JACC Heart Failure Editor's Update, May 2019
May 2018 JACC: Heart Failure—Mini-Focus Issue: The Intersection of the Kidney and the Heart
HFrEF clinical trials generally exclude patients with advanced chronic kidney disease, and we struggle with optimizing guideline-directed medical therapy in these patients, often due to concern about potential harm. This state-of-the-art review takes a deeper look at drug therapy in these patients. Aaron Hein and colleagues summarize research regarding the benefits, dangerous side effects, and comorbidities when using drugs recommended for HFrEF patients if those patients also have advanced chronic kidney disease. Research on the use of implantable devices was also explored in an effort to provide guidance on a range of safe and effective therapies for this high-risk population.
Medical Management of Heart Failure With Reduced Ejection Fraction in Patients With Advanced Renal Disease
Aaron M. Hein, Julia J. Scialla, et al.
Fluid balance and changes in weight are widely used as proxies for sodium excretion to guide treatment for advanced decompensated heart failure (ADHF). Daniel Hodson et al looked at the prognostic value of measuring urinary sodium versus fluid loss. Sodium plays a central role in both the pathophysiology and therapy of congestion in ADHF. Fluid metrics have known limitations and they measure sodium excretion indirectly. The possibility of monitoring and guiding treatment through the measurement of urinary sodium was explored in this retrospective analysis of the ROSE-AHF trial data.
Natriuretic Response Is Highly Variable and Associated With 6-Month Survival: Insights From the ROSE-AHF Trial
Daniel Z. Hodson, Matthew Griffin, et al.
Is a higher albumin-to-creatine ratio (ACR) associated with hospitalization for heart failure? Excess urinary albumin excretion is strongly associated with stroke and coronary artery disease risk in black individuals, and black adults are at a higher risk of developing heart failure. Luke Bailey and colleagues examined the ACR data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study to determine if higher ACR was associated with increased risk of hospitalization for heart failure, and if the results varied by type of heart failure and by race.
Association of Urine Albumin Excretion With Incident Heart Failure Hospitalization in Community-Dwelling Adults
Luke N. Bailey, Emily B. Levitan, et al.
Low urinary sodium concentration (Una) has been shown to be linked to hospital admission and mortality during episodes of acute heart failure. Could this measurement have prognostic value in chronic heart failure patients? A correlation between Una and heart failure disease state makes it an interesting potential biomarker for severity of heart failure. Martens et al analyzed various types of Una measurement in chronic heart failure patients on guideline directed medical therapy to determine if Una measurement can predict progression to acute heart failure.
Urinary Sodium Profiling in Chronic Heart Failure to Detect Development of Acute Decompensated Heart Failure
Pieter Martens, Matthias Dupont, et al.
Heart Failure Hall of Fame—Getting to Know the Pioneers Who Inspire Us
Our Heart Failure Hall of Fame series brings information about leaders in the field of heart failure beyond what we know from their publications and extensive work. This month we present an interview with Professor Karl Swedberg.
What first made you interested in a career in heart failure?
When I started to work at the Department of Cardiology, Sahlgrenska University Hospital in Gothenburg in April 1974, I came across a couple of patients with idiopathic dilated cardiomyopathy (IDCM) who had been treated with a beta-blocker by Finn Waagstein. They had improved dramatically. The first seven cases were summarized by Waagstein et al and published in British Heart Journal early 1975 (1). As Waagstein was doing research with beta-blockers in ACS, I was assigned by Dr Hjalmarson to explore these observations further. My studies resulted in my thesis in October 1978. During this time, I learned a lot about myocardial function and the treatment of heart failure, which made it interesting to explore heart failure further.
Which of your many accomplishments are you most proud of?
Probably the CONSENSUS project as this was investigator initiated by Dr Kjekshus and myself. We convinced MSD, where Kjekshus had good contacts, to sponsor a survival study in heart failure with enalapril. I had studied the acute hemodynamic effects of this agent in heart failure when I worked at Moffitt Hospital in San Francisco 1981-82. There was limited interest at first, but when we designed a trial powered for only 400 patients, we received support. To power such a small trial on mortality we needed to include very sick patients with high event rate. The criticism to include only patients in NYHA class IV was that they were too sick to be helped by enalapril. This fear was refuted by the clear beneficial effects on mortality. The study was stopped by the DMC after 253 patients and published in NEJM 1987 as the first survival trial with an ACE-inhibitor. (2)
Who inspires you, in your career or otherwise?
The most inspiring person I have worked with was the head of medicine, Dr Hakan Ljunggren, at the county hospital in Halmstad on the west coast of Sweden where I spent three years in internal medicine from 1971-74. Dr Ljunggren had an almost endless energy and was dedicated to helping his patients. He took the narratives of all patients himself and he checked all the records that we, his co-workers, had produced to control that the records were correct. In addition, he knew almost everything and when he did not know, he read and learned.
Professor Lars Rydén, whom I met in 1974 when I joined cardiology in Gothenburg, was also energetic and sharp. We became friends. Dr Rydén left Gothenburg in 1976 for a county hospital north of Gothenburg. In 1989 he became professor and Head of Cardiology at the Karolinska Institute in Stockholm. Later, he also became president of ESC. We have kept close contact during all these years.
Another inspiring person was Professor Kanu Chatterjee in San Francisco for his interest in clinical work together with education and research. I spent a sabbatical there in 1981-82.
What is your favorite, or last book you read?
The Big Fat Surprise, which I read recently, by Nina Teichholz is one of the most exciting books I have read. She has meticulously checked the scientific background for all dietary recommendations in cardiovascular disease. The big surprise is that there is very little evidence at all for recommendations in particular for fat restrictions. Her findings are backed up by 60 pages of references and a bibliography of 50 pages. Very impressive and a book I recommend to all cardiologists in particular. (3)
My absolute latest book (read today) is The New Atlantis by Francis Bacon from 1627. Interesting if you are interested in the history of science. (4)
3 Things People May Not Know About Me
- I think only a few in the heart failure world know of my interest in person-centered care (PCC), which has progressed over the last 10 years. The background was that cardiology developed enormously from the 1980s onwards due to the technological development. I experienced that patients were reduced to their diagnosis based on biomarkers and imaging. Dr Inger Ekman had been engaged in PCC and she attracted a large federal grant in 2009, which led to the start of Gothenburg University Center for Person-Centered Care (GPCC–www.gpcc.gu.se). I was invited to be a scientific advisor with my experience in controlled clinical trials. In PCC we use “person” as we all are persons all the time and now and then become patients. We define PCC as based on the patient's narrative, creation of a partnership and the documentation of the partnership in a health plan. (5) GPCC has stimulated a lot of interest and research not only in Sweden but on an international level as well.
- My interests in golf and off-piste (deep snow) skiing are probably better known of.
Dr. Swedberg is Senior Professor of Cardiology and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden and Visiting Professor of Cardiology, National Heart and Lung Institute, Imperial College, London. His research interests include beta-blockers and angiotensin-converting enzyme inhibitors (ACEIs) and their effects on heart failure (HF) and myocardial infarction (MI), neuroendocrine activation in HF and the treatment of chronic HF. Professor Swedberg was the first to report on the survival benefits of a beta-blocker (1979), ACEI (1987), and angiotensin receptor blocker (2003) in chronic HF. He has published widely. Professor Swedberg received the European Society of Cardiology Gold Medal 2007 for his outstanding contributions to the cardiovascular field and in 2016 the Lifetime Achievement Award from Heart Failure Association (HFA). Professor Swedberg was Editor-in-Chief of the European Journal of Heart Failure from 2005 to 2009 and has been Associate Editor of the European Heart Journal since 2012.
1. Waagstein F, Hjalmarson A, Varnauskas E, Wallentin I. Effect of chronic beta-adrenergic receptor blockade in congestive cardiomyopathy. Br Heart J. 1975;37:1022-1036.
2. Group TCTS. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian enalapril survival study (CONSENSUS). N Engl J Med. 1987;316:1429-1435.
3. Teicholtz N. The Big Fat Surprise. New York: Simon & Schuster Paperbacks, 2014.
4. Bacon F. The New Atlantis. 1627.
5. Ekman I, Swedberg K, Taft C, et al. Person-centered care—ready for prime time. Eur J Cardiovasc Nurs. 2011;10:248-51.
Call for Papers: Heart Failure in the Elderly
Heart failure is a significant global epidemic; however, in the elderly, there may be differences in treatment effects, treatment options, epidemiology, pathophysiology, risk factors, and outcomes. JACC: Heart Failure is focusing on the growing body of literature with a special issue on this topic. In line with our commitment to advance scientific understanding and patient care, we will publish a uniquely themed issue to highlight this emerging theme.
Topics spanning this theme will be considered, including epidemiology, diagnosis and prognosis, short- and long-term outcomes, clinical management, phenotyping, emerging therapies, comorbidities, the role of biomarkers, and other relevant issues.
How will this process work?
- We welcome papers addressing the broad topic of "Heart Failure in the Elderly" – these can be in the form of original research, clinical trials, meta-analysis, or position statements from societies or advocacy groups. Other formats will be considered if sufficiently rigorous and impactful.
- Interested authors should submit their papers via https://www.jaccsubmit-heartfailure.org on or before August 1, 2019. When entering manuscript information, please select "Heart Failure in the Elderly" from the "Special Issues" pull-down menu in the Keywords, Categories, Special Sections tab.
- We plan for the final publication to appear in the December 2019 issue of JACC: Heart Failure. Please see instructions to authors on the Journal webpage (https://heartfailure.onlinejacc.org).
- Accepted papers will also be displayed on the JACC: Heart Failure website in an “online before print” format.