Magazine article Clinical Psychiatry News

Major Message: Most Heart Failure Is Preventable

Magazine article Clinical Psychiatry News

Major Message: Most Heart Failure Is Preventable

Article excerpt


SNOWMASS, COLO. -- More than 960,000 new cases of heart failure will occur in the United States this year--and most of them could have been prevented, Gregg C. Fonarow, MD, said at the Annual Cardiovascular Conference at Snowmass.

Preventing heart failure does not require heroic measures. It entails identifying high-risk individuals while they are still asymptomatic and free of structural heart disease --that is, patients who are stage A, pre-heart failure, in the American College of Cardiology/American Heart Association classification system for heart failure--and then addressing their modifiable risk factors using evidence-based, guideline-directed medical therapy, said Dr. Fonarow, professor of cardiovascular medicine and cochief of cardiology at the University of California, Los Angeles, and director of the Ahmanson-UCLA Cardiomyopathy Center.

The two top risk factors for the development of heart failure are hypertension and ischemic heart disease. Close to 80% of patients presenting with heart failure have antecedent hypertension, and a history of ischemic heart disease is nearly as common. Other major risk factors include obesity, diabetes, smoking, dyslipidemia, metabolic syndrome, and renal insufficiency.

A special word about obesity: A Framingham Heart Study analysis concluded that, after other cardiovascular risk factors were controlled for, obese individuals had double the risk of new-onset heart failure, compared with normal weight subjects, during a mean follow-up of 14 years. For each one-unit increase in body mass index, the adjusted risk of heart failure climbed by 5% in men and 7% in women (N Engl J Med. 2002 Aug 1;347[5]:305-13). And that spells trouble down the line.

"You can imagine, with the marked increase in overweight and obesity status now affecting over half of U.S. adults, what this will mean for a potential rise in heart failure prevalence and incidence unless we do something further to modify this," the cardiologist observed.

Dr. Fonarow is a member of the writing group for the ACC / AHA guidelines on management of heart failure. The group recommends as a risk reduction strategy identification of patients with stage A pre-heart failure and addressing their risk factors: treating their hypertension and lipid disorders, gaining control over metabolic syndrome, discouraging heavy alcohol intake, and encouraging smoking cessation and regular exercise (J Am Coll Cardiol. 2013 Oct 15;62[16]:e 147-239).

What kind of reduction in heart failure risk can be expected via these measures?

Antihypertensive therapy

More than a quarter century ago, the landmark SHEP trial (Systolic Hypertension in the Elderly Program) in more than 4,700 hypertensive seniors showed that treatment with diuretics and beta-blockers resulted in a 49% reduction in heart failure events, compared with placebo. And this has been a consistent finding in other studies: A meta-analysis of all 12 major randomized trials of antihypertensive therapy conducted over a 20-year period showed that treatment resulted in a whopping 52% reduction in the risk of heart failure (J Am Coll Cardiol. 1995 Apr; 27[5]: 1214-8).

"If you ask most people why they're on antihypertensive medication, they say, 'Oh, to prevent heart attacks and stroke.' But in fact the greatest relative risk reduction that we see is this remarkable reduction in the risk of developing heart failure with blood pressure treatment," Dr. Fonarow said.

There has been some argument within medicine as to whether aggressive blood pressure lowering is appropriate in individuals over age 80. But in HYVET (Hypertension in the Very Elderly Trial) conducted in that age group, the use of diuretics and/ or ACE inhibitors to lower systolic blood pressure from roughly 155 mm Hg to 145 mm Hg resulted in a dramatic 64% reduction in the rate of new-onset heart failure (N Engl J Med. …

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