Consensus statement on the current pharmacological prevention and management of heart failure

Introduction: This consensus statement of Australian clinicians provides new recommendations for the pharmacological management of heart failure based on studies reported since the publication of the 2018 Australian heart failure guidelines.Main recommendations:▪ Use of sodium–glucose cotransporter 2 (SGLT2) inhibitors to prevent hospitalisation for heart failure in type 2 diabetes mellitus can be extended to patients with multiple cardiovascular risk factors, albuminuric chronic kidney disease, or atherosclerotic cardiovascular disease.▪ New evidence supports the use of a mineralocorticoid receptor antagonist (finerenone) to prevent heart failure in type 2 diabetes mellitus associated with albuminuric chronic kidney disease.▪In addition to renin angiotensin system inhibitors (angiotensin receptor neprilysin inhibitor preferred), beta blockers and mineralocorticoid receptor antagonists, an SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in all patients with heart failure with reduced left ventricular ejection fraction (LVEF ≤ 40%) (HFrEF). Lower quality evidence supports these therapies in patients with heart failure with mildly reduced LVEF (41- 49%) (HFmrEF).▪A soluble guanylate cyclase stimulator (vericiguat), selective cardiac myosin activator (omecamtiv mecarbil) and, if iron deficient, intravenous iron (ferric carboxymaltose) provide additional benefits in persistent HFrEF.▪ An SGLT2 inhibitor (empagliflozin) should be considered in patients with heart failure with preserved LVEF (≥ 50%) (HFpEF).Key changes in management from this statement: This document broadens the scope of angiotensin receptor neprilysin inhibitor use in patients with HFrEF and HFmrEF. SGLT2 inhibitor use expands to become a cornerstone therapy in HFrEF, with increasing evidence to support its use in HFmrEF and HFpEF.Andrew P Sindone, Carmine De Pasquale, John Amerena, Christine Burdeniuk, Alicia Chan, Andrew Coats, David L Hare, Peter Macdonald, Aaron Sverdlov, John J Atherto

Baseline characteristics of patients in the reduction of events with darbepoetin alfa in heart failure trial (RED-HF)

<p>Aims: This report describes the baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF) which is testing the hypothesis that anaemia correction with darbepoetin alfa will reduce the composite endpoint of death from any cause or hospital admission for worsening heart failure, and improve other outcomes.</p> <p>Methods and results: Key demographic, clinical, and laboratory findings, along with baseline treatment, are reported and compared with those of patients in other recent clinical trials in heart failure. Compared with other recent trials, RED-HF enrolled more elderly [mean age 70 (SD 11.4) years], female (41%), and black (9%) patients. RED-HF patients more often had diabetes (46%) and renal impairment (72% had an estimated glomerular filtration rate <60 mL/min/1.73 m2). Patients in RED-HF had heart failure of longer duration [5.3 (5.4) years], worse NYHA class (35% II, 63% III, and 2% IV), and more signs of congestion. Mean EF was 30% (6.8%). RED-HF patients were well treated at randomization, and pharmacological therapy at baseline was broadly similar to that of other recent trials, taking account of study-specific inclusion/exclusion criteria. Median (interquartile range) haemoglobin at baseline was 112 (106–117) g/L.</p> <p>Conclusion: The anaemic patients enrolled in RED-HF were older, moderately to markedly symptomatic, and had extensive co-morbidity.</p&gt

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Systematic review of the effects of sodium-glucose cotransporter 2 inhibitors on hospitalisation for heart failure and cardiac structure or function, and exploratory assessment of potential mechanisms

Aims: To systematically review randomised controlled trials assessing effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) on hospitalisation for heart failure (HHF) and cardiac structure/function and explore RCT-derived evidence for SGLT2i efficacy mechanisms in heart failure (HF). Methods and Results: Systematic searches of Medline and Embase were performed. In seven trials (3730–17,160 patients; low risk of bias [RoB]), SGLT2is significantly reduced the relative risk of HHF by 27%–39% versus placebo, including in two studies in patients with HF with reduced ejection fraction with or without type-2 diabetes mellitus (T2DM). Improvements in conventional cardiovascular risk factors, including glycaemic levels, cannot account for these effects. Five trials (56–105 patients; low RoB) assessed the effects of 6–12 months of SGLT2i treatment on left ventricular structure/function; four reported significant improve- ments versus placebo and one did not. Five trials (low RoB) assessed SGLT2i treatment effects on serum N-terminal pro- B-type natriuretic peptide levels; significant reductions versus placebo were reported after 8–12 months (two studies; 3730–4744 patients) but not # 12 weeks (three studies; 80– 263 patients). Limited available RCT-derived evidence sug- gests various possible cardioprotective SGLT2i mechanisms, including improved haemodynamics (natriuresis and reduced interstitial fluid without blood volume contraction/neurohormonal activation) and vascular function, enhanced erythropoiesis, reduced tissue sodium and epicardial fat/ inflammation, decreased sympathetic tone, and beneficial changes in cellular energetics. Conclusions: SGLT2is reduce HHF regardless of T2DM status, and reversal of adverse left ventricular remodelling likely contributes to this efficacy. Hypothesis-driven mechanistic trials remain sparse, although numerous trials are planned or ongoin

Age differences in virtual environment and real world path integration

Accurate path integration requires the integration of visual, proprioceptive, and vestibular self-motion cues and age effects associated with alterations in processing information from these systems may contribute to declines in path integration abilities. The present study investigated age-related differences in path integration in conditions that varied as a function of available sources of sensory information. Twenty-two healthy, young (23.8 ± 3.0 yrs.) and 16 older (70.1 ± 6.4 yrs.) adults participated in distance reproduction and triangle completion tasks performed in a virtual environment and two real world conditions: guided walking and wheelchair propulsion. For walking and wheelchair propulsion conditions, participants wore a blindfold and wore noise-blocking headphones and were guided through the workspace by the experimenter. For the virtual environment (VE) condition, participants viewed self-motion information on a computer monitor and used a joystick to navigate through the environment. For triangle completion tasks, older compared to younger individuals showed greater errors in rotation estimations performed in the wheelchair condition; and for rotation and distance estimations in the VE condition. Distance reproduction tasks, in contrast, did not show any age effects. These findings demonstrate that age differences in path integration vary as a function of the available sources of information and by the complexity of outbound pathway

Hyponatraemia in heart failure

Hyponatraemia is common in heart failure (HF). It is estimated that over 20% of patients admitted to hospital with HF have hyponatraemia. It has also been repeatedly shown to be a surrogate marker of increased morbidity and mortality in this specific population. This review focuses on the pathophysiology of hyponatraemia through the activation of neurohormonal cascades in HF, the clinical implications of sustained hyponatraemia and treatment options in the management of this challenging phenomenon