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Early diagnosis, challenge in heart failure


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The Conversation

Arantxa González Miqueo

Director of the Division of Cardiovascular Diseases of the CIMA University of Navarra

Every year, the European Heart Failureassociation and other international societies dedicate the month of May to raising awareness of heart failure, a cardiovascular disease with a high prevalence and mortality rate worldwide.

It occurs when the heart is unable to pump with the necessary intensity to meet the blood and oxygen needs of the rest of the body. It is a serious ailment, since it is estimated to affect 2% of the population, a percentage that rises to 10% in those over 70 years of age. More than 64 million people suffer from it in the world.

Moreover, its incidence is expected to increase exponentially in the coming years (especially in women), since its appearance is closely associated both with aging and with other risk factors that are widespread in our society.

Although there have been great advances in the treatment of heart failure in recent decades, it is still one of the main causes of hospitalization and has a mortality rate of up to 30% during the first year after diagnosis.

This disease also has a very negative impact on the quality of life of patients and their close environment. Daily activities such as climbing stairs, doing household chores, going for a walk or shopping become a challenge.

"Detect the undetected".

In this context, during the first week of May, the association European Heart Failure Association has launched a campaign with the slogan "detect the undetected". In this way, they wanted to focus on the need for early and more specific diagnosis of patients.

Despite the worrying data data, the social perception of the relevance of heart failure and the need to identify it in time has not been sufficiently widespread. Most cases are diagnosed in hospital in situations of acute cardiac decompensation, as previous symptoms have gone unnoticed.

This is the reason why many patients in early stages of heart failure are not diagnosed and, therefore, do not receive adequate treatment.

As with most diseases, the earlier it is detected and a therapeutic strategy is established, the more effective it will be. This involves not only drug treatment, but also lifestyle changes such as exercise, a healthy per diem expenses or giving up harmful habits such as smoking and alcohol consumption.

Damage to the heart is "camouflaged".

One of the problems in the diagnosis of heart failure is its heterogeneity, as it is often the common result of different cardiac conditions. It usually does not occur in isolation, and patients have other diseases.

Arterial hypertension and coronary artery disease (due to the accumulation of lipids such as cholesterol in the arteries that supply oxygenated blood to the heart) are the predominant factors of failure. Obesity, diabetes and chronic kidney disease also contribute to its development.

The various molecular mechanisms involved converge in the deterioration of cardiac function, which is accompanied by various clinical signs and symptoms.

Another problem that limits early detection is that, at first, its manifestations -fatigue, shortness of breath, swelling of the ankles and legs due to fluid accumulation or fainting- are not strictly speaking "cardiac symptoms". They are often not related to this pathology.

Undoubtedly, it is necessary to increase social awareness of the relevance and impact of heart failure, in order to recognize the symptoms and seek medical committee . Active involvement of patients is core topic to deepen the perception of the disease, understand its impact on different aspects of life, and improve compliance with treatment.

Personalized cardiac medicine

The slogan "detect the undetected" also leads us to the molecular field. We live in the era of precision medicine, based on identifying molecular mechanisms specific to the disease in each individual in order to make a specific diagnosis and a better estimation of risk. This makes it possible to establish personalized therapy.

In this context, the determination of blood biomarkers emerges as an option with obvious advantages. Blood analysis is a priori a simple, reliable, rapid technique that can be implemented on a large scale and at low cost.

Moreover, molecular and cellular alterations may precede the onset of symptoms or deterioration of cardiac function. Detecting them would allow us to identify individuals at high risk for heart failure, requiring more specific (but also more costly and restricted) imaging tests, specific treatment or closer follow-up by a specialist.

The development of liquid biopsy in blood samples integrates the study of extracellular vesicles (small cellular fragments that cells release in response to damage) together with the advance of massive sequencing technologies and the analysis of protein(proteomics) and metabolite(metabolomics) expression ( profile ). The vast amounts of information thus obtained open up a new universe of possibilities for exploiting the full potential of blood samples.

The integration of these data using artificial intelligence tools is making it possible to identify molecular patterns that combine several biomarkers to capture the complexity of heart failure.

We still have much to learn, but researchers are making numerous efforts to advance in the localization of biomarkers that will allow us to improve diagnosis, prognosis and treatments.

This is the goal of MINERVA and MINERVA II, two projects coordinated by the Cima University of Navarra, involving a consortium of hospitals, research centers and experts in artificial intelligence.

The aim of these efforts is to ensure that in the future-hopefully in the near future-we will have tools that facilitate early diagnosis and risk stratification in patients. This will contribute to the use of personalized medicine strategies and to slowing the progression of the heart failure epidemic.