Paciente «estable» con insuficiencia cardiaca: el momento oportuno

Data from the PARADIGM-HF clinical trial and other key studies in patients with heart failure with a reduced ejection fraction (HFrEF) show that those described as "stable" (i.e. the majority in New York Heart Association [NYHA] functional class II with no recent admission for heart failure) actually have a very poor clinical prognosis: they have a high rate of admission for heart failure and a cardiovascular mortality of 25% in the following 3 years. Moreover, most patients with HFrEF who suffer sudden death did not experience a significant deterioration in functional capacity. This "false impression of clinical stability", therefore, does not imply a good prognosis or the absence of disease progression.

In the PARADIGM-HF study, which included mostly stable patients in NYHA functional class II, treatment with sacubitril-valsartan significantly reduced the risk of death or hospitalization due to heart failure compared with enalapril. Remarkably, the risk of sudden death was also decreased significantly. Traditionally, implantable cardioverter-defibrillators (ICDs) provide the most effective way of reducing the risk of sudden death in these patients. However, they do not prevent 100% of these deaths and up to 50% of patients with ICDs experience sudden death via various mechanisms. This illustrates why we should strengthen medical treatment during the stable clinical phase, which is the scenario for which the greatest amount of solid scientific evidence is available. Once a patient has been diagnosed with HFrEF, therefore, it is essential to act in full accordance with the evidence without waiting for the next decompensation. Therapeutic inertia and delaying action until clinical deterioration is evident will only result in a "desperate empiricism". Nevertheless, the uptake of drugs such as sacubitril-valsartan in routine clinical practice is still relatively low even when their use is indicated by consensus guidelines, which undoubtedly gives pause for thought.

Supplement information: this article is part of a supplement entitled "Questions on a new era for heart failure treatment" which is sponsored by Novartis