New HF Guidelines Put Focus on Prevention, Bozkurt Says

New guidelines adopted this spring redefine stages of heart failure (HF) to emphasize prevention, Biykem Bozkurt, MD, PhD, told attendees at 2022 Congress of the American Society of Preventive Cardiology (ASPC), held July 29-31 in Louisville, Kentucky.

That’s the good news. Bozkurt said her specialty is at “a crossroads,” with a need to bring attention to both the guidelines and the general cause of HF screening.

Bozkurt, a professor of medicine and cardiology at Baylor College of Medicine in Houston, serves as director of the Winters Center for Heart Failure Research and was vice chair of the writing committee for the 2022 American College of Cardiology (ACC), American Heart Association (AHA), and Heart Failure Society of American (HFSA) 2022 Heart Failure Guidelines. To build awareness of the guidelines, she said, “I am looking for partnership with our preventive cardiologists.”

“Why is this important now?” she asked. “Because we have specific preventive strategies for heart failure.”

At long last, HF is in the public eye, Bozkurt said, and specialists in the field are working to not only educate clinicians on how to identify patients at risk, but also to get payers to develop billing codes so screening can be part of a patient’s exam.

In the past, clinicians typically waited for characteristic symptoms and left ventricular dysfunction before making a diagnosis of HF. “This is too late,” Bozkurt said. “This is like stage IV cancer. We embrace preventing this—heart failure is as malignant as cancer.”

She displayed data that showed mortality rates, explaining that rates for HF “are as high as some of the deadliest cancers for men and women.”

Unfortunately, HF gets a fraction of the awareness and funding that cancer receives, she said, even though it’s just as deadly. Cancer funding has steadily increased, she said, while funding for research into cardiosvascular disease has been flat.

In cancer, screening has helped prevent early death. Data from the American Cancer Society show that the increased focus on screening over the past generation has helped the cancer mortality rate fall 32% from its peak in 1991 through 2019, with steep drops since some cancer screenings became required without copayment under the Affordable Care Act.

Stages of Heart Failure

The new guidelines cover 4 stages of HF, with the first 2 being asymptomatic.

Stage A: At Risk for HF. Patients do not yet show structure heart disease of blood tests indicating heart injury, but conditions such as high blood pressure, diabetes, obesity, and metabolic syndrome, as well as hereditary factors or exposure to drugs such as chemotherapy put them at risk.

Stage B: Pre-HF. Still no symptoms, but patients now show evidence of structural heart disease or test for biomarkers that are indicators of heart muscle injury, such as elevated levels of B-type natriuretic peptide (BNP) or persistently elevated cardiac troponin.

Bozkurt noted the significance of biomarker abnormalities, “even in the absence of symptoms and signs” is now included in the definition of pre-HF.

Stage C: Symptomatic HF. Patients have structural heart disease with symptoms, such as shortness of breath, persistent cough, swelling in the legs/feet or abdomen, fatigue, or nausea.

Stage D: Advanced HF. Symptoms now interfere with daily life, and patients may experience repeat hospitalizations despite taking guideline-directed medical therapy.

Treatment to Prevent HF Symptoms

Bozkurt focused on what the ACC/AHA/HFSA guidelines say about treatment in Stages A and B, before patients suffer disabling effects of HF. Stage A calls for optimal treatment of hypertension, optimal management of cardiovascular disease, and use of sodium glucose cotransporter 2 (SGLT2) inhibitors for those with diabetes and cardiovascular risk or disease. SGLT2 inhibitors are now among 4 therapy classes (besides diuretics) recognized for treatment of HF with reduced ejection fraction (HFrEF), which under the revised guidelines is defined as LV ejection fraction ≤ 40%.

In addition, Bozkurt noted that the Stage A guidelines call those exposed to harmful toxic agents to receive a multidisciplinary evaluation, and for those with inherited cardiomyopathy to have genetic screening and counseling.

For patients in Stage B, the recommendations in Stage A still apply, but more medication may be required to prevent HF symptoms. For those with HFrEF, angiotensin-converting-enzyme (ACE) inhibitors are recommended, but angiotensin receptor blockers (ARBs) can be used if patients cannot tolerate ACE inhibitors. Statins are recommended to reduce low-density lipoprotein cholesterol for those with a history of a heart attack or acute coronary syndrome.

Bozkurt reviewed several studies that showed how better use diagnostics and screening for BNP allows clinicians to optimize care and reduce cardiovascular events. At all stages, she said, patients are encouraged to adopt a healthy lifestyle.

“This is living in the new paradigm,” she said. Identifying those with naturally elevated peptide levels who may require early intervention—and continuing the message of better diet and more physical activity—will allow for better and more effective care. Plant-based diets, in particular, have been showed to reduce HF risk.

Focusing on prevention, she said, will hopefully bring treatments to earlier stages of HF.

“This is [where] we need your help,” Bozkurt said to the group. “Lifestyle modification is an important component, which I want to emphasize. Regular physical activity at a normal rate, healthy dietary patterns, and avoiding smoking are all Class 1 recommendations in the guidelines to prevent future risk of heart failure.”