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RESEARCH PRODUCT

Step by Step Toward Biomarker-Based Precision Medicine in Heart Failure

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> You wouldn't wear just any pair of glasses—your prescription is tailored to your vision. This statement was made by President Obama in 2016 during the presentation and launch of the Precision Medicine Initiative. Whether we like it or not (and some politicians today seem rather indifferent), we are headed toward a new paradigm of precision medicine. This is a new era of medicine in which the right treatment is delivered at the right time to the right person. In the context of heart failure (HF)5 there is a long road ahead to fully realize the goals of precision medicine. HF is a complex syndrome with heterogeneous pathophysiology. Most medical treatments currently used in HF have been tested in large randomized clinical trials (RCTs) for the “average” patient. That is, a patient with signs and symptoms of HF, generally assessed with an inaccurate measure of functional status (1), the New York Heart Association functional class, and a measure of systolic left ventricular function, in most instances left ventricular ejection fraction by echocardiography. For the past 3 decades, all RCTs in patients with HF with reduced ejection fraction (HFrEF) have been conducted under these premises. Following these general assumptions, β-blockers, angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers, and mineralocorticoid receptor agonists have been incorporated into the care of patients with HFrEF with level IA evidence (cf. the guidelines of both the American Heart Association/American College of Cardiology and European Society of Cardiology). Although level IA evidence means mandatory treatment for all such patients because of excess benefit in RCTs, in truth, some drugs may be of value to some patients but useless to others. The Prospective comparison of angiotensin receptor-neprilysin inhibitor (ARNI) with angiotensin-converting-enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial, published in 2014, may …