Heart failure affects the quality and length of life of an estimated 64 million individuals worldwide.1 In the UK, the burden of heart failure is increasing and, as of 2018, was comparable to the combined burden of breast, prostate, lung, and bowel cancer –the four the most common cancers – combined, although uncertainties persist about precise numbers due to the difficulty of diagnosing heart failure and current methods of accounting.2 Many patients with heart failure are older and have comorbidities with symptoms that overlap with those of heart failure, but require distinct treatment programmes.3 Unfortunately, advanced age, comorbidities, and poor treatment are associated with poorer prognosis.2 In this issue of Considerations in Medicine, a panel of clinicians – with expertise in fields ranging from primary care to cardiovascular transplant to left ventricular assist devices – considers the prevention, diagnosis, and management of heart failure, as well as pressing unmet needs. This issue discusses current clinical practice and highlights critical shortcomings, with the aim of driving change to improve patient outcomes, which have stagnated over the last two decades.4

In ‘Diagnosis and Initial Management of Heart Failure’ in this issue, Pellicori et al discuss the need for early diagnosis and treatment. Current guidelines for diagnosing heart failure heavily depend on patient history and clinical signs and symptoms, which are complex, heterogeneous, and shared with many other conditions.5–7 Signs and symptoms that are commonly associated with heart failure, like breathlessness at rest and peripheral oedema, are both non-specific and characteristic of late-stage dysfunction. These confounding factors mean that many patients are first diagnosed with heart failure only after they have been hospitalised.8 These data beg the question, are we waiting too long to consider the development of heart failure, by waiting for symptoms and signs to manifest?4 New definitions of heart failure have recently been proposed that focus on the identification of patients at risk of heart failure and the determination of congestion, indicated by elevated natriuretic peptide levels in the blood, as the cause of cardiac dysfunction.9 10 Focusing on patients with risk factors, rather than symptoms, and centring congestion in this way would require a change in thinking as well as in clinical practice, but could improve early diagnosis of heart failure. Pellicori et al further suggest that broader access to and widespread application of diagnostic tools like N-terminal pro B-type natriuretic peptide testing would aid in confirming diagnosis and informing appropriate treatment.

Even beyond reflecting on early identification, Taylor et al consider approaches to prevent illness in ‘Predicting and Preventing Heart Failure’. The authors broach several tactics to prevent heart failure, first by increasing public awareness. Crucially, attempts to combat the development of heart failure with improved education should start in early life, well before risk factors begin to accumulate. Taylor et al also identify a gap in the current guidelines for heart failure diagnosis and treatment: the near absence of guidance on how to prevent heart failure in the first place. An expansion of the guidelines to directly address and include a specific framework for the prevention of heart failure could shift the way that clinicians approach patient care. In line with that aim, improvements are outlined for primary care providers, with a suggested focus on identifying individuals at risk of developing heart failure based on thorough patient histories and the presence of known risk factors, including obesity, type two diabetes, and hypertension.

After diagnosis, attention turns to treatment, as discussed by Ahmed et al in ‘Managing Heart Failure in the Longer Term’. They anticipate that defined plans for patient care – featuring designated care providers and locally agreed shared-care protocols – could aid in the establishment of optimal treatment regimens. To ensure that medications are appropriately maintained or adjusted, and that deterioration does not proceed unchecked between patient visits, the authors recommend follow-up monitoring. Among the current options for heart failure treatment, loop diuretics remain the first-line treatment for decongestion, and new classes of drugs and repurposed drugs, such as sodium-glucose co-transporter two inhibitors and glucagon-like peptide one agonists, increase treatment options. Beta blockers, digoxin, catheter ablation for atrial fibrillation, mineralocorticoid receptor antagonists, and angiotensin-converting enzyme inhibitors also form part of the treatment landscape. The authors discuss not only the range of available therapeutics, but also their limitations. In particular, they conclude that therapies for heart failure with reduced ejection fraction are well established, but there remains a particular need for additional research on effective treatments for heart failure with preserved ejection fraction.

Halliday et al envision the development of just such targeted approaches to treat heart failure with preserved ejection fraction and other treatments based on disease mechanism, in ‘Evolutions in Care, Unmet Needs, and Research Priorities in Heart Failure’. The authors identify sacubitril–valsartan and sodium-glucose co-transporter two inhibitors as emerging core treatments for patients with symptomatic heart failure with reduced ejection fraction and elevated natriuretic peptide levels, but expect vericiguat and omecamtiv mecarbil to have a more limited application. The care of patients with improved cardiac function is also discussed. The authors look toward a future in which the risk of relapse after medication withdrawal from responsive patients is managed with individualised therapies that correspond to disease mechanism in order to optimise patient quality of life.

To make the vast topic of heart failure more approachable, case studies have been included in the manuscripts. The experts assess the cases of fictional individuals, Mrs Jennifer Logan and Mr David Jones, at various stages of health and deterioration to identify missed opportunities for prevention or early detection, and recommend treatment regimens or interventions that could improve patient outcomes. These case studies also provide readers with the chance to compare and consider their own experiences and approaches to treatment.

Heart failure is a syndrome, rather than a disease, with a common final pathway of congestion. The management of heart failure, which has advanced without significantly improving patient survival after diagnosis, requires a paradigm shift that includes our basic characterisation of the disorder, public awareness, and all aspects of care. This issue of Considerations in Medicine identifies many of the limitations of our current approaches and looks toward better prevention, diagnosis, and treatment of heart failure in the future. I commend these articles to you in the hope of initiating discussion and catalysing change in our approach to dealing with heart failure.