In the words of a legend in Cardiology, Eugene Braunwald, “Heart failure may be considered the last great battleground of cardiac disease.”
The survival rate among patients with a diagnosis of heart failure (HF) continues to be low. The one-year mortality rate of HF is around 30%, and at five years, it is at least 50%. Repeated hospitalization in HF is another major problem. The clinical condition of the patient worsens progressively with each readmission. The present prevalence of HF in India is estimated to be around 10 million, with coronary heart disease, hypertension, diabetes, and rheumatic heart disease being the most common causes. Each year, we add around 1.5 to 2 million new patients with HF.
Indian patients with HF are younger, present late with severe symptoms, often have little education, negligible health insurance, and are still being treated frequently with only older drugs like digoxin and furosemide (Lasix), a water pill. We currently have 4 groups of drugs to treat the commonly seen HF. These are 1. ACEI/ARB’s/ARNI (enalapril, valsartan, and a combination of Valsartan and sacubitril). 2. Beta-blockers (metoprolol, bisoprolol). 3. SGLT2 blockers (Dapagliflozin, empagliflozin). 4. MR antagonists (spironolactone, eplerenone, finerenone). These are also called the 4 pillars of HF management.
Unmet Needs of HF Management in India:
1. Lack of Public Awareness
2. Delay in the diagnosis
3. Lack of serious efforts to put patients on GDMT at the earliest
4. Inadequate facilities for hospitalization
5. Negligible remote monitoring facilities after starting treatment
6. Lack of a multi-disciplinary team to guide and evaluate.
Public Awareness programs at all levels: Primordial Prevention: Salt reduction and Tobacco control are two cost-effective strategies for reducing cardiovascular diseases in India. Public awareness programs highlighting these on print and electronic media starting at the level of primary health centers onwards at all levels of health care.
Primary prevention programs: Effective treatment of known risk factors like Hypertension, diabetes, and dyslipidemias. The target is to reduce heart attacks (MI), the leading cause of heart failure.
Awareness Campaigns to Recognize Heart Failure at early stages: Symptoms like unexplained fatigue, shortness of breath, swelling of feet or the body, and an unusual prominence of neck veins etc need to be taken note of. These patients need to have a full clinical examination, routine biochemistry, ECG, X Ray chest, an echocardiogram. The facilities for these investigations are widely available in most parts of the country.
One of the investigations that still is very inadequately used is serum biomarkers like BNP and NT-pro BNP. These biomarkers available as point of care tests are very sensitive to diagnose heart failure and differentiate them from other causes of shortness of breath (COAD). These are very easy to use.
Patients with acute decompensated heart failure (ADHF) should always be admitted to the hospital for acute assessment and prompt management using the GDMT started at the earliest, and an attempt is made to start all of them within a few weeks of discharge if not earlier. Much depends on their blood pressure and heart rate, kidney function, and other co-morbidities, which often they have. The elderly population poses additional problems like frailty, polypharmacy, and cognitive issues. Thereby, an individualized treatment algorithm is to be initiated.
Our experience with biomarkers and their use not only in hospital practice but also in camps and the centers in remote areas set up by our NGO, Gauri Kaul Foundation, has been very gratifying. These point of care tests readily diagnose and differentiate HF from many other conditions mimicking it. The test also gives a reliable idea about the severity of the illness and after starting the GDMT helps in following up and can be used for remote monitoring. We use this test through telemedicine centers put in remote areas and guiding the treatment digitally.
There is a gross shortage of hospitals geared to manage HF patients in our country. In order to obviate this problem, starting the treatment at day care centers and then at home under the supervision of an educated/trained family member is a reasonably good alternative. The patient is then guided virtually using platforms like WhatsApp. Trained nurses and technicians living in these areas can be very useful. Periodic visits from consultants ensure the continuity of the treatment in remote areas. In those areas which get cut off during severe winter months and are near the LOC, we have tie-ups with armed forces doctors who help us in executing the management through regular feedback. The importance of starting all the drugs in appropriate doses at an early date is of utmost importance. HF patients have a short time window, and that has to be respected. The GDMT for HF consists of the 4 pillars already mentioned previously.
STRONG-HF, a recently published trial, is proof of this concept. Those patients with ADHF with raised NT-pro BNP levels were included. The study, which started in 2018, divided the subjects hospitalized with ADHF into 2 groups. Group 1, Patients were given all the 3 drugs (ACEI, Beta blockers, and aldosterone antagonists) in therapeutic maximally tolerated doses and strict follow-up within a period of 2 to 4 weeks and compared with Group 2 with usual care as per the routine practice of the hospital for inpatients and also after discharge. By the end of 3 months, the aggressively treated group had a significantly lower death or hospitalization rate of 15.8% vs 23.45% in the usual care group. This was accompanied by greater reduction in body weight, more symptomatic benefit, and lower NT-Pro BNP levels. This prospective study thus clearly shows the importance of early aggressive therapy for ADHF patients and should have a substantial impact on clinical practice and improving the outcomes in these sick patients. The messages conveyed by this trial and the previous suggestions made by experts like Mc Murray and Packer of initiating all the drugs early and, in any case, by 4 weeks, need to be brought to light to the Indian doctors managing the patients with HF, including the family physicians and internists. The social media can also play an important role to highlight how sick heart failure patients need early supervised optimal treatment with improved survival and reduced hospitalization.
Heart failure patients have a short time window, and all the measures need to be started at the earliest and expeditiously. With the availability of several groups of drugs to manage acute and chronic heart failure, the future of these sick patients is poised to improve, with a better quality of life, fewer hospitalizations, and improved survival.
The author is Padmashree and founder of Gauri Kaul Foundation