A conversation with

Hans-Peter Brunner-La Rocca

In the context of the Dutch National Research Agenda, experts at Maastricht UMC+ answer questions about science in the "A conversation with..." column. This time, cardiologist Hans-Peter Brunner-La Rocca, Professor of Cardiology & Clinical Heart Failure, deals with the following question:

Can we improve treatment and prognosis for patients with heart failure?

"In the current treatment of heart failure, medication plays a key role. Patients are usually sent home with a whole range of drugs: ACE inhibitors to dilate their blood vessels so that the heart has to work less hard, beta blockers to reduce the oxygen demand of the heart muscle, various types of diuretics, and perhaps other medications. Almost every patient is prescribed the same array of drugs. However, they are more effective in one patient than in another.

It would be much better and more efficient if we could determine the optimal combination of drugs for each individual patient. However, to do that we would need to be able to predict which patients will respond to which drugs. That would not only increase effectiveness but also cut costs. A lot of research is currently being done on what are called "biomarkers". These are substances that occur naturally in the human body and that can tell us something about a person's health. They can be measured in the blood, for example. In the case of heart failure, for example, the protein BNP (B-type natriuretic peptide) can be used as a biomarker. Overloading, a heart attack, or inflammation can cause damage to the heart muscle, leading to heart failure. Too much pressure on the heart muscle leads to BNP being released into the bloodstream. When there is a strong suspicion of heart failure, the cardiologist can measure the BNP level. This helps to diagnose heart failure and to determine how serious the situation is. In addition to BNP, there are many other substances that can be measured and can tell us something about the health of the heart. However, hardly any use is yet made of this approach in actual practice. We don't yet in fact know what relationship there is between therapy and various biomarkers.

We are currently investigating a number of different biomarkers, which we ultimately hope to use to predict which patients will benefit most from a particular combination of drugs. If the level of biomarker A is elevated, for example, we can prescribe a higher dosage of beta-blockers, but if biomarker B is elevated, then a lower dosage may be required. In this way we are looking for the ideal combination of drugs for each patient. We hope this approach will enable us to achieve at least the same effect but with fewer medications, fewer side effects, improved quality of life, and lower healthcare costs. But a lot of further research will be necessary before we can do that in actual practice.

It would of course be even better if we could detect heart failure much earlier. At the moment, that diagnosis can only be made at a late stage. It’s naturally more beneficial if it can be made earlier. An innovative new technique allows us to analyse exhaled air. By combining that analysis with clinical data, it should be possible to make a better diagnosis of heart failure. The breath test is based on the identification of patterns of “volatile organic compounds” (VOCs) in the exhaled air. In the case of a patient with heart failure, the pattern is very likely to differ from that of a healthy person. However, extensive research will be needed before we can use this method in actual practice. But the initial results are in any case promising.

Heart failure is a condition that 25 years ago could be classified as extremely serious. Almost half of patients with the condition died within one year. The survival rate has since improved greatly but the prognosis for heart failure is still worse than for most cancers. The number of patients is also constantly increasing. Currently, one to two percent of the Western population get heart failure, a figure that is expected to rise to three per cent by 2025. That amounts to some 20 million Europeans. New and innovative solutions are needed if we are to prevent healthcare costs from skyrocketing and reduce the pressure on hospitals. One of these solutions is “tele-monitoring”, i.e. monitoring patients remotely. An example is “My Heart Failure Coach”, an Internet app that supports patients in their day-to-day life. This smart digital tool identifies, amongst other things, a deterioration in the patient’s state of health, gives advice, and provides an individual treatment plan so that the patient can take action in time himself. This makes it possible to reduce the number of hospital admissions while at the same time improving the patient’s quality of life. I anticipate that these trends in self-care will definitely continue to increase. Here too, the individual needs of the patient are primary. If we want to cope effectively with heart failure, then we must continue to look for different ways to treat each patient on a personal basis.”

More information about heart failure?

- The Cardiovascular Group is a platform by and for people with a cardiovascular condition. Its website provides a lot of information about various cardiovascular conditions, including heart failure and tele‑monitoring.

- Heartfailurematters.org is a Dutch-language website with a great deal of information about heart failure.

- Health Foundation Limburg organises an annual “Walk with your doctor” event. The registration fees and sponsorship money go to support various projects at Maastricht UMC+.

- Queen of Hearts is a large-scale study which includes searching for biomarkers that may provide information about heart failure in women, especially those who have experienced preeclampsia.

You can support research on heart failure via:
- Health Foundation Limburg, Cardiovascular diseases
- Dutch Heart Foundation