In this interview, coordinated by Dr Ian Ellul, we meet Dr Alice May Moore MD, MRCP(UK). Dr moore is currently working at Mater Dei Hospital as a Higher Specialist Trainee in the Cardiology Department. She has a special interest in Heart Failure and in November 2016 she will be embarking on a one year training fellowship in this field at King’s College Hospital, London.

TS: Heart failure is a common condition worldwide, steadily increasing in prevalence over time. One in five people over the age of 40 years will develop the condition in their lifetime. How common is heart failure in Malta?

Heart failure is one of the commonest conditions in Malta. It affects around 1-2% of the whole population. That means that around 6000 Maltese people are estimated to be suffering from this condition.

TS: At what stage of the condition do patients present, early or late? Does this affect the management and outcome?

Heart failure is a clinical syndrome characterized by typical symptoms and signs caused by a structural and/or functional cardiac abnormality, resulting in reduced cardiac output. Before clinical symptoms become apparent, patients can present with asymptomatic structural or functional cardiac abnormalities, which are precursors of heart failure. Recognition of these precursors is important because they are related to poor outcomes, and starting treatment at the precursor stage may reduce mortality in patients with asymptomatic systolic left ventricular dysfunction.

TS: Worldwide, heart failure is the primary cause of hospitalization in patients aged >65 years. Is it the same in Malta? Is hospitalization due to heart failure a common cause of hospitalization in Malta? Do these patients require frequent re-hospitalization?

Despite dramatic improvement in outcomes with medical therapy, re-hospitalization rates in Malta remain high. Heart failure is a complex deteriorating condition driven by neurohormonal imbalance, leading to a downward spiral of worsening disease and punctuated by acute episodes that result in repeated hospitalizations that lead to poor outcomes. The re-hospitalization rate at Mater Dei hospital between 2013-2014 was 29%.

TS: What are we doing about heart failure in Malta? What do we offer patients? How does this help their prognosis?

In an attempt to reduce the re-admission rate, a heart failure clinic was set-up at Mater Dei Hospital. Patients suffering from the disease visit this nurse-led clinic whenever required. The main priorities of the clinic are optimization of medical therapy (according to the recent guidelines) and education of the patient. The latter focuses mainly on the nature of the heart failure process by teaching patients about regular weighing and compliance with medical therapy and fluid restriction. In 2015, a compassionate use programme was set-up in Malta with the novel heart failure drug Entresto® (sacubitril/ valsartan). Nineteen patients who attend the heart failure clinic were initiated on this therapy. Most recorded an improvement in symptoms with a significant decrease in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels. NT-proBNP is a biological marker of acute congestive heart failure.

TS: There were changes in the heart failure guidelines earlier this year. What has changed? What are your views on this? Is the treatment mentioned in the guidelines also available locally?

The new European Society of Cardiology guidelines on Acute and Chronic Heart Failure1 were presented in May 2016 in Florence at the Heart Failure Congress. Changes included a new classification and treatment algorithm. The new classification now includes: Heart failure with reduced ejection fraction (EF<40%); Heart failure with midrange ejection fraction (EF 40-49%); and Heart failure with preserved ejection fraction (EF >50%). The guidelines also indicate the use of the new compound Entresto®(sacubitril/valsartan), the first in the class of angiotensin receptor neprilysin inhibitors (ARNI): “In patients with chronic symptomatic HFrEF NHYA class II or III who tolerate an Angiotensin-converting enzyme inhibitor or Angiotensin II receptor blocker, replacement by an ARNI is recommended to further reduce morbidity and mortality” (Class I, Level of evidence B).

This novel heart failure therapy, which is now also available in Malta, proves to be very promising. The PARADIGM-HF study2 showed that when Entresto® was compared to the conventional heart failure drug enalapril, there was a 20% risk reduction in death from cardiovascular causes and a 21% risk reduction in heart failure hospitalization.

References 

1. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-200.

2. McMurray JJ, Packer M, Desai AS et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014 Sep 11;371(11):993-1004.