We have great pleasure in recommending this second issue of Cardiac Failure Review to our readers. We have a panel of exceptional experts who have reviewed topical issues varying from fundamental science underpinning the diseased heart muscle to practical advice on clinical management from the acute presentation and cardiogenic shock through to patient self-management.
In this second issue we start with a comprehensive review of disordered intra- and inter-cellular communication in the heart in chronic heart failure by Fountoulaki and colleagues from Athens, Greece. They consider the importance of the remodelling process that is so fundamental to our understanding of the pathogenesis and progression of heart failure and that involves all the major permanent cell types of the myocardium (myocytes, fibroblasts, endothelial cells, smooth muscle cells and stem cells) and also transient cell populations, such as immune and circulating stem cells.1 Of these cell types, perhaps most recent attention has been directed at the myofibroblast and its interaction with the extra-cellular matrix. Despite recent progress, our understanding of the role of cell-cell and cell-extra-cellular matrix interactions remains incomplete. Interventions that target these processes may help us unravel their significance and may lead to new therapeutic avenues, especially inhibiting myofibroblast formation and stimulating angiogenesis in the damaged myocardium. We know the importance of these cells changes in the progression of the subset of heart failure with a reduced ejection fraction. Much less is known about the subset with preserved ejection fraction,2 yet this condition is one in which alterations in myofibroblasts and extra-cellular matrix are most marked.
We then have a series of articles that are much more practical, giving advice on the most appropriate use of early diagnostic tests in acute and chronic congestion and in monitoring heart failure. Sharma and colleagues undertake a review of the major features in the history, examination and chest radiograph that can aid a timely diagnosis of acute heart failure, and identifies the main features of the history and clinical examination. Rudiger and colleagues outline the important steps in the initial management of shock in post-cardiac surgical patients – in what they describe as the ‘golden hours’ (the first 6 hours). They describe how the features of shock in cardio-surgical patients can be a dangerous marker of high morbidity and mortality. They divide the shock syndromes in this setting into cardiogenic, hypovolaemic, obstructive and distributive types and outline the therapeutic approaches in each. They stress the need for timely recognition and prompt intervention to reverse the shocked state to avoid irreversible organ dysfunction and/or death. They review recent trials based on the earlier concept of early-goal directed therapy.3 The recent trials – Australasian Resuscitation in Sepsis Evaluation (ARISE), Protocolized Care for Early Septic Shock (ProCESS) and Protocolised Management in Sepsis (ProMISe)4–6 – failed to show that early-goal directed therapy was superior to standard care in patients with early septic shock, a finding they attribute to differences in modern background therapy in this setting.
Pang and colleagues review the emerging technique of focused bedside ultrasound that they have done so much to develop. They review its role in the diagnosis of acute heart failure in the emergency setting, particularly when confounding co-morbidities are so frequently present. Lung ultrasound can be used to assess congestion more accurately, which, along with extra-vascular lung water, in the correct clinical setting is highly suggestive of acute heart failure. They summarise that focused bedside ultrasound although not replacing formal cardiac echocardiography can be an extremely useful clinical bedside diagnostic test. Henein and Wettersten then review the highly complex area of echocardiographic assessment of left ventricular diastolic function.
Turning back to more routine clinical matters, Clark and colleagues review the art of fluid management in the management of the patient with moderate to severe chronic heart failure. While subject to fewer large-scale clinical trials, this is an area of intense clinical value when performed well and one that every heart failure specialist needs to develop refined skills, as no two patients are the same and many require quite detailed consideration of optimal fluid management, The age-old question as to whether it is better to aim to keep the patient on the dry or the wet side for optimal outcomes remains unclear to this day.
Biomarkers are increasingly playing a major role in the management of chronic diseases, and in this chronic heart failure is a leader. This subject benefits enormously from three leading groups reviewing different biomarkers in various heart failure- related clinical settings and give a masterful overview of this rapidly developing field.
Pepper reviews the respective roles of coronary artery bypass grafting and percutaneous coronary intervention in the management of heart failure patients with multi-vessel coronary disease. This comprehensive and clear review of a complex area of practice for which, despite many studies, definitive evidence-based recommendations are hard to come by. Pepper reflects that design issues and patient selection have meant that recent randomised trials that have examined treatment for coronary artery disease often did not include sufficient numbers of patients with severe left ventricular dysfunction, exactly the group in whim trial evidence is so sorely needed. This article in particular is highly recommended to our readers.
Last – and extremely importantly – Riley and Hare separately review the main roles of nursing care and patent self-management in optimal chronic heart failure management programmes and in dealing with acute heart failure exacerbations.
We hope you will enjoy reading the whole issue as much as we did in helping assemble it.