Dr Clyde Yancy:

Hi, this is Clyde Yancy, Professor of Medicine, Chief of Cardiology at Northwestern Medicine in Chicago. Right now, though, I'm an AHA volunteer and delighted to be at the American Heart Association Scientific Sessions 2025. It's a great experience.

Looking at the current state of heart failure management, what do you see as the most significant opportunities for prevention before symptomatic disease develops?

Whenever I think about heart failure today, mind you, I've been thinking about heart failure for over 35 years as an investigator, as a teacher, as a leader, as someone who generates guidelines, I get excited. Now, what could excite someone when you've been doing it for 35 years?

What excites me is all of the opportunity that's on the horizon. We've gone from this dower dismal diagnosis to a situation where we can offer the majority of patients substantial hope and opportunity to recover their quality of life, do better and live better.

But where the real opportunity resides is that we can have meaningful conversations now about fundamentally preventing this disease. It doesn't have to happen. And so if we can do a pivot and think about the risk factors for heart failure and intervene on those risk factors as we have for atherosclerosis, we have an opportunity to change the natural history here.

How is precision medicine beginning to transform our approach to heart failure, and what does truly personalized HF therapy look like in practice?

One of the reasons for my enthusiasm, despite 35 years of toiling in this field, is that we're able to leverage new strategies, new tools, and most importantly, new science. It was science, breakthrough science, that allowed us to understand that pivoting from just thinking about hemodynamics or thinking about biology led to a whole portfolio of new therapeutic opportunities.

With that in mind, we've been able to leverage again new information, new science. I'm particularly pleased with new epidemiology that helps us understand with some precision who's most likely to develop heart failure. The prevent calculator has a dimension now known as PREVENT-HF calculator.

Understanding who's at risk and realising that we already have data in hand, that if we start disease modifying therapies in that stage B, that pre-heart failure space, we can attenuate the progression from stage B to stage C. Especially, especially if we engage with the current conversation, which is quite topical today, of addressing the cardiometabolic syndrome.

When we address the cardiometabolic syndrome effectively, we are modifying the natural history of several disease processes, not just diabetes, not just chronic kidney disease, but also heart failure. So I have ample reason to be enthusiastic because science, because of new epidemiology, because of new risk calculations.

How should training and practice patterns evolve to address contemporary heart failure challenges?

So I must be candid, even though I've spoken very clearly about my excitement, my enthusiasm about the opportunity that exists in heart failure. I must also acknowledge that we have significant challenges. And interestingly enough, the challenges aren't just in identifying new therapies.

The challenges now are in implementation. The challenges now are in awareness. The challenges now are in modifying the way that we train the next generation of physicians to treat the condition that I no longer call heart failure, but just heart dysfunction.

Because it's an entire array of circumstances. The cardiomyopathies, the genetic tendencies towards cardiovascular disease, the cardiometabolic space, as I mentioned once before. We need to have the current generation of trainees appreciate all the different iterations of ventricular dysfunction.

And let's be very candid, the most common presenting phenotype is no longer heart failure with reduced ejection fraction, but heart failure with preserved ejection fraction. Are we doing a sufficient enough job training the next generation of general cardiologists, but especially heart failure cardiologists, to really account for or accommodate and then treat heart failure with reserved ejection fraction? You can tell by the tone of my voice we aren't, and those are challenges we need to overcome.

What emerging therapies or technologies do you believe will have the greatest impact on HF outcomes over the next 5-10 years?

It's interesting. You get to a certain point in your career, people think that you're close enough to the end of your career that you've seen the future. I'm not sure that's a valid argument, but nevertheless, I'm frequently tasked with anticipating what's going to happen in the next five to 10 years. Let's be candid, issues of left ventricle dysfunction will remain with us, but the reasons will be different.

When I first entered the field, the reasons were very clear. There was the residual of atherosclerosis, myocardial infarction, and the loss of ventricular tissue after myocardial injury. That's not the case as often now. The case now is in fact obesity; the case now is diabetes; the case now is hypertension.

So let's be very candid, the first observation about the future is that matters of LV dysfunction will [illegible]. The second observation of the future is just like we wrestled with the human dynamics and developed some at least symptom-limiting strategies.

And then we acknowledge the neurohormonal hypothesis, began to change the natural history. And more recently I've begun to understand the necessity to think about cardiovascular metabolism and disrupting that or enhancing that, depending on the approach. Each of those eras of breakthrough leading to better outcomes for patients.

Let's anticipate that over the next 10 years, maybe longer, we'll be able to find the next realm of discovery that will further improve outcomes. Despite how much we trump the benefits of current temporary therapies, the residual risk is non-trivial.

So there's still patients who, despite being on all the right agents, have the vents. And so this gives us an opportunity to do more research. I think the tools that will get us there though are very different. It won't be the usual at the bench study, we'll use data science, we'll use proteomics, we'll use genomics, we will use powerful ways of assimilating information and develop high-yield hypotheses as opposed to high-risk hypotheses. That's what we've done in the past. In the future, I think we'll follow high-yield hypotheses. I can't wait. I hope to be a part of their future.

How can healthcare systems better integrate multidisciplinary care models to optimize heart failure management?

You know, when I think about the future, one of the circumstances that doesn't require a lot of clairvoyance is understanding that the way we've been doing things needs to change.

Everything has been centered on healthcare systems. I don't know that that's the way we need to go. I think we need to make matters of heart dysfunction topical enough that they're in lay language, the way the lay community always wants to know about heart attacks, always wants to know about cholesterol, always wants to know about atherosclerosis.

Duh. That's the same sort of paradigm we need to adopt for matters of [illegible] dysfunction. It's not the health system that's going to really change the national history of this disease. It's the everyday awareness of the everyday person. Particularly when we recognise that the epidemiology still says one in five will get heart failure before they leave this earth.

Well, when 20% of the people are likely to experience this condition, it really does matter and everyone should think about this. Let's put it this way. The likelihood of experiencing heart failure is at least on par with the likelihood of having cancer.

Everyone is conversant about cancer. We think about it, we screen for it, we're concerned about it. We don't have that kind of community awareness. So I think we need to change the way we've been doing things and get to a different approach.

What are your essential messages for cardiologists working to improve outcomes for their heart failure patients today?

You know, if I had to give you a takeaway about where we are in the world with heart failure right now, I would say this, it's no longer about failure. For years, that's always been the heavy drape, the angst, the heft that's come with this diagnosis. It's no longer about failure. The vast majority of patients will respond to current evidence-based management and therapy including devices but certainly the portfolio of meds, and we have that portfolio of meds for both reduced ejection fraction heart failure and preserved ejection heart failure.

Additionally never before have we been able to attenuate the likelihood of developing this condition. If we pivot the way we think about heart failure, remove failure from the equation, realise that it's about dysfunction and is treatable, and realise even more importantly that we can prevent it by assiduously controlling hypertension, by managing diabetes, following the hemoglobin A1c, get it to less than 6.5, get it to 6 even. When we understand if we manage medical obesity well, we can fundamentally bend the arc of this curve back towards the null.

That's amazing to think that we can do that. So from my point of view if there's one message that every care provider needs to hear about heart failure remove failure from the equation it's no longer a failing proposition.