Editorial
Clinical stability in heart failure. Myth or reality
Estabilidad clínica en la insuficiencia cardiaca. Mito o realidad
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Myth or reality" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "356" "paginaFinal" => "358" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.I. Pérez Calvo, J. Rubio Gracia" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.I." "apellidos" => "Pérez Calvo" "email" => array:1 [ 0 => "jiperez@unizar.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Rubio Gracia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria de Aragón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estabilidad clínica en la insuficiencia cardiaca. Mito o realidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">“When we have reduced needless servitude to a minimum and avoided unnecessary ills, we are still left with a long series of true evils to keep the heroic virtues alive: death, old age, incurable illnesses…”</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>(“Memoirs of Hadrian”. Marguerite Yourcenar)</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">Heart failure (HF) exemplifies (as few other diseases do) what in the words of Yourcenar would be the servitude of human nature and the heroic virtues of the physician. HF is an incurable disease that is especially prevalent in old age and that inexorably leads to death.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the emergence of effective drugs and therapies in recent decades to fight HF, its morbidity and mortality are still unacceptably high.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Only half of patients benefit from these new drugs and therapies because the treatment regimens for HF with preserved ejection fraction are unclear, and there is no proof of the actual efficacy of a specific drug group.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">HF is characterized by its chronic progression, heralded by acute decompensations that result in hospitalizations (occasionally numerous) that interfere with the lives of patients and their families. In both situations and with outpatients with apparently well-controlled HF, as well as during decompensations, HF remains symptomatic, and these patients’ risk of death is greater than that of people the same age and sex but without HF.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Pascual Figal and Bayes-Genis,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> in an intelligent and thought-provoking exercise of reflection, recently questioned whether the stability of outpatients with HF resulted in trivializing the importance and severity of HF and consequently an accommodative or nihilistic approach by the physician. The authors suggested that the term “stability” applied to HF should be omitted or better yet substituted by “optimized treatment”, as this would lead to an approach that was more prone towards a better therapeutic control.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In these conditions, what does “stability” in the context of HF mean? Can we say that an asymptomatic patient with HF is “stable”? If “stability” has some meaning, can it be measured? If so, how can it be measured? Barrrios et al., in the article published in this issue of <span class="elsevierStyleSmallCaps">Revista Clínica Española</span>,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> examined these clearly important questions. The Delphi method is a structured process that synthesizes information through rounds of consensus to generate indicators of quality; However, its use in areas of uncertainty is more questionable.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> As a result, the Delphi method is probably not the best tool for reaching conclusions in a setting as uncertain and ill-defined as that addressed by Escobar et al.,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> although the method helps identify the degree of consensus and provides an interesting overview.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The term “stable” HF is used profusely in the most widely used clinical practice guidelines (CPGs)<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2,7</span></a> although is defined only in the European Society of Cardiology (ESC) guidelines.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> A treated patient is considered stable if their signs and symptoms have remained unchanged for at least a month.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> The study by Barrios et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> appropriately adds another requirement: in addition to no changes in clinical expression, these signs and symptoms should be minimal or nonexistent. It would be very difficult to consider a patient with New York Heart Association (NYHA) functional class <span class="elsevierStyleSmallCaps">iii</span> HF as stable, even though long their symptoms do not change over time. Eighty-two percent of the 150 cardiologists who participated in the study accepted this definition, and 96% agreed that the silent nature of HF could increase the risk of death. However, 30% of the participants did not agree that cardiac structure and function deteriorate despite the absence of signs and symptoms and considered readmissions in these conditions to be rare. In other words, the concept of stability can lead to the misperception of a pathophysiological reality, namely the inexorable progression of HF.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Most participants (more than 90%) acknowledged the importance of periodic follow-up (every 6 months) in specialized units and the decisive contribution of nursing and that of primary care physicians. We fully agree with this perception. As internists, we would like to add that our viewpoint and training in caring for a syndrome as complex and comorbid<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> as HF, both with reduced and preserved ejection fraction (which is not asked about in the questionnaire), provide helpful nuances for patients and physicians.</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the study's controversial aspects was the method for assessing the stability of the patients with HF. If the definition, based on signs and symptoms, is ambiguous (as recognized by the authors), its estimate should be equally ambiguous. In fact, the correlation between functional class perceived by the patient and by the physician shows a low correlation.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> More objective methods are therefore needed. Eighty percent of the participants considered the need for increasing the dosage of loop diuretics as a good marker of instability. Seventy-seven percent of the participants found the serial reading of natriuretic peptides useful, which have shown their unquestionable usefulness in diagnosing HF in patients with dyspnea in acute conditions.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">10,11</span></a> The value of natriuretic peptides in the chronic setting of HF is more questionable, as recognized by the CPGs of ESC.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> There are also more objective methods that have shown acceptable performance for detecting subclinical degrees of congestion, such as lung ultrasound,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> the measurement of the diameter and degree of inspiratory collapse of the inferior vena cava<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13,14</span></a> and the blood concentration of carbohydrate antigen 125,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> which are already employed in daily clinical practice.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The most controversial aspect in our opinion is the approach when faced with a treated and clinically asymptomatic patient. Let us imagine a patient with a left ventricular ejection fraction of 35%, treated with 20<span class="elsevierStyleHsp" style=""></span>mg enalapril and 5<span class="elsevierStyleHsp" style=""></span>mg bisoprolol daily, with NYHA functional class <span class="elsevierStyleSmallCaps">i</span> HF for the past 18 months. According to the ESC CPGs,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> this patient is undergoing optimal treatment. Would it therefore be reasonable to add mineralocorticoid receptor blockers? Should enalapril be replaced with sacubitril/valsartan?</p><p id="par0055" class="elsevierStylePara elsevierViewall">We agree with the authors that the concept of HF “stability” is questionable. In our opinion, this means taking an active approach in searching for subclinical signs of congestion; In other words, assessing the signs of residual congestion,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">16,17</span></a> using methods complementary to the purely semiological<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">18,19</span></a> and acting accordingly. Until there are conclusive data, however, the treatment of patients with no residual congestion should be considered optimized if the treatment is in keeping with the CPGs.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The CPG recommendations will likely change in the near future, but this is not a certainty. Until then, it seems prudent to follow the guidelines, unless a reasoned clinical judgment recommends otherwise. The test of time is essential to obtaining a proper overview of the population behavior of the new drugs. For example, after the success of spironolactone in the RALES study,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> there was an increase in the incidence of morbidity and mortality attributed to hyperkalemia.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> In addition, in the clinical trial supporting the use of sacubitril/valsartan,<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> up to 20% of the patients (10% in each study branch) had to be excluded due to adverse effects or intolerance before entering the actual treatment arms.</p><p id="par0065" class="elsevierStylePara elsevierViewall">As attractive as it is to question the concept of clinical “stability” in HF, we need more than consensus opinions to change a clinical practice supported by years of research and experience.</p><p id="par0070" class="elsevierStylePara elsevierViewall">As the saying goes, “one must know the latest but apply the next to last.”</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Calvo J, Rubio Gracia J. 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