Q: What drugs treat heart failure with reduced EF?

ESC and AHA guidelines recommend four drug pillars for HFrEF, each reducing mortality independently: (1) ARNi (sacubitril/valsartan) or ACE inhibitor — blocks the renin-angiotensin system and (with sacubitril) enhances natriuretic peptides; (2) beta-blocker (bisoprolol, carvedilol, metoprolol succinate) — reduces heart rate and sympathetic activation; (3) mineralocorticoid receptor antagonist (spironolactone, eplerenone) — blocks aldosterone; (4) SGLT-2 inhibitor (dapagliflozin, empagliflozin) — the newest pillar, reduces HF hospitalisation and CV death. All four together reduce mortality by approximately 60-70% vs no treatment.

Q: What is the SGLT-2 inhibitor breakthrough?

SGLT-2 inhibitors (sodium-glucose co-transporter 2 inhibitors) were originally developed as diabetes medications — but have proven to be the most significant advance in heart failure treatment in a generation. DAPA-HF and EMPEROR-Reduced trials showed approximately 25% relative risk reduction in CV death + HF hospitalisation in HFrEF (both with and without diabetes). EMPEROR-Preserved and DELIVER trials then showed benefit in HFpEF — the first class to do so. SGLT-2 inhibitors are now first-line across all HF subtypes. Mechanism beyond diuresis: likely includes direct myocardial, mitochondrial and anti-inflammatory effects.

Q: What is advanced heart failure?

Advanced HF — NYHA class IV symptoms, recurrent hospitalisations, inadequate response to maximal medical therapy — has very poor prognosis and requires specialist evaluation. Options: heart transplantation (gold standard — waiting lists are long); left ventricular assist device (LVAD — mechanical pump supporting the heart, as bridge to transplant or as destination therapy); palliative care and goal-directed therapy for symptom relief. Survival with modern LVADs (HeartMate 3) at 2 years approaches 80% — comparable to transplant.

Q: How does heart failure relate to other conditions?

Heart failure shares risk factors with — and is caused by — most other cardiovascular conditions. Ischaemic cardiomyopathy (post-MI) is the most common HF cause in HICs. Hypertension is the most common cause in Africa and parts of Asia. Diabetes doubles HF risk and worsens outcomes. Atrial fibrillation and HF are mutually reinforcing — each causing and worsening the other. Kidney disease (cardiorenal syndrome) frequently coexists with HF, complicating diuretic management. Anaemia is common in HF and worsens outcomes.

Q: What are cardiac devices for heart failure?

Implantable cardioverter-defibrillators (ICDs): prevent sudden cardiac death from ventricular arrhythmias — recommended in HFrEF with EF ≤35% on optimal medical therapy. Cardiac resynchronisation therapy (CRT): biventricular pacing resynchronises the heart's contraction — improving EF, symptoms and survival in HFrEF with left bundle branch block (LBBB). CRT-D (with defibrillator): the preferred device when both ICD and CRT are indicated.

Q: How does GMJ News cover heart failure?

GMJ News covers ESC heart failure guidelines, SGLT-2 inhibitor trial results, sacubitril/valsartan evidence, advanced heart failure management and HF burden data. Heart failure is a major cardiovascular challenge in Georgia — driven by high rates of hypertension, ischaemic heart disease and diabetes — directly relevant to PHIG's cardiovascular programme and the Georgian Medical Journal.

Question 1

What is heart failure?

Accepted Answer

Heart failure (HF) is a clinical syndrome where the heart cannot pump enough blood to meet the body's metabolic demands at normal filling pressures — or can only do so at the cost of abnormally elevated filling pressures. It causes dyspnoea, fatigue, exercise intolerance and fluid retention (oedema, pulmonary congestion). HF is not a single disease but a common final pathway of many cardiac conditions — ischaemic cardiomyopathy (post-MI), dilated cardiomyopathy, hypertensive heart disease, valvular disease, and others.

Question 2

How many people have heart failure?

Accepted Answer

An estimated 64 million people globally have heart failure. Prevalence is rising — driven by population ageing, increasing diabetes and obesity rates, and improved survival after acute myocardial infarction (more patients surviving MI to develop HF). In Europe and North America, HF affects approximately 2-3% of the general population; prevalence exceeds 10% in adults over 70. HF is the leading cause of hospitalisation in adults over 65 in high-income countries and accounts for approximately 1-2% of all healthcare expenditure.

Question 3

What are HFrEF and HFpEF?

Accepted Answer

Heart failure is classified by left ventricular ejection fraction (EF): HFrEF (heart failure with reduced EF — EF <40%): the heart muscle is weakened and contracts poorly. The most studied form, with four drug pillars proven to reduce mortality. HFpEF (HF with preserved EF — ≥50%): the heart muscle is stiff and relaxes poorly (diastolic dysfunction), but contracts normally. Approximately 50% of all HF; predominantly in older, hypertensive, obese women; historically had no proven disease-modifying therapy until SGLT-2 inhibitors. HFmrEF (mildly reduced EF — 40-49%): intermediate category, increasingly treated like HFrEF.

Question 4

What drugs treat heart failure with reduced EF?

Accepted Answer

ESC and AHA guidelines recommend four drug pillars for HFrEF, each reducing mortality independently: (1) ARNi (sacubitril/valsartan) or ACE inhibitor — blocks the renin-angiotensin system and (with sacubitril) enhances natriuretic peptides; (2) beta-blocker (bisoprolol, carvedilol, metoprolol succinate) — reduces heart rate and sympathetic activation; (3) mineralocorticoid receptor antagonist (spironolactone, eplerenone) — blocks aldosterone; (4) SGLT-2 inhibitor (dapagliflozin, empagliflozin) — the newest pillar, reduces HF hospitalisation and CV death. All four together reduce mortality by approximately 60-70% vs no treatment.

Question 5

What is the SGLT-2 inhibitor breakthrough?

Accepted Answer

SGLT-2 inhibitors (sodium-glucose co-transporter 2 inhibitors) were originally developed as diabetes medications — but have proven to be the most significant advance in heart failure treatment in a generation. DAPA-HF and EMPEROR-Reduced trials showed approximately 25% relative risk reduction in CV death + HF hospitalisation in HFrEF (both with and without diabetes). EMPEROR-Preserved and DELIVER trials then showed benefit in HFpEF — the first class to do so. SGLT-2 inhibitors are now first-line across all HF subtypes. Mechanism beyond diuresis: likely includes direct myocardial, mitochondrial and anti-inflammatory effects.

Question 6

What is advanced heart failure?

Accepted Answer

Advanced HF — NYHA class IV symptoms, recurrent hospitalisations, inadequate response to maximal medical therapy — has very poor prognosis and requires specialist evaluation. Options: heart transplantation (gold standard — waiting lists are long); left ventricular assist device (LVAD — mechanical pump supporting the heart, as bridge to transplant or as destination therapy); palliative care and goal-directed therapy for symptom relief. Survival with modern LVADs (HeartMate 3) at 2 years approaches 80% — comparable to transplant.

Question 7

How does heart failure relate to other conditions?

Accepted Answer

Heart failure shares risk factors with — and is caused by — most other cardiovascular conditions. Ischaemic cardiomyopathy (post-MI) is the most common HF cause in HICs. Hypertension is the most common cause in Africa and parts of Asia. Diabetes doubles HF risk and worsens outcomes. Atrial fibrillation and HF are mutually reinforcing — each causing and worsening the other. Kidney disease (cardiorenal syndrome) frequently coexists with HF, complicating diuretic management. Anaemia is common in HF and worsens outcomes.

Question 8

What are cardiac devices for heart failure?

Accepted Answer

Implantable cardioverter-defibrillators (ICDs): prevent sudden cardiac death from ventricular arrhythmias — recommended in HFrEF with EF ≤35% on optimal medical therapy. Cardiac resynchronisation therapy (CRT): biventricular pacing resynchronises the heart's contraction — improving EF, symptoms and survival in HFrEF with left bundle branch block (LBBB). CRT-D (with defibrillator): the preferred device when both ICD and CRT are indicated.

Question 9

How does GMJ News cover heart failure?

Accepted Answer

GMJ News covers ESC heart failure guidelines, SGLT-2 inhibitor trial results, sacubitril/valsartan evidence, advanced heart failure management and HF burden data. Heart failure is a major cardiovascular challenge in Georgia — driven by high rates of hypertension, ischaemic heart disease and diabetes — directly relevant to PHIG's cardiovascular programme and the Georgian Medical Journal.

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