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Published online: 14 May 2018
© The Author(s) 2018
Abstract Primary care physicians play a significant role in managing heart failure (HF), with the goals of reducing mortality, avoiding hospitalization, and improving patients' quality of life. Most HF-related hospitalizations and deaths occur in patients with New York Heart Association functional class II or III, many of whom are perceived to have stable disease, which often progresses without clinical symptoms due to underlying deleterious effects of neurohormonal imbalance and endothelial dysfunction. Management includes lifestyle changes and stepped pharmacological therapy directed at the four stages of HF, with aggressive uptitration of therapies, including betablockers and inhibitors of the renin-angiotensin-aldosterone system. Recently, two new HF treatments have become available in clinical practice. Ivabradine was approved to reduce the risk of hospitalization for HF in patients with stable, symptomatic HF. Additionally, the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril/valsartan, was found to be significantly superior to enalapril in reducing risks of cardiovascular death and HF-related hospitalization. The respective 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America clinical practice guideline updates recommend that patients taking angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy be switched to ARNI therapy to further reduce morbidity and mortality. For HF management to be maximally effective, physicians must be knowledgeable about the risks and benefits of treatments and stay engaged with patients to identify signs of disease progression. This article provides an overview of the progressive nature of HF in apparently stable patients and describes areas for treatment improvement that may help to optimize patient care.
1Introduction
Heart failure (HF) is a clinical syndrome caused by structural or functional abnormalities of the heart, resulting in a reduction in cardiac output or elevation of ventricular filling pressures at rest or during exercise. The major manifestations of HF are breathlessness, decreased exercise tolerance, and fatigue, which may be accompanied by signs of fluid retention, including peripheral edema, elevated jugular venous pressure, and crackles in the lungs.
The prevalence of HF increases with age [1]. However, in the last several decades, advances in HF treatment have led to improvements in survival, both in clinical trials and in the community [2-4]. These decreases in mortality extend to very elderly patients (aged > 80 years) who have been...