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British Society for Heart Failure Autumn Meeting Report

The British Society for Heart Failure recently held its 19th annual meeting in London, attracting over 700 delegates for the two-day conference. Entitled ‘Heart Failure: the multisystem problem’, the meeting covered a wide range of topics including cardio-renal interactions, diagnostic dilemmas, devices in heart failure and a key-note lecture on ‘counting the cost of comorbidities in heart failure’(Michael Bohm, University of the Saarland, Germany). 

Guidelines and trials update

Of particular note at this event were updates on latest guidelines/ clinical trials and the management of myocarditis.

Prof John McMurray (University of Glasgow, UK) discussed recent breaking trials. The most prominent of which was ATMOSPHERE which studied the direct renin inhibitor Aliskiren either as monotherapy or in combination with Enalapril1. Over 7,000 patients were enrolled. Overall, there was no additional benefit of Aliskiren but additional risk of hypotension, renal decline and hyperkalaemia was identified. 

One of many other exciting trials discussed was the DANISH trial2. This study investigated the real world risk of death in non-ischaemic systolic heart failure (LVEF <35% and NT-proBNP >200 pg/ml). There was no significant difference in the primary outcome of death from all causes but importantly outlines that not all patients with severe systolic heart failure should necessarily be implanted with an ICD. Going forward careful thought is required to identify those with non-ischaemic cardiomyopathy that will clearly benefit from ICD therapy.  

Amongst other trials discussed were two looking at the effect of Glycogen-like peptide-1 (GLP-1) agonists. Incretin mimetics, although felt to be promising and improve glycaemic indices, do not reduce and may increase the risk of cardiovascular events and worsening HF3. Both LEADER4 and SUSTAIN-65 demonstrated no statistical benefit in heart failure outcomes.    

Looking forward, things look bright with plentiful new phase III trials underway. Driven by the success of sacubitril/valsartan and the PARADIGM-HF trial we eagerly await the results of two further studies. Of interest will be Entresto in the HFpEF population and in the setting of acute myocardial infarction with PARAGON-HF and PARADISE-MI respectively.

Difficult devices

One of the highlights of the conference was Dr Archie Rao’s (Liverpool Heart and Chest Hospital) take on the approach to device therapy in younger patients with heart failure. Refreshingly Dr Rao made it clear that we must work towards providing tailored therapy for the individual. In an effort to reduce hardware burden, complications, potential infection and the need for extraction procedures we must consider all aspects of device therapy carefully. The need for the device in the first instance should be questioned alongside the psychological impact followed by choice of generator, lead selection and appropriate programming. 

Falls, Frailty and palliative care in Heart Failure

Dr Andrew Davies (Sunderland Royal Hospital) presented a thought-provoking and entertaining overview of the assessment of falls, dizziness and basic movement problems hammering home the need for careful evaluation of the multitude of patient problems with attention to avoiding polypharmacy.   

It is important to consider the application of a multi-disciplinary team approach for frail older patients with heart failure. Frailty should be assessed by utilising a scoring system such as the FRAIL score recommended by the 2016 ESC guidelines6. Frailty is clearly linked to falls and worsening cognitive function, worsening functional condition and then confidence and independence7

The provision of specialist input when coming towards the end of life is a major unsolved issue. Recent research presented by Dr Ross Campbell (BHF Glasgow Cardiovascular Research Centre) outlined that over 25% of patients admitted to hospital have palliative care requirements but most patients with heart failure did not access specialist palliative care services. 

Kidney disease, anaemia and iron replacement in Heart Failure

We have long debated the impact of anaemia and erythropoietin deficiency and the need for iron replacement therapy in heart failure. Questions have also been raised around the best method of replacement.

Iron deficiency is a common comorbidity in HF associated with a worse prognosis8. Professor Sunil Bhandari (Hull and East Yorkshire Hospitals NHS Trust) provided an overview of the relationship between iron deficiency, impaired mitochondrial function, activation of pro-apoptotic pathways and impaired contractile function of cardiomyocytes with exceptional clarity.  

Overall, the evidence supports the use of iron replacement therapy and it is clear that intravenous administration provides benefit leading to sustained improvement in functional capacity, symptoms and hence quality of life scores6,9

Conclusion

The British Society for Heart Failure annual meeting, as always, provided a number of entertaining and outstanding presentations which were both informative and reassuring.  Sessions were designed to cover common presentations but also provide an interactive platform to discuss challenging management issues. There are few meetings with access to such a number of internationally renowned experts not only in cardiology but other medical specialities and allied health professions. The meeting itself reflects the collaborative spirit and multidisciplinary approach that is present in modern day heart failure centres and is an opportunity to meet like-minded HF enthusiasts in a supportive and welcoming environment. 

Ewan J McKay
North West Heart Centre, 
University Hospital South Manchester


Footnotes

Future meetings include the Heart Failure Day for Revalidation and Training on 2nd March 2017, the Heart Failure Nurse and Healthcare Professional Study Day on 3rd March 2017 and the 20th Annual Autumn Meeting on 23-24th November 2017.

Website: www.bsh.org.uk; Twitter: @BSHeartFailure; Email:

Acknowledgments

The BSH gratefully acknowledges support from  Medtronic, Novartis pharmaceuticals ,Servier Laboratories, Bayer, Biotronik, Boston Scientific, Merck Sharp & Dohme, St Jude Medical, Pharma Nord, Vifor Pharma and CORE Heart Failure Education (PCM scientific). 

Financial and competing interest disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

References

  1. McMurray JJV, Krum H, Abraham WT et al. Aliskiren, Enalapril, or Aliskiren and Enalapril in Heart Failure. N Engl J Med 2016; 374:1521-1532
  2. Køber L, Thune JJ, Nielsen JC et al. Defibrillator Implantation in Patients with Non-ischemic Systolic Heart Failure. N Engl J Med 2016; 375:1221-1230
  3. Gilbert RE, Krum H. Heart failure in diabetes: effects of anti-hyperglycaemic drug therapy. Lancet 2015; 385:2107–2117.
  4. Marso P, Daniels GH, Brown-Frandsen K et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016; 375:311-322
  5. Marso P, Bain SC, Consoli A et al. Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2016; 375:1834-1844
  6. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. doi:10.1093/eurheartj/ehw128. 
  7. Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc 2012;60:1478–1486.
  8. Shah R, Agarwal AK. Anemia associated with heart failure: current concepts. Clin Interv Aging. 2013; 8: 111–122. 
  9. Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Beneficial effects of long term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency. European Heart Journal 2015;36:657–668. 

 

 

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