The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure,Staffing, and Design Considerations

The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.     

Heart Failure in South Asia

South Asia (SA) is both the most populous and the most densely populated geographical region in the world. The countries in this region are undergoing epidemiological transition and are facing the double burden of infectious and non-communicable diseases. Heart failure (HF) is a major and increasing burden all over the world. In this review, we discuss the epidemiology of HF in SA today and its impact in the health system of the countries in the region. There are no reliable estimates of incidence and prevalence of HF (heart failure) from this region. The prevalence of HF which is predominantly a disease of the elderly is likely to rise in this region due to the growing age of the population. Patients admitted with HF in the SA region are relatively younger than their western counterparts. The etiology of HF in this region is also different from the western world. Untreated congenital heart disease and rheumatic heart disease still contribute significantly to the burden of HF in this region. Due to epidemiological transition, the prevalence of hypertension, diabetes mellitus, obesity and smoking is on the rise in this region. This is likely to escalate the prevalence of HF in South Asia. We also discuss potential developments in the field of HF management likely to occur in the nations in South Asia. Finally, we discuss the interventions for prevention of HF in this region     

Effects of sodium glucose cotransporter type 2 inhibitors on heart failure

Heart failure (HF) is emerging as one of the most common cardiovascular (CV) events in patients with type 2 diabetes (T2D), and the one associated with the worst prognosis. T2D and insulin resistance are strong predictors of incident HF, especially HF with preserved ejection fraction (HFpEF). Recent data suggest that even when all traditional risk factors for ASCVD are well controlled, patients with T2D continue to have a substantially greater risk of developing HF—indicating that traditional risk factor control is insufficient from a HF prevention standpoint, and highlighting the need for novel, more effective strategies for both prevention and treatment of heart failure in patients with T2D. Until recently, medications developed for glucose-lowering had, at best, neutral effect on heart failure outcomes in patients with T2D, while several classes of T2D medications had little data in regards to HF risk, and others actually increased the risk of HF hospitalization. Sodium glucose cotransporter type 2 inhibitors (SGLT-2i) have a novel and unique mechanism of action. By inhibiting sodium and glucose reabsorption in the proximal tubule, SGLT-2i result in a number of downstream effects, including glucosuria, weight loss, osmotic diuresis and natriuresis, which should theoretically be beneficial in HF. Three CVOTs of various SGLT-2i (EMPA-REG OUTCOME, CANVAS and DECLARE-TIMI 58) enrolled markedly different patient populations in terms of ASCVD risk, but have demonstrated robust and consistent benefits in reduction of hospitalization for HF. In a meta-analysis of the three outcomes trials, SGLT-2i significantly reduced the risk of cardiovascular death or hospitalization for HF by 23% and hospitalization for HF by 31%. Although the declines in HF hospitalization with SGLT-2is are impressive, only a small proportion of patients with established HF were enrolled in these trials, and these benefits, therefore, represent primarily a HF prevention signal. Whether this prevention of HF benefit will translate to better outcomes for those patients with established HF (with or without diabetes), and whether it will extend across the spectrum of HF phenotypes (HFrEF and HFpEF) is yet to be determined, and is being actively investigated in several large ongoing trials.     

Prevention of heart failure

Heart failure (HF) is a progressive process and the objective of treatment should be to prevent progression. Treatment should begin at the stage of asymptomatic left ventricular dysfunction (LVD), not only to reduce mortality but also to preserve exercise capacity and quality of life. To prevent clinical progression in patients with asymptomatic LVD or HF, left ventricular remodelling and dilatation must be prevented. The SOLVD prevention trial-the only clinical trial on the prevention of HF-showed that ACE inhibition significantly reduced the development of HF, but did not significantly reduce mortality. Plasma norepinephrine is elevated in patients with asymptomatic LVD, is further elevated in patients with overt HF, and is correlated with increased mortality. Inhibition of the sympathetic nervous system by administration of beta-blocking agents is therefore a logical treatment for patients with HF or asymptomatic LVD. Clinical trials have shown that beta-blocking agents increase left ventricular ejection fraction and reduce left ventricular dimensions in patients with HF, indicating regression of left ventricular remodelling. Almost all the patients in these studies were receiving an ACE inhibitor as part of their background medication, therefore the relative efficacy of beta-blocking agents and ACE inhibitors in the regression of remodelling is not known. CARMEN, a double-blind, randomised, parallel group study of carvedilol versus enalapril versus carvedilol + enalapril in 450 patients with mild HF, will provide this information.     

The Heart Failure Association Atlas: rationale,objectives, and methods

Heart failure (HF) constitutes the growing cardiovascular burden and the major public health issue, but comprehensive statistics on HF epidemiology and related management in Europe are missing. The Heart Failure Association (HFA) Atlas has been initiated in 2016 in order to close this gap, representing the continuity directly rooted in the European Society of Cardiology (ESC) Atlas of Cardiology. The major aim of the HFA Atlas is to establish a contemporary dataset on HF epidemiology, resources and reimbursement policies for HF management, organization of the National Heart Failure Societies (NHFS) and their major activities, including education and HF awareness. These data are gathered in collaboration with the network of NHFS of the ESC member and ESC affiliated countries. The dataset will be continuously improved and advanced based on the experience and enhanced understanding of data collection in the forthcoming years. This will enable revealing trends, disparities and gaps in knowledge on epidemiology and management of HF. Such data are highly needed by the clinicians of different specialties (aside from cardiologists and cardiac surgeons), researchers, healthcare policy makers, as well as HF patients and their caregivers. It will also allow to map the snapshot of realities in HF care, as well as to provide insights for evidence‐based health care policy in contemporary management of HF. Such data will support the ESC/HFA efforts to improve HF management ant outcomes through stronger recommendations and calls for action. This will likely influence the allocation of funds for the prevention, treatment, education and research in HF.     

Dietary factors and risk of heart failure: A systematic review

Heart failure (HF) remains the leading cause of hospitalization among older individuals and is associated with a higher health care and societal burden. With increasing life expectancy in the United States, more people will live to develop HF. Whereas noticeable advances in medical treatment of HF have been made over the past decade, primary prevention remains critical to curb the HF epidemic. Many of the key risk factors for HF, including hypertension and coronary heart disease, can be influenced by diet and lifestyle factors, thereby reducing the risk of HF. The present paper reviews current evidence on the effects of dietary factors, such as moderate alcohol consumption, whole grain consumption, fish intake and omega-3 fatty acids, vitamins, and minerals, on the development of HF. Current literature provides strong support for the hypothesis that the risk of HF in the population can be substantially reduced by certain dietary factors.     

内质网应激与肝纤维化关系研究进展*

肝纤维化（HF）的防治是一项重大的医学难题。目前普遍认为肝星状细胞（HSC）的激活和细胞外基质（ECM）的过度沉积是HF发生发展的重要因素,而越来越多的研究发现内质网应激（ERS）参与HF的发生发展和逆转过程。本文讨论了ERS与 HF发生的关系,以为防治HF拓展新的视野。     

Devices and interventions for the prevention of adverse outcomes of tachycardia on heart failure

Heart failure (HF) is the leading cause of hospitalization in the USA. Despite advances in pharmacologic management, the incidence of HF is on the rise and survivability is persistently reduced. Sympathetic overdrive is implicated in the pathophysiology of HF, particularly HF with reduced ejection fraction (HFrEF). Tachycardia can be particularly deleterious and thus has spurred significant investigation to mitigate its effects. Various modalities including vagus nerve stimulation, baroreceptor activation therapy, spinal cord stimulation, renal sympathetic nerve denervation, left cardiac sympathetic denervation, and carotid body removal will be discussed. However, the effects of these modalities on tachycardia and its outcomes in HFrEF have not been well-studied. Further studies to characterize this are necessary in the future.     

Artificial intelligence and heart failure: A state-of-the-art review

Heart failure (HF) is a heterogeneous syndrome affecting more than 60 million individuals globally. Despite recent advancements in understanding of the pathophysiology of HF, many issues remain including residual risk despite therapy, understanding the pathophysiology and phenotypes of patients with HF and preserved ejection fraction, and the challenges related to integrating a large amount of disparate information available for risk stratification and management of these patients. Risk prediction algorithms based on artificial intelligence (AI) may have superior predictive ability compared to traditional methods in certain instances. AI algorithms can play a pivotal role in the evolution of HF care by facilitating clinical decision making to overcome various challenges such as allocation of treatment to patients who are at highest risk or are more likely to benefit from therapies, prediction of adverse outcomes, and early identification of patients with subclinical disease or worsening HF. With the ability to integrate and synthesize large amounts of data with multidimensional interactions, AI algorithms can supply information with which physicians can improve their ability to make timely and better decisions. In this review, we provide an overview of the AI algorithms that have been developed for establishing early diagnosis of HF, phenotyping HF with preserved ejection fraction, and stratifying HF disease severity. This review also discusses the challenges in clinical deployment of AI algorithms in HF, and the potential path forward for developing future novel learning-based algorithms to improve HF care.     

Review of advanced heart failure device diagnostics examined in clinical trials and the potential benefit from monitoring capabilities

Over the past decade, emerging clinical trial data supported the usefulness of implanted therapeutic cardiac devices (pacemakers and defibrillators) for the treatment of heart failure (HF). Interest has now developed in evaluating the potential of device diagnostics to identify HF patients at risk for clinical events and to be used in the management of HF patients. Initial studies have provided inconsistent results. A number of trial design elements have likely played a role in the lack of positive results, including cohort risk determination, intensity of usual care, intensity of the intervention, and selection of end points for the study. These issues will be important to understand when evaluating future clinical trial results and developing new studies, particularly in other HF patient cohorts such as HF with preserved left ventricular function.     

Comparison of usefulness of echocardiographic Doppler variables to left ventricular end-diastolic pressure in predicting future heart failure events

We sought to determine whether the echocardiographic Doppler parameters of left ventricular diastolic dysfunction predict future heart failure (HF) events and, if so, which parameters best predict HF. We also examined whether the predictive ability of echocardiographic Doppler parameters was related to their prediction of left ventricular end-diastolic pressure (LVEDP). We studied patients who underwent cardiac catheterization and echocardiography performed within a 30-day period. The end point was HF, defined as new-onset or recurrent HF diagnosed by a physician and requiring the initiation or modification of treatment of HF. We identified 289 patients (mean age 63.5 +/- 12.6 years) with a mean follow-up of 10.9 +/- 10.2 months. A total of 24 HF events occurred. LVEDP was a significant predictor of HF univariately and independently in multiple regression models after adjustment for ejection fraction. In Cox models adjusted for age, gender, LVEDP, and ejection fraction, only the left atrial volume index and early mitral inflow to early diastolic tissue velocity (E/e') ratio remained predictive of HF. A multiple regression model, including all echocardiographic variables, showed a persistent, although attenuated, relation of early to late mitral inflow velocity (E/A) ratio and E/e' with LVEDP (p = 0.06 and p = 0.002, respectively). The addition of E/e' or the left atrial volume indexed to body surface area, but not E/A, to the clinical history and left ventricular ejection fraction provided incremental prognostic information. A LVEDP of > or =20 mm Hg, E/e' ratio of > or =15, and left atrial volume index of > or =23 ml/m(2) identified those with a higher risk of HF. In conclusion, invasively determined LVEDP is an independent predictor of future HF events. E/e' and the left atrial volume indexed to body surface area are the best independent predictors of future HF and provide prognostic information incremental to the clinical history and left ventricular ejection fraction.     

Heart Failure Prevention: Special Considerations for Women

Heart failure (HF) is a growing epidemic in the USA, and the American Heart Association estimates there are 550,000 new cases of HF in men and women annually. Despite advances in evidence-based cardiovascular care including improved awareness of women’s cardiovascular disease, important gender discrepancies persist in the diagnosis and management of HF. Coronary heart disease (CHD) is a leading cause of HF in the USA, and despite advancing therapies for acute coronary syndromes, young women (age?<?55) are the only population with increasing mortality from CHD. Women stand to greatly benefit from improved efforts targeting HF prevention; therefore, the purposes of this paper are to review the current literature pertaining to HF prevention in women and to identify areas where opportunities exist for improving cardiovascular care for women as well as topics that warrant further investigation.     

Preventing childhood obesity in Asia: an overview of intervention programmes

The rapid economic growth in Asia in the past few decades has contributed to the global increase in childhood obesity prevalence. Yet, little is known about obesity prevention efforts in this region. This systematic review provides an overview of child obesity prevention programmes in Asia. Searches were performed in six electronic databases. Out of 4,234 studies, 17 were included, among them 11 controlled trials (of which five were randomized). Only one study was published before 2007. Identified studies were predominantly conducted in China and Thailand and targeted primary school children in a school setting. Most studies implemented different programmes, frequently targeting behavioural modification through nutrition/health education lectures and/or physical activity sessions. Programme effects related to obesity outcome measures were mixed. Most substantial effects were found for outcomes such as improved health knowledge and/or favourable lifestyle practices. The relatively small number of relevant publications in Asia highlights the need for scientific evaluations of existing and future programmes. This will help ensure the implementation and dissemination of evidence‐based approaches that have been proven to be effective in the Asian context. Targeting preschool settings and applying a comprehensive multisectoral approach may increase the effectiveness and sustainability of childhood obesity prevention programmes.     

An overview of hypertension and cardiac involvement in Asia: Focus on heart failure

Cardiovascular Disease (CVD) is the leading cause of deaths worldwide, contributing to about 30% of all deaths. Half of the cases of CVD are estimated in Asia, the world's most populous continent. Hypertension, a major modifiable risk factor for CVD, results in more deaths than any other CV risk factors in the Asian regions. The total number of patients with hypertension is likely to grow as the population ages. The proportion of the elderly population aged 65 years or more in Asia is expected to increase from 7.4% in 2015 to 10.9% in 2030. It is important to note that more than half (54%) of the world's population live in Asia. Aside of being the biggest single risk factor for global deaths, hypertension is also an important precursor and most common risk factor of heart failure (HF). An increase in HF prevalence is clearly related to the rapid epidemiological transition caused by changes in lifestyle in Asian countries. However, the availability of data on HF burden and health care delivery is limited in Asia compared with Europe and North America. This reality has driven the working group of Asian experts for example the HOPE Asia Network to concentrate on hypertension as risk factors for CVD, with the mission to improve the management of hypertension resulting in organ protection toward a goal of achieving “ZERO” CV event in Asia. This paper aims to give an overview regarding the heart problems caused by hypertension in Asia, focus on HF.     

亚洲血吸虫病及其他人畜共患病区域网络(RNAS+)的发展与作用

亚洲血吸虫病及其他人畜共患病区域网络（Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses, 简称RNAS+）对于亚洲地区蠕虫病的研究与控制规划起了重要的推动作用。本文概述了RNAS+的发展历程,回顾了RNAS+历年会议概况,通过问卷调查和专家访谈法评价了RNAS+对于促进各国蠕虫病防控的作用,总结了RNAS+运行中的经验,并提出今后发展方向。     

Treatment of osteoporosis: facing the challenges in the Asia‐Pacific

The prevalence of osteoporosis and fractures is projected to increase rapidly in the Asia‐Pacific region in coming decades. At the societal level, healthcare providers will face the challenges of paucity of information, lack of awareness among physicians, resource constraints, lack of organization, absence of policies of cost reimbursement, insufficient representation of the problem in curricula and lack of effective, inexpensive and convenient therapy. Poverty, illiteracy, lack of awareness and interest in future quality of life, and co‐morbidities with seemingly greater importance, will all act as challenges at the level of individual patients. Lack of compliance is a function of lack of awareness and motivation, cost, complexity of administration, side‐effects and absence of immediately perceivable benefit. The challenges may be overcome through systematic collection of data, formation or activation of national osteoporosis planning and coordinating groups, development of national guidelines, programs of education of healthcare providers, patients and the general public, adoption of a population‐based prevention strategy, cost‐effective opportunistic screening using clinical decision rules like the osteoporosis self‐assessment tool for Asians, use of the fracture risk assessment tool for therapeutic decision‐making, giving due emphasis to the problem in curricula and development of mechanisms for cost reimbursement. The Asia‐Pacific League of Associations for Rheumatology may take a lead in stimulating, organizing and coordinating these activities.     

Statins and prevention of atrial fibrillation in patients with heart failure

Statins are highly effective and widely used lipid-lowering agents in clinical practice, that also display a number of pleiotropic properties beyond cholesterol lowering. Several trials have demonstrated that they reduce cardiovascular morbidity and mortality in both primary and secondary prevention. Atrial fibrillation (AF) and heart failure (HF) represent 2 world-wide epidemics. Recent evidence suggests that statins may have beneficial effects on cardiovascular outcomes in patients with HF, and specifically in the prevention of AF. The anti-arrhythmic mechanisms of statins regarding AF prevention in HF patients are not fully understood but are possibly related to their pleiotropic effects including anti-inflammatory, antioxidant, atrial remodeling attenuation, ion channel stabilization, and autonomic nervous system regulation.