Foreword

We have great pleasure in introducing the latest issue of Cardiac Failure Review to our readers. We are proud that over such a short period the quality of Cardiac Failure Review has been recognised so that the journal has been listed in Pubmed Central and its articles from renowned experts have been widely recognised and enjoyed. This issue tackles major areas of advance in heart failure. Mark Noble, one of the pioneers of the clinical use of measures of left ventricular contractility offers and personal insight and perspective into this area. We no longer hear as much concerning the central role reduced left ventricular contractility plays in the pathophysiology of chronic heart failure, nor the role that agents that increase contractility may play in the future. Of course this is largely because attempts in the 1980s and early 1990s to develop drugs to increase myocardial contractility were either neutral or harmful from the perspective of mortality, despite in many cases, improving symptoms and exercise capacity. Have we been measuring the right things? Perhaps the drugs that were developed in the past had unacceptable side-effects and that newer more targeted pharmacological effects or an appreciation of the complexity of heart failure pathophysiology¹ may allow us to develop interventions to increase contractility without calcium overload, pro-arrhythmic effects or increased mortality. We await developments with interest. There remains substantial interest in developing newer, safer positive inotropic agents and devices, both in acute^2–6 and in chronic heart failure.^7,8

There is a very useful review of the role of natriuretic peptides in heart failure, something that has taken a mainstream position in all recent heart failure guidelines,⁹ but which still lags behind in routine clinical practice.^10,11 Their role is continuing to extend to broader aspects of chronic heart failure care.¹² Health-care systems have less well-developed systems for assessing and introducing new diagnostic tests compared to new therapies where the pathway is better understood and considerably more well-trodden, to the benefit of all our patients.^13,14 These modern advances are being incorporated into developing world systems for heart failure management^15,16 in a way that may allow them to speed up improvement in health care and avoid the exorbitant costs that is so problematic for the developed world health-care industries.

The natriuretic peptides are increasingly blurring the distinction between diagnostic test and therapeutic agent.^17,18 There is also an excellent review on the prognostic value of cardiac magnetic resonance (CMR), which is indeed creeping ever more frequently into routine practice, despite the expense of the equipment,^19–22 challenging the once uncontested role of advanced echocardiography, a review of 3D applications of which is also covered in this issue.

Comorbidities in chronic heart failure play a very important role in the therapy and outlook of our patients,²³ due to the increasing age of patients and our achievements in decades past to improve prognosis in many once rapidly fatal chronic disorders. We see reviews on frailty, sleep-disordered breathing, cardio-oncology and an overview by Simon Stewart of how to put it all together. All these topics have attracted considerable attention of late, and efforts abound to interpret the quality of care throughout the world by the use of patient reported outcomes and overall (including co-morbidity-related) quality of life.²⁴ Frailty is seen as a major barrier to effective care, requiring specialist attention.^25–28 Sleep apnoea can be the cause of very disabling symptoms for many of our chronic heart failure patients, and yet it remains a poorly understood and baffling complication to many heart failure specialists.^29,30 Both central and obstructive sleep apnoea are common in chronic heart faiture, and even overlap in the same patient, yet the optimal screening tests³¹ and therapy^32–34 for each may be very different. There has been much recent discussion on the importance of sleep and the complexity of therapy in the chronic health failure patient,³⁵ and the excellent review by Maria-Rosa Costanzo is well recommended.

Cardio-oncology is a rapidly expanding field, and Radek Pudil reviews the role of the emerging specialist cardio-oncologist. There is much similarity between systemic complications of cancer and chronic heart failure, even similar prognostic markers,³⁶ raising the possibility that cardiovascular therapies may play a role in chronic cancer-related syndromes.³⁷ Cancer is known to directly affect the heart,³⁸ in addition to the well-documented toxic effects of many modern anticancer agents.³⁹ Cancer can also be increased in chronic heart failure patients,^40,41 as of interest are cardiovascular end-points in cancer trials.⁴²

Finally, but very importantly, we have a review of the dosing choices for diuretics in heart failure, one of the first therapies in chronic heart failure, yet one with the fewest number of adequately-sized randomized clinical trials.

Acknowledgements

The authors are proud to be the editors of Cardiac Failure Reviews. We acknowledge the importance of ethical publishing, and hereby state that we abide by the statement of ethical publishing in biomedical journals.⁴³