Prof Andrew Coats, Monash University of Melbourne, Australia

Andrew Coats, Professor, Researcher & Cardiologist, and Director of the Monash-Warwick Alliance Strategy, Monash University of Melbourne, Australia, speaks to Cardio Debate about novel developments for the treatment of chronic heart failure.


What was your talk about today at the International Workshop on Treatment of Cardiovascular Disease in 2016?
In my talk today I covered the development for heart failure treatments, what has changed since the last European Guidelines that were in 2012, while we wait for the new guidelines at the end of this month.

We highlighted changes in drug treatment, particularly two new trials that have come out – the PARADIGM-HF and the ATMOSPHERE study. And in addition, what’s on the horizon for new devices.

Which are the main developments to highlight regarding new developments and challenges in the management of patients with heart failure?
So the two most important trials have come out, and those are ATMOSPHERE, which is the renin-inhibitor that showed no advantage of using a renin-inhibitor either as an alternative to an ACE-inhibitor or an addition. So I think it shows that renin inhibition doesn’t seem to add a lot in the treatment of chronic heart failure.

In contrast, PARADIGM-HF looked at the combination of valsartan with a neutral endopeptidase inhibitor in the drug that was called LCZ696 – now called sacubitril/valsartan – that showed a substantial superiority over enalapril, the ACE inhibitor.

So the question now is how do we implement those changes in practice? How many of the patients that see a heart failure cardiologist or general physician are suitable for the swap-over to the new drug?

According to the results of the trial, could the new treatment be extended to more patients?
PARADIGM-HF was a very important trial. It showed that sacubitril/valsartan was superior to enalapril. The issue is how widely can we apply that in practice?

Because the trial was the first of it’s kind with that particular combination pill agent, and as a result we only have that trial to go by.

The question is, the patients in that trial were very highly selected. They had to have established heart failure, they had to have elevated nateuretic peptides, but they had to have already tolerated relatively high doses of ACE inhibitor and the trial medication. So when we have patients who aren’t on high dose ACE-inhibitor or haven’t tolerated that, we really don’t know whether the drug would be as superior in that patient population.

So in my own belief, I think we need another trial to answer that question in a broader patient population.