Heart Failure in 2015/2016

    Authors

    DOI

    https://doi.org/10.15836/ccar2016.269

    Full Text

    ## Introduction A number of studies on heart failure (HF) have been published in recent years, most of these revealing no significant discoveries in terms of diagnosis or therapy. However, some interesting conclusions have been reached. In addition, new Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC) were launched at the European Heart Failure Congress, held on May 21, 2016 in Florence, Italy ( 1 , 2 ). ## ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure The new Guidelines bring the following major changes relative to the previous 2012 version: A new term has been introduced for patients with HF and left ventricular ejection fraction (LVEF) of 40%-49%: “HF with medium (mildly reduced) EF (HFmrEF)”. Identification of this specific subgroup is believed to stimulate research focused on determining the characteristics, pathophysiology and management of these patients. Distinct recommendations have been issued for diagnosing HF with reduced EF (HFrEF), mildly reduced EF (HFmrEF) and preserved EF (HFpEF). A new algorithm for diagnosing HF in non-acute states has been recommended; it is based on evaluating the likelihood of HF. There are recommendations with the aim to prevent or delay development of symptomatic HF, or to prevent mortality before the onset of symptoms. Indications have been established for administration of a novel combined drug, sacubitril/valsartan, the first one in the class of angiotensin receptor/neprilysin inhibitors (ARNIs). Indications for cardiac resynchronization therapy (CRT) have been changed. The concept of early initiation of appropriate therapy is recommended, i.e. the diagnosis and therapy of acute HF should be performed in parallel – the ‘time to therapy’ approach (adopted in the management of acute coronary syndrome for years now). A new algorithm for the diagnosis and treatment of acute HF, based on the presence or absence of congestion or hypoperfusion, has been issued. The criteria for heart failure subtypes are as follows: HFrEF : LVEF <40%, with symptoms and signs of HF; HFmEF : LVEF 40%-49%, with symptoms and signs of HF, elevated natriuretic peptide levels, and at least one of the additional criteria: relevant structural heart disease or diastolic dysfunction; and HFpEF : LVEF ≥50%, with symptoms and signs of HF, elevated natriuretic peptide levels, and at least one of the additional criteria: relevant structural heart disease or diastolic dysfunction. ## The new algorithm for diagnosing heart failure in non-acute states In patients presenting with symptoms or signs of HF for the first time and in non-acute form, it should first be established at the family physician office or hospital polyclinic whether it is a case of HF. The diagnosis is based on patient history (coronary heart disease, arterial hypertension, cardiotoxic drugs, irradiation, use of diuretics, etc.), symptoms (moist rales, orthopnea, paroxysmal nocturnal dyspnea, heart murmur), physical finding (bilateral edema, elevated jugular venous pressure, etc.) and 12-lead electrocardiogram (the possible presence of abnormalities). If all these elements prove normal, the diagnosis of HF is not likely and other causes should be looked for. Finding at least one abnormality requires natriuretic peptide analysis. In case of elevated natriuretic peptide levels (or if natriuretic peptide analysis is not available), echocardiography should be performed. Positive values of the brain natriuretic peptides (BNP) are as follows: BNP ≥35/pg/mL and NT-proBNP ≥125/pg/mL. Upon making the diagnosis, the etiology should be determined and appropriate treatment introduced. ## Recommendations aiming to prevent or delay development of symptomatic heart failure or to prevent mortality before the onset of symptoms There are data indicating that the onset of HF can be delayed or prevented by interventions for correction of risk factors or therapy for asymptomatic systolic left ventricular dysfunction. For example, in individuals older than 40 with known cardiovascular risks, analysis of natriuretic peptides can prove helpful. It is of paramount importance to treat arterial hypertension as one of the best known risk factors for HF (SPRINT study). Recent data show that empagliflozin, a sodium-glucose cotransporter 2 inhibitor, improves prognosis of patients with diabetes mellitus type 2 (including reduced mortality and hospitalization for heart failure). Smoking cessation can also have favorable effects. The individuals using moderate amounts of alcoholic drinks are at a lower risk of de novo HF occurrence. Moderate physical activity is also useful. Glycemic impairment and overweight should also be treated properly. Statins reduce the risk of some cardiovascular events and mortality, thus potentially preventing or delaying the occurrence of HF indirectly. In patients with coronary heart disease (CHD), the use of angiotensin-converting enzyme (ACE) inhibitors can prevent or delay the occurrence of HF, thus reducing cardiovascular as well as total mortality. In acute myocardial infarction with ST-segment elevation (STEMI), primary coronary intervention (PCI) can prevent or delay the occurrence of HF by reducing the infarct zone. The administration of ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRA) immediately after myocardial infarction, along with statins, can also prove useful. In asymptomatic patients with chronic reduction of the left ventricular systolic function (irrespective of etiology), using ACE inhibitors can reduce the risk of hospital treatment for HF. The use of implantable cardioverter defibrillators (ICD) is recommended in patients with: asymptomatic left ventricular systolic dysfunction (LVEF ≤30%) of ischemic etiology, if at least 40 days have elapsed since acute myocardial infarction; and asymptomatic non-ischemic dilatative cardiomyopathy (LVEF ≤30%) receiving optimal medicamentous therapy. ## A new drug for heart failure treatment with good results Neurohormonal antagonists (ACE inhibitors, MRA and beta-blockers) have been demonstrated to improve survival in patients with HFrEF and are recommended for treatment of all patients with HFrEF unless there is a contraindication for their use or patient intolerance. A new combined drug (LCZ696) consists of the angiotensin receptor blocker (ARB) valsartan and the neprilysin (NEP) inhibitor sacubitril. Results of a recent study with strict inclusion/exclusion criteria showed it to be superior to ACE inhibitors (enalapril) in reducing the risk of death and hospitalization due to HF. Therefore, sacubitril/valsartan has been recommended as a substitute for ACE inhibitor in outpatients with HFrEF having remained symptomatic despite optimal therapy and meeting the study criteria. Drugs from the group of angiotensin receptor blockers failed to demonstrate significant reduction of mortality in patients with HFrEF, therefore their use should be limited to patients not tolerating ACE inhibitors or those taking ACE inhibitors but not tolerating MRA. Ivabradine decreases elevated heart rate, which is frequently recorded in HFrEF patients, and has been associated with improved survival in HF patients; it is therefore recommended to include it in patient therapy, in line with the respective criteria. The above mentioned drugs are administered together with diuretics in patients with symptoms and/or signs of HF. ## Modified indications for cardiac resynchronization therapy Cardiac resynchronization therapy (CRT) improves cardiac parameters in selected patients diagnosed with HF, thus reducing the symptoms, overall morbidity and mortality, while upgrading the patient general condition. The following are recommendations for CRT in HF patients: CRT is recommended in symptomatic patients with HF in sinus rhythm, with QRS complex width ≥150 msec, QRS showing left bundle branch block (LBBB) morphology, and LVEF ≤35% while on optimal therapy, in order to reduce the symptoms, morbidity and mortality (I A according to Guidelines); CRT should be considered in symptomatic patients in sinus rhythm, with QRS width ≥150 msec, QRS not showing LBBB morphology, and LVEF ≤35% while on optimal therapy, in order to reduce the symptoms, morbidity and mortality (IIa B); CRT is recommended in symptomatic patients in sinus rhythm, with QRS width 130-149 msec, QRS showing LBBB morphology, and LVEF ≤35% despite therapy, in order to reduce the symptoms, morbidity and mortality (I B); CRT should be considered in symptomatic patients in sinus rhythm, with QRS width 130-149 msec, QRS not showing LBBB morphology, and LVEF ≤35% despite optimal medicamentous therapy, in order to reduce the symptoms, morbidity and mortality (IIb B); CRT rather than right ventricular stimulation is recommended in patients with HFrEF (irrespective of NYHA class) that have an indication for ventricular stimulation and high grade AV block, in order to reduce morbidity. This also includes patients with atrial fibrillation (I A); CRT should be considered in patients with LVEF ≤35% in NYHA class III-IV despite optimal medicamentous therapy, in order to reduce the symptoms, morbidity and mortality, if there is atrial fibrillation and QRS width ≥130 msec (IIa B); CRT can be considered in patients diagnosed with HFrEF having already received conventional pacemaker or ICD but have experienced HF exacerbation despite optimal therapy, along with high right ventricular stimulation. This does not apply to patients in stable stage HF (IIb B); CRT is contraindicated in patients with QRS duration <130 msec (III A); and implantation of defibrillator with CRT (CRT-D) should be considered in patients with QRS width <130 msec. ## The concept of early initiation of appropriate therapy is recommended The diagnosis and therapy of acute HF should proceed in parallel, implying the ‘time to therapy is crucial’ principle. Such an approach to treatment has been successfully employed in the management of acute coronary syndrome (ACS) for quite a long time now. It is of utmost importance to timely diagnose and treat particular comorbidities such as CHD, arterial hypertension, valvular disease, arrhythmias (atrial fibrillation and ventricular rhythm abnormalities in particular), diabetes, pulmonary diseases (COPD, asthma), central nervous system diseases (depression, stroke, autonomic dysfunction, etc.), sleep disorders, anemia, renal insufficiency, electrolyte imbalance (hypokalemia and hyperkalemia in particular), dyslipidemia, cachexia/obesity, uric diathesis, arthritis, and erectile dysfunction. ## The New Algorithm for Diagnosis and Treatment of Acute Heart Failure The new algorithm for diagnosis and treatment of acute heart failure (AHF), based on the presence or absence of the signs of congestion or hypoperfusion, has been issued. The diagnosis of AHF implies abrupt occurrence or exacerbation of the symptoms and/or signs of HF. It is a life threatening state that requires urgent diagnosis, treatment and hospitalization. AHF occurs de novo or as chronic HF exacerbation, and can be caused by primary cardiac dysfunction or precipitating factors. The most common causes include myocardial dysfunction (ischemia, inflammation, toxic agents), acute valve insufficiency, and pericardial tamponade. Chronic HF exacerbation can occur independently, but it is most frequently associated with precipitating factors such as infection, uncontrolled hypertension, rhythm abnormalities, and inappropriate medication and food intake. The classification of AHF relies on the patient clinical examination, which should reveal the symptoms and signs of congestion (‘moist’/’dry’ state; yes/no) and hypoperfusion (‘cold’/’warm’ state; yes/no). Using this combination, four groups are distinguished: warm and moist (good perfusion and congestion); cold and moist (hypoperfusion and congestion); cold and dry (hypoperfusion without congestion); and warm and dry (good perfusion, no congestion). This classification helps determine therapy in the initial stage and may provide useful prognostic information. Urgent diagnosis and early treatment initiation are of utmost importance in AHF patients. ## Selected Reading from Recent Studies on Heart Failure Sleep apnea is a frequent comorbidity in HF patients with decreased systolic left ventricular function. Two types of the disorder have been described, i.e. obstructive sleep apnea and central sleep apnea. The prevalence of central sleep apnea that usually manifests as Cheyne-Stokes respiration increases with the severity of heart failure. This form of the disease is associated with poorer prognosis. The aim of the SERVE-HF study was to assess the effect of adaptive servo-ventilation (ASV), which provides the servo-controlled inspiratory pressure support based on expiratory positive airway pressure in patients with moderate to severe form of HF and LVEF ≤45% that predominantly suffer from central sleep apnea. The study included 1325 patients in NYHA class III HF on appropriate standard therapy, randomized to ASV or control therapy. Surprisingly, a significant increase in total and cardiovascular mortality was recorded in the ASV group. Results of the SERVE-HF study were opposite to the results of some earlier small studies. One of the potential explanations of this increase in cardiovascular mortality in central sleep apnea may imply the compensatory mechanism, as reduction of this adaptive respiratory mechanism may be detrimental in combination with ASV. Another explanation is that the use of positive pressure upon the respiratory system may modify cardiac function, in particular in patients with decreased pulmonary capillary pressure. An important implication of the negative result of the SERVE-HF study is that this procedure should not be advised in patients with HF, reduced systolic left ventricular function and central sleep apnea, and that it should be discontinued in such patients currently using it. However, the procedure can be used in patients with obstructive sleep apnea. ## Hypoglycemic agents and heart failure The EMPA-REG OUTCOME study tested two doses of empagliflozin, a sodium-glucose cotransporter 2 inhibitor, in comparison with placebo in 7020 patients with diabetes mellitus type 2 and high cardiovascular risk. Following 3.1-year observation, the primary endpoint (death from cardiovascular events, nonfatal myocardial infarction or nonfatal stroke) was significantly reduced by 14% in the empagliflozin group. Interestingly, hospitalization for HF and composite outcome consisting of hospitalization for HF or death from cardiovascular events were also significantly reduced. It is concluded that this novel antidiabetic agent administered along with standard therapy is not only safe for use in HF patients but is also beneficial for prevention of hospitalization for HF in patients with diabetes mellitus type 2. ## Alcohol and risk of heart failure Excessive alcohol consumption leads to cardiac dysfunction and occasionally to alcoholic cardiomyopathy. However, the association of moderate alcohol consumption and the risk of HF is a controversial issue. The ARIC study analyzed data obtained in 14,629 subjects (without HF diagnosis at study entry) having made records of their use of alcoholic drinks. During a mean 24-year follow up, HF developed in 1271 male and 1237 female subjects. The men that reported taking up to 7 drinks per week (1 drink = 14 g alcohol) had a lower risk of HF development as compared with alcohol abstainers (HR=0.80; 95% CI 0.68-0.94; p=0.006). This ‘protective’ effect was less pronounced in women (HR=0.84; 95% CI 0.71-1.00; p=0.05). In subjects taking alcoholic drinks in excess, the risk of HF did not differ from that recorded in abstainers, irrespective of sex. These results suggest that moderate intake of alcoholic drinks may be associated with a lower risk of HF development.

    Cardiologia Croatica
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    Heart Failure in 2015/2016

    Editorial
    Issue7
    Published
    Pages269-275
    PDF via DOIhttps://doi.org/10.15836/ccar2016.269

    Authors

    Duška Glavaš*ORCIDCroatia

    Full Text

    ## Introduction A number of studies on heart failure (HF) have been published in recent years, most of these revealing no significant discoveries in terms of diagnosis or therapy. However, some interesting conclusions have been reached. In addition, new Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC) were launched at the European Heart Failure Congress, held on May 21, 2016 in Florence, Italy ( 1 , 2 ). ## ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure The new Guidelines bring the following major changes relative to the previous 2012 version: A new term has been introduced for patients with HF and left ventricular ejection fraction (LVEF) of 40%-49%: “HF with medium (mildly reduced) EF (HFmrEF)”. Identification of this specific subgroup is believed to stimulate research focused on determining the characteristics, pathophysiology and management of these patients. Distinct recommendations have been issued for diagnosing HF with reduced EF (HFrEF), mildly reduced EF (HFmrEF) and preserved EF (HFpEF). A new algorithm for diagnosing HF in non-acute states has been recommended; it is based on evaluating the likelihood of HF. There are recommendations with the aim to prevent or delay development of symptomatic HF, or to prevent mortality before the onset of symptoms. Indications have been established for administration of a novel combined drug, sacubitril/valsartan, the first one in the class of angiotensin receptor/neprilysin inhibitors (ARNIs). Indications for cardiac resynchronization therapy (CRT) have been changed. The concept of early initiation of appropriate therapy is recommended, i.e. the diagnosis and therapy of acute HF should be performed in parallel – the ‘time to therapy’ approach (adopted in the management of acute coronary syndrome for years now). A new algorithm for the diagnosis and treatment of acute HF, based on the presence or absence of congestion or hypoperfusion, has been issued. The criteria for heart failure subtypes are as follows: HFrEF : LVEF <40%, with symptoms and signs of HF; HFmEF : LVEF 40%-49%, with symptoms and signs of HF, elevated natriuretic peptide levels, and at least one of the additional criteria: relevant structural heart disease or diastolic dysfunction; and HFpEF : LVEF ≥50%, with symptoms and signs of HF, elevated natriuretic peptide levels, and at least one of the additional criteria: relevant structural heart disease or diastolic dysfunction. ## The new algorithm for diagnosing heart failure in non-acute states In patients presenting with symptoms or signs of HF for the first time and in non-acute form, it should first be established at the family physician office or hospital polyclinic whether it is a case of HF. The diagnosis is based on patient history (coronary heart disease, arterial hypertension, cardiotoxic drugs, irradiation, use of diuretics, etc.), symptoms (moist rales, orthopnea, paroxysmal nocturnal dyspnea, heart murmur), physical finding (bilateral edema, elevated jugular venous pressure, etc.) and 12-lead electrocardiogram (the possible presence of abnormalities). If all these elements prove normal, the diagnosis of HF is not likely and other causes should be looked for. Finding at least one abnormality requires natriuretic peptide analysis. In case of elevated natriuretic peptide levels (or if natriuretic peptide analysis is not available), echocardiography should be performed. Positive values of the brain natriuretic peptides (BNP) are as follows: BNP ≥35/pg/mL and NT-proBNP ≥125/pg/mL. Upon making the diagnosis, the etiology should be determined and appropriate treatment introduced. ## Recommendations aiming to prevent or delay development of symptomatic heart failure or to prevent mortality before the onset of symptoms There are data indicating that the onset of HF can be delayed or prevented by interventions for correction of risk factors or therapy for asymptomatic systolic left ventricular dysfunction. For example, in individuals older than 40 with known cardiovascular risks, analysis of natriuretic peptides can prove helpful. It is of paramount importance to treat arterial hypertension as one of the best known risk factors for HF (SPRINT study). Recent data show that empagliflozin, a sodium-glucose cotransporter 2 inhibitor, improves prognosis of patients with diabetes mellitus type 2 (including reduced mortality and hospitalization for heart failure). Smoking cessation can also have favorable effects. The individuals using moderate amounts of alcoholic drinks are at a lower risk of de novo HF occurrence. Moderate physical activity is also useful. Glycemic impairment and overweight should also be treated properly. Statins reduce the risk of some cardiovascular events and mortality, thus potentially preventing or delaying the occurrence of HF indirectly. In patients with coronary heart disease (CHD), the use of angiotensin-converting enzyme (ACE) inhibitors can prevent or delay the occurrence of HF, thus reducing cardiovascular as well as total mortality. In acute myocardial infarction with ST-segment elevation (STEMI), primary coronary intervention (PCI) can prevent or delay the occurrence of HF by reducing the infarct zone. The administration of ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRA) immediately after myocardial infarction, along with statins, can also prove useful. In asymptomatic patients with chronic reduction of the left ventricular systolic function (irrespective of etiology), using ACE inhibitors can reduce the risk of hospital treatment for HF. The use of implantable cardioverter defibrillators (ICD) is recommended in patients with: asymptomatic left ventricular systolic dysfunction (LVEF ≤30%) of ischemic etiology, if at least 40 days have elapsed since acute myocardial infarction; and asymptomatic non-ischemic dilatative cardiomyopathy (LVEF ≤30%) receiving optimal medicamentous therapy. ## A new drug for heart failure treatment with good results Neurohormonal antagonists (ACE inhibitors, MRA and beta-blockers) have been demonstrated to improve survival in patients with HFrEF and are recommended for treatment of all patients with HFrEF unless there is a contraindication for their use or patient intolerance. A new combined drug (LCZ696) consists of the angiotensin receptor blocker (ARB) valsartan and the neprilysin (NEP) inhibitor sacubitril. Results of a recent study with strict inclusion/exclusion criteria showed it to be superior to ACE inhibitors (enalapril) in reducing the risk of death and hospitalization due to HF. Therefore, sacubitril/valsartan has been recommended as a substitute for ACE inhibitor in outpatients with HFrEF having remained symptomatic despite optimal therapy and meeting the study criteria. Drugs from the group of angiotensin receptor blockers failed to demonstrate significant reduction of mortality in patients with HFrEF, therefore their use should be limited to patients not tolerating ACE inhibitors or those taking ACE inhibitors but not tolerating MRA. Ivabradine decreases elevated heart rate, which is frequently recorded in HFrEF patients, and has been associated with improved survival in HF patients; it is therefore recommended to include it in patient therapy, in line with the respective criteria. The above mentioned drugs are administered together with diuretics in patients with symptoms and/or signs of HF. ## Modified indications for cardiac resynchronization therapy Cardiac resynchronization therapy (CRT) improves cardiac parameters in selected patients diagnosed with HF, thus reducing the symptoms, overall morbidity and mortality, while upgrading the patient general condition. The following are recommendations for CRT in HF patients: CRT is recommended in symptomatic patients with HF in sinus rhythm, with QRS complex width ≥150 msec, QRS showing left bundle branch block (LBBB) morphology, and LVEF ≤35% while on optimal therapy, in order to reduce the symptoms, morbidity and mortality (I A according to Guidelines); CRT should be considered in symptomatic patients in sinus rhythm, with QRS width ≥150 msec, QRS not showing LBBB morphology, and LVEF ≤35% while on optimal therapy, in order to reduce the symptoms, morbidity and mortality (IIa B); CRT is recommended in symptomatic patients in sinus rhythm, with QRS width 130-149 msec, QRS showing LBBB morphology, and LVEF ≤35% despite therapy, in order to reduce the symptoms, morbidity and mortality (I B); CRT should be considered in symptomatic patients in sinus rhythm, with QRS width 130-149 msec, QRS not showing LBBB morphology, and LVEF ≤35% despite optimal medicamentous therapy, in order to reduce the symptoms, morbidity and mortality (IIb B); CRT rather than right ventricular stimulation is recommended in patients with HFrEF (irrespective of NYHA class) that have an indication for ventricular stimulation and high grade AV block, in order to reduce morbidity. This also includes patients with atrial fibrillation (I A); CRT should be considered in patients with LVEF ≤35% in NYHA class III-IV despite optimal medicamentous therapy, in order to reduce the symptoms, morbidity and mortality, if there is atrial fibrillation and QRS width ≥130 msec (IIa B); CRT can be considered in patients diagnosed with HFrEF having already received conventional pacemaker or ICD but have experienced HF exacerbation despite optimal therapy, along with high right ventricular stimulation. This does not apply to patients in stable stage HF (IIb B); CRT is contraindicated in patients with QRS duration <130 msec (III A); and implantation of defibrillator with CRT (CRT-D) should be considered in patients with QRS width <130 msec. ## The concept of early initiation of appropriate therapy is recommended The diagnosis and therapy of acute HF should proceed in parallel, implying the ‘time to therapy is crucial’ principle. Such an approach to treatment has been successfully employed in the management of acute coronary syndrome (ACS) for quite a long time now. It is of utmost importance to timely diagnose and treat particular comorbidities such as CHD, arterial hypertension, valvular disease, arrhythmias (atrial fibrillation and ventricular rhythm abnormalities in particular), diabetes, pulmonary diseases (COPD, asthma), central nervous system diseases (depression, stroke, autonomic dysfunction, etc.), sleep disorders, anemia, renal insufficiency, electrolyte imbalance (hypokalemia and hyperkalemia in particular), dyslipidemia, cachexia/obesity, uric diathesis, arthritis, and erectile dysfunction. ## The New Algorithm for Diagnosis and Treatment of Acute Heart Failure The new algorithm for diagnosis and treatment of acute heart failure (AHF), based on the presence or absence of the signs of congestion or hypoperfusion, has been issued. The diagnosis of AHF implies abrupt occurrence or exacerbation of the symptoms and/or signs of HF. It is a life threatening state that requires urgent diagnosis, treatment and hospitalization. AHF occurs de novo or as chronic HF exacerbation, and can be caused by primary cardiac dysfunction or precipitating factors. The most common causes include myocardial dysfunction (ischemia, inflammation, toxic agents), acute valve insufficiency, and pericardial tamponade. Chronic HF exacerbation can occur independently, but it is most frequently associated with precipitating factors such as infection, uncontrolled hypertension, rhythm abnormalities, and inappropriate medication and food intake. The classification of AHF relies on the patient clinical examination, which should reveal the symptoms and signs of congestion (‘moist’/’dry’ state; yes/no) and hypoperfusion (‘cold’/’warm’ state; yes/no). Using this combination, four groups are distinguished: warm and moist (good perfusion and congestion); cold and moist (hypoperfusion and congestion); cold and dry (hypoperfusion without congestion); and warm and dry (good perfusion, no congestion). This classification helps determine therapy in the initial stage and may provide useful prognostic information. Urgent diagnosis and early treatment initiation are of utmost importance in AHF patients. ## Selected Reading from Recent Studies on Heart Failure Sleep apnea is a frequent comorbidity in HF patients with decreased systolic left ventricular function. Two types of the disorder have been described, i.e. obstructive sleep apnea and central sleep apnea. The prevalence of central sleep apnea that usually manifests as Cheyne-Stokes respiration increases with the severity of heart failure. This form of the disease is associated with poorer prognosis. The aim of the SERVE-HF study was to assess the effect of adaptive servo-ventilation (ASV), which provides the servo-controlled inspiratory pressure support based on expiratory positive airway pressure in patients with moderate to severe form of HF and LVEF ≤45% that predominantly suffer from central sleep apnea. The study included 1325 patients in NYHA class III HF on appropriate standard therapy, randomized to ASV or control therapy. Surprisingly, a significant increase in total and cardiovascular mortality was recorded in the ASV group. Results of the SERVE-HF study were opposite to the results of some earlier small studies. One of the potential explanations of this increase in cardiovascular mortality in central sleep apnea may imply the compensatory mechanism, as reduction of this adaptive respiratory mechanism may be detrimental in combination with ASV. Another explanation is that the use of positive pressure upon the respiratory system may modify cardiac function, in particular in patients with decreased pulmonary capillary pressure. An important implication of the negative result of the SERVE-HF study is that this procedure should not be advised in patients with HF, reduced systolic left ventricular function and central sleep apnea, and that it should be discontinued in such patients currently using it. However, the procedure can be used in patients with obstructive sleep apnea. ## Hypoglycemic agents and heart failure The EMPA-REG OUTCOME study tested two doses of empagliflozin, a sodium-glucose cotransporter 2 inhibitor, in comparison with placebo in 7020 patients with diabetes mellitus type 2 and high cardiovascular risk. Following 3.1-year observation, the primary endpoint (death from cardiovascular events, nonfatal myocardial infarction or nonfatal stroke) was significantly reduced by 14% in the empagliflozin group. Interestingly, hospitalization for HF and composite outcome consisting of hospitalization for HF or death from cardiovascular events were also significantly reduced. It is concluded that this novel antidiabetic agent administered along with standard therapy is not only safe for use in HF patients but is also beneficial for prevention of hospitalization for HF in patients with diabetes mellitus type 2. ## Alcohol and risk of heart failure Excessive alcohol consumption leads to cardiac dysfunction and occasionally to alcoholic cardiomyopathy. However, the association of moderate alcohol consumption and the risk of HF is a controversial issue. The ARIC study analyzed data obtained in 14,629 subjects (without HF diagnosis at study entry) having made records of their use of alcoholic drinks. During a mean 24-year follow up, HF developed in 1271 male and 1237 female subjects. The men that reported taking up to 7 drinks per week (1 drink = 14 g alcohol) had a lower risk of HF development as compared with alcohol abstainers (HR=0.80; 95% CI 0.68-0.94; p=0.006). This ‘protective’ effect was less pronounced in women (HR=0.84; 95% CI 0.71-1.00; p=0.05). In subjects taking alcoholic drinks in excess, the risk of HF did not differ from that recorded in abstainers, irrespective of sex. These results suggest that moderate intake of alcoholic drinks may be associated with a lower risk of HF development.