NewsMedical speaks with Prof. Martin Cowie, Interim Senior Vice President Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D at AstraZeneca, and Dr. Lisa Anderson, Heart Failure Specialist and Consultant Cardiologist at St George's Hospital, London, UK.
They discuss findings from the REVOLUTION HF and OverTTuRe studies, emphasizing the need for early diagnosis and intervention to improve patient outcomes and reduce healthcare costs.
Could you please start by introducing yourself, detailing your professional background, and your current role?
Prof. Cowie: I am the Interim Senior Vice President Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D at AstraZeneca. Previously, I served as the Chair of the Digital Health Committee of the European Society of Cardiology (2019-2022) and from 2016-2020 was a Non-Executive Director of the National Institute for Health and Care Excellence (NICE) in the UK.
I was also a Consultant Cardiologist at the Royal Brompton Hospital, London and led the multi-professional heart failure service from 2001 until 2022. As a cardiologist, I’ve seen first-hand the devastating impact of complex cardiovascular disease, including heart failure, and I’ve been privileged to help thousands of people manage their health issues during my time in clinical practice.
Dr. Anderson: I am a Heart Failure Specialist and Consultant Cardiologist at St George’s Hospital, London, UK, and currently chair the British Society for Heart Failure, the NHS England Heart Failure Expert Advisory Group and the ESC HFA Women in HF Taskforce.
I am committed to advancing research of cardiovascular disease to improve patient outcomes. My ongoing research interests include V122I TTR cardiac amyloid, cardiorenal HF and acute heart failure, and I have worked closely with colleagues, commissioners and St George’s Hospital to improve community and hospital heart failure services since my appointment in 2005, opening the first acute HF Unit in the UK in 2016.
You recently released new data underscoring the critical need for early diagnosis and intervention in heart failure. What do you believe are the most critical findings from the REVOLUTION HF program and the OverTTuRe study, and why are they significant for the future of heart failure management?
Dr. Anderson: We know heart failure is a complex disease that worsens over time. In fact, heart failure affects 64 million people worldwide and approximately half of people with heart failure die within 5 years of diagnosis. Earlier accurate diagnosis and rapid initiation of guideline-directed medical therapy (GDMT) is critical to improving outcomes for the millions of people impacted by this serious medical condition.
The REVOLUTION HF data that we recently presented at the European Society of Cardiology Heart Failure Congress underscores this urgent need to make changes in how we treat and manage care for these patients. From this study, we can see an immediate and very high risk of adverse outcomes, including hospitalisation and death, while patients with signs and symptoms of heart failure await a formal diagnosis.
The initiation of treatment with lifesaving, evidence-based medicines in these patients is often delayed until a specialist performs an echocardiogram (a sound wave scan of the heart that shows where the problems are). And yet, as shown by results from REVOLUTION HF, patients with suspected heart failure did not receive an echocardiogram for a median of 40 days.
Not only is this critical time lost, it also imposes a significant economic burden, as patients are admitted while still waiting for tests: the cost of care for these patients rose steeply immediately after heart failure was suspected and was four-fold higher in patients with suspected heart failure than those without signs and symptoms or a history of the disease.
We also know that heart failure has several stages and types and can be a result of a collection of different diseases. Understanding the different types of heart failure is critical to identifying what is driving the disease.
For example, a possible underlying cause of the type of heart failure with preserved ejection fraction (HFpEF) is a lesser-known condition called transthyretin amyloid cardiomyopathy (ATTR-CM), which is fatal if left untreated. It is estimated that ATTR-CM accounts for up to 15% of people with HFpEF.
Results from OverTTuRe show the interconnection between ATTR and cardiac problems, including heart failure symptoms, years before an accurate diagnosis is determined. Up to approximately 40% of patients showed a record of a cardiac condition, including heart failure, up to 5 years before their ATTR amyloidosis diagnosis.
However, this specific diagnosis is often missed, or only made after visits to several doctors over many months. This needs to change as there are treatment options available and more innovations on the horizon.
Taken together, these findings show that earlier interventions in heart failure present a significant opportunity to improve patient care, reduce preventable hospital admissions, and lower costs for health systems across the world.
In your view, how do the findings from REVOLUTION HF challenge the current paradigms of heart failure management?
Dr. Anderson: Findings from REVOLUTION HF highlight the need to establish rapid diagnosis and prompt initiation of life-saving therapies among patients with suspected heart failure.
Patients with signs and/or symptoms of heart failure in combination with elevated NT-proBNP levels have very high rates of mortality and morbidity shortly after presentation. Despite this, delays in diagnosis and treatment persist, even in a well-organized health system.
These findings highlight the need for a revolution in heart failure management, with the timely introduction of evidence-based medications once the NT-proBNP, signs and symptoms indicate a high likelihood of heart failure. This could start during the wait for full phenotyping by echocardiogram to reduce the burden on healthcare systems and reduce unnecessary admissions.
Image Credit: Komsan Loonprom/Shutterstock.com
REVOLUTION HF emphasizes the economic burden of delayed heart failure diagnosis. Can you discuss the potential economic benefits of earlier intervention?
Prof. Cowie: As people live longer—often with multiple comorbidities— heart failure is becoming more common. We also see clear cardiometabolic and cardiorenal interconnections with heart failure.
Almost half of patients with heart failure have chronic kidney disease. Hypertension, type 2 diabetes and obesity are often closely linked to heart failure. It is therefore critical that we better detect and treat such risk factors earlier to delay the onset of heart failure.
The burden continues to increase because of under-recognition, misdiagnosis, and multiple visits to healthcare providers; all of which generates significant costs to society. The annual global burden of heart failure is a staggering $346bn USD and is projected to increase by 127% by 2030.
Many people do not realize that heart failure is the leading cause of hospitalisations in people aged 65+ and has the highest 30-day readmission rate among all medical conditions.
The REVOLUTION HF findings highlight the urgency for timely heart failure diagnosis and rapid initiation of GDMT to enable early disease management and, ultimately improve patient morbidity and mortality and prevent burdening healthcare systems.
Could you elaborate on the importance of multi-disciplinary approaches in improving outcomes for heart failure patients?
Prof. Cowie: The implementation of best practice care models across multidisciplinary teams within both primary and secondary care has the potential to significantly improve patient outcomes and experience of care, and reduce associated costs.
As the REVOLUTION HF data highlights, the cost of care for patients substantially increased immediately after they began to show signs and symptoms of heart failure and had an elevated NT-proBNP, mainly driven by heart failure, followed by cardiorenal complications such as chronic kidney disease.
Such conditions can be hard to define and treat in routine clinical practice and in cases of heart failure where there is an underlying disease, there is a need for different specialists to come together and identify the cause and appropriate treatment.
REVOLUTION HF suggests a need for political prioritization of heart failure. What policy changes would be necessary to incorporate these findings into practice across different healthcare systems?
Prof. Cowie: Data suggests that awareness and recognition of heart failure are still too low among decision-makers and the public. There is an urgent need for political prioritisation of heart failure and support of effective strategies to reduce hospitalisations and improve outcomes for those affected by this condition.
Some areas for improvement that have been highlighted by heart failure experts include:
- Early diagnosis of heart failure in a community setting: Evidence in England suggests that early detection of heart failure patients reduced hospitalization by 45%. Further data also suggests that patients diagnosed in the community setting as opposed to emergency admission live longer and result in cost savings for health systems. The use of the NT-proBNP blood test is one low-cost method to enable rapid diagnosis of heart failure in the community setting. However, limited awareness, understanding, and reimbursement of this test hinders its use.
- Guideline-directed medical therapy (GDMT) interventions: A low threshold for GDMT initiation in patients suspected of heart failure with signs and/or symptoms and elevated NT-proBNP needs to be adopted to improve morbidity and mortality. It is essential to raise awareness among policymakers and decision makers about global guidelines and advocate for the timely integration of the latest guidelines into key documents, including national strategies, local care pathways, professional guidance, patient information, regulatory frameworks, quality metrics, and reimbursement policies.
- Multidisciplinary and integrated models of heart failure care: Implementation of best practice models which include specialist-led programs and integration between community and specialist care to potentially reduce heart failure hospitalization rates and lead to significant cost reductions.
Image Credit: Jarun Ontakrai/Shutterstock.com
These findings were discussed at the recent European Society of Cardiology Heart Failure Congress in Lisbon, Portugal. How important are conferences like this for sharing and advancing research in heart failure? What do you hope to achieve at future conferences?
Prof. Cowie: These medical meetings are crucial for the scientific community to share and exchange knowledge and advances that can potentially transform clinical practice and change patients’ lives.
Our attendance at meetings like the European Society of Cardiology Heart Failure Congress is rooted in our commitment to better understanding the changes we need to make in the treatment and management of this disease with the ultimate aim of transforming care and improving outcomes.
Personally, what has been your most significant insight or learning from being involved in this research?
Prof. Cowie: The heart failure landscape has changed greatly since I first entered the medical profession more than 30 years ago, and there is the promise of more scientific advances ahead. However, there are many gaps in the delayed detection and diagnosis of heart failure and the existing treatment and management of heart failure which require urgent political prioritisation.
As Dr. Anderson mentioned, we’re seeing this play out even in the most well-funded and organized healthcare systems. Understanding potential pathways to a heart failure diagnosis, when coupled with effective policy change to prioritise timely detection and management of heart failure, will make the outlook brighter for the millions of people around the world affected by this condition.
Dr. Anderson: Through both REVOLUTION HF and OverTTuRe, we now have further evidence of what we are seeing in clinical practice: the need for early intervention and recognition of the signs and symptoms of heart failure as well as the interconnectedness of heart failure with other diseases.
Through a relatively simple blood test earlier in the patient journey, we have the potential to make a significant impact in patient and clinical outcomes and ease the economic burden of this disease on healthcare systems in the process.
Considering the global increase in heart failure, how can different countries apply these findings to reduce the overall burden of heart failure?
Prof. Cowie: While improving heart failure patient outcomes through early symptom recognition and effective approaches to diagnosis is a key area of focus, there are other opportunities to drive change.
Scientific advances have led to the use of therapies that can delay disease progression, significantly improving patient outcomes, but further innovation is needed to tackle the underlying causes of disease.
Delaying the onset of heart failure by better detection and treatment of risk factors such as hypertension, coronary heart disease, diabetes, and obesity is also something we all need to do better.
Based on the latest data, what are the next steps in research that you believe are crucial for further improving heart failure management?
Prof. Cowie: Science is advancing our understanding of the biology of heart failure diseases and enhancing our ability to develop the next wave of innovations. Our efforts in ATTR-CM are one example of AstraZeneca’s broader heart failure strategy, diving deeply into the root cause of heart failure to determine what difference we need to make in how we treat disease, transform care and ultimately improve patient outcomes.
By harnessing the power of next generation therapeutics and digital innovations we aim to halt disease progression, protect vital organs and, ultimately, pave the way to a cure for heart failure.
Dr. Anderson: It is critical to understand all potential pathways to a heart failure diagnosis to help determine the specific type and root causes. Clinicians now have much earlier opportunities in the patient journey to recognise and act on specific factors associated with heart failure, including ATTR amyloidosis, when patients present with cardiac comorbidities or manifestations.
Where can readers find more information?
About Professor Martin Cowie
Professor Martin Cowie is the Interim Senior Vice President Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D at AstraZeneca. He previously served as the Chair of the Digital Health Committee of the European Society of Cardiology (2019-2022) and was a Non-Executive Director of the National Institute for Health and Care Excellence (NICE) in the UK from 2016-2020.
Prof. Cowie was also a Consultant Cardiologist at the Royal Brompton Hospital, London, where he led the multi-professional heart failure service from 2001 until 2022. As a cardiologist, he has seen the devastating impact of complex cardiovascular disease, including heart failure, and has been privileged to help thousands of people manage their health issues during his time in clinical practice.
About Dr. Lisa Anderson
Dr. Lisa Anderson is a Heart Failure Specialist and Consultant Cardiologist at St George’s Hospital, London, UK. She currently chairs the British Society for Heart Failure, the NHS England Heart Failure Expert Advisory Group, and the ESC HFA Women in HF Taskforce. Dr. Anderson is committed to advancing research in cardiovascular disease to improve patient outcomes.
Her ongoing research interests include V122I TTR cardiac amyloid, cardiorenal HF, and acute heart failure. Since her appointment in 2005, she has worked closely with colleagues, commissioners, and St George’s Hospital to improve community and hospital heart failure services, opening the first acute HF Unit in the UK in 2016.
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