Why are we still under-diagnosing the second-most fatal disease in the country?

An announcement this summer about the results of a landmark trial for a drug for a previously untreatable type of heart failure went unnoticed by most Canadians. But for healthcare professionals and researchers in cardiology, and for the hundreds of thousands of Canadians living with this complex condition, it was tremendous news. The trial, which focused on a molecule called empagliflozin, is significant because it marked the first time a drug has been shown to be effective in reducing the risk of death or hospitalization–by as much as 21 per cent–from heart failure with preserved ejection fraction, which accounts for half of the estimated 670,000 heart failure cases in Canada. The same drug also demonstrated a 25 per cent reduction in risk of death or hospitalization from the other main form of this disease: heart failure with reduced ejection fraction. This adds to existing treatments for patients with this type of heart disease, which is typically addressed with four therapeutic drug classes as standard therapy, sometimes combined with other novel treatments. Another drug, dapagliflozin, also showed promising results in a recent trial focused on heart failure with reduced ejection fraction, with lower rates of hospitalization, urgent hospital visit or death among patients who took the drug versus those who took a placebo. The bottom-line news from all of this is that today, we know a drug exists that can give all patients with heart failure–whether characterized by preserved or reduced ejection fraction–a strong fighting chance. That’s a giant step forward from yesterday, when only half of heart failure patients could hope to avoid hospitalization and survive their heart disease–the second leading cause of death among Canadians, after cancer. Read: Diagnosing acute aortic syndrome: new guideline for hard-to-diagnose condition But for patients to benefit from innovative therapies, their condition must first be recognized and diagnosed correctly, by way of an NT-pro B-type natriuretic peptide blood test and echocardiogram. Sadly, too many patients with heart failure aren’t getting the right diagnosis and care. One review of heart failure literature found that the rate of misdiagnosis ranged from just over 16 per cent in hospital settings to close to 70 per cent when general practitioners referred patients to specialists. The most common misdiagnosis was chronic pulmonary disease, according to the review. In some cases, the symptoms of heart failure are simply dismissed as normal signs of ageing (although heart failure affects young people as well–some of my patients were children when they were first diagnosed with heart failure. As a result, patients can spend months or years without the proper interventions which, in addition to medication for those with reduced ejection fraction, might include making heart-healthy lifestyle choices such as limiting salt consumption, aiming for a healthy weight, exercising regularly and avoiding or limiting alcohol. How can physicians do better for patients with heart failure? What can we change in our practice to ensure we’re identifying those who may have this disease so that we can test and treat them appropriately? As a start, we need to include heart failure in our mental list of possible conditions when people present with exercise intolerance, difficulty breathing, coughing, fatigue, general weakness, and fluid buildup in the lungs or the limbs–symptoms that are often attributed mistakenly to other illnesses such as asthma or chronic obstructive pulmonary disease. We also need to educate our patients about heart failure so that they can become better-informed advocates for their diagnosis and care. When I participated in two virtual roundtables this year–one for heart failure patients and another for physicians treating heart failure patients–I heard from patients that they often felt shocked, lost or isolated after they were diagnosed with heart failure and some even felt they were somehow to blame for their condition. Many could not fathom how the disease would change their lives. Those who turned to the Internet for guidance were often overwhelmed by the amount of debatable information online. Physicians, too, expressed concerns during the virtual roundtable. A couple of them noted that the lifetime commitment to a daily management routine that includes monitoring weight and blood pressure is highly challenging for many patients. The doctors also observed that, despite evidence suggesting heart failure patients followed by both primary care and specialist physicians had much better survival rates than those followed only by primary care or specialists, getting specialty care remains difficult, especially for Canadians who live in small or remote communities. My hope is that greater awareness about heart failure will also lead to more advocacy and concerted action at the provincial and federal levels. We need more funding, not only to advance and deepen research into heart failure, but also to support resources such as local peer support groups and mental health programs for heart failure patients and their caregivers. The medications for heart failure with reduced ejection fraction are already here, and another one which is shown to be effective in addressing both types of heart failure is awaiting review and approval from Health Canada. For heart failure patients, their families and care providers, there has never been a more hopeful time. Read: Study shows risks for COPD varies across Canada Dr. Anique Ducharme is a professor of medicine at the Université de Montréal, and director of the Heart Failure Clinic at Montreal Heart Institute Research Centre. Dr. Anique is also president of the Canadian Heart Failure Society.

Why are we still under-diagnosing the second-most fatal disease in the country?

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