Historical aspects and current advances in pharmacological therapy for chronic heart failure

This review presents a synthesis of major Russian and international research findings on chronic heart failure and current principles of its management. Russian, American, and European clinical guidelines on heart failure were analyzed. This study examined and reinterpreted the results of international multicenter randomized trials such as “Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure,” “Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitors with Angiotensin-Converting Enzyme Inhibitors to Determine Impact on Global Mortality and Morbidity in Heart Failure,” and “Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure” and statistical data on cardiovascular diseases from the American Heart Association. Based on left ventricular ejection fraction, three main phenotypes of chronic heart failure were distinguished: reduced, mildly reduced, and preserved ejection fraction. American cardiology societies recommend the term heart failure with improved ejection fraction for patients whose left ventricular ejection fraction has increased to >40% during treatment and increased by >10% over time. Differentiation among these phenotypes is crucial owing to differences in comorbidities and treatment response. Overall, treatment approaches for chronic heart failure have changed over time; however, in the past few decades, they have undergone dramatic transformations. In the mid-20th century, the only drugs used for treatment were cardiac glycosides and loop diuretics; the modern approach provides for the use of quadruple therapy. Comparative analysis of the international multicenter randomized trials demonstrated significant advantages of combination therapy. Nevertheless, despite clear advances in treatment and prevention, the number of patients with chronic heart failure continues to increase. In the United States, over 6.5 million people suffer from heart failure, whereas in the Russian Federation, the prevalence of chronic heart failure increased from 6.7% in 2002 to 8.2% in 2017. Moreover, mortality from heart failure among the population remains high. In the United States, the 5-year mortality after diagnosis is approximately 50%, and in the Russian Federation, an average of 414,000 people with functional class III–IV chronic heart failure die each year. These indicate the need to continue searching for new therapeutic approaches and drug targets.