Editorial comments: focus on heart failure and cardiomyopathies

This issue of the European Journal of Preventive Cardiology focuses on the crucial aspects of heart failure (HF) and cardiomyopathy diagnosis across various clinical scenarios, as well as on improving the risk stratification of HF patients to provide proper guidance for effective treatment. Association between HF and autoimmune disease (AID) has already been observed in scientific literature. Indeed, several different AID conditions, such as rheumatoid arthritis, systemic sclerosis, and systemic lupus erythematosus, have been linked to an increased risk of HF,1,2 although the exact mechanism is not fully understood. In this paper, Guoli et al.3 compared all-cause mortality and HF hospitalizations in a large cohort of patients with AID and HF, matched with patients affected only by HF, with a follow-up period of 3.2 years. An increased risk of all-cause mortality has been observed, with no differences in terms of HF hospitalizations. Despite the interesting findings of this study, other research should be conducted to explain the excess rate of mortality in this group of patients, in order to improve their treatment and care. Arrhythmogenic cardiomyopathy (ACM) was initially recognized as a primary disease of the right ventricle (ACM-RV).4 However, thanks to cardiac tissue characterization provided by cardiac magnetic resonance, it is now widely accepted that ACM may involve both ventricles or even only the left ventricle. Despite this progress, there is currently a lack of widely accepted and externally validated international criteria for left ventricle ACM (ACM-LV) or biventricular ACM (ACM-BV). Thanks to cardiac magnetic resonance and genetic testing, it is now possible to accurately differentiate between ACM-LV or ACM-BV and other cardiac diseases that may mimic ACM (e.g. dilated cardiomyopathy, myocarditis, and idiopathic ventricular arrhythmias).5 Tini et al.6 have observed that diagnosing ACM correctly is not easy. In many cases of ACM, there has been a diagnostic delay, especially when the left ventricle is involved, and this can significantly impact patients’ prognosis. Therefore, specific cardiac diseases should be evaluated with a cardiomyopathy mindset and comprehensive patient evaluation should be conducted, with particular attention given to tissue characterization using cardiac magnetic resonance and genetic testing. Cardiovascular diseases and cancer are still the leading causes of mortality in developed countries.7,8 Sayed et al.9 observed that patients with a cancer diagnosis and prior cardiovascular disease are more likely to underuse blood pressure drugs, lipid-lowering drugs, aspirin, smoking cessation, exercise, and cardiovascular rehabilitation. Several aspects should be taken into consideration when implementing cardiovascular prevention in patients with cancer. Firstly, the psychological impact of a cancer diagnosis can be significant and may affect the patient’s adherence to cardiovascular treatment. Secondly, there is a possibility of drug interactions between cardiovascular medications and chemotherapy. Undoubtedly, there is much more that can be done in terms of cardiovascular prevention, especially in specific settings such as cancer. It is essential to establish a multidisciplinary team to address the complex needs of these patients and provide comprehensive care that considers both cardiovascular and oncological aspects. By doing so, overall health outcomes and quality of life for individuals dealing with cancer and cardiovascular disease simultaneously can be improved. Chronic kidney disease (CKD) has been associated with increased mortality and morbidity in patients with acquired HF.10 A complex interaction exists between HF and CKD, creating a vicious circle in which one condition worsens the other. Krishnathasan et al.11 have demonstrated that CKD is the strongest predictor of mortality, transplantation, or ventricular assist device implantation in patients with HF. Therefore, an adequate renal evaluation should be conducted in HF patients to prevent renal dysfunction. Heart failure patients usually suffer from various cardiac and non-cardiac comorbidities (NCC) that significantly impact their management and prognosis.12 Chioncel et al.13 conducted an analysis on the correlation between NCC and in-hospital and post-discharge cardiovascular prognosis in a large registry of acute HF patients. The most frequent NCC in the total population were anaemia, diabetes, and kidney dysfunction, irrespective of ejection fraction (EF). A greater number of NCC were found to be significantly associated with higher in-hospital mortality and an increased risk of post-discharge all-cause mortality, cardiovascular death, and HF hospitalization. The prevalence of NCC varied among acute HF patients based on their left ventricular EF, suggesting an ‘EF-specific’ multidisciplinary approach that should be applied post-discharge to reduce the risk of hospitalization and death. Beverages with added sugar have been linked to a higher risk of obesity, hypertension, type II diabetes mellitus, and cardiovascular disease. Zhang et al.14 have demonstrated that the consumption of sugar-sweetened and artificially sweetened beverages is related to a higher risk of developing HF, even when adjusted for several different risk factors in a large prospective cohort. Conversely, the consumption of fruit/vegetable juices has been found to be inversely associated with the HF incidence. Proper cardiovascular prevention should encompass not only a thorough evaluation of the typical HF risk factors but also a heightened focus on dietary consumption. The Metabolic Exercise Test data combined with Cardiac and Kidney Indexes (MECKI) score has been demonstrated to be one of the most accurate prognostic scores in HF patients.15 Adamopoulos et al.16 conducted an external validation in a multicentre study with a long follow-up period (1998–2019). The authors confirmed the prognostic role and risk stratification of the MECKI score. Given the challenging decisions involved in listing patients for heart transplantation against a backdrop of limited availability of organs, it is important to implement this score in clinical practice to better stratify patients and determine appropriate treatment. An accurate and simple risk stratification score in HF with preserved ejection fraction (HFpEF) patients remains a challenge in clinical practice. In this preliminary study, Han et al.17 performed a microarray analysis on a small group of HFpEF patients. They developed a transcriptional and genetic model (HF-PRS) comprising 69 variants. This model was then tested on a large HFpEF cohort, demonstrating significant discriminative capability that outperformed the clinical risk scores. Genetic data, especially when incorporating transcriptional information, can not only enhance patient stratification but also shed light on potential pathophysiological mechanisms, paving the way for the development of new pharmacological therapies. Further studies are required to validate these preliminary findings. To comprehensively understand the impact of a disease and effectively target appropriate prevention and therapeutic interventions, epidemiological studies are frequently required. These studies aid in identifying the disease’s prevalence and the specific populations where optimal prevention and treatment strategies should be directed, ultimately leading to a reduction in HF incidence and improved prognosis. To address this need, Cai et al.18 conducted an epidemiological study focusing on various stages of HF in China. Within this patient cohort, both pre-clinical and clinical HF burdens were found to be substantial, exhibiting variations influenced by age, gender, and urbanization. As the diagnosis of HF continues to rise due to an aging population, enhancing our comprehension of its burden becomes imperative in guiding targeted cardiovascular preventive measures.