LAUSR

Health-related quality of life (HRQL) is affected by multiple factors and is a major endpoint for clinical trials in patients with heart failure (HF).1–4 Johansson et al.5 investigated the impact of country’s income on HRQL in 23 292 patients with HF from 40 different countries enrolled in the Global Congestive HF study (40% with New York Heart Association [NYHA] class III–IV symptoms). Symptom severity, rather than social factors, was the main determinant of HRQL. Pagnesi et al. assessed the prognostic value of the criteria for advanced HF used in recent guidelines. Out of 4753 patients with HF, 1149 (24.3%) presented at least one high-risk criterion and 193 (16.8%) met the Heart Failure Association definition of advanced HF.6,7 Patients meeting all these criteria had a higher risk of all-cause mortality or first HF hospitalization compared to the others (hazard ratio 2.23, 95% confidence interval 1.82–2.74, p< 0.001) with a 69.3% all-cause death or HF hospitalization event rate at 1 year.7 Hospitalizations for acute HF are associated with high mortality and rehospitalization rates.8–10 These findings were furthered by a recent study on 283 048 patients hospitalized for HF from 2008–2017 in Australia and New Zealand. Survival rates were of 48%, 34% and 17% at 3, 5 and 10 years, respectively. Compared with the general population, HF was associated with a loss of 7.3 years in life expectancy.11 Pathophysiology and biomarkers Sex affects clinical characteristics of patients with HF.12,13 Ravera et al.14 compared the expression of 363 different biomarkers in men and women with HF from two independent cohorts. Increased activity of pathways associated with lipid metabolism was observed in women, whereas pathways associated with neuro-inflammatory response were more active in men, possibly explaining differences in clinical phenotypes. N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels are lower in obese patients.12 Adjusting the concentration of NT-proBNP in such patients allows a higher accuracy for the early diagnosis of acute HF.15 Cardiac fibrosis may be assessed by two markers, procollagen type I C-terminal propeptide (PICP) and procollagen type III N-terminal propeptide (PIIINP). The HOMAGE (Heart ‘OMics’ in AGEing) trial showed a reduction in serum PICP concentration following the administration of spironolactone in a population at risk of HF.16 PICP was associated with cardiac structural and functional impairment and the use of spironolactone led to an improvement in diastolic dysfunction, namely a decrease in E/e’ ratio.17 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Better knowledge of pathophysiological mechanisms in cardiogenic shock is necessary.6,18 Scolari et al.19 showed that patients with cardiogenic shock are more prone to present gene mutations related to clonal haematopoiesis, particularly TET2 and AXSL1 mutations which are associated with reduced survival and a dysregulation of inflammatory cytokines.