CFR 4.1 by Radcliffe Cardiology

Foreword

Andrew JS Coats is the inaugural Joint Academic Vice-President of Monash University, Australia and the University of Warwick, UK and Director of the Monash Warwick Alliance

Giuseppe Rosano is Professor of Pharmacology, Director of the Centre of Clinical and Experimental Medicine at the IRCCS San Raffaele, Italy and Professor of Cardiology and Consultant Cardiologist (Hon) at St George's University of London, UK

e have great pleasure in introducing the latest issue of Cardiac Failure Review. We have been impressed with the extra information that has flooded in concerning the new classification of heart failure (including for the first time heart failure with mid-range ejection fraction [HFmrEF]) popularised by the influential 2016 European Society of Cardiology and Heart Failure Association Guidelines.1 What we were aiming for by introducing this new classification was twofold: a clearer separation between HFrEF, where many treatments had been proven to be effective and heart failure with preserved ejection fraction (HFpEF) where none had, and the encouragement for further analyses and trials in this new group with left ventricular ejection fraction (LVEF) in the range of 40–49 %. The second aim will take some time to complete in terms of new trials, as these take many years to design and complete. The first part of this, however, has come through brilliantly, with new analyses of both the CHARM programme of Candesartan cilexetil2 and the beta-blocker trialists' meta-analysis group.3 In both cases, we can clearly say now that there is prospective evidence

that mortality and morbidity outcomes are improved by these two treatment classes also in HFmrEF, and we can also say the absence of benefit in HFpEF still remains. Nadar and Tariq in this issue elegantly review the aetiology and pathophysiology of HFmrEF, its clinical profile, the most appropriate diagnosis and the prognosis for these patients. Yuri Lopatin also reviews the therapies available for HFmrEF, noting that doctors are already treating HFmrEF, with multiple registries showing that the rate of prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists and beta-blockers is quite high in patients with HFmrEF, probably because of analyses showing that HFmrEF patients, in contrast to patients with HFpEF, had a benefit in prognosis similar to those with HFrEF when guideline-recommended therapies were tested. In addition to the two examples we quote above, Lopatin also reviews evidence from a post-hoc analysis of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial) that revealed a reduction in the primary endpoint (a composite of death from cardiovascular causes, aborted cardiac arrest or HF hospitalisation) in HFpEF patients on the lower end of the ejection fraction spectrum – LVEF 45–49 %, but not when LVEF was >60 % (LVEF <50 %: HR=0.72; LVEF ≥60 %: HR=0.97, p=0.046). This will not be the end of this particular story, because clinicians are already asking whether we should consider patients with stable LVEF in the 40–49 % range differently to those with recovered ejection fraction, where it has increased from levels <40 % after the introduction of effective therapies for HFrEF. As always, more trials and more analyses are needed to answer this important question. Later in the issue, Yalta and colleagues review the very contemporary issue of the implication of different clinical patterns of left ventricular dysfunction in the setting of Takotsubo cardiomyopathy. They raise the worrying suggestion that, despite apparent recovery in left ventricular function after a bout of Takotsubo, microscopic changes at the cellular level may cause long-term damage to myocardial function, including persistent diastolic dysfunction and subclinical left ventricular systolic dysfunction. The implications of this phenomenon on subsequent symptomatology and prognosis, particularly exercise- or stress-induced complications among Takotsubo cardiomyopathy survivors, is deserving of further study. Gallagher and colleagues review the emerging crisis of heart failure in sub-Saharan Africa. The co-existence of multiple trends is impacting on this region. Its growing population, the ageing of its population and the rapidly increasing prevalence of atherosclerotic risk factors are making heart failure much more common, adding ischaemic and age-related heart failure to the hitherto more common aetiologies in Africa, such as rheumatic heart disease and endomyocardial fibrosis. This combined with a relative deficiency in access to care and diagnostic techniques, such as echocardiography, which when combined with a patchy availability of guideline-recommended treatments, means that there is much avoidable mortality and morbidity due to heart failure in this region. They highlight the potential future role of more widespread biomarkers to facilitate access decisions to sub-optimally available resources, such as clinical echocardiography, for these patient populations. DOI: 10.15420/cfr.2018.4.1.FO1

Access at: www.CFRjournal.com

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05/05/2018 22:18