Heart Failure Reviews最新文献

In recent years, sodium-glucose co-transporter 2 inhibitors (SGLT2i) emerged as promising therapeutic agents in managing heart failure (HF). They demonstrated a significant impact on reducing HF hospitalizations and related mortality in patients with reduced and preserved ejection fraction. However, evidence supporting their use in patients with left ventricular assist device (LVAD) and heart transplant (HT) recipients is still limited. We identified six key studies investigating the safety and efficacy of SGLT2i in LVAD and HT recipients. In patients with LVAD, prescription of SGLT2i was predominantly associated with improved fluid management and reduced pulmonary artery pressures. However, the results regarding their effects on body weight, hemoglobin A1c, diuretic use, and right ventricular function were contradictory. In terms of safety, SGLT2i were generally well-tolerated in the LVAD population, and the reported incidence of adverse events was low. In HT recipients, SGLT2i were associated with better glycemic control and weight reduction. No relevant adverse events were reported. Despite these encouraging results, the long-term safety and efficacy of SGLT2i in these vulnerable patient populations are yet to be investigated. Future randomized controlled trials are needed to address existing gaps in evidence and help integrate SGLT2i into clinical practice for LVAD and HT recipients.

Heart failure with preserved ejection fraction (HFpEF) poses a significant challenge in contemporary medicine, characterized by poor quality of life, high healthcare costs, and increased mortality. Despite advancements in medical research, treatment strategies for HFpEF remain elusive, with unclear guidance on the use of beta-blockers. While sympathetic overstimulation is common in HFpEF, beta-blockers, though potentially beneficial in reducing sympathetic activity, may exacerbate chronotropic incompetence and decrease exercise tolerance. Additionally, their impact on outcomes in HFpEF patients with concurrent atrial fibrillation is uncertain. Some studies suggest the potential benefits of beta-blockers on diastolic function, yet evidence on clinical endpoints remains inconclusive. Recent research indicates a potential reduction in all-cause mortality with beta-blocker use in HFpEF, although their effect on combined mortality or HF hospitalizations is less clear. Moreover, beta-blocker efficacy may vary depending on ejection fraction subgroups, with more favorable outcomes observed in HFmrEF compared to HFpEF. Current literature underscores the need for large-scale randomized clinical trials to clarify the role of beta-blockers in HFpEF management. Given the limitations of existing evidence, future research is essential to inform updated treatment guidelines and therapeutic protocols tailored to the contemporary clinical landscape.

Peripartum cardiomyopathy is an idiopathic and nonischemic systolic dysfunction with onset toward the end of pregnancy and up to 5 months postpartum. Its clinical phenotype overlaps with pregnancy-associated cardiomyopathy rendering both a continuum of the same disease. Incidence varies geographically and is highest in areas where risk factors are prevalent. The understanding of its pathophysiology is constantly evolving, but a proposed two-hit model of dysfunctional vasculogenesis and genetic predisposition exacerbated by the hemodynamic stressors of pregnancy is widely accepted. The catalysis of the cleavage of prolactin into an anti-angiogenic fragment provoked by unbalanced oxidative stress forms the bedrock of its pathogenesis. Furthermore, miRNA signaling, placenta-produced factors, and a potential underlying genetic susceptibility convene to disrupt cardiac and endothelial metabolic homeostasis. The role of anti-adrenergic and anti-sarcomeric antibodies, nutritional deficiency, and mutated viral cardiotropes are understudied. There are limited randomized controlled trials for disease-specific drugs; however, most trials are targeted at the D2 receptor agonist bromocriptine. Positive primary endpoints in a large German clinical trial led to its approved use in Europe, but the U.S.A. still renders it experimental with ongoing trials evaluating its long-term efficacy and safety. Despite its popularity since the 1900s, multiple gaps in evidence regarding long-term management after myocardial recovery, management of subsequent pregnancies, optimal anticoagulation strategy, and alternative pathophysiological pathways remain unknown.

Heart failure (HF) is a major clinical challenge characterized by significant morbidity and mortality. Electrical conduction abnormalities play a critical role in HF pathophysiology and progression, often leading to suboptimal outcomes with conventional pacing techniques. Con-duction system pacing (CSP), encompassing His bundle pacing and left bundle branch area pacing, has emerged as a novel approach. Despite data come from observational studies, recent guidelines recommend that a specific population may benefit from CSP. However, significant practical considerations and challenges need to be clarified before CSP can be routinely implemented in clinical practice. The reliance on observational studies means that long-term clinical outcomes for HF patients remain uncertain until data from randomized controlled trials (RCTs) become available. Current CSP practices face challenges with lead implantation, mechanical stress on leads, and the need for more advanced tools and artificial intelligence integration to improve procedure efficacy and safety. Future large-scale RCTs are essential to identify optimal candidates and address these technical challenges, potentially leading to a paradigm shift in HF management.

Cardiogenic shock related to acute myocardial infarction (AMI-CS) remains a severe condition associated with a high risk of mortality despite increased availability of primary percutaneous coronary intervention and improvements in pharmacologic and device-based therapy. The results of the DanGer Shock trial stand out compared with the outcomes of the previous trials and mark the first mechanical circulatory support (MCS) strategy to show a benefit in patients with AMI-CS, a population that has always been challenging to study. Notably, negative findings from previous trials may mask positive treatment effects in specific subgroups and patient category. We systematically reviewed the design of all contemporary randomized controlled AMI-CS trials and identified four distinct features, which likely provide reasons why DanGer Shock became the first positive randomized controlled trial to support MCS in AMI-CS. DanGer Shock was the first RCT that established MCS in the context of AMI-CS. Key features were (1) patient phenotype that 1)  includes STEMI and 2) excludes severe RV failure and persistent comatose state after out-of-hospital cardiac arrest; (3) optimal timing of MCS deployment, as soon as possible (lower SCAI stage) and before revascularization efforts; and (4) rigorous intensive care management protocols on hemodynamic and MCS monitoring.

Natural language processing (NLP) is a burgeoning field of machine learning/artificial intelligence that focuses on the computational processing of human language. Researchers and clinicians are using NLP methods to advance the field of medicine in general and in heart failure (HF), in particular, by processing vast amounts of previously untapped semi-structured and unstructured textual data in electronic health records. NLP has several applications to clinical research, including dramatically improving processes for cohort assembly, disease phenotyping, and outcome ascertainment, among others. NLP also has the potential to improve direct clinical care through early detection, accurate diagnosis, and evidence-based management of patients with HF. In this state-of-the-art review, we present a general overview of NLP methods and review clinical and research applications in the field of HF. We also propose several potential future directions of this emerging and rapidly evolving technological breakthrough.

Delivering valvular intervention for all eligible patients with valvular heart disease (VHD) in a timely manner remains a challenge. Therefore, a high number of patients with heart failure (HF) and VHD receive pharmacotherapy while awaiting intervention or as destination therapy if they are deemed inoperable. The sodium-glucose co-transporter-2 inhibitors (SGLT2i) are recommended with a class I indication for patients with chronic HF throughout the spectrum of left ventricular ejection fraction. However, all randomized trials of SGLT2i in HF patients have consistently excluded patients with significant VHD. Considering the proven benefit of SGLT2i for stable outpatients and acutely hospitalized patients with HF, SGLT2i could potentially be used for patients with HF secondary to significant VHD. This article highlights the unmet need to produce robust clinical evidence for the pharmacological management of patients with HF and significant VHD while summarizing the potential benefit from SGLT2i in the management of these patients.

Hyperkalemia is a potentially life-threatening condition frequently encountered in clinical practice, particularly among patients with chronic kidney disease, heart failure, diabetes, and hypertension and those undergoing treatment with renin-angiotensin-aldosterone system inhibitors (RAASi). The management of chronic and acute hyperkalemia is complex and requires timely intervention to prevent severe complications such as cardiac arrhythmias and sudden death. Traditional therapeutic approaches to chronic hyperkalemia, including dietary potassium restriction, use of diuretics, and administration of cation-exchange resins like sodium polystyrene sulfonate, often suffer from limitations like gastrointestinal side effects, variable efficacy, delayed onset of action, and RAASi treatment discontinuation. In recent years, the development of new potassium binders, specifically patiromer and sodium zirconium cyclosilicate (SZC), has revolutionized the management of hyperkalemia. Patiromer, a non-absorbed polymer, binds potassium in the gastrointestinal tract in exchange for calcium, thus facilitating its excretion. SZC operates by exchanging sodium and hydrogen ions for potassium, leading to efficient potassium removal. Both agents have demonstrated rapid and sustained reductions in serum potassium levels, coupled with favorable safety and tolerability profiles, in multiple clinical trials. This review article, authored by a multidisciplinary group of Portuguese experts in hyperkalemia management, provides an in-depth analysis of the efficacy and safety of current therapeutic strategies and highlights the clinical potential of new potassium binders. The introduction of patiromer and SZC offers significant advantages over traditional therapies, providing effective and better-tolerated options for patients. The review highlights the role of these novel agents in contemporary hyperkalemia management and calls for ongoing research to further refine treatment protocols and improve patient outcomes.

Activation of the sympathetic nervous system has been attributed to the development of hypertension. Two established approaches for treating hypertension are pharmacotherapy and lifestyle changes. With an improved understanding of renal nerve anatomy and physiology, renal denervation has been proposed as an alternative treatment for hypertension. Specifically, it has been shown that the interruption of sympathetic nerves connecting the kidney and the sympathetic nervous system can reduce blood pressure. Here, we present a review on how renal denervation can help hypertension patients, specifically focusing on our novel understanding of renal nerve anatomy, denervation technique, and subsequent clinical trials, and how it may be used to treat other cardiovascular diseases like heart failure.