Rethinking Advanced Heart Failure: Treat the Disease, Not the Symptoms

In the latest episode of Moving the Needle in Medicine, host Alex Hajduczok, MD, a cardiologist and heart failure specialist at Oklahoma Heart Institute, sits down with Philip Adamson, MD, MSc, chief medical officer at CVRx, to discuss ongoing paradigm changes in heart failure care and prevention.

Check out the full episode on Adamson’s full cardiology career here.

The discussion focuses on the evolving understanding of advanced heart failure and the need to move beyond symptom-based treatment paradigms toward earlier, mechanism-driven intervention. The guest argues that current clinical practice often allows left-sided heart failure to "metastasize," with progressive pulmonary vascular disease and right ventricular dysfunction developing long before patients meet conventional definitions of advanced heart failure. He explains that therapies are typically initiated only after patients become overtly symptomatic, despite the underlying pathophysiology having progressed for months or years. To address this gap, he describes the rationale behind the Team HF trial, which is designed to identify physiological markers that can better define the transition to advanced heart failure and determine which patients may benefit from earlier left ventricular offloading before irreversible disease progression occurs.

The speakers discuss the limitations of relying on traditional clinical assessments such as New York Heart Association (NYHA) functional class, noting that congestion and elevated filling pressures may be present regardless of symptom burden. They emphasize that symptoms often poorly reflect the severity of the underlying disease because the body is capable of compensating for substantial physiological disturbances before decompensation becomes clinically apparent. This disconnect, they argue, has led clinicians to justify treatment primarily on the basis of symptom relief rather than targeting the biological processes responsible for disease progression.

Building on this concept, the conversation explores the broader implications of adopting a mechanism-based approach to heart failure management. The guest reflects on his recent work investigating the autonomic nervous system, highlighting its central role in driving the progression of heart failure. Rather than focusing on downstream surrogate markers, he advocates for therapies that directly modify maladaptive autonomic signaling, suggesting that advances in neuromodulation may offer opportunities to fundamentally alter the disease trajectory. He draws parallels to emerging neurotechnology in other fields, arguing that cardiovascular medicine should similarly embrace innovative approaches capable of modifying the underlying mechanisms of disease.

The discussion also examines secondary pulmonary hypertension as a frequently overlooked consequence of left-sided heart failure. The guest cites findings demonstrating that a large proportion of patients with relatively mild, NYHA class II heart failure harbor significant pulmonary hypertension despite appearing clinically stable, underscoring how conventional symptom-based assessment may fail to identify patients at risk for progressive right ventricular dysfunction. Because these patients often would not undergo invasive hemodynamic evaluation in routine practice, important pathological changes may remain undetected until advanced disease develops.

The episode concludes with an overview of emerging therapeutic strategies targeting the pulmonary circulation, including pulmonary artery denervation to reduce maladaptive sympathetic tone. The speakers discuss the potential for these approaches to slow disease progression, attenuate secondary pulmonary hypertension, preserve right ventricular function, and ultimately redefine the treatment of advanced heart failure by intervening earlier in the disease course. Collectively, they emphasize that future advances in heart failure care will depend on identifying physiological mechanisms of progression and developing therapies that address these processes before irreversible clinical deterioration occurs.

Editors’ Note: Hajduczok reports disclosures with CVRx, Edwards Lifesciences, and Impulse Dynamics. Adamson reports employment with CVRx.