Riccardo M. Inciardi, Mauro Riccardi, Gianluigi Savarese, Marco Metra, Muthiah Vaduganathan, Scott D. Solomon
{"title":"Tailoring medical therapy for heart failure with preserved ejection fraction","authors":"Riccardo M. Inciardi, Mauro Riccardi, Gianluigi Savarese, Marco Metra, Muthiah Vaduganathan, Scott D. Solomon","doi":"10.1002/ejhf.3558","DOIUrl":null,"url":null,"abstract":"<p>Heart failure with preserved ejection fraction (HFpEF) accounts for half of the hospitalization for heart failure (HF) worldwide, and the prevalence is expected to increase along with population aging and increasing burden of cardio-kidney-metabolic disorders.<span><sup>1</sup></span> Treatment options for chronic HFpEF have expanded in recent years.<span><sup>2</sup></span> Sodium–glucose cotransporter 2 inhibitors (SGLT2i) are now guideline-recommended as a first-line treatment in patients with mildly reduced and preserved ejection fraction. In a meta-analysis of the EMPEROR-Preserved and DELIVER trials, SGLT2i reduced cardiovascular (CV) death or first hospitalization for HF by 20% with consistent reductions in both components (12% risk reduction in CV death and 26% risk reduction in first hospitalization for HF), among HF patients with left ventricular ejection fraction (LVEF) >40%.<span><sup>3</sup></span> In the PARAGON-HF trial, treatment with sacubitril/valsartan led to a marginal reduction of total hospitalizations for HF and CV death compared to valsartan in patients with HF and LVEF ≥45%, with a more pronounced benefit observed in those with an LVEF below normal.<span><sup>4</sup></span> Based on the results of this trial, sacubitril/valsartan received indications for use in patients with HF with mildly reduced ejection fraction (HFmrEF) and selected patients with HFpEF with an LVEF below normal in the United States. Lastly, in the FINEARTS-HF trial, the non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone showed a 16% relative risk reduction of worsening HF events and death from CV causes compared to placebo among patients with HF and LVEF ≥40%.<span><sup>5</sup></span></p><p>These advances in HFpEF pharmacotherapy, along with the substantial residual risk of this population, highlight the need for an accelerated optimization of foundational medical therapy.</p><p>The rising prevalence worldwide, the burden on the healthcare system and costs related to hospitalization represent critical challenges in the management of HFpEF. Novel therapeutic options advocate a transformative change in the care of chronic HFpEF patients encompassing recognition of multiple treatments, along with the management of comorbidities according to specific HFpEF phenotype. An upfront combination of foundational therapies, potentially enhancing tolerance and persistence of each other, should represent the bedrock of HFpEF treatment by targeting multiple pathophysiological drivers. A simultaneous or rapid sequence initiation of SGLTi and the non-steroidal MRA finerenone may be considered along with tailored therapies including incretin-based therapies and ARNI (<i>Figure</i> 1), based on clinical phenotype and settings, to optimally improve health status and clinical outcomes of patients with HFpEF.</p>","PeriodicalId":164,"journal":{"name":"European Journal of Heart Failure","volume":"27 2","pages":"190-193"},"PeriodicalIF":16.9000,"publicationDate":"2024-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ejhf.3558","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"European Journal of Heart Failure","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1002/ejhf.3558","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}
引用次数: 0
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for half of the hospitalization for heart failure (HF) worldwide, and the prevalence is expected to increase along with population aging and increasing burden of cardio-kidney-metabolic disorders.1 Treatment options for chronic HFpEF have expanded in recent years.2 Sodium–glucose cotransporter 2 inhibitors (SGLT2i) are now guideline-recommended as a first-line treatment in patients with mildly reduced and preserved ejection fraction. In a meta-analysis of the EMPEROR-Preserved and DELIVER trials, SGLT2i reduced cardiovascular (CV) death or first hospitalization for HF by 20% with consistent reductions in both components (12% risk reduction in CV death and 26% risk reduction in first hospitalization for HF), among HF patients with left ventricular ejection fraction (LVEF) >40%.3 In the PARAGON-HF trial, treatment with sacubitril/valsartan led to a marginal reduction of total hospitalizations for HF and CV death compared to valsartan in patients with HF and LVEF ≥45%, with a more pronounced benefit observed in those with an LVEF below normal.4 Based on the results of this trial, sacubitril/valsartan received indications for use in patients with HF with mildly reduced ejection fraction (HFmrEF) and selected patients with HFpEF with an LVEF below normal in the United States. Lastly, in the FINEARTS-HF trial, the non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone showed a 16% relative risk reduction of worsening HF events and death from CV causes compared to placebo among patients with HF and LVEF ≥40%.5
These advances in HFpEF pharmacotherapy, along with the substantial residual risk of this population, highlight the need for an accelerated optimization of foundational medical therapy.
The rising prevalence worldwide, the burden on the healthcare system and costs related to hospitalization represent critical challenges in the management of HFpEF. Novel therapeutic options advocate a transformative change in the care of chronic HFpEF patients encompassing recognition of multiple treatments, along with the management of comorbidities according to specific HFpEF phenotype. An upfront combination of foundational therapies, potentially enhancing tolerance and persistence of each other, should represent the bedrock of HFpEF treatment by targeting multiple pathophysiological drivers. A simultaneous or rapid sequence initiation of SGLTi and the non-steroidal MRA finerenone may be considered along with tailored therapies including incretin-based therapies and ARNI (Figure 1), based on clinical phenotype and settings, to optimally improve health status and clinical outcomes of patients with HFpEF.
期刊介绍:
European Journal of Heart Failure is an international journal dedicated to advancing knowledge in the field of heart failure management. The journal publishes reviews and editorials aimed at improving understanding, prevention, investigation, and treatment of heart failure. It covers various disciplines such as molecular and cellular biology, pathology, physiology, electrophysiology, pharmacology, clinical sciences, social sciences, and population sciences. The journal welcomes submissions of manuscripts on basic, clinical, and population sciences, as well as original contributions on nursing, care of the elderly, primary care, health economics, and other related specialist fields. It is published monthly and has a readership that includes cardiologists, emergency room physicians, intensivists, internists, general physicians, cardiac nurses, diabetologists, epidemiologists, basic scientists focusing on cardiovascular research, and those working in rehabilitation. The journal is abstracted and indexed in various databases such as Academic Search, Embase, MEDLINE/PubMed, and Science Citation Index.