according to new statistics."
CDC: "Heart Failure."
Physicians' Academy for Cardiovascular Education: "FDA Fast Track designation for novel selective cardiac myosin activator in HF."
US Cardiology Review: "New Drugs For the Treatment of Heart Failure."