December 2021 at a glance: focus on medical treatment, valvular heart disease and prognostic models

Guideline-directed medical therapy (GDMT) represents a powerful tool to prevent and reduce cardiovascular mortality and hospitalizations in patients with heart failure (HF) with reduced ejection fraction (HFrEF).1 In clinical practice, many factors may lead to GDMT underutilization and only a minority of patients receive target doses used in the landmark trials.2-5 Seferovic et al.6 proposed new strategies for the implementation of GDMT. Professional education, motivation, and training, as well as patient empowerment for self-care, modern technologies, multidisciplinary team management, novel drugs and better patient profiling are possible solutions to implement GDMT. ACTIVITY-HF is a randomized controlled trial that enrolled 201 patients with HFrEF and aimed at comparing the effects of sacubitril/valsartan versus enalapril on exercise capacity. The primary endpoint of change from baseline to 12 weeks in peak oxygen consumption did not differ between groups.7 Results are consistent with previous findings form the OUTSTEP-HF trial.8 Sacubitril/valsartan was compared to valsartan alone in patients with HF with preserved ejection fraction (HFpEF) in the Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF) trial.9-11 Suzuki et al.12 showed that non-completion of the run-in period, an event occurring in 16.1% of the 4822 randomized patients, was associated with multiple factors, including lower systolic blood pressure, lower serum sodium and haemoglobin, worse renal function, higher N-terminal pro-B-type natriuretic peptide, higher New York Heart Association functional class, prior HF hospitalization, and lack of prior use of renin–angiotensin system inhibitors or beta-blocker. Most of these factors seem to be related to a more advanced disease. Heart failure with preserved ejection fraction is a heterogeneous syndrome with multiple aetiologies and phenotypes.13-15 Kammerlander et al.16 investigated the prevalence of HFpEF following left-sided valve repair. Out of 973 patients included, 673 underwent surgery and 300, with HFpEF, did not (control group). After surgery, 67.4% of patients fulfilled the criteria for the diagnosis of HFpEF, 20.6% were without HF and 12% developed HF with either mid-range or reduced ejection fraction. Of note, only a minority of patients were correctly diagnosed with HFpEF by cardiologists at follow-up. Patients who developed HF, irrespective of ejection fraction, had a higher risk of death, compared to those without HF, and a similar risk compared to the HFpEF control group. The role of biomarkers for the prognostic stratification of HF patients is well established.17, 18 In a cohort of 708 patients with aortic stenosis, several biomarkers were associated with the endpoints of death and death or HF hospitalizations. Using a machine-learning method, interleukin-6 (a marker of inflammation) and fibroblast growth factor-23 (a marker of calcification) resulted the most strongly associated with adverse outcomes.19 Many risk prediction models have been developed.20, 21 Codina et al.22 proposed a head-to-head comparison of different prediction models, including Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC-HF) risk score, Seattle Heart Failure Model (SHFM), PARADIGM Risk of Events and Death in the Contemporary Treatment of Heart Failure (PREDICT-HF) and Barcelona Bio-Heart Failure (BCN-Bio-HF) risk calculator. A total of 1166 patients were included. The four scores had similar performance. However, correlation between them was relatively poor. Furthermore, SHFM and PREDICT-HF underestimated, whereas BCN-Bio-HF, even if it showed the best accuracy, overestimated the risk of events. The outcome of patients with acute myocarditis and life-threatening ventricular arrhythmias is still unsettled. Gentile et al.23 retrospectively studied the incidence and the predictors of recurrent major arrhythmic events (MAEs), defined as sudden cardiac death or successfully defibrillated ventricular fibrillation, or sustained ventricular tachycardia (sVT) after discharge. Out of 156 patients, 58 (37.2%) experienced MAEs after discharge. MAEs with sVT at presentation, late gadolinium enhancement involving ≥2 myocardial segments and absence of positive short-tau inversion recovery at first cardiac magnetic resonance were identified as valuable tools for risk stratification. Peripartum cardiomyopathy (PPCM) usually occurs during pregnancy or soon after delivery, in the absence of other causes of HF.24, 25 The extent of hypertension in women with PPCM has been investigated by Jackson et al.26 using data from the European Society of Cardiology EURObservational Research Programme PPCM Registry. Maternal and neonatal outcomes were analysed in three phenotypes of women: PPCM with no hypertension (PPCM-noHTN), hypertension with no pre-eclampsia (PPCM-HTN) and PPCM with pre-eclampsia (PPCM-PE). Women with PPCM-PE presented with more severe symptoms and signs of HF than those with PPCM-noHTN, despite having better baseline left ventricular ejection fraction and a greater likelihood of left ventricular recovery. Differences were also found in neonatal outcomes.

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