BSH 2023: collaboration, coordination and cooperation

Multidisciplinary experts in heart failure care from across the UK and wider afield gathered for the recent 26th British Society of Heart Failure (BSH) annual meeting. This year’s programme sought to highlight how collaboration, coordination and cooperation would ultimately be vital for the delivery and success of the flagship 25in25 initiative. The meeting, held at the Queen Elizabeth II Centre, London, on 30th November and 1st December 2023, offered thought-provoking plenary sessions, focused masterclasses, a new ‘technology in action’ demonstration area, plus a number of high-quality poster presentations. Dr Aaron Henry reports highlights from the meeting.

25in25

The meeting began with an update on the 25in25 initiative from BSH Chair-Elect Dr Lisa Anderson (St George’s University Hospital, London). This national quality improvement initiative, led by the BSH in collaboration with over 54 national and international healthcare organisations, has the goal of reducing heart failure deaths by 25% over the next 25 years. With already over one million people in the UK living with heart failure, a number which is expected to double by 2040, the ambitious initiative is eagerly awaited. In the UK alone this could translate to over 10,000 lives saved per year.

A population health approach underpins the initiative, with an emphasis on national collaboration. The initial steps involve the implementation of fast-track communities (FTC), inspired by the HIV fast track cities model.¹ This approach includes the creation of a dashboard to assess metrics across four key areas:

Identification of those at risk of heart failure
Accurate and timely diagnosis
Guideline directed-medical therapy
Quality of life and wellbeing

Table 1. British Society for Heart Failure ‘25in25’ fast track communities

Swansea

Blackpool

North West Anglia

Birmingham

Liverpool

Jersey

Glasgow

Seven sites have been announced for the initiation of the FTC project (see table 1), which started in January 2024. The plan is to roll out the project nationally in 2025, with significant engagement from EU governments and international societies promising further expansion internationally.

Cardiometabolic clinics

Dr Mimi Chen (St George’s University Hospital, London), a Consultant Endocrinologist, shared experiences of developing a successful cardiometabolic clinic at St George’s. The significance of this clinic stems from the alarming global prevalence of diabetes – affecting one in 11 adults, and expected to rise to over 600 million by 2045.² These patients are at a two- to three-fold increased risk of heart disease. Similarly, the prevalence of obesity, a recognised contributor to heart failure, is increasing with almost two-thirds of UK adults overweight or obese.³

This clinic adopts a multidisciplinary approach, integrating the expertise of a heart failure cardiologist, an endocrinologist, and a heart failure pharmacist. Its primary function is to address cardiovascular disease (CVD) in patients who are living with diabetes or obesity. The clinic accepts referrals from within trust specialists, encompassing cardiology, metabolic, and surgical departments, as well as from community heart failure teams. Collaboration with other specialisms is a key feature of the clinic, involving sleep clinics, hepatology, bariatric surgery, community heart failure and lymphoedema teams. A large focus is placed on the American Heart Association’s (AHA) ‘Life’s Simple 7’⁴ prescription for cardiovascular health:

Stop smoking
Eat better
Get active
Lose weight
Manage blood pressure
Control cholesterol
Reduce blood sugar

The clinic also emphasises the importance of early initiation of triple therapy for those with cardiovascular disease and ‘diabesity’—a combination of metformin, a sodium-glucose co-transport-2 (SGLT2) inhibitor, and a glucagon-like peptide 1(GLP-1) receptor agonist. There are, of course, challenges, including sick day rules, medication side-effect profiles, insulin adjustment, medication discontinuation, and the national shortage of GLP-1 receptor agonists. The clinic’s approach offers several advantages: it leverages multiple areas of expertise, reduces waiting times for cross-referral (shortening this period by at least six months), and promotes early intervention and admission avoidance. Looking forward, the clinic aims to expand its multidisciplinary team by including a nephrologist to evolve into a CardioRenalMetabolic clinic, enhancing its scope and efficacy in treating complex patients.

Obesity and heart failure

Professor Naveed Sattar (University of Glasgow) explained why heart failure specialists should know about obesity. It is strongly linked to heart failure. This is due to both increases in risk factors, such as hypertension, diabetes and dyslipidaemia but also a direct effect, which is much harder to measure and likely includes haemodynamic, cellular factors over nutrition and inflammatory mechanisms. Moreover, data from registries and genetic studies implicate obesity in having a causal role in the development of heart failure.^5,6

It follows that treating obesity will reduce the likelihood of developing heart failure, and non-randomised studies of bariatric surgery have shown significant reductions in heart failure incidence following weight loss surgery.⁷ More recent studies have shone a light on targeting obesity in those living with heart failure. The STEP HFpEF (Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity) trial, presented at last year’s European Society of Cardiology (ESC) Congress, showed that the GLP-1 receptor agonist semaglutide was associated with both a 13% decrease in body weight and a remarkable improvement in quality of life.⁸ Putting this improvement in symptoms into context, the results were significantly greater than those seen in trials investigating SGLT2 inhibitors or mineralocorticoid receptor antagonists (MRAs) for heart failure with preserved ejection fraction (HFpEF).⁹ Outcome trials of weight loss therapies in heart failure are now eagerly awaited, especially with a suggestion of lower heart failure hospitalisations from the recently published SELECT (Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes) trial.¹⁰ Excitingly, new weight loss therapies are in development including a combined triple agonist (GLP-1, gastric inhibitory peptide [GIP] and glucagon), retatrutide, achieving weight loss similar to that seen in bariatric surgery.¹¹

Philip Poole-Wilson Memorial Lecture

Professor John McMurray giving the Phillip Poole-Wilson Memorial Lecture

The 2023 Memorial Lecture was given by Professor John McMurray (University of Glasgow), who highlighted the significant advancements in heart failure treatment and understanding that have taken place over the past 15 years since the passing of Professor Poole-Wilson, the founding chair of the BSH.

He began by reflecting on the 2008 heart failure guidelines, where ACE inhibitors and beta blockers were the cornerstone treatments. He discussed the role of MRAs, citing RALES (Randomised Aldactone Evaluation Study),¹² and the development of sacubitril/valsartan, emphasising its impact as revealed in the PARADIGM-HF (Global Mortality and Morbidity in Heart Failure) study.¹³ Of course, a recent highlight has been the development of SGLT2 inhibitors which have shown benefit in heart failure irrespective of ejection fraction as evidenced in DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure),¹⁴ DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure),¹⁵ EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure and a Reduced Ejection Fraction),¹⁶ and EMPEROR-Preserved (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction)¹⁷ trials.

Professor McMurray also outlined three fundamental shifts in the new 2023 update to the 2021 ESC guidelines for heart failure management:¹⁸

The urgency of early treatment initiation, underscoring the importance of prompt action.
The primacy of initiation of treatment over conventional dose titration, emphasising the importance of starting all four pillars of therapy.
The flexibility in the order and sequence of medication administration, allowing for tailored patient care.

He also touched upon the development of chemically-engineered drugs like omecamtiv mecarbil¹⁹ and the ongoing efforts to understand the role of intravenous iron in heart failure, referencing the IRONMAN (Intravenous Ferric Derisomaltose in Patients with Heart Failure and Iron Deficiency in the UK)²⁰ and HEART-FID (Ferric Carboxymaltose in Heart Failure with Iron Deficiency)²¹ studies. He also discussed the increasingly recognised importance of managing arrhythmias in heart failure, particularly atrial fibrillation, citing the CASTLE HF (Catheter Ablation for Atrial Fibrillation with Heart Failure)²² trial and the upcoming CRAAFT-HF and CABA-HFpEF studies.

Concluding his lecture, Professor McMurray discussed the exploration of new therapies in heart failure. This included more selective MRAs (FINEARTS-HF trial), the investigation into the role of inflammation in heart failure (HERMES trial), and the impact of obesity on heart failure, as highlighted in the STEP HFpEF and SUMMIT trials.

Natriuretic peptides

At this year’s meeting, the focus on natriuretic peptides (NPs) included discussions led by Professor Antonio Bayes-Genis (University Hospital Germans Trias i Pujol de Badalona, Barcelona, Spain) and Dr Clare Taylor (University of Oxford). Professor Bayes-Genis introduced the ‘Peptide for Life’ initiative,²³ which aims to standardise NP testing access in primary care and emergency departments across Europe. Endorsed by the ESC, this initiative emerged from the Heart Failure Association Atlas, highlighting the varied use of NPs in different regions. Its goal is to enhance early detection and management of heart failure through consistent and widespread use of NP testing.

Dr Taylor examined the use of NPs in UK primary care. She noted that heart failure patients diagnosed in the community have better survival rates than those diagnosed in hospitals, emphasising the importance of NP testing. Despite a 17-fold increase in NP testing from 2004 to 2018, the diagnosis rate has remained at about 10%, with the median NP level at diagnosis (around 1200 pg/ml for NT-proBNP) suggesting late-stage detection.²⁴

She also addressed the debate on NP thresholds, comparing the National Institute for Health and Care Excellence (NICE) (<400 pg/ml NT-proBNP) and ESC (<125 pg/ml NT-proBNP) guidelines. Large GP datasets indicated a sensitivity of 82% at >400 pg/ml, missing roughly one in five heart failure cases, versus 95% sensitivity at >125 pg/ml.²⁵ Lowering the threshold, however, raises concerns about overburdening cardiology services.

Dr Taylor also presented data linking NP levels at diagnosis to hospitalisation and mortality risks. Alarmingly, over 50% of patients were hospitalised within a year of diagnosis, with a median delay of 101 days between testing and diagnosis.²⁶ High NT-proBNP levels (>2000 pg/ml) doubled the risk of hospitalisation and increased heart failure mortality by 50% at one, five, and 10 years, highlighting the need for prompt diagnosis and intervention.

Early Investigator Award

Three excellent candidates presented their work in the Early Investigator Award session. Dr Fardad Soltani (University of Manchester) presented work in phenogrouping HFpEF using electronic healthcare records and machine learning. Utilising the National Institute for Health and Care Research (NIHR) Health Informatics Cardiovascular database from five hospital trusts, Dr Soltani analysed data from 2000 patients with left ventricular ejection fraction (LVEF) >40%. This led to the identification of three distinct phenogroups (table 2). Notably, the third group was found to have a threefold risk of death, underscoring the potential of machine learning in enhancing our understanding of HFpEF.

Table 2. Early Investigator Award

Investigator	Location	Title	Take away message
Fardad Soltani	Manchester	Phenogrouping HFpEF using electronic health record data	Three phenogrpups identified Younger, female, cardiometabolic risk factors Male, frail, AF Diabetes, renal dysfunction and high CRP
Ramesh Nadarajah	Leeds	Prediction of incident HF in community-based electronic health records: systematic review, meta-analysis and UK prediction model development and validation	There are a large number of models which predict five- and 10-year risk of HF but they have limited performance in predicting short- term HF. This model is scalable and accurately predicts both short- and long-term HF.
Daniel Hammersley	London	Myocardial tissue remodelling in DCM in clinical remission	Remission of DCM phenotype was associated with regression of interstitial fibrosis and reduction of subclinical myocardial inflammation, but this could not be predicted.
Key: AF = atrial fibrillation; CRP = C-reactive protein; DCM = dilated cardiomyopathy; HF = heart failure; HFpEF = heart failure with preserved ejection fraction

Dr Ramesh Nadarajah (University of Leeds) focused on predicting heart failure in community-based health records through a systematic review and meta-analysis of 59 prediction models. Although these models excelled in long-term (five and 10 year) predictions, their performance in short-term (within one year) diagnosis was variable and uncertain. Dr Nadarajah then worked on developing a novel decision support tool with high accuracy in both short- and long-term prediction, using a half-million patient derivation cohort and a nearly 100,000 patient validation cohort.

Lastly, Dr Daniel Hammersley (National Heart and Lung Institute, London) explored myocardial tissue remodelling in dilated cardiomyopathy (DCM). The REMIT-DCM (Reverse Remodelling Markers In the Serial Evaluation of Recent-onset Dilated Cardiomyopathy) study, involving baseline, two to three months, and 12-month follow-ups with cardiac MRI and blood tests, found that 31% of patients experienced DCM remission. Interestingly, no baseline clinical or MRI parameters could predict 12-month remission. The study revealed that regression of myocardial fibrosis and reduction in subclinical myocardial inflammation were common in those who improved, suggesting these as potential therapeutic targets. It was also noted that replacement fibrosis does not preclude DCM remission.

Congratulations to all three early career investigators and especially to the winner Dr Nadarajah.

BSH Research Fellows

We also enjoyed an update from current BSH Research Fellows on their progress. Janine Beezer (South Tyneside and Sunderland Foundation Trust), Jo Bilak (University of Leicester), Elton Luo (Castle Hill Hospital, Hull) and Matthew Sadler (King’s College Hospital, London) all provided updates on their studies (table 3). Dr Simon Beggs (University of Glasgow), past BSH Research Fellow, also presented evidence on the RHYTHM-HF study. This study sought to inform on how arrhythmias contribute to death or rehospitalisation in heart failure patients. Patients were recruited during index hospitalisation for heart failure and received an injectable cardiac monitor. Dr Begg showed that in those with an adjudicated pump failure death, the cause of death may be due to an unidentified alternative pathology, such as a myocardial infarction or pulmonary embolus, although this cannot be extrapolated from the terminal rhythm. Dr Begg also showed that adjudicated sudden cardiac deaths may be due to unidentified pathology including non-cardiac pathology, and these may be associated with a secondary ventricular arrhythmia. Again, the underlying cause of death could not be extrapolated from the terminal rhythm.

Table 3. BSH Research Fellows

BSH Research Fellow	Project
Janine Beezer	Polypharmacy in heart failure: investigating the relationship between treatment and outcomes – the POTION study
Jo Bilak	A Multi-Ethnic, multi-centre randomised, controlled trial of a low-energy diet for improving functional status in heart failure with preserved ejection fraction – the AMEND-Preserved study
Elton Luo	Study using two large primary care networks to identify patients on loop diuretics who are not on the heart failure registry
Matthew Sadler	Role of clonal haematopoiesis (CHIP) in ventricular remodelling after myocardial infarction

Heart failure clinical trials update

An update on heart failure clinical trials (table 4) was given by Professor John Cleland (University of Glasgow). He also made the case for following the lead of our oncology colleagues, who aim to have 20% of their patients enrolled in clinical trials. This would equate to around 200,000 heart failure patients in the UK enrolled in a clinical trial.

Table 4. Update on heart failure clinical trials

Trials	Summary
Recently Completed
IRONMAN²⁰	IV iron appeared to lower the risk of HF hospitalisation in patients with HFrEF and iron deficiency
REVIVED²⁷	PCI did not improve outcomes in patients with severe ischaemic left ventricular systolic dysfunction
Recruiting
HFpEF Registry²⁸	Redefining HFpEF into more distinct phenogroups using multiomics
REACH-HFpEF²⁹	Investigating a home-based cardiac rehabilitation programme in HFpEF
SUBCUT-HF II	Subcutaneous furosemide to enable early supported discharge in HF
PROTECT-HF	Assessing ventricular pacing by right ventricle pacing vs conduction system pacing in patients with an LVEF >35%
BRITISH³⁰	Effectiveness of an ICD/CRT-D in patients with non-ischaemic cardiomyopathy (LVEF <35%) and scar present on CMR
Funded
CONTEMP-ICD	ICD vs medical therapy alone in patients with HFrEF and LVEF <35% who have a lower risk of arrhythmic than non-arrhythmic death
CRAAFT-HF	AF ablation in patients with HFrEF and HFmrEF
CORAL	Assessing clinical and cost effectiveness of co-enzyme Q10 in patients with HFrEF
SOPHIST	Sotagliflozin for HF and type 1 diabetes, assessing quality of life and safety
CROSS-HF	Invasive or non-invasive imaging for coronary disease in patients with new HF
STITCH3-BCIS4³¹	PCI or CABG in patients with ischaemic LV dysfunction and multivessel disease
Pilots
IDEAL-HF	Delaying ICD therapy in HFrEF patients medically optimised with an LVEF <35% until echo reassessment at 12 months
THINK-HF	Feasibility trial of electronic health record ‘intelligent tooling’ in primary care for quicker diagnosis of HF
Key: CABG = coronary artery bypass graft; CMR = cardiac magnetic resonance; CRT-D = cardiac resynchronisation therapy – defibrillator; HF = heart failure; HFmrEF = heart failure with mildy reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; ICD = implantable cardioverter defibrillator; IV = intravenous; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention

Acute heart failure – diuretics

Professor Andrew Clark (University of Hull) delivered an entertaining and insightful lecture on diuretic management in acute heart failure. He summarised trials conducted in acute heart failure and the evidence generated from these trials (table 5). Despite many decades of diuresing patients, there is still not a consensus on how diuretics should be used and what the goal of treatment should be. What is clear, however, is that congestion is a negative prognostic marker, and the more congestion you have the worse your outcome is likely to be. Professor Clark concluded by saying: “Patients rarely fail to respond to diuretics, but we commonly fail to prescribe enough diuretics”.

Table 5. Trials of diuretic therapy

Trial	Details	Summary
DOSE³²	AHF receiving either bolus (12 hourly) or infusion of either high (2.5 x home dose) or low (home) dose furosemide	No statistical difference in symptoms or kidney function across groups, but trend towards improved symptoms in high dose group
CARESS-HF³³	AHF with cardiorenal syndrome, randomised to stepped pharmacological therapy or ultrafiltration	Ultrafiltration is associated with more adverse events, worsening renal function and no change in weight compared to medical therapy
CLOROTIC-HCTZ³⁴	Addition of HCTZ to IV furosemide in patients with AHF	The addition of HCTZ to loop diuretic therapy improved diuretic response, worsened renal function without causing significant hyponatraemia or hypokalaemia
ADVOR³⁵	Acetazolamide in addition to loop diuretics in AHF	The addition of acetazolamide for 3 days improves the proportion who achieved decongestion
3T³⁶	Comparison of metolazone versus chlorothiazide versus tolvaptan in addition to furosemide in AHF	Good weight loss across groups with no significant difference between groups
PUSH-HF³⁷	Does natriuresis-guided diuretic therapy improve outcomes in AHF	Measuring urinary sodium, with increased diuretic intensity if <70mmol/L, improved natriuresis and diuresis
Key: AHF = acute heart failure; HCTZ = hydrochlorothiazide; IV = intravenous

Ejection fraction – time to move on?

In the penultimate session of the meeting, attention turned to ejection fraction (EF) as a measure of left ventricular function. Dr Sarah Hudson (Wye Valley NHS Trust) opened the session with a history of EF, from its first use by Folse and Braunwald in 1962 to the first cardiac magnetic resonance (CMR) scan in 1985. Professor Chris Miller (University of Manchester) then discussed how imaging techniques such as CMR and computed tomography (CT) can provide a wealth of data beyond EF to further understand aetiology, prognosis and aid treatment. Dr Joe Cuthbert (University of Hull) however outlined how recent clinical trial evidence supports the use of EF to guide treatment, and therefore we would need a very good reason to move on from its use. It may be less important at certain times, such as acute presentation with congestion and end of life. Finally, Dr Fozia Ahmed (Manchester University NHS Foundation Trust) raised the important issue of sex-specific differences in cardiac structure and function, where females tend to have a higher normal EF (e.g. >60%). This is important as emerging evidence suggests women may benefit from neurohormonal blockade up to a higher EF. Further research is needed to investigate these sex-specific differences.

BSH diary dates

29th February 2024: Deadline for BSH Fellowship 2024–25 applications
25th–26th April 2024: BSH MDT meeting, Glasgow
21st–22nd November 2024: 27th Annual Meeting of the BSH, London

Conflicts of Interest

None declared.

J. Aaron Henry
Cardiology Fellow, Jersey General Hospital
Visiting Researcher, University of Oxford
[email protected]

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BSH 2023: collaboration, coordination and cooperation – 25in25

First published online 20th February 2024