Legend states that as penance for an act of homicidal madness, Hercules, the mythological Greek demigod, agreed to perform 12 labors, feats that are now metaphors for accomplishments of prodigious difficulty. After completion of the 10th labor, he created the Pillars of Hercules, which the modern world knows as the Straits of Gibraltar. Ancient commentators were undecided about his motives, but one theory was that he intended the pillars to mark the end of the world, a warning that beyond that point nothing exists. Heart failure provides clinicians a modern-day Herculean labor: its prognosis is often described as cancerlike, its clinical manifestations are often progressive and sometimes refractory, and the number of affected patients is expected to grow by a staggering amount in the next few decades as the population ages. Evidence to extend life expectancy of reasonable quality past the “nothing further beyond” pillars that a diagnosis of heart failure has historically conveyed has developed slowly over the past 30 years. Starting with trials showing the prognosis-modifying potential for angiotensin-converting enzyme (ACE) inhibitors, followed by β-blockers, angiotensin II receptor blockers (ARBs), and then mineralocorticoid receptor antagonists, clinical science has developed an impressive portfolio of what works in heart failure. However, clinical practice has consistently underperformed in the use of these agents relative to what both pivotal trial results and clinical practice guidelines would have us do.1
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Chew DS, Mark DB. Dapagliflozin—Does Cost Make 4-Pillar Heart Failure Therapy Too Herculean a Labor for Medicine? JAMA Cardiol. 2021;6(8):875–876. doi:10.1001/jamacardio.2021.1448
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