The inaugural meeting of the Heart Failure Professional Committee of the Chinese Physicians Association and the Summit Forum on China’s Heart Failure Prevention and Treatment Strategy was held in Beijing on July 4, 2015. Academician Gao Runlin from Fu Wai Hospital of Chinese Academy of Medical Sciences gave a detailed presentation on the current situation and research progress of heart failure in China.
I. Epidemiology and disease burden of heart failure
Heart failure has become a global health burden, and there are currently about 26 million heart failure patients worldwide. In Europe and the United States, the prevalence of heart failure in people over 70 years of age is ≥10%. 74% of heart failure patients have at least one comorbidity during the course of their disease, and such patients are more likely to experience disease progression, leading to high rates of rehospitalization and mortality.
The prognosis of advanced heart failure is worse than that of some solid tumors and myocardial infarction, with a 5-year survival rate of less than 20% in severe cases. In Europe and North America, heart failure accounts for 1-4% of hospital admissions, 46% of discharged patients are readmitted within 2 months due to worsening heart failure, and the average length of stay is 5-10 days, occupying a large amount of medical resources. Total spending on heart failure patients is expected to increase by 50-100% over the next 10 years.
Data from the 2003 China Heart Failure Epidemiology Survey showed that the prevalence of heart failure among people aged 35 to 75 years was 0.9%, with a conservative estimate of 4.5 million heart failure patients in 2003. 2013 meta-analysis showed that the prevalence of heart failure in China was 1.3%, an increase of 0.4% from 2003. There is an urgent need to establish new epidemiological data on heart failure in China. An epidemiological survey of 50,000 people based on echocardiography and questionnaires as a diagnostic basis was organized by the National Center for Cardiovascular Diseases during the 12th Five-Year Plan, and the study is ongoing, with preliminary results expected in the second half of next year.
The China Heart Failure Patient Registry Study (China-HF) is an ongoing prospective, multicenter, and the largest in-hospital heart failure patient registry study in China, involving more than 100 hospitals. Based on clinical data from 8,516 heart failure patients from 88 hospitals submitted to the data center by the end of 2014, the study has newly published the results of a preliminary analysis of etiology, clinical characteristics and treatment: the most predominant etiology of hospitalized heart failure patients in China is hypertension (54.6%), followed by coronary artery disease (49.4%), non-ischemic cardiomyopathy (26.9%), diabetes mellitus (21.7%) percent), valvular heart disease (17.6 percent), and congenital heart disease (3.5 percent). The causes of acute heart failure include infection (45%), overexertion (26.0%), heart volume overload (16.8%) and ischemia (23.1%), etc.
Second, the progress of drug treatment of heart failure
Studies have shown that ACEI/ARB, β-blockers and aldosterone receptor antagonists are the main drugs to improve the prognosis of heart failure and reduce death, and about 50% of Chinese heart failure patients use these drugs after discharge, while the use rate of foreign patients is more than 80%, so there is a need to fully strengthen the use of these drugs in domestic patients to improve the prognosis of heart failure.
On average, Chinese heart failure patients are hospitalized twice per year, and each hospitalization costs an average of $7,000 to $9,000 per person. An analysis of heart failure studies in China, the United States and Japan showed that the average age of Chinese heart failure patients was lower than that of patients in the United States and Japan, while other characteristics were not significantly different, and the in-hospital mortality rate was between that of the United States and Japan, indicating that the level of heart failure treatment in China is in line with the overall international level, but there is still much room for improvement.
Digitalis was the first drug used in heart failure treatment, followed by diuretics, vasodilators and non-digitalis positive inotropic drugs, but these drugs can only improve the symptoms of heart failure, but can not really prolong the life of patients. It was not until the 1990s that the application of ACEI/ARB, β-blockers and aldosterone receptor antagonists reduced the morbidity and mortality rate of patients, so neuroendocrine inhibitor therapy is an important milestone in the pharmacological treatment of heart failure. 2014 Chinese heart failure guidelines recommend the basic treatment regimen for chronic HF-REF as an ACEI/ or ARB-β-blocker-aldosterone antagonist consisting of “golden triangle”.
In the exploration of new drugs for heart failure, we have been expecting drugs that act directly on damaged cardiomyocytes, improve cardiomyocyte structure and function, induce cardiomyocyte regeneration, and reverse ventricular remodeling, with the aim of reducing mortality. The recombinant human neuregulin-1 (rhNRG-1) is a drug that acts directly on cardiomyocytes and is currently under clinical investigation. rhNRG-1/ErbB signaling system is involved in the differentiation and regulation of cardiomyocyte and cardiac embryonic development, and is closely related to the pathological processes of adult heart function, heart failure onset, progression and even prognosis. The rhNRG-1/ErbB signaling system is involved in the regulation of cardiomyocyte and cardiac embryonic development, and is closely related to the pathology of adult cardiac function, heart failure development, and even prognosis.
The results showed that rhNRG-1 can bind to ErbB4 receptors in cardiomyocytes, enhance cardiomyocyte contractility, improve pumping function, reverse cardiac dilatation, improve long-term prognostic indicators, and reduce readmission and mortality in patients with class II and III heart failure. The results of clinical trials on the treatment of chronic heart failure with Astragalus membranaceus capsules showed that Astragalus membranaceus capsules significantly reduced NTPro-BNP and improved the quality of life in the treatment of chronic heart failure.
Progress in non-pharmacological treatment of heart failure
On the basis of conventional drug therapy, non-pharmacological treatment for chronic heart failure can further improve the prognosis of patients. Cardiac resynchronization therapy, buried cardioverter-defibrillators and cardiac mechanical assist devices are rapidly developing as well as non-pharmacological treatments such as gene and stem cell transplantation and phytomedical interventions are being explored. In recent years, the effectiveness of some non-pharmacological treatments has brought a turnaround to heart failure patients, and non-pharmacological treatments are widely used in heart failure.
Non-pharmacologic treatments for heart failure include: revascularization (interventional or surgical), surgical or interventional treatment (mitral valve repair, left ventricular decompensation, etc.), biventricular pacing (CRT), ICD, ventricular assist devices, ultrafiltration, hemodialysis, artificial heart, and heart transplantation.
The EVEREST II randomized clinical trial comparing mitral valve clamping (MitraClip system) with surgical repair showed that MitraClip system treatment was significantly safer than control (9.6% vs. 57.0%) and non-inferiority, and the device will be studied in China next year in a pre-market study.
Data suggest that only 50% of Chinese heart failure patients receive timely reperfusion therapy after an infarction, and patients who do not receive timely reperfusion are prone to ventricular wall motion abnormalities that can affect cardiac function. The parachute device can seal the apical dilatation site and achieve volume reduction through intervention, avoiding surgical procedures. Studies have shown that parachutes can reduce left ventricular end-systolic volume and left ventricular end-diastolic volume at 3 months in patients with heart failure. The device may enhance cardiac systolic function by increasing the coordination of left ventricular contraction, improving cardiac function grading and improving patients’ quality of life.
IABP is very effective in the treatment of patients with myocardial ischemia, and the related therapeutic experience is relatively extensive and widely used, but the effect of increasing cardiac output is limited and not satisfactory in patients with severe heart failure. Impelia is a device that can improve left ventricular function to some extent by implanting a motor under the left ventricular aortic valve to increase cardiac output.
Extracorporeal membrane pulmonary oxygenator (ECMO) can improve both cardiac pumping and pulmonary gas exchange, maintain effective circulation, and reduce cardiac work and drug application. However, ECMO is a constant flow state with poor tissue perfusion, so it can be used in combination with IABP (pulsatile blood flow) to achieve a complementary effect. HeartMate II is a mechanical assist device with more mature applications, and the FDA has approved the device for marketing.
IV. Directions for future efforts
Once heart failure occurs, the heart enters a process of progression and exacerbation of failure, and the process of ventricular remodeling in the failing heart cannot be reversed. The prevention and treatment of heart failure should be moved forward to effectively treat the primary disease – hypertension, diabetes, coronary artery disease, and early application of drugs to prevent cardiac remodeling. Future efforts should focus on: advancing the prevention of acute heart failure, reducing the hospitalization rate, establishing a reasonable mechanism for acute heart failure diagnosis and treatment transit, improving and enhancing the level of care for end-stage heart failure, further exploring research on new treatment methods, promoting interdisciplinary collaborative research on heart failure, strengthening quality control and assessment of heart failure diagnosis and treatment, improving patient education and support system effectiveness, and providing equitable medical care for all patients. conditions, while the role of Chinese medicine in the treatment of heart failure should be emphasized and the clinical practice of Chinese medicine in the treatment of heart failure should be standardized.