Addressing Unmet Needs in Chronic Heart Failure

Chronic heart failure (CHF) is the syndrome of breathlessness, fatigue and congestion resulting from reduced cardiac output at rest or during exercise. In recent decades, dramatic improvements in survival have been achieved largely due to the more widespread implementation of pharmacological and device therapies. Despite this, the impact of these therapies on symptoms and quality of life have been less consistent and whether the benefits of these agents extend to populations who were largely excluded from the relevant trials remains unknown. This thesis comprises a series of prospective and retrospective observational studies which aim to address key unmet needs in CHF. I show that people with CHF often have co-morbidities, and these individuals are the least likely to receive therapies for CHF, although appear to derive the greatest benefits. I also show that for those with less severe CHF for whom there is little data to support their use, pharmacological therapies are associated with similar benefits compared to those with more severely impaired heart function. Additionally, I show that patients with CHF and normal heart function according to current definitions often have subtle systolic dysfunction which could be more easily identified by simple imaging techniques. In a prospective, observational study I show the ‘Surprise Question’ is able identify those within the last year of life and be used by a diverse range of healthcare professionals. I also show that for people hospitalised with CHF, advanced care planning is seldom utilised. In a retrospective cohort study in a setting where advanced care planning became routine, I show that ceiling of care decisions were made broadly in line with known predictors of a poor prognosis, with no suggestion these decisions were associated with worse outcomes. Based on these novel findings, I can conclude that the benefits of pharmacological therapies extend to many more people with CHF than previously thought. However, advanced care planning and palliative care in this population remains underutilised, despite evidence of benefit and clear need.