Worsening heart failure comes into focus, chronic heart failure takes a backseat

Abstract

This article refers to 'The different risk of new-onset, chronic, worsening, and advanced heart failure: A systematic review and meta-regression analysis' by A. Shakoor et al., published in this issue on pages 216-229.Heart failure (HF) is a progressive and complex disease with a substantial variability in risk over time. 1 Once new-onset HF is diagnosed, periods of clinical stability defined as chronic HF (CHF) with a reduced residual risk under aggressive use of guideline-directed medical therapy (GDMT), may be disrupted by episodes of worsening HF (WHF). 2,3 Indeed, WHF episodes are markers of increased clinical risk which lastly progress to advanced HF refractory to GDMT. After decades improving the therapeutic armamentarium for CHF patients, a higher acknowledgement of the severity of WHF and new-onset HF should put the focus into a different type of patient with a higher underlying risk.In this issue of the Journal, Shakoor and colleagues 4 present the results of a comprehensive meta-regression-analysis of 66 contemporary observational studies evaluating 860 112 HF patients grouped into four different stages: new-onset HF (576 897 patients [67.1%]), CHF (203 651 [23.7%]), WHF (71 555 [8.3%]) and advanced HF (8009 [0.9%]). After pooling the data, they found that 1-year mortality was highest in patients with advanced HF (29.7%), followed closely by WHF (26.8%), new-onset HF (21.2%) and CHF (8.5%). These findings highlight that 'stable' CHF patients have better prognosis compared with 'unstable' (new-onset HF and WHF) as they have already survived an initial critical phase after diagnosis (survivor bias), 5 while unstable patients are in a turning point of the HF clinical course.