Foreword
One day update on heart failure
* Corresponding author.E-mail address: mcrelei{at}canalejo.org
The complex clinical syndrome called heart failure (HF) is characterized by increasingly high prevalence, high mortality, poor quality of life, and need for increasingly complex therapeutic regimens. The good news discussed here is that many advances have been made in the last 15 years that have led to the ability to improve both morbidity and survival in patients with HF. However, knowledge about HF is accumulating so rapidly that individual clinicians may be unable to accumulate and synthesize the information and this has led to clinical under-utilization of many therapies that have been shown to be effective. In this setting, guidelines which are periodically updated and that collate and codify the evidence base that exists for therapy or diagnosis are extremely useful. In this supplement, Sharon A Hunt and Markku Nieminem summarize the state-of-the-art codified in the latest Guidelines on HF from the USA and Europe with focus on the suggested A, B, C, D-based approach to chronic HF therapy in the US and the key issues of ESC approach to acute HF.
Neurohormonal activation and over-compensation have been considered important mechanisms in understanding the pathophysiology of HF. It is increasingly recognized that systems other than the sympathetic and renin–angiotensin systems are involved. Eulalia Roig focuses on the usefulness of neurohormonal markers in the diagnosis as well as therapy of HF. The natriuretic peptides show a great potential in HF both as therapeutic agents and biomarkers. Human recombinant ANP (Carperitide) has been approved for the clinical management of acute decompensated congestive HF in Japan; human recombinant BNP (Nesiritide) has been approved by the FDA for the same clinical indication in the US since 2001 and human recombinant Uro (Ularitide) is currently undergoing phase III clinical trials in Europe. Serum levels of both BNP and NT-proBNP are currently used clinically to aid the diagnosis of HF and assess its severity and to aid in risk stratification in patients with coronary artery diseases. Horn H Chen and John C Burnett Jr give us an overview of the physiological properties of natriuretic peptides and the clinical application of these peptides in HF.
In recent years, there has been controversy regarding the usefulness of using haemodynamic measurements provided by the pulmonary artery catheter to ‘tailor’ therapy in patients with HF. Sharon A Hunt describes the ESCAPE trial which suggests that routine use of such measurements does not influence outcomes and goes on to outline a list of clinical scenarios where they are most likely useful.
There is no doubt that a complete two-dimensional echo and Doppler study at rest is the single most useful diagnostic test to assess the aetiology of HF and, consequently, to plan appropriate treatments and follow-up. Stephano Ghio reviews what echocardiographers need to know, providing echo information is relevant for the clinicians who treat HF patients and what the clinicians should look for in the interpretation of the echo exam.
Anticoagulation therapy prevents thromboembolic events in patients with HF. Ajith Nair, Brett Sealove, Geoffrey Webber, and Valentine Fuster, in their chapter ‘Who, When and Why’, review the indications for anticoagulation in patients with HF with or without atrial fibrillation, and strategies to decrease the risk of haemorrhagic complications.
Marisa Crespo-Leiro and Jose J Cuenca-Castillo describe the role of surgical therapy for HF, including heart transplantation and ventricular restoration surgery. Heart transplantation is the only established surgical therapy for end-stage HF; however, the shortage of donors remains a major limitation.
Cell-based cardiac repair represents an exciting approach for remodelling the injured heart. During the last decade, a variety of cell types have been proposed for such therapy, including foetal cardiomyocytes, skeletal myoblasts, bone marrow-derived haematopoietic and mesenchymal stem cells, mouse and human stem cells, and resident cardiac progenitor cells. Oren Caspi and Lior Gepstein in their chapter focus particularly on the human embryonic stem cell, describing their excellent work on the possible future role of these cells in cardiovascular regenerative medicine as well as the steps required to harness their potential.
The overall message from this symposium and from the papers in this supplement is that many important advances have been made and are being made in the field of HF. The ability to provide better ways of applying that knowledge will help greatly in assuring that these advances are translated into clinical practice.
Acknowledgements
This supplement is based on the meeting titled, ‘One Day Update in Heart Failure’, held on 3 February 2006, in Madrid. Speakers at the meeting covered a variety of topics germane to the diagnosis and management of the heart failure syndrome in 2006. The meeting session and publication were supported by an unrestricted educational grant from Novartis.
1 Area del Corazón, CHU Juan Canalejo, La Coruña, Spain
2 Stanford University, USA
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