[The wearable cardioverter defibrillator]

Sudden cardiac death affects close to half a million people a year in Europe and accounts for 50 % of cardiovascular deaths. Unfortunately, only a minority of these events occur in front of witnesses, which reduces the chances of survival. In order to limit this risk, an internal automatic defibrillator can be implanted in patients at risk of sudden cardiac death. However, there are circumstances when the patient is at risk of sudden cardiac death and this device cannot be implanted. In order to limit this risk, certain patients can be equipped with a wearable defibrillator.

[Heart failure with preserved ejection fraction (HFpEF). What's up?]

Heart failure with preserved left ventricular ejection fraction (HFpEF) is a serious condition with a constantly increasing prevalence which is in correlation with the increase of this disease's risk factors incidence (obesity, arterial hypertension, diabetes, etc.) and the aging of the population. The first challenge is the diagnosis of HFpEF. Two score-based algorithms have been proposed by the European (ESC HFA-PEFF score) and the American (ACC/AHA H2FpEF score) Cardiology Societies to help the clinician in the differential diagnosis of exertional dyspnea; these scores include the association of various signs of elevated ventricular filling pressures at rest and/or during exercise. According to the ESC recommendations, the management of HFpEF is currently based on symptomatic treatment with diuretics, treatment of co-morbidities and treatment of the underlying etiology if it is identified at the end of the diagnostic approach. The prognosis of this disease is pejorative because no treatment had demonstrated its effectiveness for all HFpEF phenotypes in controlled studies until now. The management algorithm could change soon due to the publication of the EMPEROR-Preserved study, which demonstrated the efficacy of empagliflozin, an SGLT2 inhibitor, concerning a significant reduction of the mortality rate and cardiac hospitalization, regardless of left ventricular ejection fraction. That said, there are many ongoing studies in the field, and treatment prospects will likely be more targeted on the HFpEF phenotype in a near future, due to the heterogeneous nature of this clinical entity.

[Cardiogenic shock : etiology and management]

Cardiogenic shock is one of the four types of circulatory shock (cardiogenic, distributive, hypovolemic and obstructive). It is a serious complication associated with a hypoperfusion state of terminal organs and possible multivisceral failures, with a high mortality rate of nearly 50 %. It is secondary to an acute myocardial infarction in 8 out of 10 cases but only complicates it in 5 to 10 %. It is more frequently encountered in pluri-troncular coronary diseases. Coronary revascularization and supportive care are the main treatments.

[Acute right heart failure]

Even though, it has long been considered as a passive channel allowing communication between the systemic and pulmonary circulations, it is now clearly established that the right ventricle plays an essential role in cardio-pulmonary couple physiology. Its failure results in a clinical presentation that reflects the systemic congestion and reduced cardiac output. It is the consequence of two pathological situations frequently encountered in intensive care including pulmonary vascular resistance increase and right ventricle contraction alteration. Mechanical ventilation, certain drugs and volume overload can also participate. The management of the acute right heart failure is based on the combination of supportive treatment and causal treatment, specific to the etiology. Supportive therapy aims to optimize filling pressures, reduce afterload and support cardiac contractibility. With the growing number of therapeutic options used according to co-morbidities, decision-making by a multidisciplinary heart team seems essential.

[Left ventricular non-compaction : diagnosis and management]

Isolated left ventricular non-compaction (LVNC) is a congenital disorder characterized by prominent myocardial trabeculations and deep intertrabecular recesses. Although LVNC is diagnosed by echocardiography and cardiac magnetic resonance, there is no evidence-based imaging diagnostic criteria. Affected individuals are at risk of left ventricular failure, life-threatening arrhythmias and cardio-embolism. The diagnosis may be difficult in the atypical forms. The management remains controversial and depends on the clinical manifestations. Familial forms exist, ordering for genetic counseling. The aim of this article is to optimize the knowledge and the management of LVNC by reminding the diagnostic criteria used.

Layer-specific strain and the degree of left ventricular thickness in patients with hypertrophic cardiomyopathy

Background

Left ventricular (LV) wall thickness is an important parameter for the diagnosis of hypertrophic cardiomyopathy (HCM) and is also associated with long-term clinical outcome in HCM patients. However, conventional tools have failed to analyze the mechanisms of structural and functional abnormalities that occur at the cellular level in hypertrophied myocardial tissue. Recently, technological progression of 2D-speckle tracking echocardiography (2D-STE) has enabled the estimation of layer-specific strain (LSS), such as epicardial, mid-myocardial, and endocardial longitudinal strain, respectively. LSS may have the potential to elucidate the detailed mechanisms of myocardial dysfunction.

Purpose

The aim of this study was (i) to clarify the detailed mechanisms of structural and functional abnormalities of myocardial tissue in HCM using LSS (ii) to investigate the diagnostic accuracy of LSS for HCM.

Methods

Forty-one patients with HCM and preserved LV ejection fraction (LVEF) (66% male, 52±18 years, LVEF 62.9±3.7%) and 41 controls matched for age and sex (66% male, 52±20 years, LVEF 63.5±8.2%) underwent 2D-STE (GE-Healthcare, Vivid-E9). Quantitative strain values of epicardial, mid-myocardial, and endocardial layers were measured.

Results

LV wall thickness including interventricular septum thickness (HCM vs. Controls; 18.9±5.0 vs. 9.1±1.8, p<0.001), posterior wall thickness (11.5±2.5 vs. 8.8±1.9, p<0.001), and maximum wall thickness (20.1±4.3 vs. 9.4±0.4, p<0.001) were significantly lower in HCM than in Controls. Absolute values of LSS for all layers were lower in HCM than in Controls (HCM vs. Controls; epicardial; −13.1±3.3 vs. −19.5±1.6, p<0.001; mid-myocardial; −15.8±3.3 vs. −21.4±1.7, p<0.001; endocardial; −18.9±3.9 vs. −23.6±1.9, p<0.001). End/Epi ratio was higher in HCM than in Controls (HCM vs. Controls; 1.5±0.2 vs. 1.2±0.0, p<0.001). Next, we investigated the echocardiographic parameters that correlated with LV maximal wall thickness (MWT). End/Epi ratio was an independent predictor of LV MWT (β=0.96, p<0.001). Receiver operating characteristic analysis revealed that a higher End/Epi ratio (≥1.3) was the strongest predictor of diagnostic criteria for HCM (LV wall thickness ≥15 mm) (area under the curve 0.99, p<0.001, sensitivity 98%, specificity 97%).

Conclusions

In HCM patients with preserved LVEF, (i) LSS was lower and End/Epi ratio was higher than in controls. (ii) End/Epi ratio (≥1.3) was the strongest predictor of abnormal wall thickness of HCM. The mechanism of higher End/Epi ratio in HCM might be attributable to the more common myofibrillar disarray in mid- and epicardial layers. Variations of LSS represented by End/Epi ratio might have the potential to accurately detect HCM and to elucidate the pathophysiology of impaired LV wall motion at cellular level in HCM.

Funding Acknowledgement

Type of funding source: None

[Natriuretic peptides in heart failure]

The diagnosis of heart failure can sometimes be challenging for the clinician because presentation circumstances and heart failure phenotypes are varied. The identification and validation of sensitive and specific biomarkers for this condition are still a subject of intensive research. Among them, natriuretic peptides (ANP, BNP, NTproBNP) are widely used and validated as markers of heart failure. Their appropriate use and correct interpretation, however, require knowledge of their indications, specificities and limitations. The European Society of Cardiology has recently issued recommendations in this regard. This article summarizes them in order to facilitate the understanding and the use of natriuretic peptides in clinical practice. It also discusses their use in the etiological diagnosis of pleural effusions caused by heart failure.

[Therapeutic revolution in heart failure]

The introduction of basic treatment for heart failure dates to the late 1990s. Since that time, apart from a few new developments reserved for selected patients, there has been little progress. During these years, the epidemiology of the disease has evolved. The number of patients is constantly increasing and the prognosis is often darker than most oncological pathologies. With the arrival of the sacubitril/valsartan combination, Entresto®, a new therapeutic class has emerged. It has shown a significant reduction in mortality and hospitalizations for heart failure. The additional benefits to be expected from this molecule are still being evaluated. Significant positive remodeling seems to be a reality for many patients. This spectacular advance, however, is not the final solution. In addition, patients with preserved heart failure do not seem to benefit the same from this molecule. Other advances are being assessed. Sacubitril/valsartan is the first revolution, perhaps, in a long series.

[The PARAGON-HF trial]

The «Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction» (PARAGON HF) trial is a multicenter, randomized, double-blind study comparing the incidence of heart failure hospitalization and cardiovascular mortality in patients with heart failure with preserved ejection fraction (HFpEF) treated with sacubitril/valsartan (Entresto®) versus valsartan alone. After a median follow-up of 35 months, the primary endpoint was reduced by 13 % in the sacubitril/valsartan group compared to the valsartan group (relative risk: 0.87, 95 % IC: 0.753-1.005, p = 0.058). Despite this lack of significance, the incidence of hospitalizations for heart failure was reduced (RR 0.85, 95 % CI: 0.72-1.00), whereas no benefit was observed on cardiovascular mortality. A subgroup analysis suggested that women and patients with an intermediate ejection fraction could get more benefit from the treatment. Concerning secondary criteria, a significant improvement in quality of life and in heart failure symptoms was observed in the group sacubitril/valsartan. There was a greater incidence of arterial hypotension and angioneurotic edema, but a lower incidence of hyperkalemia in the group sacubitril/valsartan.

[Why and how to treat iron deficiency in heart failure ?]

Anemia and iron deficiency are two common comorbidities in heart failure with reduced ejection fraction (HFrEF) and are associated with a poor prognosis. In contrast to iron oral supplementation, administration of intravenous ferric carboxymaltose (Injectafer®) improves quality of life, exercise capacity, and seems to reduce hospitalizations for heart failure. Unfortunately, although anaphylactic reactions are extremely rare, it is recommended to administer Injectafer® in a suitable medical environment. This limitation hinders Injectafer® administration and may cause reluctance from both physician and patient. The aim of this article is to optimize and harmonize management of iron deficiency in heart failure, by proposing a simple solution for the patient and the practitioner.

[Cardiovascular effects of alcohol consumption]

Alcohol consumption is a serious problem in terms of public health because it remains a major cause of illness and premature death. The effects of alcohol on cardiovascular system are particularly complex. Current data report both favourable and adverse effects depending on the level of consumption, the type of alcohol consumed and the pathology considered. The goal of this review is to describe the spectrum of cardiovascular events associated with alcohol consumption.

[Increased heart rate as a risk factor and treatment target in patients with heart failure]

Numerous epidemiological studies have shown that a high resting heart rate is associated with an increased cardiovascular morbidity and mortality, particularly in heart failure. The resting heart rate is not only a risk marker in heart failure, but it is also a risk factor, i.e., modifying heart rate also modifies the risk. Chronotropic drugs have shown benefits in terms of morbidity and mortality. Nevertheless, there is a major difference between the recommended heart rate and the patients’ everyday life heart rate. Indeed, even if the proportion of heart failure patients on beta-blockers is satisfactory, the number of patients with an optimal heart rate remains insufficient. The aim of this article is to examine the deleterious effect of an elevated resting heart rate in heart failure with systolic dysfunction, in order to overcome the therapeutic inertia and to improve the outcome in this patient group.

[CARDIOVASCULAR INVOLVEMENTS IN BEHÇET'S DISEASE: "ANGIO-BEHÇET"]

Behçet's disease is a relapsing, immune-mediated systemic vasculitis that may affect blood vessels of all types and sizes. Nowadays, the etiology remains unclear. In the absence of a biological marker or pathognomonic radiology, the diagnosis is mainly based on clinical manifestations. The cardiovascular involvement, known as "angio-Behçet", is relatively common and affects up to 40% of patients. It typi- cally occurs in a young male, usually during the onset of the disease. In general, immunosuppressive and anticoagulant therapies initiated early are likely to induce a remarkable cli- nical improvement. Nevertheless, prompt recognition of the polymorphous cardiovascular manifestations of the disease is challenging and may be responsible for some considerable delay prior to initiation of adequate therapy. The aim of this article is to describe the spectrum of cardiovascular involve- ments of Behçet's disease in order to optimize detection and therapeutic management.