New perspectives and future directions in the treatment of heart failure

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  Fig. 1. The present and future of heart failure. Conventionally, the prevalence of heart failure is thought to be about 1.5% in the adult population. However, it might be substantially greater than that, as many cases remain undiagnosed, particularly amongst older people, and are usually only identified when symptoms are severe enough to require hospital admission. Several ongoing trials target different pathways that might contribute to disease progression. Success provides tentative insights into the likely mechanisms of progression, although off-target effects may lead to serendipitous effects (this is probably true of most effective treatments for heart failure). There may be many reasons for failure other than the lack of importance of the targeted mechanism. This may include a smaller than anticipated benefit with consequent lack of power, lack of target engagement, a mechanism that is important but only works in a specific subgroup (e.g., heart rate reduction in sinus rhythm) or one that is overwhelmed by competing risks (e.g., rivaroxaban 2.5 mg bd for advanced heart failure in sinus rhythm). Processing large volumes of routinely collected electronic health records using novel…