Interview with Prof. Mitja Lainscak

Interview with Prof. Mitja Lainscak, Heart Failure 2018 Congress Chair, conducted in June 2018 in Los Angeles by Kirsten Westphal

Reflecting on Heart Failure 2018 and his time as Congress Chair, Prof. Mitja Lainscak shares his top priorities and how they have influenced the Heart Failure Association, as well as his hopes for the future.



Professor Lainscak, what do you consider the highlights of this year’s ESC Heart Failure 2018 congress?

"In line with the main theme ‘Heart Failure: classical repertoire, modern instruments', the HFA has transformed itself to broaden its understanding of heart failure and its treatment, and that is how Heart Failure 2018 differs from previous congresses. We have to consider heart failure in the context of cardiovascular disease as a whole in order to see the bigger picture. There are some established therapies that we might change, and some new strategies will need to be introduced. The congress focussed on a range of devices and interventions that improve patient outcomes. There was also a great emphasis on novel drugs or drugs in development. Although very few studies have been published in the last ten years, there has been much progress. These studies have not yet reached the stage of outcome trials, but we need to embrace these scientific findings as it is necessary to show what is happening in the course of heart failure. Also, we put much emphasis on patient management because we should focus on more than just symptoms. We have to take care that the quality of life is adequate in the years patients gain due to therapy."

Why is it so important to increase the awareness for chronic heart failure?

"Awareness for heart failure is relatively low. We don't have ambassadors like breast cancer has, for example. Usually, heart disease is seen as a disease of elderly people, which is one reason for the low awareness. Another reason is that the general perception and the perception among decision makers remains that having a malignant disease is dreadful and deadly, and that it is going to kill you in a matter of time. Whereas the impact of other diseases on your life and quality of life is not perceived as equally severe. We know this is definitely not true, and the HFA sees it therefore as our task to change these perceptions. The message is that heart failure is common and has poor outcomes, but that it can be managed."

How common is chronic heart failure, and what are the main underlying conditions?

"Over the years, the underlying conditions have stayed more or less the same, with ischaemic heart disease and arterial hypertension being the two main drivers around the globe. Knowledge about prevalence is another issue. We still ‘preach’ that prevalence of heart failure is 1-2 percent, but this insight comes from older studies. There have only been a handful of well-designed studies that have looked at prevalence. Since then, the population has aged, diagnostic criteria have changed, and we have introduced another phenotype in heart failure. We lack insight into incidence and prevalence numbers and need to do more epidemiology, because without numbers we cannot adequately discuss anything."

Why is it so difficult to make an early diagnosis?

"As I said earlier, the typical heart failure patient is an elderly person. We all have some shortness of breath in older age, like oedema or early fatigue. These symptoms are shared with other diseases or perceived as symptoms of old age. Moreover, if subjects are experiencing difficulties in daily life, they often adjust their daily activities to avoid them. They subsequently forget about the symptoms, which allows the disease to progress. Often, hospitalisation is the first mark indicating heart failure. This shouldn't happen. We should be able to detect the disease much earlier on. Unfortunately, we currently don't have any well-designed programmes in Europe, and this needs to change. We can only do this with strong support on a political level. With that support we can start defining screening strategies. The two main questions are: how will we do the screening, and who will do it?"

Where will the future path of heart failure therapy lead?

"There are some exciting on-going studies that include patients with preserved ejection fraction (HFpEF). For these patients, we still don't have any therapies that will be approved as lifesaving. This is definitely an unmet need. Then, over the years, we have been able to enrich our armamentarium of therapies for heart failure with reduced ejection fraction (HFrEF). In patients that survive longer, we are confronted with new complications and new consequences of the disease, which need to be addressed. Currently, an exciting pharmacotherapeutic path is focusing on patients with HFpEF, and there are additional promising strategies with new devices and operative interventions, which focus on both sides of the heart. Where we still don't have any large, randomised, controlled trials is the HFm-recEF, the ‘middle child’ with ejection fraction 40 to 50. Here, we still don't know which way to go. There is some emerging data from registries and trials that suggests that managing HFm-recEF should not be too different from the management of HFrEF."

Which area of heart failure has made the most progress in recent years?

"We have witnessed some progress in every single area – basic research, diagnostics, and therapy. Unfortunately, we haven’t have seen any ground-breaking trials in recent years. The last ground-breaking trail was the PARADIGMHF in 2014 with sacubitril/valsartan taking drug therapy for HFrEF to the next level. Understandably, it took some years to make that drug available for clinical practice. Since then, we haven’t seen trials of a similar magnitude. Though we have seen some recently published studies in terms of interventions."

What do you consider the most important issues in treatment heart failure today? How does Heart Failure 2018 help to push these forward?

"We have to acknowledge the need to improve strategies for early detection of heart failure, and we need proper diagnostics to see what the cardiac function is and which other diseases are present to be more precise with comprehensive management. We know that many patients who are labelled with heart failure don't actually have heart failure and that many patients with heart failure remain undiagnosed."

What would you like your legacy as chairman of Heart Failure 2018 to be?

"The most important thing is that the people were excited and happy with the congress. The delegate number exceeded 5,000. This is a respectable number and likely a result of the first-class programme put together by the Scientific Committees. Personally, I am excited about the increased focus on devices and multidisciplinary interventions at this year’s meeting. We have moved on from the days when drugs were the mainstay of heart failure treatment. Now, specialists also use a range of devices and interventions to improve patient outcomes. I really hope that there were remarkable sessions for everybody with impact on clinical practice, maybe even affecting some change in routine in clinical or scientific aspects."

How has this congress expanded the HFA’s educational mission worldwide?

"The HFA wants to invest in the future by supporting young investigators and encouraging them to present research at this meeting, the largest heart failure congress in the world. To make this congress accessible to as many members as possible, the HFA has once again made travel grants available to young specialists – Heart Failure Specialists of Tomorrow – who are first authors on an accepted abstract or clinical case and who have difficulty obtaining funding from other sources. For Heart Failure 2018, an incredible 150 travel grants have been awarded. The HFA is going global."

Do you have something you would like to share with your fellow cardiologists?

"Yes, we need to stay strong in our clinical practice and in our research activities. We need to increase awareness of heart failure, and we need to be very, very clear that heart failure can be approached, treated, and managed. Therefore, we have to be conclusive in the diagnostic part and then embrace patients as a whole with all their comorbidities in a comprehensive manner."



Posted on 29 May 201817 March 2021