Who Would Be Branded With Failure?

Abstract

There was no specialty of heart failure (HF) 35 years ago. When therapies were minimally effective, most cardiologists were equally qualified to deliver them. In the early 1980s, improved outcomes with cyclosporine led to reimbursement for cardiac transplantation. Although performed in >120 000 patients, its major epidemiological contribution may have been concentration of HF at centers where physiology, team management, and therapies could be explored. As the impact of therapies has extended the HF journey (Figure1), further intervention to decrease disease progression may now be hindered by the term “heart failure” itself. Figure. Comparison of the patient journeys with heart failure (HF) in the era early after approval of cardiac transplantation and in the current era realizing the benefit of therapies that have decreased HF progression and decreased sudden death (red arrows). Blue shaded areas encompass patients with typical HF syndromes. Pink shaded area includes patients for whom a neutral label such as “cardiomyopathy” might encourage emphasis on therapy to prevent disease progression. ADHF indicates acute decompensated heart failure; EF, ejection fraction; and RV, right ventricular. Adapted from Udelson and Stevenson1 with permission. © 2016, American Heart Association, Inc. In the early era, most patients presented with class IV symptoms and died of pump failure or sudden death within a year without transplantation. All HF was assumed to be low-ejection-fraction HF, with congestion and hypoperfusion inseparable and inevitable. When therapy was limited to digitalis and diuretics to …