May 2022 at a glance. Focus on treatment: from epidemiologic data to randomized trials and new devices

The COVID-19 pandemic had several consequences on epidemiology and treatment of patients with heart failure (HF).1–4 Data from Italian Medicines Agency (AIFA) registries reported a worrisome underprescription of life-saving drugs, including sacubitril/valsartan, during the pandemic, mostly due to the lockdown and safety measures. The long-term effects, in terms of mortality and HF hospitalization, are still to be determined.5 Kidney function is a major determinant of the use of guideline-directed medical therapy (GDMT) in patients with HF.6 The indications for treatment may change depending on how glomerular filtration rate (GFR) is estimated. The new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for estimating GFR is based on serum creatinine but does not take into account race. An analysis of 43 128 ambulatory patients from 12 clinical trials showed a substantial switch from an estimated GFR category to another, namely among Black patients, when CKD-EPI was applied. These results may have implications regarding eligibility for treatment of HF with reduced ejection fraction (HFrEF) patients.7 Guideline-directed medical therapy should be initiated as early as possible.8–10 The association between use, combination and dosages of GDMT and outcomes was analysed in 17 809 HFrEF patients from the Swedish Heart Failure Registry (SwedeHF). Higher doses of renin–angiotensin system inhibitors, angiotensin receptor–neprilysin inhibitors and beta-blockers were associated with a lower risk of cardiovascular death and HF hospitalization. However, receiving more different medications was associated with better outcomes than receiving less drugs at higher doses. The prescription of two drug classes at 50–99% target dose was more beneficial than one drug class at 100% target dose.11 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Effects of treatments Changes in left ventricular ejection fraction and worsening heart failure DeVore et al.12 assessed the association between improvement in left ventricular ejection fraction (LVEF) and health status or clinical events among 2092 patients with chronic HF (median LVEF 30%) included in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry. A ≥10% improvement in LVEF was observed in 33% of patients and was associated with better Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) overall summary score and with a reduced risk of subsequent all-cause death or HF hospitalization (adjusted hazard ratio 0.50, 95% confidence interval 0.41–0.61). The Heart OMics in AGing (HOMAGE) randomized to spironolactone or standard care patients aged >60 years, at high risk of developing HF, with a LVEF ≥45%.13 A higher LVEF was mostly associated with higher circulating levels of chemokines and inflammatory markers and lower levels of stretch, injury, and fibrosis markers. Spironolactone reduced the levels of natriuretic peptides and collagen type I alpha 1 chain (COL1A1) irrespective of LVEF.14