Do the Current Guidelines for Heart Failure Diagnosis and Treatment Fit with Clinical Complexity?

Paolo Severino,Silvia Prosperi,Massimo Mancone,Corrado Poggesi,Anna Vittoria Mattioli,Federico Schena,Sabina Gallina,Francesco Fedele,Roberto Pedrinelli,Pasquale Pagliaro,Alessandra Dei Cas,Maria Prat, ,Giuseppina Novo,Antonio Cevese,Riccardo Raddino,Andrea D’Amato

doi:10.3390/jcm11030857

Abstract

Heart failure (HF) is a clinical syndrome defined by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to inadequate cardiac output and/or increased intraventricular filling pressure. Importantly, HF becomes progressively a multisystemic disease. However, in August 2021, the European Society of Cardiology published the new Guidelines for the diagnosis and treatment of acute and chronic HF, according to which the left ventricular ejection fraction (LVEF) continues to represent the pivotal parameter for HF patients’ evaluation, risk stratification and therapeutic management despite its limitations are well known. Indeed, HF has a complex pathophysiology because it first involves the heart, progressively becoming a multisystemic disease, leading to multiorgan failure and death. In these terms, HF is comparable to cancer. As for cancer, surviving, morbidity and hospitalisation are related not only to the primary neoplastic mass but mainly to the metastatic involvement. In HF, multiorgan involvement has a great impact on prognosis, and multiorgan protective therapies are equally important as conventional cardioprotective therapies. In the light of these considerations, a revision of the HF concept is needed, starting from its definition up to its therapy, to overcome the old and simplistic HF perspective.

Highlights

Heart failure (HF) is a clinical syndrome characterised by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to insufficient cardiac output and/or increased intraventricular filling pressure [1,2].Currently, in Europe, HF incidence reaches 5 cases for 1000 people [1,3,4], with a prevalence around 1–2% in adults [1,5,6]
According to the latest European Society of Cardiology (ESC) Guidelines [1], HF is classified into three types based on left ventricular ejection fraction (LVEF) values: HF with preserved EF (HFpEF), if LVEF is ≥50%, in the presence of abnormalities of heart structure and/or function and/or increased natriuretic peptides values, as well symptoms presence; HF with reduced HF (HFrEF), if LVEF ≤40%, and HF
HF is comparable to cancer: (i) the heart involvement may be considered as the primary neoplastic lesion; (ii) lungs represent the lymph nodes of the heart; (iii) kidneys, liver, bone marrow and nervous central system involvement is comparable to metastasis spread (Table 2)

Summary

Introduction

Heart failure (HF) is a clinical syndrome characterised by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to insufficient cardiac output and/or increased intraventricular filling pressure [1,2]. Efforts to optimise HF classification are still needed and more emphasis should be given to multisystemic and progressive multiorgan involvement, which makes HF similar to cancer Several clinical aspects, such as kidney and lung involvement, anaemia, iron deficiency, liver dysfunction and nervous central system disorders, as well as specific circulating biomarkers are often neglected, they have a great impact on mortality and morbidity in HF patients, regardless of LVEF [1,17]

The Pitfalls of Left Ventricular Ejection Fraction

The Confusing New York Heart Association Classification

Heart Failure Pathophysiology Paradigm

Heart Failure Therapeutic Management

Conclusions