September 2016 at a Glance: Pregnancy, Hypertrophic Cardiomyopathy, Epidemiology, Medical Treatment

Peripartum cardiomyopathy is a major cause of heart failure (HF) towards the end of pregnancy and in the months after delivery. Its prevalence and clinical characteristics are collected in a large registry by the EURObservational Research Programme.1 In this issue of the journal, practical recommendations for the diagnosis and management of severe acute peripartum cardiomyopathy are given by the task force of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC).2 In another article, based on the ESC Registry Of Pregnancy and Cardiac Disease, Sliwa et al. analyse the clinical characteristics and outcomes of 151 women with pulmonary hypertension during pregnancy.3 Maternal and fetal mortality remains excessively high in these subjects with a high rate of HF (27%) and of fetal complications. These were particularly high in the mothers with severe pulmonary hypertension and idiopathic pulmonary arterial hypertension.3 Current treatment of hypertrophic cardiomyopathy is reviewed by Ammirati et al.4 In addition to traditional medical therapy, specific clinical problems, such as treatment of dynamic outflow obstruction, HF caused by end-stage progression, and prevention of atrial fibrillation and ventricular arrhythmias are assessed. Future developments with new treatments, based on pre-clinical research, starting to be assessed in randomized clinical trials, are also discussed.4 Farré et al. present data on all the 88 195 cases with HF detected in Catalonia (Spain) in 2012. One-year mortality rate was 14%, and 53.4% and 30.8% of the patients needed at least one emergency department visit or an unplanned hospitalization, respectively. The costs for HF treatment encompassed 7.1% of the total healthcare budget with hospitalizations and co-morbidities as its main determinants.5 These data confirm those of previous studies,6, 7 and are collected in a large cohort of unselected patients from the single geographical area of Catalonia. Fifteen-year trends in the prevalence, management and outcomes of cardiogenic shock in France are shown by Aissaoui et al.8 Consistent with recent data from other countries,9 the Authors show a decrease in mortality, concomitant not only with the larger use of percutaneous coronary interventions but also with better global patients' assessment and follow-up.8 A consistent proportion of patients with non-valvular atrial fibrillation, and a potential indication to non-vitamin K antagonist oral anticoagulants (NOACs), have HF.10, 11 Analyses from the recent trials comparing them with warfarin are therefore important.12 In this issue of the journal, Magnani et al. examine the results of edoxaban, compared with warfarin, in the 8145 patients with HF enrolled in the ENGAGE AF-TIMI 48 trial. Similar to the overall results of the trial, edoxaban, in its higher dose regimen, was effective in preventing stroke and systemic thromoboembolic events and was associated with a lower risk of major bleeding, compared with warfarin, in the patients with HF.13 The potential impact of renal function on treatment with NOACs in patients with HF and atrial fibrillation is examined by Hawkins et al. using the data from the CHARM programme.14 Patients with atrial fibrillation had a worse renal function compared with those in sinus rhythm. Patients with atrial fibrillation had at least a moderate impairment in renal function in a quarter of the cases, at baseline, and in a third, at the end of the study, with almost half who had renal dysfunction at least once during follow-up. Hence, the projected need for NOAC dose reduction was high, though with differences between individual NOACs due to different criteria for adjustment. Need of cessation would have been, however, rare.14 An analysis from the EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and SurvIval Study in Heart Failure) trial shows the lack of impact of aspirin on the beneficial effects of eplerenone on outcomes with, therefore, different results from those described with ACE inhibitors in some studies.15 The impact of chronic exposure to ivabradine on early readmissions in patients hospitalized for HF during the course of the SHIFT study (Systolic Heart Failure treatment with the If inhibitor ivabradine Trial) is analysed by Komajda et al.16 Ongoing ivabradine treatment was associated with fewer all-cause hospitalizations at 1, 2 and 3 months, confirming its beneficial effects on rehospitalizations.16 Senni et al. have compared two uptitration protocols of sacubitril/valsartan from 50 to 200 mg twice daily (target dose), over 3 and 6 weeks, respectively, in HF patients. Rates for adverse effects (hypotension, renal dysfunction, hyperkalaemia) were similar with the two regimens. The proportion of patients who achieved and maintained the target dose of sacubitril/valsartan 200 mg twice was similar, except in the pre-specified group of patients who were initially on low ACE inhibitor/angiotensin receptor blocker doses, who reached target sacubitril/valsartan doses at higher rates with the slow uptitration regimen, compared with the faster one (85% vs. 74%, P = 0.030).17

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