The Enabling Potential of Device Therapy for Heart Failure

Abstract

Patients with heart failure (HF) have poor prognoses despite substantial advances in therapeutic development. Comprehensive guideline-directed medical therapy (GDMT) is infrequently achieved in practice, especially at target doses. 1 Greene SJ Fonarow GC DeVore AD Sharma PP Vaduganathan M Albert NM et al. Titration of medical therapy for heart failure with reduced ejection fraction. J Am Coll Cardiol. 2019; (21): 2365-2383 Google Scholar The effects of GDMT on hemodynamic, electrolyte and renal parameters limit clinicians’ eagerness to initiate and titrate these drugs. Indeed, the most common reason for the inability to achieve target GDMT is that a patient is on “maximally tolerated” therapy. 2 Fiuzat M Ezekowitz J Alemayehu W Westerhout CM Sbolli M Cani D et al. Assessment of limitations to optimization of guideline-directed medical therapy in heart failure from the GUIDE-IT Trial: a secondary analysis of a randomized clinical trial. JAMA Cardiol. 2020; 5: 757-764 Google Scholar GDMT intolerance is associated with particularly unfavorable outcomes. 3 Morris AA Khazanie P Drazner MH Albert NM Breathett K Cooper LB et al. Guidance for timely and appropriate referral of patients with advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2021; 144: e238-e250 Google Scholar Whether this is related to fragile hemodynamic status, lack of exposure to beneficial therapies, or some combination of the 2 has not been fully elucidated. Some patients who have this clinical profile are eligible for advanced therapies, but the vast majority will not undergo cardiac replacement. 4 Truby LK Rogers JG. Advanced heart failure: epidemiology, diagnosis, and therapeutic approaches. JACC Heart Fail. 2020; 8: 523-536 Google Scholar ,5 Birks EJ Drakos SG Patel SR Lowes BD Selzman CH Starling RC et al. Prospective multicenter study of myocardial recovery using left ventricular assist devices (RESTAGE-HF [Remission from Stage D Heart Failure]): medium-term and primary end point results. Circulation. 2020; 142: 2016-2028 Google Scholar Thus, there is an ongoing need for strategies that can facilitate GDMT tolerance. Drug therapies have long been used to facilitate tolerance of beneficial devices (eg, dual antiplatelet therapy after percutaneous coronary intervention) and other drugs (eg, potassium binders to facilitate renin-angiotensin-aldosterone system inhibitor use), but most cardiac devices have not been intentionally applied to facilitate tolerance of beneficial drugs (Fig. 1), some notable exceptions being myocardial recovery in patients with durable mechanical circulatory support (MCS)5 and pacemaker implantation to facilitate beta-blocker tolerance for arrhythmia management.