Improving outcomes in heart failure requires improving implementation of heart failure therapy

摘要

In the 1970s and 1980s, clinicians observed thatheart failure (HF) got worse spontaneously, inde?pendently of the initial insult. This led to the neu?rohormonal hypothesis, in which compensatoryneurohormonal responses are considered mal?adaptive in the long run, causing further mal?adaptive remodeling in a vicious circle. Sincethe 1980s, numerous trials have demonstrat?ed that neurohormonal antagonism improvesoutcomes in HF with reduced ejection fraction(HFrEF). There has been substantial advance?ment in evidence?based interventions for thistype of HF. Indeed, randomized controlled tri?als in HFrEF demonstrated that drug and devicetherapy reduced mortality by 10% to 40%,1,2 anduntil 2000, survival in HF had improved consis?tently.3 After the year 2000, there have been fur?ther additions to the HF treatment armamentari?um, but the improvements in prognosis may haveflattened out.4 Angiotensin receptor–neprilysininhibitors (ARNIs) demonstrated superiority toangiotensin?converting enzyme inhibitors,5 butthe extent of implementation of ARNI therapy isstill poorly studied. To further improve outcomesin HF, efforts need to be directed at improving im?plementation of current guideline–recommendedevidence?based treatments in HFrEF.