The year in cardiovascular medicine 2021: heart failure and cardiomyopathies

Abstract

In the year 2021, the universal definition and classification of heart failure (HF) was published that defines HF as a clinical syndrome with symptoms and/or signs caused by a cardiac abnormality and corroborated by elevated natriuretic peptide levels or objective evidence of cardiogenic congestion. This definition and the classification of HF with reduced ejection fraction (HFrEF), mildly reduced, and HF with preserved ejection fraction (HFpEF) is consistent with the 2021 ESC Guidelines on HF. Among several other new recommendations, these guidelines give a Class I indication for the use of the sodium-glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and empagliflozin in HFrEF patients. As the first evidence-based treatment for HFpEF, in the EMPEROR-Preserved trial, empagliflozin reduced the composite endpoint of cardiovascular death and HF hospitalizations. Several reports in 2021 have provided novel and detailed analyses of device and medical therapy in HF, especially regarding sacubitril/valsartan, SGLT2 inhibitors, mineralocorticoid receptor antagonists, ferric carboxymaltose, soluble guanylate cyclase activators, and cardiac myosin activators. In patients hospitalized with COVID-19, acute HF and myocardial injury is quite frequent, whereas myocarditis and long-term damage to the heart are rather uncommon.

Keywords: Activators of soluble guanylate cyclase; Angiotensin receptor–neprilysin inhibitors; Artificial intelligence; Biomarkers; Device therapy; Epidemiology; Heart failure; Imaging; Pharmacotherapy; SGLT-2 inhibitor.

Graphical Abstract

Summary of the universal definition and EF classification of heart failure; management of HFrEF according to 2021 ESC guidelines for heart failure and results of the EMPEROR-preserved trial.

Figure 1

(A) Universal definition of heart failure (upper left panel) and new classification of heart failure according to left ventricular ejection fraction (lower panel) and stages of heart failure (upper right panel). Reprinted from Bozkurt et al. (B) Overview of the management of pharmacological treatment of heart failure with reduced ejection fraction according to 2021 ESC Guidelines on Heart Failure. Reprinted with permission from McDonagh et al.

Figure 2

Long-term joint exposure to various air pollutants, including PM2.5, PM10, PM2.5–10, NO2, and NOx is associated with an elevated risk of incident heart failure in an additive manner. Persons with genetic higher susceptibility to heart failure displayed a particularly high risk of heart failure. Reprinted with permission from Wang et al.

Figure 3

SGLT2 inhibition (EMPEROR-Preserved). (A) EMPEROR-Preserved enrolled 5988 patients with heart failure with preserved ejection fraction and followed them up for a mean of 26 months. The primary endpoint (a composite of cardiovascular death or heart failure hospitalization) was reduced by 21%, translating in a number needed to treat of 31. (B) In a pooled analysis of the EMPEROR-Reduced and -Preserved trials, it was observed that in the higher left ventricular ejection fraction range, the relative benefit of the SGLT2 inhibitor empagliflozin may be attenuated. In the figure, the effects of empagliflozin HF hospitalization and renal outcomes are visualized for the left ventricular ejection fraction 40–50, 50–60, and >60% categories. There is a significant trend towards lesser efficacy in the higher left ventricular ejection fraction categories. Reprinted with permission from https://www.nejm.org/doi/full/10.1056/NEJMoa2107038.

Figure 4

Myocardial injury in recovered COVID-19 patients assessed by cardiovascular magnetic resonance. Myocarditis-like injury can be encountered, with limited extent and minimal functional consequence. Reprinted with permission from Kotecha et al.