Heart Failure (HF) occurs when the heart muscle doesn’t pump blood as well as it should and this leads to less blood supply to the important organs of the body. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.
Certain heart conditions gradually leave the heart too weak or stiff to fill and pump blood properly. These conditions include high blood pressure, heart attacks due to blocked arteries of the heart, long standing diabetes, diseased valves and cardiomyopathy where the cause is ill defined. A weak heart is often defined as having low left ventricular ejection fraction (LVEF). Normal LVEF is more than 50-55%. An EF from 41 to 49 percent might be considered too low. It does not always indicate that a person is developing heart failure, but it could indicate damage, perhaps from a previous heart attack.
An ejection fraction measurement under 40 percent might be evidence of heart failure or cardiomyopathy. In severe cases it can be even much lower than 40. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath, fatigue and dizziness on effort. In Indian patients HF typically occurs at least a decade earlier, needs more hospitalizations and has a higher mortality both in short and long term.
The level of LVEF is not a good guide to the symptoms or the condition of the patient. They can present acutely as Acute HF for the first time or may gradually develop symptoms of shortness of breath which progresses insidiously till they are incapacitated. This is chronic HF. Proper treatment may improve the symptoms of HF and may help people live longer.
Over the years we have good drug treatment for heart failure with low LVEF besides improving the life style measures. These drugs include 4 groups also termed as the 4 pillars. These belong to 1. ACEI/ARB/ARNI (enalapril/valsartan/sacubitril, valsartan combination) 2. Beta blockers(metoprolol, carvedilol,, bisoprolol ) 3. SGLT2 inhibitors (dapagliflozin and empagliflozin) 4. MRA’s (spironolactone, eplerenone, finerenone).
Patients with low LVEF and chronic HF on full treatment remain well for long periods of time but this life history is often punctuated by worsening Heart Failure.
What is Worsening Heart Failure (WHF)
Patients with chronic heart failure with low LVEF who have been stable and are compliant with their treatment if they get increased symptoms needing a hospital emergency visit and a diuretic injection (like I/V Lasix or its equivalent), increase in their dosage of diuretic (, water pills or addition of a water pill), or a hospitalization to stabilize their heart failure symptoms. This is called WHF. Serum bio-markers especially NT-proBNP is very useful in confirming the diagnosis. These episodes of worsening symptoms and signs are associated with poorer quality of life, increased risk of hospitalization and death. This all is associated with a major burden on health care resources.
They usually require adding of diuretics either intra venous or oral escalation of smaller doses to higher doses to get rid of the fluid burden which has led to it. Hospital admission is often necessary but treatment in the emergency service or in outpatient clinics or by primary care physicians has become increasingly used. Recent years have given us a new drug acting by a very different mechanism of action for treating WHF, in addition to the 4 pillars. The drug is verciguat a stimulator of soluble guanylate cyclase (sGC ) given in appropriate dosage protocol. This is also called the 5th pillar but at present is meant for only managing WHF as an addition to the existing treatment.
Prevention of first and recurring episodes of worsening HF is an essential component of HF treatment and this may be achieved through early recognition and rapid administration of appropriate treatment. WHF is a subject of great clinical interest and is being studied by the experts worldwide. Newer therapeutic agents are needed to improve the treatment of this very serious condition in the life history of a patient with chronic HF.
Prof Upendra Kaul, Padmashri and Dr B C Roy Awardee. Dean Academics and Research Batra Hospital and Medical Research Centre, New Delhi and Founder Director Gauri Kaul Foundation
