We have great pleasure in introducing the latest issue of Cardiac Failure Review. As we gear up for the annual heart failure congress of the European Heart Failure Association (29 April–2 May 2017), we reflect on the successes and failures since the influential European guidelines were published in Florence a year ago.
In this 12-month period we have seen the promotion of a new category of chronic heart failure; the so-called heart failure with mid-range ejection fraction (HFmrEF). A major driver for this no category was the desire for more clinical trials in a group of patients that includes both those with minor systolic dysfunction and some who have improved from more severe heart failure with reduced ejection fraction-type dysfunction and no longer fall into that category. Our major clinical trials, on which almost all treatment recommendations are based, have variably included some of the patients but not enough to be confident we know how to treat this group. As we all know, major clinical trials take many years to complete so we will not see answers for some time, but it is encouraging to see observational studies on HFmrEF already coming out.
When it comes to major trials in heart failure, the only major mortality and morbidity trial to report recently (RELAX-AHF-2) was disappointingly neutral, with no added benefit of serelaxin in the setting of acute heart failure.
Comorbidities are attracting increasing attention as we struggle to evaluate and treat our ever-ageing population of heart failure patients. Foremost of these in terms of rapidly accumulating evidence is diabetes. Following a run of newer agents that have sometimes lead to an increased risk of heart failure at least we have an hypoglycemic agent with major cardiovascular benefit in high-risk diabetic patients with cardiovascular disease. The SGLT2 inhibitor (“gliflozin”), empagliflozin, was studied in patients with high cardiovascular risk in the EMPA-REG OUTCOME trial and this demonstrated reduced cardiovascular death and a significant reduction in new-onset heart failure. These findings will now be further explored in specific heart failure populations by the up-coming two EMPEROR HF clinical trials: EMPEROR HF-Preserved [NCT03057951] in heart failure with preserved ejection fraction, and EMPEROR HF-Reduced [NCT03057977] in heart failure with reduced ejection fraction. Another agent of a different class, the GLP1 receptor agonist liraglutide, showed an overall benefit on cardiovascular mortality in the recent LEADER study. Who better to review the complex and rapidly changing area of the management of the diabetic patient with heart failure for our readers this issue than Rosano and Seferovic?
We also cover vital topics such as how and when to get the best from neurohormonal blockade, how to up-titrate (and not overdo the complexity of our treatments), the role of combination pills to ease patient compliance, and how to manage the hyperkalaemia that can lead to premature discontinuation of potentially life-saving therapies. These are masterfully covered by von Lueder et al, Atherton and Hickey, Werdan et al, and Lainscak, in turn.
Savarese and Lund review the increasing global burden of heart failure as the West ages, the East adopts poorer Western diets and the developing world rapidly grows economically stronger, but sadly weaker in terms of healthy diets and lifestyles. There are two very informative articles on the emerging field of cardio-oncology, where both some of the newer anti-cancer drugs can be bedevilled by cardiac damage side-effects, and even cancer itself has been implicated in causing an new form of cardiomyopathy. Lastly we review the impact of abnormal ventriculo-aortic haemodynamic coupling putting additional stress on the already damaged ventricle. We review the care of the older chronic heart failure patient and we look at the complexity of managing acute heart failure in the presence of active lung disease that can so confuse the clinical picture.
We hope you enjoy reading our latest issue of Cardiac Failure Review.