Prevention Must Be Prioritized in Heart Failure Care: HFSA/ASPC

Prevention—be it primary, secondary, or even tertiary—should be the primary focus in heart failure (HF) care, according to a new scientific statement published jointly by the Heart Failure Society of America (HFSA) and the American Society for Preventive Cardiology (ASPC).

The statement, published online last week in both the Journal of Cardiac Failure and American Journal of Preventive Cardiology, reframes HF not as an inevitable outcome but something that can be avoided if proper measures are taken early enough.

“Traditionally, it’s thought prevention is on one end of the spectrum of health and then heart failure is at the way other end, where things have already escalated to the point where you need a heart transplant or LVAD or palliative care,” lead author Anu Lala, MD (Icahn School of Medicine at Mount Sinai, New York, NY), told TCTMD. “Rather than it being a line, I see it more as a circle where they meet each other.”

With one in four adult Americans at risk for developing heart failure, Lala said there is a need to evolve beyond thinking about prevention only for conditions such as atherosclerotic cardiovascular disease and MI.

“By 2050, we’re predicting over 11 million Americans living with heart failure,” she said.

Even though more options exist than ever before for treating HF, the field has faced challenges both with maintaining optimal medical therapy for these patients as well as making sure there are enough trained professionals to care for them. Because of this, heart failure care needs to be thought of holistically, the statement’s authors argue.

“It’s not isolating just one portion of the cardiovascular disease spectrum,” said senior author Martha Gulati, MD (Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA). “Prevention of all forms of heart disease needs to be prioritized, but certainly now that we have therapies to prevent heart failure, this should be incredibly important.”

Thinking Ahead Across the Spectrum

The writing committee outlined preventative measures according to their defined stages of HF: at risk (stage A) and pre-HF (stage B) as primary prevention; symptomatic (stage C) to advanced (stage D) as secondary prevention; and post-advanced therapy including transplant and ventricular assist devices as tertiary prevention.

Several aspects of HF prevention are common regardless of stage, including the use of nonsteroidal mineralocorticoid receptor antagonists and GLP-1 receptor antagonists, cardiac rehab (from stage B on), genetic screening/counseling, natriuretic peptide assessment, maintaining psychological well-being, and adhering to the American Heart Association’s Life’s Essential Eight.

“All of the things that we talk about are applicable no matter where you are—whether you’re in your twenties or whether you’re in your eighties, whether you have heart failure or you just have hypertension or you have none of the above,” Lala said.

The document also highlights both traditional and nontraditional risk factors for HF. Hypertension, diabetes, obesity, CAD, and albuminuria and chronic kidney disease round out the former category, but there are underrecognized risk factors, too, related to genetics, sex (especially pregnancy, breast cancer, autoimmune disease, and nonobstructive coronary events), social determinants of health, psychological status, and cardiotoxicity.

Given the breadth of HF risk factors, the authors stress the need for multidisciplinary care that includes nursing, pharmacists, as well as nutrition and behavioral care experts. A section of the paper even delves into the role spirituality can play in improving outcomes for HF patients.

“The future of HF care lies in proactive, not reactive, intervention,” the authors write. “Through coordinated, multidisciplinary efforts that leverage predictive analytics, advanced therapeutics, and equitable care models, the medical community can fundamentally alter the trajectory of HF and redefine the standard of cardiovascular care.”

‘Total Paradigm Shift’

Gulati said prevention has already been embraced as an important tenet of HF care, including in the most recent American HF guidelines. But while there has been a lot of talk, action is a different story, she commented. Often, by the time a patient is seen by a HF specialist, “there’s so much that we could have done upstream if we really focused on prevention more and prioritized it.”

The fact that the latest US hypertension guidelines have embraced the PREVENT risk calculator is a good first step, Gulati continued. “Hopefully [with] that conversation about not just your risk for atherosclerosis, but your risk for heart failure, people will be more proactive and preventative to be thinking about what we can do to prevent that risk,” she said.

This goes not only for HF specialists but for general cardiologists, in particular, “because they’re going to see the majority of these patients,” Gulati said. “We're not getting people to check [urinary albumin-to-creatinine ratios] at the rates that they should be getting checked, given this epidemic of cardio-kidney-metabolic disease. Part of the reason to make this statement was to help everyone recognize [that they] see these patients.”

Ultimately, the document’s creators are calling for “a total paradigm shift to integrated models of care,” Lala said. That “whole person health” should ideally lead to fewer siloes, she specified, as well as more reimbursement for underutilized preventative services like cardiac rehab, nutrition counseling, and behavioral support.

“I think weaving together cardiovascular prevention and heart failure into one cohesive framework is empowering not only for clinicians to take meaningful action, but also for patients,” she said.