Should we still be using some of the traditional IV drugs used in acute and advanced heart failure?

At the European Society of Cardiology (ESC) Congress 2019 in Paris, the results of the GALACTIC trial were reported by Professor Müller (Basel). Early intensive vasodilation using personalised high doses of nitrates, oral hydralazine and rapid up-titration of ACE inhibitors or angiotensin II receptor blockers did not improve 180-day mortality in a cohort of 781 acute heart failure (AHF) patients. This trial is notable, among other things, for the fact that short-term use of conventional ‘tried and tested’ (and extremely cheap) vasodilators, administered in an intensive regime and at high dose was just as ineffectual at influencing longer-term mortality as novel agents such as ularitide and serelaxin.

The inability to demonstrate survival benefit, even from drugs that are established as part of the therapeutic armamentarium for AHF, highlights some fundamental issues contributing to the paucity of new drug therapies in recent decades. For example, are we targeting the wrong pathological processes in our drug development programmes or are we privileging inappropriate endpoints in clinical trials and therefore hampering the regulatory approval of useful new agents?

The general lack of evidence for an ongoing survival benefit from acute-phase treatments for AHF requires some reflection. While perhaps not fully subscribing to its philosophical outlook, we find much to agree with in the views of McCullough, who has argued that AHF (and by extension advanced heart failure [AdHF]) is a situation often long in the making and that to expect any therapy administered for <48 h to make a robust difference to survival or rehospitalisation many months after the index admission, is to misunderstand the pathophysiology of these conditions. 

Hospitalisation for heart failure, whether as a presentation of AHF or a decompensation in the context of AdHF, results in a down-shift in the trajectory of the syndrome that is associated with worsening outcomes and patient quality of life plus increased costs of care. Medical progress to address these challenges has substantially stalled in the past 20 years, but advances in data technology and analytics, along with developments in clinical trial design, now offer opportunities to re-envision heart failure as a complex pathophysiological continuum in ways that may help to bring a new generation of therapies into clinical use. Meanwhile it would be advisable for clinicians to evaluate if the near total lack of evidence of benefit with some of the traditional IV drugs used in AHF and AdHF (such as the catecholamines) warrants their elimination from routine use in favour of treatments where such evidence has accrued.

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