October 2021 at a glance: focus on imaging, biomarkers and comorbidities

Imaging and biomarkers are the backbone of heart failure (HF) management.1-4 A position paper by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) highlights the indications regarding the use of imaging techniques, combined with biomarkers, in the screening, diagnosis, prognostic stratification and treatment of patients with HF.5 Circulating HF biomarkers, beyond natriuretic peptides, are reviewed by Meijers et al.6 Obese patients may represent a peculiar phenotype of HF with preserved ejection fraction (HFpEF).7, 8 Patients with obesity and HFpEF had higher circulating biomarkers of volume expansion, myocardial fibrosis and systemic inflammation, compared to non-obese HFpEF or obese non-HFpEF patients.9 At invasive haemodynamic exercise testing evaluation, HFpEF patients presented a reduced venous compliance and an increased estimated stressed blood volume (eSBV). Exercise eSBV was directly correlated with higher body mass index (BMI) (r = 0.77, P < 0.0001) and inversely correlated with right ventricular–pulmonary arterial coupling (r = –0.57, all P < 0.0001).10 In patients with HF and reduced ejection fraction (HFrEF), a higher BMI is paradoxically associated with better survival. This was confirmed in a post-hoc analysis of the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF) trial. The beneficial effects of dapagliflozin were independent of baseline BMI.11 Iron deficiency (ID) is common and associated with a worse prognosis in patients with HF.12 Among 435 anaemic HF patients, those with high levels of erythropoietin (EPO), defined as EPO-resistant, had greater 1-year mortality than those with EPO deficiency. Iron deficiency was associated with EPO resistance.13 The AFFIRM-AHF trial showed the beneficial effects of ferric carboxymaltose (FCM) in patients hospitalized for acute HF, with a left ventricular ejection fraction <50% and ID.14, 15 A pharmacoeconomic analysis of this trial showed that FCM was a highly cost-effective treatment across different countries with different healthcare systems, due to reduced HF events.16 Hyperkalaemia is a frequent cause of mineralocorticoid receptor antagonist (MRA) discontinuation.17, 18 Among 39 518 patients initiating MRA in the Observational study from the Stockholm CREAtinine Measurements (SCREAM) project 2006–2018, 7366 developed hyperkalaemia. Trevisan et al.19 compared patients who withdrew the drug after an episode of hyperkalaemia vs. those who continued. Although the discontinuation of MRA led to a reduction in recurrent high-potassium episodes, a higher risk of death or cardiovascular events was reported among these patients. Cancer is a risk factor for HF.20-23 In a prospective cohort study of 146 817 post-menopausal women, Leedy et al.24 showed that HF was associated with an increased risk of subsequent cancer [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.11–1.48], namely obesity-related, lung and colorectal cancers. In patients treated with immune checkpoint inhibitors (ICIs), pharmacovigilance data analysis reported an incidence of 4.2% of cardiac events, including myocarditis, which was often burdened by a high mortality. The incidence of cardiac events was higher in those patients with dual ICI therapy.25 A grading system for ICI myocarditis, based on endomyocardial biopsy, was developed.26 A post-hoc analysis including patients of the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF) revealed that moderate-severe mitral regurgitation (MR) was common (41.1%) and associated with an increased risk of the primary outcome of all-cause death or HF hospitalization.27 Percutaneous mitral valve repair (pMVR) using a MitraClip device should be considered in selected HFrEF patients with secondary MR (SMR), not eligible for surgery, who fulfil the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) selection criteria.28, 29 Among 221 patients with HFrEF and SMR ≥3+ successfully treated with pMVR, 88 patients (40%) had an improvement in right ventricular function, defined as right ventricular fractional area change (ΔRVFAC) ≥5% at early follow-up (median time 4 months). This finding was independently associated with lower risk of death or heart transplantation (HR 0.52, 95% CI 0.29–0.94, P = 0.030).30 The multicentre, single arm, prospective MitrAl ValvE RepaIr Clinical (MAVERIC) trial investigated the safety and efficacy of the ARTO, a transcatheter annular reduction device, in patients presenting functional MR and high surgical risk. At 2 years, the composite safety outcome was met. Furthermore, ARTO was associated with a reduction in MR, left ventricular dimensions, and HF hospitalizations.31 Patients with right HF and tricuspid regurgitation may have different phenotypes based on cardiac output. A total of 132 patients, undergoing isolated transcatheter tricuspid valve repair (TTVR), were classified according to their cardiac output (CO) into three groups. Those with high CO (cardiac index >2.6 L/min/m2) had the highest mortality rate and also presented venous congestion, liver dysfunction, higher incidence of ascites and markedly reduced systemic vascular resistance as compared to TTVR patients in other CO states.32 Patients ineligible for heart transplantation may receive a left ventricular assist device (LVAD) as a destination therapy, and this is leading to an increasing number of patients with LVAD.33 Guidance for the management of these patients, especially in non-specialized settings, is published in this issue.34