ABC Heart Fail Cardiomyop 2023; 3(2): e20230085

Where are the Benefits of Treating Acute HF in Light of Evidence-Based Medicine?

Carlos Eduardo Lucena Montenegro , Marcely Bonatto , Jefferson Luis Vieira , Fabiana G. Marcondes-Braga , Lídia Ana Zytynski Moura

DOI: 10.36660/abchf.20230085

Over the last 35 years, cardiology, especially the field of heart failure (HF), has witnessed a true therapeutic revolution based on scientific evidence. First, with vasodilators, moving on to the neurohumoral pathophysiological hypothesis with ACE inhibitors (ACEI), beta-blockers, mineralocorticoid antagonists, and, more recently, neprilysin inhibitors and SGLT2 inhibitors, caused a reduction in morbimortality rarely seen in the history of medicine. However, virtually all evidence associated with this impressive reduction in events comes at the expense of benefits in patients with chronic HF. The treatment of acute HF, despite its unequivocal biological plausibility, did not demonstrate the same success when tested in light of the best scientific evidence. Nevertheless, where has evidence-based medicine failed?

The first point to be discussed is the heterogeneity of patients with acute HF. In this spectrum, we can range from individuals with sudden changes in blood pressure or patients with acute myocardial infarction, leading to ventricular dysfunction, to patients with chronic ventricular dysfunction, with recent decompensation of the compensatory mechanisms of their disease. Still on this topic, we need to understand that the same syndrome can involve everything from extremely congested cases to people with hypovolemia, hypertensive emergencies, or extreme states of poor perfusion, leading each phenotype to different treatments and prognoses.

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