Modern Heart Failure Drugs: SGLT2 Inhibitors, ARNIs, and Beyond Digoxin

The traditional Indian vegetarian population was genuinely following something close to this diet. What changed was cooking oil. Industrial cooking oils were repackaged and marketed under omega fatty acid branding — omega-3, then omega-6, now omega-9 — persuading consumers to abandon traditional cooking fats like mustard oil and olive oil for artificially processed, packaged products whose health claims aren't supported by meaningful clinical evidence. If the population simply returned to traditional cooking oils, it would likely cut the cardiac disease burden significantly. The pyramid isn't the problem; the oil in the pan is.

No, it does not. Gyms typically require only a basic medical certificate, not triglyceride, homocysteine or CRP levels. The supplement industry is enormous, largely unregulated and mostly not FDA-approved. And building muscle mass ignores that the heart is also a muscle — when it hypertrophies beyond physiological bounds, that's called hypertrophic cardiomyopathy, not fitness. The footballer Christian Eriksen is instructive: he had a cardiac event at Euro 2020, received an ICD, returned to professional football, and years later the ICD detected and treated an arrhythmic episode with a single defibrillation — he felt dizzy, walked off, and was alive. Shane Warne's death, by contrast, fit the classic pattern: lifelong smoking, crash diets, and heavy alcohol.

For patients above 55, LVADs have to a reasonable extent already replaced transplantation as destination therapy — they can run fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression needed. Three developments will transform deceased-donor transplant over the next decade: donation after circulatory death, which could roughly double the donor pool; ex vivo machine perfusion devices like the TransMedics Organ Care System, which keep a donor heart beating outside the body for twelve to twenty-four hours or more, making cross-continental transport feasible; and xenotransplantation, with genetically modified pig hearts already transplanted into two human recipients. It's unlikely any engineered device will fully replicate a natural heart, though — transplantation will stay relevant for at least the next fifteen to twenty-five years.

The first step is an urgent echocardiogram to establish ejection fraction precisely using Simpson's biplane method — the clinical picture at 35% and at 20% are entirely different territories. Below 20%, options are very limited; diuretics alone won't fully resolve the oedema. The Aquadex SmartFlow ultrafiltration system, with a 15ml prime volume removing 60 to 100ml of fluid per hour, is the logical next step when diuretics are failing. But with ejection fraction below 20% in the context of HIV and TB, and hypotension further constraining options, the situation is close to endgame — peritoneal dialysis is theoretically possible, but introducing a device into the body cavity of a patient with active communicable disease carries an infection risk that makes it unsafe in most circumstances.

The tricuspid valve is more often repaired than replaced. Even in a moderately aged patient in the 50 to 60 age group, if tricuspid valve replacement is necessary, a bioprosthetic valve is preferable to a mechanical valve — the right side is a low-pressure circuit, so a mechanical valve there carries a very high thrombosis risk that can embolise to the lung and be fatal. The preferred approach overall is tricuspid repair, either a traditional DeVega repair or an annuloplasty ring. TEER (TriClip for the tricuspid, MitraClip for the mitral) warrants real caution — for the mitral valve it's the surgical community's last resort, used only when every other repair technique and replacement are precluded by financial or anatomical constraint. With today's preoperative 3D imaging of the mitral annulus, a surgeon can nearly always plan intervention in advance instead.

Empagliflozin, because its dose does not need adjustment even below a glomerular filtration rate of 30ml/min, making it well suited to patients with chronic kidney disease.

ARNIs, the combination of sacubitril and valsartan, which block neprilysin, augment natriuretic peptide effect, and prevent harmful cardiac remodelling.

A newer non-steroidal mineralocorticoid receptor antagonist, sold as Kerendia at a standard 10mg dose, now accessible in many African markets alongside traditional spironolactone.

Roughly 25 to 50%; below 25% requires a substantially more intensive treatment approach.