The Role of Anemia in the Progression of Congestive Heart Failure: Is There a Place for Erythropoietin and Intravenous Iron?

Sex Differences in Heart Failure: What Do We Know?

Heart failure (HF) remains an important global health issue, substantially contributing to morbidity and mortality. According to epidemiological studies, men and women face nearly equivalent lifetime risks for HF. However, their experiences diverge significantly when it comes to HF subtypes: men tend to develop HF with reduced ejection fraction more frequently, whereas women are predominantly affected by HF with preserved ejection fraction. This divergence underlines the presence of numerous sex-based disparities across various facets of HF, encompassing aspects such as risk factors, clinical presentation, underlying pathophysiology, and response to therapy. Despite these apparent discrepancies, our understanding of them is far from complete, with key knowledge gaps still existing. Current guidelines from various professional societies acknowledge the existence of sex-based differences in HF management, yet they are lacking in providing explicit, actionable recommendations tailored to these differences. In this comprehensive review, we delve deeper into these sex-specific differences within the context of HF, critically examining associated definitions, risk factors, and therapeutic strategies. We provide a specific emphasis on aspects exclusive to women, such as the impact of pregnancy-induced hypertension and premature menopause, as these unique factors warrant greater attention in the broader HF discussion. Additionally, we aim to clarify ongoing controversies and knowledge gaps pertaining to the pharmacological treatment of HF and the sex-specific indications for cardiac implantable electronic devices. By shining a light on these issues, we hope to stimulate a more nuanced understanding and promote the development of more sex-responsive approaches in HF management.

DIAGNOSIS AND MANAGEMENT OF SUSPECTED CONGESTIVE HEART FAILURE SECONDARY TO DILATED CARDIOMYOPATHY IN A SAND TIGER SHARK (CARCHARIAS TAURUS) WITH ESTABLISHMENT OF PRELIMINARY NORMAL ECHOCARDIOGRAPHIC INDICES

Elasmobranch cardiac anatomy and physiology has been well described; however, there is a dearth of information regarding cardiac disease. In support of a clinical case of suspected congestive heart failure in a 22-yr-old male sand tiger shark (Carcharias taurus), a study was undertaken to identify feasible echocardiographic imaging planes and preliminary indices for this species. Eleven echocardiograms were performed on six apparently healthy sand tiger sharks. Echocardiographic parameters are presented using descriptive statistics, including mean, median, standard deviation (SD), minimum and maximum values. These data were utilized for the diagnosis and clinical management of the affected shark. The shark initially presented with increased respiratory effort, dependent, peripheral edema, and anemia. Echocardiography revealed atrial, ventricular, and sinus venosus dilation. As congestive heart failure secondary to dilated cardiomyopathy was strongly suspected, therapy was initiated with oral benazepril and torsemide, and later pimobendan. After a year of therapy, clinical signs resolved. Cardiac size and function improved on echocardiography with a reduction in sinus venosus dilation, maximum and minimum atrial and ventricular inner diameters, and an increase in atrial and ventricular fractional shortening. Cardiac disease in elasmobranchs may be underdiagnosed, so it may be necessary to develop standardized ultrasound techniques and cardiac measurements for each species of elasmobranch managed within zoos and aquaria.

Anemia of cardiorenal syndrome

Cardiorenal syndrome includes a spectrum of disorders of the kidneys and heart in which loss of function in one organ contributes to reduced function in the other organ. Cardiorenal syndrome is frequently complicated by comorbid anemia, which leads to reciprocal and progressive cardiac and renal deterioration. The triad of heart failure, chronic kidney disease (CKD), and anemia is termed cardiorenal anemia syndrome (CRAS). There are currently no evidence-based recommendations for managing patients with CRAS; however, the treatment of these patients is multifactorial. Not only must the anemia be controlled, but heart failure and kidney injury must be addressed, in addition to other comorbidities. Intravenous iron and erythropoiesis-stimulating agents are the mainstays of treatment for anemia of CKD, addressing both iron and erythropoiesis deficiencies. Since erythropoiesis-stimulating agent therapy can be associated with adverse outcomes at higher doses in patients with CKD and is not used in routine practice in patients with heart failure, treatment options for managing anemia in patients with CRAS are limited. Several new therapies, particularly the hypoxia-inducible factor-prolyl hydroxylase inhibitors, are currently under clinical development. The hypoxia-inducible factor-prolyl hydroxylase inhibitors have shown promising results for treating anemia of CKD in clinical trials and may confer benefits in patients with CRAS, potentially addressing some of the limitations of erythropoiesis-stimulating agents. Updated clinical practice guidelines for the screening and management of anemia in cardiorenal syndrome, in light of potential new therapies and clinical evidence, would improve the clinical outcomes of patients with this complex syndrome.