November 2021 at a glance: focus on prevention, comorbidities, cardiogenic shock and novel devices

The role of imaging in the management of heart failure (HF) is well established.1-3 Less evidence is available regarding its role in HF prevention. The Copenhagen City Heart Study investigated the prognostic value of whole wall, endomyocardial, and epimyocardial global longitudinal strain (GLS) in the general population. In the sex-stratified analysis, whole wall and epimyocardial GLS were found to be significant predictors of prognosis in males, while no GLS parameter was useful in females.4 Another study investigated the presence of subclinical congestion, assessed by three ultrasound (US) variables (inferior vena cava diameter, jugular vein distensibility ratio, the number of B-lines from a 28-point lung US), in patients with at least one risk factor for HF, including diabetes, ischaemic heart disease, and hypertension. Subclinical congestion was common and was described in 30% of subjects. Plasma natriuretic peptide concentrations were more closely related to left atrial volume than other US measures of congestion.5 Treatment with intravenous ferric carboxymaltose (FCM) in patients with HF and iron deficiency (ID) improves outcome, functional capacity and quality of life.6, 7 Despite the indication in current and previous guidelines, assessment of ID and, to an even larger extent, its treatment are still underused. An analysis of the Swedish HF Registry showed that only 27% of enrolled patients were screened for ID. Among tested patients, about a half had ID but only 19% of them received FCM.8 Myocardial and epicardial adipose tissue (EAT) are possible causes of HF with preserved ejection fraction (HFpEF).9-11 Pugliese et al.12 compared the impact of EAT, measured by echocardiography, in patients with HFpEF, HF with reduced ejection fraction (HFrEF) and control subjects and showed its opposite clinical significance in these two groups of HF patients. Patients with HFpEF had the highest EAT, whereas those with HFrEF had lower values compared with the control group. Increased EAT was directly associated with troponin T and C-reactive protein levels and with right ventricular to pulmonary artery uncoupling and inversely correlated with peak oxygen consumption and peripheral extraction in patients with HFpEF. Conversely, low EAT was associated with more severe left ventricular dysfunction and a worse prognosis in patients with HFrEF.12 Biomarkers and proteomic research may yield novel findings regarding HF pathogenesis and outcomes.11, 13 A study investigating urinary proteomic profile showed significant differences in multiple urinary peptides with a greater collagen turnover and inflammation in patients with HF compared with healthy controls.14 The impact of COVID-19 on hospitalizations and clinical course of HF patients has been widely shown.15-20 Recently, it has been hypothesised that COVID-19 might induce an HFpEF-like syndrome.21 Accordingly, Hadzibegovic et al.22 showed that patients hospitalized for COVID-19 had a higher likelihood of presenting HFpEF, assessed by the HFA-PEFF score, compared to subjects with similar age, sex, and comorbidity status and without COVID-19. Long-term effects of COVID-19 are less known. Lassen et al.23 compared the echocardiographic data of 91 consecutive patients hospitalized for COVID-19 with sex and age-matched COVID-19-free subjects. Patients were studied during the initial hospitalization and after 2 months. Troponin and N-terminal pro B-type natriuretic peptide plasma levels and parameters of right ventricular function were abnormal during hospitalization but improved during follow-up whereas left ventricular GLS remained abnormal also during follow-up.23 In another study, vascular and endothelial dysfunction, similar to that reported in untreated hypertensive patients, was observed at 4-month follow-up after COVID-19.24 Cardiogenic shock (CS) is still burdened by an extremely poor prognosis.25, 26 Data from the Nationwide Readmissions Database showed that a regional ‘hub-and-spoke’ triage system, with direct admission to CS hubs or transfer to hubs, is associated with a lower mortality.27 Mechanical circulatory support (MCS) may be useful in the management of CS.26 However, data from randomized controlled trials (RCTs) seem not to reflect real-world practice. Schrage et al.28 applied enrolment criteria from the main RCTs about MCS use in CS to 1305 patients with CS admitted to a tertiary care hospital between 2009 and 2019. Only one third of this real-world population with CS was eligible for any trial. This was mostly due to the exclusion of CS not secondary to acute myocardial infarction (AMI), but even in a post-AMI CS scenario only 65.4% of patients were eligible.28 A meta-analysis including six studies and 226 patients who received an interatrial shunt device showed an increase in 6-min walking distance by 28.1 m, an improvement in quality of life and a decrease in pulmonary capillary wedge pressure.29 Percutaneous edge-to-edge mitral valve repair has been widely studied for the treatment of secondary mitral regurgitation (SMR).30-32 Other procedures are currently studied. In a post-hoc pooled analysis, 68 patients with mild or moderate SMR were treated with percutaneous mitral annuloplasty in the TITAN, TITAN II, or REDUCE-FMR trials. This analysis showed an improvement in 6-min walking distance, quality of life and SMR grade at 1 year. Furthermore, New York Heart Association class did not worsen in almost all patients, with 89% 1-year survival.33