The Future of Heart Failure Diagnosis, Therapy, and Management

Over the past 4 decades, patients with heart failure (HF) have derived substantial benefit from the major advances in our understanding of pathophysiology of the HF syndrome, which have led to evolving treatment paradigms. Morbidity and mortality for patients as documented in clinical trials for HF with reduced ejection fraction (HFrEF) have steadily decreased, and many patients with this syndrome have also enjoyed improved functional capacity and quality of life. However, there are major unmet needs. Hospital discharges with a primary HF diagnosis, an index of population disease burden and economic impact, remain >1 million annually with little change between 2000 and 2010.1 According to the American Heart Association’s Heart and Stroke Facts,2 the prevalence of HF will increase ≈50% between 2012 and 2030, resulting in >8 million people ≥18 years of age with HF.3 This daunting future reflects the increased prevalence of HF as the population ages, acute myocardial infarction survival improves, and HF survival itself increases at rates that exceed our impact to prevent the development of HF. The national and, indeed, international burden of HF reflects a growing component of HF with preserved ejection fraction (HFpEF), for which trials have been neutral, in contrast to the progress for HFrEF. These frustrating trial results reflect our incomplete understanding of the more heterogeneous complex of the HFpEF syndrome, which was only defined as an entity more recently. Knowledge in this area has evolved over the past few years, however, suggesting that positive results may be enabled by more targeted treatments rather than broad-brush interventions and a shift in focus to symptoms and daily quality of life as primary outcomes. In this review, we will use the lessons of the recent past to illuminate pathways forward in how the HF syndrome is conceptualized, how we might better …