The Year in Cardiology

Heart Failure: the Year in Cardiology 2019

John G.F. Cleland; Alexander R. Lyon; Theresa McDonagh; John J.V. McMurray


Eur Heart J. 2020;41(12):1232-1248. 

In This Article

Epidemiology and Prevention

In cardiology, the term prevention is often used to mean delaying the onset of disease; in other words, procrastination. Failure to appreciate the difference between prevention and procrastination leads to problems in projecting future healthcare needs and costs. Older people have more co-morbid conditions that complicate management but may also offer more opportunities for intervention; consequently, more time and resources are required to manage older patients well.

A detailed report on heart failure in the UK shows that the median age of onset has risen to about 80 years, consistent with improvements in the treatment of hypertension and other risk factors for atherosclerosis and better management of myocardial infarction.[5] Unfortunately, data on left ventricular ejection fraction (LVEF) were not available for this report. Analyses of the diagnostic pathway in primary care in the UK suggest that key investigations are often not done.[6–8] Similar data from other countries are urgently required. Several large epidemiological surveys[9,10] and analyses of large trials[11,12] have recently been published that allow the demographics, aetiology, and management of heart failure to be compared internationally.

Mineralocorticoid receptor antagonists (MRAs) are effective anti-hypertensive agents that also improve the prognosis of patients with heart failure and a reduced (HFrEF) and possibly preserved (HFpEF) LVEF.[13] Whether MRAs have specific effects on reducing other potential drivers of the progression to heart failure such as inflammation and fibrosis is currently under investigation.[14,15]

Genetic propensity to greater body fat was associated with the risk of developing heart failure in an analysis on 367 703 UK Biobank participants.[16] However, the incidence of heart failure was only 1% (4803 patients), the diagnostic criteria were not robust, and the increase in risk was modest (odds ratio 1.22; 95% CI 1.06–1.41). Further analyses on this population showed a strong relationship between cardio-respiratory fitness and grip strength and future incidence of heart failure.[17] A study of 4403 people considered for bariatric surgery in Sweden and followed for 22 years, found that 188 (9%) of the 2003 who had surgery (25–35 kg weight loss; BMI 1 year after surgery 32 kg/m2) developed heart failure compared with 266 (13%) of 2030 who did not (BMI after 1 year observation 40 kg/m2).[18] Although these data suggest links between obesity and the risk of developing heart failure, it is possible that obesity just provokes similar symptoms. Once heart failure has developed, obesity is associated with a lower mortality, but this may also reflect earlier diagnosis rather than a protective effect.[19] Randomized controlled trials (RCTs) of effective interventions for obesity are required to demonstrate whether weight loss improves symptoms (likely) and clinical outcomes (less certain).

A report from 'the Atherosclerosis Risk in Communities' (ARIC) study confirmed the association between influenza epidemics and hospitalizations for heart failure, reinforcing guideline-recommendations for vaccination;[20] an RCT is underway.[21] Extended follow-up (median 18.9 years) of the Women's Health Initiative Hormone Therapy trials, which randomized 27 347 women to various hormone replacement regimens, showed that they had no effect on the incidence of HFrEF or pEF.[22]

The ISCHEMIA trial (presented at the American Heart Association 2019) compared strategies of early coronary revascularization, predominantly percutaneous, with conservative management for stable CAD, some of whom had mild symptoms of heart failure and/or a reduced LVEF. Revascularization did not reduce the risk of myocardial infarction or death but increased the risk of stroke almost four-fold and did not reduce new-onset heart failure over the following 4 years.