Diagnosis of HF in a Resource-Limited Setting: Practical Approach

Consensus 1 Diagnosis of heart failure relies on clinical suspicion and physical examination, aided by electrocardiography (ECG), chest X-ray, N-terminal pro-brain natriuretic peptide (NT-proBNP), and 2D echocardiography.

Panel discussion A detailed physical examination and strong clinical suspicion are core for diagnosing HF in a resource-limited setting. Abnormal ECG and chest X-ray showing cardiomegaly and congestion are indicators of HF. NT-proBNP and 2D echocardiography (2D echo) imaging are essential tests for diagnosing and phenotyping HF. Diagnosing HFpEF is more challenging compared to HFrEF. Assessment of diastolic function in 2D echo shall be done to diagnose HFpEF. The H2FPEF scoring system could be helpful in such clinical situations. The chances of HFpEF are high in elderly patients with atrial fibrillation (AF), hypertension, and obesity. The use of modified stress diastology, such as the 6-min walk test, E/e′ ratio, and mitral velocities, are a few additional tests that aid in diagnosing HFpEF. Thus, for diagnosis, the clinical acumen of a primary physician is essential. For diagnosing HFpEF, the cardiologist’s expertise in diastology is crucial for correct diagnosis. Also, available resources for diagnosis are to be considered. In resource-limited settings where access to advanced investigations and expensive treatments for heart failure (HF) may be restricted, clinicians must prioritize their diagnostic approach. While both brain natriuretic peptide and echocardiography play crucial roles in HF diagnosis and prognosis, their availability and affordability might be limited. In such contexts, clinicians should focus on utilizing basic diagnostic tools that offer valuable insights. For instance, ECG emerges as a pivotal tool, offering both screening and prognostic information. Although ECG findings are highly sensitive indicators for HFrEF, they lack specificity, and a normal ECG virtually excludes HFrEF. However, the sensitivity of ECG in HFpEF is lower, with normal findings present in a significant portion of patients. Therefore, in resource-limited settings, clinicians can prioritize utilizing ECG alongside basic diagnostic methods to effectively screen and manage patients with HF, leveraging available resources for optimal patient care (Fig. 1).

Fig. 1

Diagnostic approach for heart failure. HFpEF heart failure with preserved ejection fraction, LVEF left ventricular ejection fraction, HFrEF heart failure with reserved ejection fraction, HF heart failure, CBC complete blood count, NT pro-BNP N-terminal pro hormone of brain natriuretic peptide, HFmrEF heart failure with mid-range ejection fraction, BNP brain natriuretic peptide

Evidence In clinical practice, HF diagnosis commonly relies on symptoms and clinical signs, followed by ECG and NT-proBNP measurements. In case of abnormal tests, a referral for echocardiography should be made to confirm the diagnosis and differentiate between the three main HF types, HFpEF, HFmrEF, and HFrEF, and detect correctable anomalies. These cases are almost invariably of a slow start; acute onset HF is usually diagnosed in the hospital and is occasionally preceded by a period of complaints that are not recognized as HF symptoms [13]. Biomarkers such as soluble ST2 (sST2), galectin-3 (Gal-3), and growth-differentiation factor-15 (GDF-15) are currently emerging as promising indicators of heart failure. Clinical guidelines offer a Class IIb recommendation to contemplate the measurement of sST2 and Gal-3 as supplementary risk factors in heart failure [14]. Telemedicine consultations in HF care provide convenience and time savings, especially for clinically stable patients, making them suitable for outpatient management. In-person assessments are necessary for symptom deterioration, and telemedicine is particularly advantageous in reducing costs, travel expenses, and the need for regular hospital visits, especially in rural areas [15].

In resource-limited India, point-of-care (POC) diagnostic devices offer significant advantages, enhancing healthcare accessibility for a large population. POC enhances diagnostic capacity for severe diseases at a lower cost, making them affordable for many and also offers convenience for continuous monitoring and follow-up tests, reducing turnaround time significantly [16]. This rapid diagnosis is crucial for managing heart failure, especially in remote areas where travel costs are a concern. Recent studies demonstrate the effectiveness of POC testing, such as NT-proBNP testing with the FLEX analyser, in diagnosing and prognosticating congestive heart failure, showcasing the potential of POC devices to improve healthcare outcomes in resource-limited settings [17].

Criteria for Referral to a Cardiology Consultation

Consensus 2 Referral decisions should not delay the initiation or optimization of prognostic-modifying therapy.

Panel discussion In certain medical conditions, particularly in patients with anemia and infections, general practitioners (GPs) play a crucial role in both diagnosing and managing anemia in individuals suffering from HF. Identifying and addressing anemia becomes a critical aspect of comprehensive patient care. In resource-limited settings, where access to specialized healthcare may be constrained, the initial stages of anemia treatment can be undertaken by skilled nursing professionals. This collaborative approach ensures that timely interventions are implemented, even in environments with limited resources, contributing to better outcomes for patients managing both heart failure and anemia (Table 1).

Table 1 Criteria for referral to a cardiology consultation

Evidence The criteria for referral depend on the type of heart failure—HFrEF, HFmrEF, HFpEF, or de novo HF. HF with improved ejection fraction (HFimpEF) is a new classification that is distinctly defined as symptomatic HF with a baseline LVEF ≤ 40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF > 40% [15]. The choice to refer a patient for a hospital consultation should not impede the prompt commencement or enhancement of prognostic-modifying therapy. Such therapy is valuable for the cardiovascular protection of the patient while awaiting a hospital consultation. An increased rate of referrals to specialty care follow-up may indicate the challenges primary care physicians face in coordinating the growing complexity of modern heart failure (HF) care, such as new pharmacotherapies, catheter-based procedures, and device or surgical therapies [19, 20].

Current Guidelines Recommendations for HF

Consensus 3 Management of heart failure should be individualized based on each patient's clinical characteristics, preferences, and comorbidities.

Evidence The use of pharmacological therapy is a cornerstone of HF management. Guidelines are constantly evolving as new evidence emerges. Thus, Tables 2 and 3 represent different guideline recommendations for managing heart failure.

Table 2 Guideline recommendations from ESC and ACC/AHA/HFSA for quadruple therapy across HF types [6, 9]Table 3 Guideline recommendation of SGLT2i for management of heart failureClinical Strategies to Optimize the Management of HFClinical Inertia

Consensus 4 Increasing physician awareness to address the clinical inertia is crucial in tackling the problem, particularly among HF specialists who can develop strategies to alleviate it.

Panel discussion Clinical inertia in heart failure treatment is influenced by various factors, such as lack of familiarity with guidelines, diagnostic difficulties, comorbidities, patient-related issues, system-related challenges, physician-related factors, and communication problems. To address clinical inertia, it is crucial to implement measures such as educating healthcare providers, improving guideline accessibility, promoting patient engagement, and optimizing healthcare systems. These steps involve standardizing care, educating providers, utilizing technology, involving patients in decision-making, and establishing accountability through quality metrics.

Evidence Clinical inertia is a prevalent phenomenon in chronic illnesses, particularly when patients present few symptoms, leading to a higher incidence of delayed and underdiagnosed cases. This inertia is primarily ascribed to physicians, with numerous surveys indicating that patients often do not receive optimal treatment despite doctors claiming adherence to guidelines. Soft excuses such as patient non-adherence, time constraints during appointments, and hesitancy to modify therapy can also contribute to clinical inertia. Moreover, the lack of education, training, and organization are significant factors that contribute to this inertia. All physicians need to recognize the relevance and seriousness of clinical inertia and actively work to address it. Raising awareness through conferences, continuing medical education (CME), and keeping abreast of the latest guidelines for heart failure (HF) management among specialists treating HF should facilitate the development of strategies that can mitigate or eliminate clinical inertia [21].

Patient Education and Compliance

Consensus 5 The approach to improve compliance involves educating and counseling patients to increase their knowledge about HF therapy.

Panel discussion The Trivandrum heart failure registry showed that GDMT is used in only 25% of the patients. Caveats for the use of anti-renin–angiotensin–aldosterone system (RAAS) agents, beta-blockers, and MRAs are another reason for not offering the GDMT to patients. In India, the primary goal includes implementing guideline-directed medical therapy. Providing patient education, using the teach-back method, and involving family and caregivers are all measures to raise patient awareness of HF and enhance compliance with HF therapy. These measures involve a patient-centered approach emphasizing clear communication, engagement, and emotional support to improve patient understanding and compliance. Improving patient awareness and compliance with HF therapy can improve health outcomes and reduce hospitalizations.

Evidence Individuals experiencing heart failure need to have a comprehensive understanding of their condition and actively participate in decisions regarding its management. Encouraging self-care practices is crucial for improving patients’ quality of life and preventing exacerbations. Rehabilitation programs that incorporate exercise, lifestyle adjustments, education, and psychological support can provide significant benefits to patients with heart failure. Non-compliance with medication and dietary recommendations can exacerbate symptoms and lead to hospitalization [22]. Unfortunately, patients with heart failure often struggle to adhere adequately and consistently to self-care recommendations. Positive predictors of adherence include being male, having no chronic comorbidities, and possessing a good understanding of heart failure. To enhance adherence, it is essential to improve heart failure patients' knowledge of the signs, symptoms, and management strategies associated with their condition. Additionally, there is a need to increase awareness, accessibility, and adoption of medications for heart failure management, especially in resource-limited settings [23].

Financial Burden and Access to Treatment

Consensus 6 Despite substantial support for the idea of the Health Impact Fund, there are concerns about scalability, generalizability, and the impact on access to medicines.

Panel discussion In India, between 50 and 65% of the population faces difficulty accessing medicines, and while affordability is a crucial factor, all stakeholders perceive access to medication as a severe concern. A more radical approach might be taken by the Health Impact Fund and other novel drug-related health policies, like operating outside the existing intellectual property rights framework, focusing on both branded and generic pharmaceuticals, or expanding to research and development. However, In India, generic versions of ARNi and SGLT2i such as dapagliflozin are available, making them more accessible and affordable for patients with heart failure and diabetes. The increased availability of generic ARNi and SGLT2i provides clinicians with valuable options for optimizing treatment strategies and improving outcomes for patients in India and other resource-limited settings.

Evidence Heart failure is a significant cause of hospitalizations in India, accounting for 1.8 million admissions annually, and it affects between 2 and 3% of the global population. The in-hospital mortality rate for patients with heart failure in India is much higher, at 10–30.8% than the rate of 4–7% observed in Western countries. According to global data, India is the Southern Asian country that spends the most on heart failure, estimated at approximately $1186 million, representing 1.1% of the total global spending on heart failure [24]. According to a WHO estimate, India spent over $236 billion between 2005 and 2015, over 10 years, on the management of CVDs. It places a significant financial burden on regions with low per-capita health budgets [25]. Based on a 20% capacity-to-pay threshold, the Prospective Urban Rural Epidemiology study (n = 16,874 homes) showed that the combination of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins would be unaffordable for 59% of Indian households [26].

Management of Heart Failure in Patients with/Without Diabetes Mellitus

Consensus 7 GDMT for patients of HF is the same irrespective of the presence or absence of diabetes mellitus.

Panel discussion HF therapy needs to be tailored to each patient's individual needs. Before initiating drugs such as SGLT2i, ARNi, BB, and MRAs, it is crucial to assess renal function through tests like serum creatinine, estimated glomerular filtration rate (e-GFR), and serum potassium to identify potential contraindications. The initiation of the four pillar drugs in the quadruple therapy should begin with small doses in the ICU once inotropes are discontinued, and the patient is stabilized (usually after 48 h). Gradual up-titration of the dose should occur over 4–6 weeks, reaching the target dose within 6 months as the patient tolerates it. Unnecessary drugs like nitrates and hydralazine should be discontinued.

In patients with acute kidney injury during hospitalization for acute HF treatment, MRAs can be started later. Iron therapy should be considered in HF management, especially as improvement is faster when correcting iron levels. According to the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA), intravenous iron replacement may reasonably enhance functional status and quality of life in patients with New York Heart Association (NYHA) class II and III HF and iron deficiency. Intravenous ferric carboxymaltose (IV FCM) should be considered for treating iron deficiency in symptomatic patients with a left ventricular ejection fraction (LVEF) < 45% to alleviate symptoms, improve exercise capacity, and enhance quality of life (Fig. 2).

Fig. 2

GDMT dose titration in management of heart failure. ARNI angiotensin receptor neprilysin inhibitor, ACEI angiotensin-converting enzyme inhibitor, MRAs mineralocorticoid receptor antagonists, DAPA dapagliflozin, EMPA empagliflozin, GDMT guideline-directed medical therapy

Evidence Recent guidelines from the ESC and an expert consensus update by the ACC in 2023 have highlighted the significant benefits of SGLT2i in the treatment of heart failure, regardless of the patient's diabetes status [8, 32]. In particular, the DAPA-HF and EMPEROR trials revealed a significant 30% reduction in heart failure rehospitalization when employing SGLT2i for patients with HFrEF [33]. Moreover, irrespective of diabetes, ARNi has been shown to lower cardiovascular mortality and hospital admissions in individuals with HFrEF. Additionally, ARNi has positively affected left ventricular reverse remodeling, as indicated by decreased N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. MRAs were linked to a lower risk of hospitalization for all causes in older patients with heart failure and concurrent diabetes mellitus or renal insufficiency despite a higher risk of hospitalization for hyperkalemia or acute renal insufficiency. It is worth noting that while MRAs was considered safe for a carefully chosen group of patients with heart failure with concomitant diabetes mellitus or renal insufficiency, the enhanced risk of adverse events was primarily seen in patients with borderline or preserved ejection fraction (Table 4) [34].

Table 4 Landmark clinical trials for the management of HF

Consensus 8 SGLT2i shall be recommended in all individuals with HF irrespective of diabetes status in individuals with high cardiovascular risk.

Panel discussion SGLT2i is recommended for heart failure irrespective of diabetes status, and ejection fraction plays a role in the prevention of HF in those with type 2 diabetes. Sotagliflozin may be a future SGLT2i in India, showing beneficial CV benefits. Every single patient of HF is a candidate for SGLT2i regardless of whether they have DM or not. SGLT2i reduces rehospitalization and mortality. In patients with HF, continuous use of SGLT2i improves renal function.

Evidence Diabetes is a significant comorbidity in patients with HF, and its presence dramatically increases the risk of cardiovascular morbidity and mortality. Therefore, treating both conditions with optimal therapy as early as possible is essential. The management of concomitant diabetes and HF is complex and still presents therapeutic challenges. To improve patient outcomes, it is crucial to use early and differentiated drug therapy, exhausting all possible treatment options. SGLT2i stands out as the initial class of blood glucose-lowering agents capable of decreasing the incidence of heart failure-related hospitalizations and cardiovascular mortality in diabetic and nondiabetic patients. Therefore, SGLT2i should be used as a first-line therapy for patients with diabetes and HF. Based on data from the DAPA-HF and EMPEROR-Reduced trials, it is anticipated that SGLT2i will be established as a permanent component in the guidelines for treating HF, both in patients with and without diabetes [35] (Fig. 3).

Fig. 3

Optimal treatment strategy of patients with heart failure combined with diabetes mellitus. HbA1c glycated hemoglobin, SGLT2i sodium/glucose co-transporter-2 inhibitors

In the SOLOWIST-WHF trial, sotagliflozin yielded comparable results to the placebo in terms of the primary composite outcome (51.0 vs. 76.3%; HR 0.67; 95% CI 0.52–0.85; p < 0.001) which involved patients with T2DM who had recently been hospitalized due to HF [36]. Likewise, in the VERTIS CV trial involving individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, ertugliflozin exhibited noninferiority to the placebo in terms of MACE [37]. These trials provided evidence of the positive effects of these drugs on heart failure. However, it is essential to note that these benefits did not extend to cardiovascular outcomes, emphasizing that the positive impact on heart failure might not be generalized to all cardiovascular outcomes.

Drug Initiation and Titration in HF

Consensus 9 Consider initiating or continuing SGLT2i in patients with acute heart failure (once the patient is stabilized) regardless of diabetes status.

Panel discussion SGLT2i has been shown to reduce the risk of hyperkalemia and slow the progression of kidney dysfunction, which are favorable features for both short-term and long-term tolerance of ARNi and MRAs therapy, according to studies. Despite the significant clinical risk, medication discontinuation is standard in patients with HF hospitalized for HF, both during and after hospitalization. This increases the risk of subsequent clinical occurrences. To maximize medication tolerance and prevent withdrawal of other life-saving medications, in-hospital SGLT2i introduction should be prioritized as a part of a comprehensive strategy.

Evidence Initiating SGLT2i therapy in the hospital offers several compelling reasons, with one of the strongest being the prompt and significant clinical benefits that become evident within days to weeks of starting treatment, as reported in studies. For instance, empagliflozin exhibited a remarkable 58% relative decrease in mortality, HF hospitalization, or urgent HF visit 12 days after initiation [38]. The findings of SOLOIST-WHF reinforce these early benefits since initiating sotagliflozin in the hospital or early post-discharge led to early clinical event curve separation [36]. Failure to prescribe SGLT2i to eligible patients at discharge results in a clinically significant increased risk of death and readmission in the first few days to weeks after discharge [38].

Consensus 10 ARNi can be initiated in individuals with diabetes and HFrEF and is preferred to ACEI or ARB.

Panel discussion The management of HFrEF typically involves ARNi as foundational therapy. ARNi has been shown to increase LVEF even in patients previously taking ACEI or ARB, reduce the risk of hospitalization or death, and improve health status.

Evidence ARB is employed only for patients who cannot tolerate ACEI, making ACEI the cornerstone of treatment for patients with HFrEF for many years. The ACEI and ARB are no longer regarded as the gold standard renin-angiotensin inhibitors for the treatment of HFrEF due to the development of the ARNi sacubitril/valsartan. The landmark PARADIGM-HF trial demonstrated that compared to enalapril, treatment with sacubitril/valsartan was linked to a 20% decrease in cardiovascular death or HF hospitalization; this effect was also seen in individuals with diabetes. As a result, sacubitril/valsartan has been embedded as class I in clinical practice guidelines and is the preferred frontline treatment for HFrEF [39].

Consensus 11 Regular monitoring of serum potassium levels is needed using MRAs and other RAAS blockers in patients with HFrEF.

Panel discussion Large-scale prospective, double-blind trials have shown that the steroidal MRAs spironolactone and eplerenone lower cardiovascular mortality and HF hospitalizations among patients with HFrEF. These medications are crucial components of GDMT for HFrEF. The risk of hyperkalemia and acute renal insufficiency, however, may limit the ability to provide these beneficial medications to people with diabetes. Regular monitoring of potassium levels and the use of potassium-binding agents may facilitate the use of MRAs in these individuals.

Evidence Finerenone, a non-steroidal selective MRAs with more potent anti-inflammatory and antifibrotic effects than steroidal MRAs, has been proven in recent studies to offer more significant benefits in diabetic kidney disease (DKD). Treatment with finerenone was related to a decreased risk of DKD progression, cardiovascular events, myocardial infarction, and hospitalization for HF in the FIDELIO-DKD trial, which included 5734 people with CKD and T2DM [40]. Similarly, in the FIGARO-DKD trial, which involved 7400 individuals with T2D and DKD, finerenone significantly reduced cardiovascular death and nonfatal cardiovascular disease endpoints, including hospitalization for HF. However, finerenone is associated with a risk for hyperkalemia and requires careful serum potassium monitoring when used, like other MRAs [41].

Role of SGLT2i in Heart Failure: Pleiotropic Effects and Implications for Practice

Consensus 12 SGLT2i therapy improves renal outcomes in patients with HF.

Panel discussion SGLT2i has been demonstrated to reduce the composite renal endpoint in patients by decreasing proximal nephron salt reabsorption, resulting in lower intraglomerular hydrostatic pressures and TGF restoration. Patients with diabetes tend to have a more significant acute decline in the estimated glomerular filtration rate (eGFR) (Table 5).

Table 5 Summary of clinical trials highlighting renal outcomes with SGLT2i in HF

Evidence Growing evidence from randomized, controlled trials supports the benefits of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on cardiac and renal complications. The indications for SGLT2i have expanded to include glycemic control, reducing atherosclerotic cardiovascular disease (ASCVD), heart failure, diabetic kidney disease, and nondiabetic kidney disease. Although atherosclerosis, cardiac disease, and heart failure are all conditions worsened by kidney disease, there are currently no drugs that specifically protect renal function. However, recent randomized trials, namely DAPA-CKD and EMPA-Kidney, have demonstrated the clinical benefits of dapagliflozin and empagliflozin in improving outcomes for patients with chronic kidney disease. SGLT2i consistently provides cardiorenal protection, reducing the progression of kidney disease and the risk of cardiovascular-related deaths in patients with and without diabetes mellitus [49, 50]. A meta-analysis has shown that SGLT2i alters the risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk but also in patients with chronic kidney disease or heart failure, regardless of diabetes status, primary kidney disease, or kidney function. Another meta-analysis found that irrespective of the estimated glomerular filtration rate (eGFR) levels, SGLT2i significantly lowers the risk of primary renal outcomes in individuals with chronic kidney disease. Consistent benefits have also been observed in patients with type 2 diabetes. However, renal advantages in individuals with ASCVD were mainly identified in those with chronic kidney disease with microalbuminuria, while no discernible benefits were seen in those whose eGFR was less than 60 ml/min/1.73.(57) m2 [51]. A meta-analysis of 20 randomized controlled trials involving 63,604 patients with type 2 diabetes, heart failure, or chronic kidney disease found that SGLT2i (dapagliflozin, canagliflozin, empagliflozin, and ertugliflozin) were associated with a significant reduction in the risk of incident atrial fibrillation (AF) compared to the control group. However, there was no significant impact on the risk of stroke. The study suggests that SGLT2i may lower the risk of AF but does not have a substantial effect on the risk of stroke in patients with and without type 2 diabetes [52]. In another meta-analysis of 42 trials involving 61,076 patients with type 2 diabetes indicates that treatment with SGLT2i is associated with a reduced incidence of major adverse cardiovascular events, myocardial infarction, cardiovascular mortality, and all-cause mortality compared to control groups [53].

Consensus 13 SGLT2i is effective for the treatment of heart failure regardless of ejection fraction.

Panel discussion SGLT2i has robust clinical data for HFpEF compared to other GDMT (ARNi, MRAs, BB). SGLT2i have proven effective across the spectrum of HF (HFrEF, HFmrEF, HFpEF). The patient must receive an SGLT2i as soon as the patient becomes euvolemic and is off inotropes. The metabolic side effects need not be monitored for SGLT2i.

Evidence The meta-analysis of data from the DELIVER, EMPEROR-Preserved, and three other trials involving a total of 21,947 participants found that SGLT2i significantly reduced the risk of composite cardiovascular death or hospitalization for heart failure, cardiovascular death, hospitalization for heart failure, and all-cause mortality. These benefits were observed consistently in heart failure with mildly reduced or preserved ejection fraction across all five trials. The analysis also revealed that, for the primary endpoint, treatment effects on all categories, including ejection fraction, were relatively consistent. These findings support the use of SGLT2i for all types of HF, regardless of ejection fraction [54].

A recent meta-analysis of the DAPA-HF and EMPEROR-Reduced trials noticed no heterogeneity in CV mortality, even though the EMPEROR-Reduced trial did not significantly reduce CV mortality. Therefore, whether patients with HFrEF have diabetes, dapagliflozin, and empagliflozin are recommended with an ACEI/ARNi, MRAs, and a beta-blocker. Due to their diuretic/natriuretic effects, SGLT2i has additional advantages in reducing congestion and may reduce the need for loop diuretics [36]. According to the meta-analysis of two trials, DAPA-HF and DELIVER, dapagliflozin reduced the risk of death from cardiovascular causes, death from any cause, total hospital admissions for heart failure, and major adverse cardiovascular events (MACEs). The study suggests that dapagliflozin could be an effective treatment for patients with heart failure regardless of ejection fraction [55]. Sotagliflozin has also been demonstrated in hospitalized patients with diabetes and HF and was found to reduce CV death and hospitalization for HF. However, treatment involving SGLT2i might increase the likelihood of recurring genital fungal infections and a minor decline in eGFR upon initiation. However, this reduction is reversible and should not prompt premature discontinuation of the medication [36].

Novel Therapies for Heart Failure

In recent years, research has unveiled novel routes and molecular targets that play crucial roles in the progression of HF. This understanding has led to the development of newer pharmacological drugs that specifically target these sites, offering promising prospects for HF treatment. However, it is important to note that despite their potential benefits, these innovative medications may not be readily available in resource-limited settings due to factors such as cost and infrastructure constraints. Thus, while these advancements hold great promise for improving HF management, their widespread accessibility remains a challenge in certain healthcare environments (Table 6) [57].

Table 6 Newer therapies in HF managementUnmet Need in HF Management

There is an unmet requirement for establishing evidence-based therapy for each patient individually with better understanding of pathogenesis of HF. The expertise required in interpreting the results of imaging has to be improved. Hemodynamic sensors/non-invasive strips that can help monitor filling pressure can help de-escalate the dose of diuretics. Controlling risk factors for better clinical outcomes is essential. Even with symptomatic disease, significant barriers to early diagnosis and treatment of HF remain, such as poor awareness of the disease among the general population and suboptimal diagnosis by non-specialist healthcare practitioners, who may have limited access to diagnostic tools such as echocardiography. This is especially concerning in light of the variable clinical presentation of HF and the symptoms (shortness of breath and exercise intolerance) of the conditions with common comorbidities, such as chronic obstructive pulmonary disease, chronic kidney disease (CKD), anemia, and diabetes mellitus. Delays in HF diagnosis are linked to more extended treatment periods, prolonged hospital stays, and death [58].