Heart failure is a clinical syndrome that carries a significant burden of morbidity and is associated with poor long-term prognosis. Treatment of heart failure is constantly evolving, with large amounts of research going into the development of new medications, in the hopes of improving symptom management as well as reducing morbidity and mortality.
Area of Uncertainty:
One of the major areas of uncertainty regarding recent advances in heart failure management is the applicability of data from existing trials to the geriatric population. The majority of current research focuses on patients in a younger age group with a median age around 60, and there is a lack of randomized control trials assessing efficacy in the geriatric population specifically.
Three new medications are examined in this review: sacubitril/valsartan, ivabradine, and nesiritide. Sacubitril/valsartan is a combination of neprilysin inhibitor and angiotensin receptor blocker that acts to increase natriuretic peptides and block the effect of angiotensin, leading to diuresis and vasodilation. The resultant reduction in systemic blood pressure and intravascular volume leads to decreased cardiac stress. This drug has Class 1B recommendation for the treatment of heart failure with reduced ejection fraction, with superior improvement in cardiovascular mortality and hospitalization rate compared with enalapril. Ivabradine is an If channel inhibitor that allows for selective reduction in heart rate without hindering cardiac contractility. This drug has Class IIa-B recommendation for heart failure with reduced ejection fraction with evidence of reduction in hospital admission rate. Nesiritide is a recombinant human brain natriuretic peptide that causes arterial and venous dilation and suppression of the renin–angiotensin–aldosterone system. Clinical trials have shown that this medication has some positive effect with patients in acute heart failure exacerbation; however, no benefit in long-term management has been shown.
As the population of the United States continues to age, the number of patients with heart failure will continue to rise. Understanding the wide range of treatment options available to elderly patients is increasingly important for clinicians. Determining whether any of the new therapeutic options is appropriate for a patient will be a collaborative effort between a clinician and patient and will depend heavily on the patient's comorbidities, functional status, and goals of care.