Stage B, A Precursor of Heart Failure, Part II

Abstract

This second issue of our series on “Stage B, a precursor of heart failure” deals with the clinical detection and possible management of this pathophysiological process. The structural abnormalities and the various mechanismsthatmaycontributetotheirprogression were extensively covered in the first issue. Based on these descriptions, time-dependent worsening of the structural abnormalities and the development of a symptomatic functional abnormality are likely consequences. Thus, clinical assessment to detect and monitor these structural abnormalities and therapeutic approaches to slow or reverse them become a challenge in clinical management. This issue provides the insights of experts who have long grappled with these problems. Potential monitoring toolsareexplored in depth, bothimaging procedures and biomarker assays. The sensitivity and specificity of these tools are critical in determining their usefulness in the clinical setting. Neurohormonal inhibiting therapy has served as the cornerstone of treatment for symptomatic patientstoinhibitprogressionofthestructuralchanges. Nitric oxide enhancement appears to provide additional benefit for at least some patients with heart failure. A review of these therapeutic approaches is providedbyclinicalscientistswhohavebeendirectly involvedinevaluatingtheseagents.Howthesedrugs can or should be used in asymptomatic individuals with structural changes remains largely unexplored. Such trials will be necessary to document efficacy before widespread utilization can be advocated. Clinical trials in asymptomatic patients with structural abnormalities of the heart will require screening to identify an at-risk population. Much controversyexists onthewholeissueofpopulation screening to prevent cardiovascular morbidity and mortality. The rationale for screening and the possible strategies for screening are addressed in the last section of this issue. These are critical issues if we are to move forward in an effort to prevent symptomatic heart failure rather than to deal only with its escalating incidence. An effective strategy to detect and treat these structural precursors of the functional disorder we call “heart failure” could have profound beneficial effects on our exploding health care expenditures.