Failure to prevent most heart failure could be avoided

(2nd of two parts)

SGLT-2inhibition

Until the randomized EMPA-REG-OUTCOME trial of the sodium-glucose transporter 2 (SGLT-2) inhibitors empagliflozin (Jardiance), no glucose-lowering drug available for treatment of type 2 diabetes had shown any benefit in terms of reducing diabetic patients’ elevated risk of heart failure. Neither had weight loss. Abundant evidence showed that glycemic control had no impact on the risk of heart failure events. So EMPA-REG OUTCOME was cause for celebration among heart failure specialists, with its demonstration of a 35% reduction in the risk of hospitalization for heart failure compared with placebo, in more than 7,000 randomized patients. The risk of death because of heart failure was chopped by 68%. Sharp reduction in other cardiovascular events were also seen with empagliflozin.

Similar benefits were subsequently documented with another SGLT-2 inhibitors, canagliflozin (Invokana), in the CANVAS study program.

The reduction in cardiovascular mortality achieved with empagliflozin in EMPA-REG OUTCOME was actually bigger than seen with ACE inhibitors and angiotensin- receptor blockers (ARBs) in earlier landmark heart failure trials.?“We now for the first time in patients with diabetes have the ability to markedly prevent heart failure as well as cardiovascular death,” the cardialogist commented.

Ace inhibitors and ARBs

The ACC/AHA heart failure guidelines give a Class I recommendation to the routine use of ACE inhibitors or ARBs in patients at high risk for developing heart failure because for a history of diabetes, hypertension with associated cardiovascular risk factors, or any form of atherosclerotic vascular disease.

Lifestyle modification

Heavy drinking is known to raise the risk of heart failure. However, moderate alcohol consumption may be protective.

In a classic prospective cohort study, individuals who reported consuming 1.5-4 drinks per day in the previous month has a 47% reduction in subsequent new-onset heart failure compared with teetotalers in a multivariate analysis adjusted for conventional cardiovascular risk factors. Those who drank less than 1.5 drink per day had 21% reduction in heart failure risk, compared with the nondrinkers.?In the prospective observational Physicians’ Health Study of nearly 21,000 men, adherence to six modifiable healthy lifestyle factors was associated with an incremental stepwise reduction in lifetime risk of developing heart failure. The six lifestyle factors – a forerunner of the AHA’s life’s Simple 7 – were maintaining a normal body weight, stopping smoking, getting exercise, drinking alcohol in moderation, consuming breakfast cereals, and eating fruits and vegetables. Male physicians who shunned all six had a 21.2% lifetime risk of heart failure; those who followed at least four of the healthy lifestyle factors had a 10.1% risk. In a separate analysis from the Physicians’ Health Study, men who engaged in vigorous exercise to the point of breaking a sweat as little as one to three times per month had an 18% lower risk of developing heart failure during follow up, compared with inactive men.

What’s next in prevention of heart failure

Heart failure is one of the most expensive health care problems in the United States, and one of the deadliest. Today an estimated 6.5 million Americans have symptomatic heart failure. But that’s just the tip of the iceberg. “Countless millions more are likely to manifest heart failure in the future,” doctors warned, noting the vast prevalence of identifiable risk factors.

It’s time for a high-visibility public health campaign designed to foster community education and engagement regarding heart failure prevention. “We have a lot of action and events around preventing atherosclerotic cardiovascular disease. But can you think of any campaign you’ve seen focusing specifically on heart failure? Heart failure isn’t one of the endpoints in the ACC/AHA Atherosclerotic Cardiovascular Disease Risk Calculator or even the new hypertension risk calculator, so we need to take is whole lot more seriously,” the cardiologist said.

The 2017 focused update of the ACC/AHA heart failure guidelines  endorsed a novel strategy of primary care-centered, biomarker-based screening of patients with cardiovascular risk factors as a mean of triggering early intervention to prevent heart failure. This strategy, which received a Class II a recommendation, involves screening measurement of a natriuretic peptide biomarker.