Adam DeVore, MD, MHS Duke University

1. Navigating Worsening HF Events: What is
Worsening HF and How to Recognize It?
Duke Heart Failure Symposium
Adam DeVore, MD, MHS
Associate Professor of Medicine
May 4, 2024

2. • Research grants: Biofourmis, Bodyport, Cytokinetics, American Regent, Inc,
the NIH and NHLBI, Natera, Novartis, Story Health, and Ventricle Health
• Consulting and/or Honoraria: Abiomed, Bodyport, Cardionomic, LivaNova,
Myovant, Natera, NovoNordisk, and Zoll
Disclosures

3. •What is worsening HF (and do we really need another
term in HF)?
•Should patients with worsening HF receive different
therapies?
Objectives

4. Worsening Heart Failure
Greene SJ et al. J Am Coll Cardiol. 2023 Jan 31;81(4):413-424.

5. • Do we really need another term in HF?
• Escalating HF signs or symptoms in patients with chronic HF despite
previously stable therapy + requires an urgent escalation of care
– should not be defined by need for hospital-based care
• Other names: Persistent HF, Stage C2 HF, Severe HF
Worsening HF: Terminology and Definition
Bozkurt B et al. JACC Heart Fail. 2024 Mar;12(3):595-598
Greene SJ et al. J Am Coll Cardiol. 2023 Jan 31;81(4):413-424
Carroll AM et al. J Card Fail. 2023 May;29(5):818-831

6. Stage C HFPossible Categories
Modified from Bozkurt B et al. JACC Heart Fail. 2024 Mar;12(3):595-598
- HF in Remission
- Improving HF
- Severe/Worsening HF (10-25%?)
--insufficient response to foundational therapy aka
“standard GDMT”
--persistent congestion +/- frequent hosps
or
--symptoms, arrhythmia burden, biomarkers,
imaging, ↓ exercise performance, and/or
hemodynamics
What about discordant data?

7. So Just Worry More?

8. Now What?
2. Ensure Adequate Foundational Therapy
--HFrEF: ARNI, BB, MRA, SGLT2i
--HFmrEF/HFpEF: SGLT2i, ?MRA, ?ARNI
Modified from Bozkurt B et al. JACC Heart Fail. 2023 Jun;11(6):729-732
3. Adjunctive Therapies by a Specialist
• Better decongestion?
• Cardiac rehab
• Ivabradine
• Soluble guanylate cyclase (sGC) stimulators
• Hydralazine/nitrates
• maybe digoxin
• IV iron
• Atrial fibrillation
• Treat other comorbid conditions (e.g., sleep apnea)
• Valvular disease (TV and MV)
• Cardiac resynchronization therapy
• CardioMEMS and disease management
• Barostim and cardiac contractility modulation
• Investigational therapies
1. Identify Severe/Worsening HF
--insufficient response to foundational therapy
--persistent congestion +/- frequent hospitalizations
--symptoms, biomarkers, ↓ exercise performance,
and/or abnormal hemodynamics
4. Evaluate Response to Therapy
--Perhaps we delay advanced HF therapies
but maintain extreme paranoia

9. What is Needed?
• Improved characterization of a patient’s HF status (ID worsening HF)
-terminology for patients who have progressed beyond early-stage C HF
-an advanced HFpEF phenotype
• Clinical trials of pharmacologic and nonpharmacologic treatments in
participants with severe HF
-infrastructure necessary for rapidly identifying appropriate participants
-data on medical therapy and devices
• New ways to teach & deliver specialty HF care outside of transplant
and LVAD centers to address inequities in care

10. Worsening HF: Escalating HF signs or symptoms in patients with
chronic HF despite previously stable therapy + requires urgent care
Recognized by: Symptomatic nonresponse, functional nonresponse,
cardiac function/structural nonresponse, biomarker nonresponse
Treatment: Important role for specialty care and adjunctive therapies
Conclusions

11. Questions?
Adam DeVore
adam.devore@duke.edu

12. Thank You
Adam DeVore
adam.devore@duke.edu