Frederik Hendrik Verbrugge

Acute heart failure (AHF) represents a major cause of emergency medical care worldwide and continues to carry a substantial burden of morbidity and mortality despite advances in chronic heart failure management. Most patients with AHF present to emergency departments (EDs), where the first hours of care are critical to determine prognosis. Of these, some have been previously evaluated and treated by prehospital emergency medical services before ED arrival. This consensus document summarizes the current evidence and provides practical advice to emergency physicians for the diagnosis, treatment, and disposition of patients with AHF in these emergency settings (emergency medical services and ED). It emphasizes the importance of a rapid phenotypic classification into acute decompensated heart failure, acute pulmonary oedema, isolated right ventricular failure, or cardiogenic shock, as a key tool to guide early management and triage decisions. It reviews evidence on prehospital and ED management, including the use of biomarkers, imaging, ventilatory support, diuretic and vasodilator strategies, and early initiation or continuation of guideline-directed medical therapy. It also discusses risk stratification and disposition decisions supported by validated tools. Finally, it identifies major knowledge gaps and future research priorities, including pragmatic trials to assess prehospital interventions, biomarker-guided therapy, and early initiation of disease-modifying treatments. Ultimately, this consensus document is aimed to contribute to the improvement of outcomes in AHF.

Heart failure (HF) remains a major public health challenge in Belgium and worldwide, associated with high morbidity and mortality. Recent advances in pharmacological therapy have significantly impr...

BACKGROUND: Atrial functional mitral regurgitation (AFMR) characterizes a high-risk phenotype in heart failure with preserved ejection fraction (HFpEF). Although sacubitril/valsartan reduces functional mitral regurgitation (MR) in HF with reduced EF (HFrEF), its impact on exercise hemodynamics and the dynamic burden of AFMR in HFpEF remains to be elucidated. METHODS: This multicenter, randomized, open-label trial with blinded primary endpoint assessment assigned 84 patients with symptomatic HFpEF and at least moderate AFMR within the previous year to sacubitril/valsartan (n=41) or standard-of-care (SOC; n=43). The primary outcome was the 6-month change in the exercise mean pulmonary arterial pressure to cardiac output (mPAP/CO) slope, assessed using cardiopulmonary exercise testing with simultaneous echocardiography (CPETecho). Secondary outcomes included changes in peak oxygen consumption (peak VO ₂ ), Kansas City Cardiomyopathy Questionnaire (KCCQ), N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels, left atrial (LA) volume and function, and AFMR severity in rest and during stress. RESULTS: At 6 months, sacubitril/valsartan significantly improved the mPAP/CO slope compared with SOC (adjusted between-group difference in change, –0.93 mm Hg/L/min; 95% CI, –1.80 to –0.07; P =0.035). This hemodynamic benefit was accompanied by improvements in peak VO ₂ (mean change, +0.9 versus –0.6mL/kg/min; P =0.002) and KCCQ (median increase, 10 versus 2 points; P =0.002). Significant reductions in NT-proBNP and LA volume were observed ( P P =0.020). Target dose was achieved in 60% of patients, with symptomatic hypotension as the primary titration-limiting factor. CONCLUSIONS: In HFpEF and AFMR, sacubitril/valsartan was associated with improvements in exercise hemodynamics and peak VO ₂ , along with attenuation of the exercise-induced increase in AFMR. These findings suggest a phenotype-specific benefit, warranting confirmation in larger, placebo-controlled, clinical outcome trials. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05991284. EudraCT: 2023-506634-70-00