Neuromodulation in heart failure

This issue in the EHJ Supplement-the Heart of the Matter on neuromodulation in heart failure (HF) is very timely. Indeed, although most HF literature is busy with the latest results from the sodium/glucose cotransporter 2 inhibitors, and despite the remarkable recent major advances in HF drug therapy, across the spectrum of ejection fraction, the residual risk in this disease is still unacceptably excessively high. In the most recent drug trials, patients suffering from HF with reduced ejection fraction (HFrEF) receiving the best guideline-directed medical therapy (GDMT) have an annual rate of HF hospitalization and cardiovascular death around 18%, up to 25% in HF with EF below 25%. In an ideal world, if HFrEF patients receive all four foundational drugs, allcause mortality as well as the risk of cardiovascular death and HF hospitalization may decrease by up to 60%. Although, admittedly, addition of SGLT2i therapy may be more straightforward, despite strong professional recommendations through guidelines, GDMT use among eligible HFrEF patients remains suboptimal. In this context, device therapy may be a most welcome addition in HF therapy. So far, only cardiac resynchronization therapy, with cardiac defibrillator therapy, has gained high level of evidence and strong recommendation in international guidelines. However, this therapy is effective only in patients with large QRS, ideally with a left bundle branch block. Other candidate HF device therapies are on high demand.