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"documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2024;163:32-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Avances en insuficiencia cardiaca" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "32" "paginaFinal" => "39" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Advances in heart failure management" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1562 "Ancho" => 3341 "Tamanyo" => 340375 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diagnóstico de amiloidosis cardiaca. La escala Perugini se basa en la cuantificación visual de la capación cardiaca del radiotrazador y se establecen cuatro grados. Grado 0: ausencia de captación en área cardiaca; grado 1: captación leve, menor que el hueso; grado 2: captación moderada, igual al hueso; grado 3: captación elevada, mayor a la del hueso.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ATTR; amiloidosis por transtiretina; IC: insuficiencia cardiaca; RMC: resonancia magnética cardiaca; SPECT: tomografía computarizada de emisión de fotones.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Luis Zamorano, Alejandra González Leal" "autores" => array:2 [ 0 => array:2 [ "nombre" => "José Luis" "apellidos" => "Zamorano" ] 1 => array:2 [ "nombre" => "Alejandra" "apellidos" => "González Leal" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624002481" "doi" => "10.1016/j.medcle.2024.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624002481?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324000708?idApp=UINPBA00004N" "url" => "/00257753/0000016300000001/v1_202407010442/S0025775324000708/v1_202407010442/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "S2387020624002638" "issn" => "23870206" "doi" => "10.1016/j.medcle.2024.01.019" "estado" => "S300" "fechaPublicacion" => "2024-07-12" "aid" => "6605" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2024;163:40-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Economic impact of introducing a multidisciplinary diabetic foot clinic in a tertiary hospital" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "40" "paginaFinal" => "45" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto económico de la introducción de una clínica multidisciplinar de pie diabético en un hospital terciario" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1493 "Ancho" => 2508 "Tamanyo" => 217204 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Circuit of a diabetic foot patient before and after the multidisciplinary diabetic foot clinic implementation. DFC: diabetic foot clinic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandra Pérez-Montes de Oca, Laura Ricou Ríos, Francesc López Seguí, Núria Alonso" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alejandra" "apellidos" => "Pérez-Montes de Oca" ] 1 => array:2 [ "nombre" => "Laura" "apellidos" => "Ricou Ríos" ] 2 => array:2 [ "nombre" => "Francesc" "apellidos" => "López Seguí" ] 3 => array:2 [ "nombre" => "Núria" "apellidos" => "Alonso" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624002638?idApp=UINPBA00004N" "url" => "/23870206/0000016300000001/v2_202407071325/S2387020624002638/v2_202407071325/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S238702062400247X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.12.024" "estado" => "S300" "fechaPublicacion" => "2024-07-12" "aid" => "6556" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2024;163:25-31" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Ambulatory blood pressure monitoring. Current status and future perspectives" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "25" "paginaFinal" => "31" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorización ambulatoria de la presión arterial. Situación actual y perspectivas futuras" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1239 "Ancho" => 2341 "Tamanyo" => 137062 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Typical distribution of blood pressure phenotypes when combining office and ABPM measurement. Nomenclature refers to untreated population.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Adapted from Gorostidi et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ABPM: ambulatory blood pressure monitoring; BP: blood pressure; HT: hypertension.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandro de la Sierra" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Alejandro" "apellidos" => "de la Sierra" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775324000666" "doi" => "10.1016/j.medcli.2023.12.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324000666?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062400247X?idApp=UINPBA00004N" "url" => "/23870206/0000016300000001/v2_202407071325/S238702062400247X/v2_202407071325/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Advances in heart failure management" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "32" "paginaFinal" => "39" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Luis Zamorano, Alejandra González Leal" "autores" => array:2 [ 0 => array:4 [ "nombre" => "José Luis" "apellidos" => "Zamorano" "email" => array:1 [ 0 => "zamorano@secardiologia.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alejandra" "apellidos" => "González Leal" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Avances en insuficiencia cardiaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1235 "Ancho" => 2925 "Tamanyo" => 279429 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estimation of LV pressures.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LA: left atrium; E/A: ratio of early ventricular filling wave to atrial contraction; TR: tricuspid regurgitation; LV: left ventricle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a syndrome that encompasses signs and symptoms of a wide variety of aetiologies. The emergence of treatments with prognostic impact in patients with left ventricular ejection fraction (LVEF) < 40% has been decisive for its classification.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although therapies have emerged in recent decades that increase the survival of these subjects, their overall prevalence is increasing due to the ageing of the population. Recent registries report a prevalence of 1%–2% in adults (more than 10% in those over 70) and mortality of up to 50% over five years, with higher mortality in HF with reduced LVEF.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">The diagnosis of HF is established when there are a series of suggestive signs and symptoms together with evidence of cardiac dysfunction. Therefore, in addition to an appropriate physical examination, additional tests are recommended.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Biomarkers</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are different circulating biomarkers that can provide information about the existence of congestion. The classically used and still the most important is B-type natriuretic peptide (BNP), which correlates with left heart pressures, as when these increase it is released into the plasma.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Numerous studies support the diagnostic and prognostic use of BNP in HF, but it is increased in the absence of congestion (atrial fibrillation [AF], renal disease, etc.); it may not be increased in right HF and is inversely related to body mass and directly related to age. Their usefulness in guiding therapy has not been demonstrated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In recent years, new biomarkers have emerged to improve the diagnosis of HF.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Among them, the most outstanding is carbohydrate antigen 125 (CA 125), a glycoprotein present on the cell surface of the coelomic epithelium (pleura, peritoneum and pericardium). It has been observed that increased hydrostatic pressure, mechanical stress and inflammation in the context of congestion can activate mesothelial cells and lead to overexpression and release of this protein.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The advantage of this compared to natriuretic peptides is that its levels do not depend on ventricular distension and do not change with body mass, age or renal function. On the other hand, its interpretation must take into account that it has a longer half-life (five to 12 days) and it is possible that at the onset of congestion its values are not altered and that high levels can be found in the first few days after adequate volume depletion.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In addition, high values have recently been associated with increased mortality and readmission,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and it has been found to be useful in guiding depletion therapy, although studies have shown little statistical power.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Imaging tests</span><p id="par0040" class="elsevierStylePara elsevierViewall">Echocardiography remains the main test to identify cardiac dysfunction and guide risk stratification and therapeutic decisions. The development of advanced echocardiographic techniques allows for a more complete assessment and more accurate diagnosis. However, this method has a number of limitations and it is sometimes necessary to resort to more sophisticated imaging modalities.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Another aspect that has been gaining prominence is the assessment of congestion, as adequate depletion at discharge has been shown to reduce, among other things, the rate of hospital readmissions.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Echocardiography</span><p id="par0050" class="elsevierStylePara elsevierViewall">Fundamental technique for the diagnosis and classification of HF (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). It allows assessment of systolic function and determination of whether diastolic dysfunction is present. The latter has been a controversial issue and, in recent years, different parameters have emerged that reflect increased pressure or alteration of the left ventricular (LV<span class="elsevierStyleSmallCaps">)</span> ratio, recommending their combined use (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In the last decade, global longitudinal strain (GLS), which has been shown to be more sensitive than ejection fraction in measuring LV systolic dysfunction, has gained importance because ejection fraction reflects circumferential shortening of the LV, whereas GLS measures longitudinal shortening. The myofibrils responsible for longitudinal shortening are mainly located in the vulnerable subendocardium, which is usually affected from the outset. Therefore, a reduction in GLS often precedes a reduction in LVEF.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Cardiac magnetic resonance imaging and computed tomography</span><p id="par0060" class="elsevierStylePara elsevierViewall">The role of cardiac magnetic resonance imaging (CMR<span class="elsevierStyleItalic">)</span> in the evaluation of HF patients is constantly evolving. It allows for volumetric estimation, tissue characterisation and cardiac stress assessment. In addition to providing more accurate information about LVEF, it also provides data on the underlying aetiology, allowing targeted therapies to be established.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">However, CMR has certain limitations that make it not a routine test when HF is suspected. Some of these are cost, availability, acquisition time or contraindication in wearers of implanted metal devices.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand, cardiac computed tomography (CT) can provide information on the existence of coronary abnormalities and allow treatment planning. Recent studies have shown that CT myocardial assessment, specifically fibrosis/oedema, correlates well with CMR (the gold standard in this respect), although further research is needed.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Invasive tests</span><p id="par0075" class="elsevierStylePara elsevierViewall">Cardiac catheterisation is reserved for those cases in which there is discordance between signs/symptoms and complementary tests. It can exclude diseases that may simulate HF (pulmonary hypertension [PHT], obesity, etc.), rule out coronary pathology or unmask diastolic dysfunction by recording pressure during exercise or volume loading.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Congestion assessment</span><p id="par0080" class="elsevierStylePara elsevierViewall">In recent years, lung ultrasound has become a reliable and affordable tool to assess congestion. When congestion is present, the penetrating ultrasound beam is reflected producing reverberation artefacts called B-lines. Detection of these has been shown to indicate a cardiogenic origin of dyspnoea with a sensitivity of 85% and a specificity of 92% (superior to pleural effusion and echocardiography and comparable to natriuretic peptides), and their absence rules out HF with a negative predictive value close to 100%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">It is well known that in HF, dysfunction of other organs can be observed as a consequence of retrograde transmission of cardiac pressures. Therefore, the diameter of the inferior vena cava has classically been used as an indicator of increased right atrial (RA) pressures and thus congestion. However, it has been observed that congestion induces changes in the venous flow patterns of abdominal organs, which provides more comprehensive information. This has led to the introduction of point-of-care ultrasound (PoCUS) into clinical practice to complement and enhance the physical examination of the patient. Currently, Doppler is used for the evaluation of hepatic, renal and portal vein flow to assess venous congestion (VExUS).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Another novel practice is the use of electromechanical energy for the assessment of lung congestion, which appears to decrease the rate of re-hospitalisation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Artificial intelligence</span><p id="par0095" class="elsevierStylePara elsevierViewall">Artificial intelligence (AI) is emerging as a tool to improve HF detection. In South Korea, a diagnostic algorithm was developed based on clinical, laboratory and echocardiographic data from 1198 HF patients. Subsequently, the diagnosis of 97 subjects with dyspnoea was compared between AI and HF experts. In 98% of cases, the AI-based diagnosis corresponded with that of the experts.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Following this line, a pragmatic, prospective and randomised study (AI-Guided Screening for Low Ejection Fraction [EAGLE]) is being developed to determine whether ECG assessment by AI can diagnose ventricular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><p id="par0105" class="elsevierStylePara elsevierViewall">In recent decades, new drugs have revolutionised the treatment of HF, improving survival, hospitalisation rates and quality of life for these patients.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Acute heart failure</span><p id="par0110" class="elsevierStylePara elsevierViewall">Acute HF has a poor prognosis, but at present there are no therapies that have been shown to reduce mortality, but treatment is limited to providing haemodynamic support and decongestion. However, it should be made clear that in this context it is difficult to conduct randomised studies that provide solid evidence.</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Respiratory support</span><p id="par0115" class="elsevierStylePara elsevierViewall">Non-invasive positive pressure mechanical ventilation improves respiratory symptoms and has considerably reduced the need for orotracheal intubation (OTI). Although there are studies with contradictory results as to whether it improves survival, it is a common practice in any Emergency Department. OTI is reserved for cases in which there is a low level of consciousness or in which adequate support is not achieved with non-invasive measures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Diuretic treatment</span><p id="par0120" class="elsevierStylePara elsevierViewall">Depletion therapy is essential in acute HF. Intravenous loop diuretics are generally used because of their availability and rapid action. It is unclear whether bolus or continuous infusion is preferable, but early initiation is necessary. In the Diuretic Optimisation Strategy Evaluation (DOSE) trial, the use of high doses of these diuretics was found to improve congestion data compared with low doses (prescribed outpatient), but with greater deterioration in renal function. Subsequently, a <span class="elsevierStyleItalic">post hoc analysis</span> showed that this deterioration was associated with fewer adverse events.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Therefore, it is now recommended to initiate them intensively.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vasodilators</span><p id="par0125" class="elsevierStylePara elsevierViewall">The most commonly used vasodilator agents are intravenous nitrates and nitroprusside. They generate arterial and venous vasodilatation, resulting in decreased venous return, decreased afterload and relief of congestion. However, they are reserved for cases of acute HF and high systolic pressures as their sustained use does not show better results than management with diuretics.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Inotropic drugs</span><p id="par0130" class="elsevierStylePara elsevierViewall">These drugs should not be used routinely because of the limited evidence for their use and potential harms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> They are currently used when hypotension or signs of hypoperfusion are present.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Within this family, there are no data to indicate the superiority of one over another, so it is essential to consider the clinical context.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Omecamtiv mecarbil is an inotropic agent that selectively activates myosin and leads to increased myocardial function. The randomised ATOMIC-AHF trial started in 2016, comparing different doses of the drug with placebo in patients hospitalised for decompensated HF. The results regarding symptom control were promising at high doses with no increased incidence of adverse events but showed no differences with respect to hard targets. It is not currently approved for use.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Vasopressors</span><p id="par0140" class="elsevierStylePara elsevierViewall">Vasopressor drugs are used in acute HF to increase organ perfusion. Although the evidence is limited (few studies and small samples), the drug of choice is noradrenaline. The SOAP II study compared dopamine and noradrenaline in patients in cardiogenic shock, with higher mortality in the dopamine group at 28 days.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Another trial, OptimaCC (noradrenaline versus adrenaline), had to be stopped prematurely when a higher rate of refractory shock was observed in the adrenaline arm in patients with cardiogenic shock secondary to ischaemic heart disease (IHD).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Opioids</span><p id="par0145" class="elsevierStylePara elsevierViewall">Opioids have traditionally been used in the treatment of acute HF to relieve symptoms and provide patient <span class="elsevierStyleItalic">comfort</span>, but as early as the first decade of the 2000s studies questioned their use. A recent meta-analysis found that morphine use is associated with increased mortality, intensive care unit (ICU) admission and a number of other adverse events.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> For this reason, the latest clinical practice guidelines recommend considering its use only in selected cases such as when there is pain and anxiety or in the palliative context.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Mechanical circulatory support</span><p id="par0150" class="elsevierStylePara elsevierViewall">Mechanical circulatory support is exceptionally used in refractory cardiogenic shock to increase cardiac output, but there is very little evidence for this.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Neuromodulatory treatment initiation</span><p id="par0155" class="elsevierStylePara elsevierViewall">The STRONG-HF study was published in 2022, in which it was observed that rapid and intensive initiation of treatment with prognostic benefit drugs in HF reduced the readmission rate.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This is why the latest update of the European HF management guidelines recommends early initiation and titration and close follow-up in the first weeks after discharge.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Chronic heart failure</span><p id="par0160" class="elsevierStylePara elsevierViewall">In chronic HF, it is essential to classify patients according to LVEF in order to establish treatment.</p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Heart failure with reduced left ventricular ejection fraction</span><p id="par0165" class="elsevierStylePara elsevierViewall">This group has benefited most from the emergence of new treatments in recent decades. In this sense, we can classify therapies into those that improve survival and those that do not.</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Drugs that improve survival</span><p id="par0170" class="elsevierStylePara elsevierViewall">Inhibition of the renin-angiotensin-aldosterone system and the sympathetic nervous system (SNS) has been known to have a beneficial effect on HF since the last decades of the 20th century. Until recently, beta-blockers and angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs) were the mainstays of treatment for HF with reduced LVEF, but in recent years new drugs have emerged that are revolutionising the treatment of HF.</p><p id="par0175" class="elsevierStylePara elsevierViewall">In 2014 the PARADIGM-HF study was published, comparing the effect of sacubitril/valsartan versus enelapril.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Sacubitril is a neprilysin inhibitor and its suppression increases natriuretic peptides, bradykinin and adrenomedullin, counteracting the neurohormonal overactivation that contributes to vasoconstriction, sodium retention and remodelling. The study found that cardiovascular mortality and HF hospitalisations were significantly reduced in patients treated with this drug.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Subsequently, sodium-glucose cotransporter type 2 (SGLT2) inhibitors were shown to reduce the number of admissions for HF. In addition to their diuretic effect, these drugs reduce oxidative stress, fibrosis, inflammation, sympathetic activity and have some effect on cardiac remodelling. These benefits were confirmed in 2019 with the publication of DAPA-HF. In this randomised, double-blind study, dapagliflozin was found to significantly reduce mortality and HF hospitalisations compared to placebo.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These good results in SGLT2i are further strengthened by the publication of the EMPEROR-Reduced study, which showed that empagliflozin also had a prognostic impact in these patients.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">For all these reasons, the latest European clinical practice guidelines on HF recommend the use of these four groups from the time of diagnosis, without prioritising one over another.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Nitric oxide (NO) is known to play an important role in HF. It is released by the endothelium and binds to soluble guanylate cyclase (sGC) generating cyclic guanosine monophosphate (cGMP), a key molecule in the regulation of vascular tone, inflammation and fibrosis. In HF, endothelial dysfunction results in decreased NO production and a reduction in cGMP.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In this regard, the recently published VICTORIA study showed that treatment with vericiguat (sGC stimulator) in HF with reduced LVEF decreased cardiovascular mortality and hospitalisations due to HF.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It is currently approved for use in patients with LVEF < 40% who have had recent decompensations requiring intravenous diuretics despite optimal medical therapy (OMT).</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Drugs that reduce hospitalisations or improve symptomatology</span><p id="par0195" class="elsevierStylePara elsevierViewall">Although there are no studies showing that diuretic treatment improves survival, diuretics remain essential in the treatment of HF in order to reduce symptoms. Loop diuretics are commonly used because of their ability to produce more intense diuresis, although others such as thiazides (mainly in combination with loop diuretics because of their synergistic action) can be used.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The use of cardiac glycosides in these patients has been questioned since the publication of DIG in the late 20th century. This study compared digoxin with placebo and found that, although it decreased the rate of hospitalisation, it had no effect on mortality.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Therefore, this drug can be considered primarily in HF and AF patients with OMT to reduce hospitalisations. However, the DIGIT-HF study is currently underway and will shed more light on this issue.</p><p id="par0205" class="elsevierStylePara elsevierViewall">In recent years, the effect of certain myotropic drugs has been studied in HF patients. These selectively activate cardiac myosin, increasing myocardial function without increasing myocardial oxygen consumption or modifying intracellular calcium. Specifically, the GALACTIC-HF study was published in 2021, showing that omecamtiv mecarbil significantly reduced the composite of HF decompensation or cardiovascular death, but did not reduce cardiovascular mortality alone.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> So far, it is not approved for the treatment of HF.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Devices in patients with heart failure and reduced left ventricular ejection fraction: implantable cardioverter defibrillator</span><p id="par0210" class="elsevierStylePara elsevierViewall">The implantable cardioverter defibrillator (ICD) continues to be used in a subgroup of patients in order to prevent sudden death secondary to malignant arrhythmias, and is therefore indicated for secondary prevention, provided there are no co-morbidities that would result in a life expectancy of <1 year.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Subcutaneous defibrillators, which do not require a ventricular lead, have been developed in recent years. They have been shown to be a good alternative for a certain group of patients as they cannot treat bradyarrhythmia or deliver antitachycardia therapies and cardiac resynchronisation.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Cardiac resynchronisation therapy</span><p id="par0220" class="elsevierStylePara elsevierViewall">Since the early 2000s, studies of cardiac resynchronisation therapy (CRT) have established the profile of patients who would benefit from it. QRS complex amplitude has been shown to be related to response to CRT, but it is less clear whether it is also related to morphology. Left bundle branch block (LBBB) has a higher rate of arrhythmic events, but tends to have longer QRS, so it is now thought that it is duration rather than morphology that is associated with a better response to CRT.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Their recommendation is summarised in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Other devices</span><p id="par0225" class="elsevierStylePara elsevierViewall">There are some devices that, although there is little solid evidence to support their recommendation, are used in some patients with advanced HF who are refractory to other treatments.</p><p id="par0230" class="elsevierStylePara elsevierViewall">The autonomic dysregulation that occurs in HF has classically been the main pharmacological therapeutic target, but devices are also emerging that attempt to modulate adrenergic activity by inhibiting SNS activity and increasing parasympathetic (PNS) activity in order to reduce myocardial remodelling, peripheral vasoconstriction and electrolyte retention. The most commonly used are those implanted in the carotid sinus to activate its baroreceptors. Although no hard target benefits have been demonstrated, there are randomised trials such as HOPE 4HF<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and BeAT-HF<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> and some meta-analysis<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> which show that these therapies improve functional class, quality of life and reduce natriuretic peptides. Therefore, since 2019, they have been approved for use in the US in patients with reduced LVEF who are not CRT candidates.</p><p id="par0235" class="elsevierStylePara elsevierViewall">There are also devices that stimulate the vagus nerve and thus the PNS with similar results.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Cardiac remodelling and ventricular dysfunction are largely due to neurohormonal factors, but mechanical elements also play an important role. Improvement in cardiac contractility achieved by resynchronisation devices is known to be beneficial in patients with ventricular asynchrony and wide QRS. However, it is postulated that improved cardiac contractility may also be beneficial in patients with narrow QRS. Along these lines, cardiac contractility modulation (CCM) therapies have emerged that involve the application of biphasic electrical signals to the interventricular septum during the myocardial absolute refractory period. This stimulation produces a series of intracellular modifications that improve cardiac contractility. The studies that support their use are FIX-HF-5 and FIX-HF-5C, which demonstrated that they could improve exercise response and quality of life in patients with a <span class="elsevierStyleItalic">New York Heart Association</span> (NYHA) functional class III-IV, LVEF between 25%–45% and QRS < 130 ms.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33,34</span></a> Therefore, they are only indicated in patients who meet these criteria and who do not improve despite OMT.</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Other interventions</span><p id="par0245" class="elsevierStylePara elsevierViewall">HF causes diaphragm dysfunction due to structural and metabolic changes. This has a haemodynamic impact by decreasing venous return. A pilot study suggests that diaphragmatic pacing/synchronisation may improve the response to exercise in patients with ventricular dysfunction, but these results need to be confirmed with more robust evidence.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">It is known that up to 30% of the total blood volume may be contained in the splanchnic circulation. Activation of the SNS that regulates this vasculature would cause some of this volume to migrate into the central venous circulation significantly increasing filling pressures. A study is underway to determine whether splanchnic nerve ablation has an impact on symptom improvement.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Different devices and percutaneous techniques that modify the LV structure are being studied but are not currently approved by the Food and Drug Administration (FDA).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Heart failure with mildly reduced left ventricular ejection fraction</span><p id="par0260" class="elsevierStylePara elsevierViewall">New European guidelines on the management of HF were published in 2021, but until then there were no randomised clinical trials looking exclusively at different therapies in this patient group, so recommendations were weak.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Recently, some studies have emerged that have led to SGLT2i becoming an IA recommendation in these patients in the latest update of these guidelines<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0270" class="elsevierStylePara elsevierViewall">One of them was <span class="elsevierStyleItalic">EMPEROR-Preserved</span> which studied the effect of empagliflozin in patients with HF and LVEF > 40%. Empagliflozin reduced the primary endpoint (cardiovascular deaths and HF hospitalisation or ED visits) at the expense of reduced HF hospitalisations.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Shortly thereafter, DELIVER showed similar results with dapagliflozin.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> A meta-analysis including both studies was conducted in 2022 and supports the results obtained separately.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">In exceptional cases, an artificial shunt may be considered to reduce left chamber pressures and improve clinical outcomes. The REDUCE LAP-HF II trial included more than 600 patients with LVEF > 40%, pulmonary capillary pressure > 25 mmHg and right atrial pressure > 5 mmHg. This technique was found to have no impact on the primary endpoint (combined death, stroke, HF episodes and improvement in quality of life). However, a <span class="elsevierStyleItalic">post hoc</span> analysis showed that statistical significance was achieved in patients with pulmonary vascular resistance < 1.74 UW. Several studies are currently underway in this regard.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Heart failure with preserved left ventricular ejection fraction</span><p id="par0280" class="elsevierStylePara elsevierViewall">So far, SGLT2i are the only ones that have been shown to have some impact (without reducing mortality) in this patient group.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36,37,39</span></a> For this reason, in the latest update of the European guidelines for the management of HF, they have been given a class IA recommendation.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Special situations</span><p id="par0285" class="elsevierStylePara elsevierViewall">Cardiac amyloidosis has become increasingly important in recent years due to its non-negligible prevalence due to the ageing population and the emergence of specific treatments.</p><p id="par0290" class="elsevierStylePara elsevierViewall">Amyloidosis is a pathology caused by the deposition of amyloid fibrils in the extracellular space of the heart. Depending on the type of amyloid, there are two main types of cardiac amyloidosis, transthyretin amyloidosis (ATTR) and light chain amyloidosis (AL). Their diagnosis is summarised in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">In the early stages of the disease, patients with cardiac amyloidosis usually have preserved LVEF, but in more advanced stages, ventricular dysfunction may occur. In addition, amyloid deposition also affects the nervous system, leading to significant dysautonomia. It is therefore important to avoid the use of bradycardic and hypotensive drugs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">The treatment for AL amyloidosis is the treatment for the underlying disease, whereas for ATTR there are specific drugs.</p><p id="par0305" class="elsevierStylePara elsevierViewall">Tafamidis is the drug of choice in this group of patients whose life expectancy is more than two years. It is a transthyretin stabilizer that prevents tetramer dissociation and amyloid deposition. The ATTR-ACT study compared treatment with tafamidis versus placebo in patients with ATTR and found a significant reduction in mortality in the experimental group, as well as improved quality of life and response to exercise.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Diflunisal is an alternative treatment for patients who are not suitable candidates for tafamidis. This is a non-steroidal anti-inflammatory agent that also prevents fibril fragmentation and deposition, although it has not shown mortality benefits<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> and is very poorly tolerated. It is therefore not considered a first-line drug.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Other agents that may be considered in ATTR with peripheral nervous system involvement are patisiran (RNA interference molecule) and inotersen (antisense oligonucleotide TTR inhibitor) which prevent hepatic amyloid production. Their use is based on a randomised study comparing patisiran with placebo in patients with ATTR and polyneuropathy, which found that in the subgroup of patients with cardiac involvement, natriuretic peptide levels, ventricular thickness and the incidence of systolic dysfunction were reduced.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><p id="par0320" class="elsevierStylePara elsevierViewall">Natriuretic peptides and echocardiography remain the cornerstone of HF diagnosis, but other tools such as CT and CMR are becoming increasingly significant.</p><p id="par0325" class="elsevierStylePara elsevierViewall">Treatment of acute HF is based on decongestion and haemodynamic stabilisation.</p><p id="par0330" class="elsevierStylePara elsevierViewall">ACE inhibitors, beta-blockers and MRAs remain the first choice in HF with reduced LVEF. In recent years, other drugs such as angiotensin-neprilysin receptor inhibitors (ARNIs) and SGLT2i have emerged and have been positioned at the same level, although there are no clear recommendations on how to initiate neuromodulatory therapy in these patients.</p><p id="par0335" class="elsevierStylePara elsevierViewall">SGLT2i are the only agents that so far have a class IA recommendation in this group, although they have not been shown to reduce cardiovascular mortality (although HF hospitalisations have been reduced).</p><p id="par0340" class="elsevierStylePara elsevierViewall">Therapies such as CCM or baroreceptor modulation are used in some patients because they appear to improve quality of life and exercise response, although there are gaps in the evidence.</p><p id="par0345" class="elsevierStylePara elsevierViewall">There are many trials underway, both of drugs and of devices or interventions that may change the approach to HF in the future.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Funding</span><p id="par0350" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflict of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">Dr. José Luis Zamorano has participated in events sponsored by companies such as Daiichi Sankyo, Bayer AG and Novartis over the past two years. These collaborations have addressed topics related to HF, and the author has received honoraria for his participation and contribution. The authors guarantee that the research presented in this article has been conducted in an objective manner and that potential conflicts of interest have not influenced the collection, analysis and interpretation of the data.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2199477" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1846076" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2199476" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1846075" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Diagnosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Biomarkers" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Imaging tests" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Echocardiography" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Cardiac magnetic resonance imaging and computed tomography" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Invasive tests" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Congestion assessment" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Artificial intelligence" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Treatment" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0055" "titulo" => "Acute heart failure" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Respiratory support" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Diuretic treatment" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Vasodilators" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Inotropic drugs" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Vasopressors" ] 5 => array:2 [ "identificador" => "sec0085" "titulo" => "Opioids" ] 6 => array:2 [ "identificador" => "sec0090" "titulo" => "Mechanical circulatory support" ] 7 => array:2 [ "identificador" => "sec0095" "titulo" => "Neuromodulatory treatment initiation" ] ] ] 1 => array:3 [ "identificador" => "sec0100" "titulo" => "Chronic heart failure" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0105" "titulo" => "Heart failure with reduced left ventricular ejection fraction" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Drugs that improve survival" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Drugs that reduce hospitalisations or improve symptomatology" ] 2 => array:2 [ "identificador" => "sec0120" "titulo" => "Devices in patients with heart failure and reduced left ventricular ejection fraction: implantable cardioverter defibrillator" ] ] ] 1 => array:2 [ "identificador" => "sec0125" "titulo" => "Cardiac resynchronisation therapy" ] 2 => array:2 [ "identificador" => "sec0130" "titulo" => "Other devices" ] 3 => array:2 [ "identificador" => "sec0135" "titulo" => "Other interventions" ] ] ] 2 => array:2 [ "identificador" => "sec0140" "titulo" => "Heart failure with mildly reduced left ventricular ejection fraction" ] 3 => array:2 [ "identificador" => "sec0145" "titulo" => "Heart failure with preserved left ventricular ejection fraction" ] ] ] 7 => array:2 [ "identificador" => "sec0150" "titulo" => "Special situations" ] 8 => array:2 [ "identificador" => "sec0155" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0160" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0165" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-14" "fechaAceptado" => "2023-12-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1846076" "palabras" => array:4 [ 0 => "Heart failure" 1 => "Advances in heart failure" 2 => "Treatment of heart failure" 3 => "Innovations in heart failure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1846075" "palabras" => array:4 [ 0 => "Insuficiencia cardiaca" 1 => "Avances en insuficiencia cardiaca" 2 => "Tratamiento de insuficiencia cardiaca" 3 => "Novedades en insuficiencia cardiaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Heart failure is a pathological condition characterized by substantial prevalence and mortality, particularly in the Western world. Over recent decades, both pharmacological and non-pharmacological interventions have emerged, significantly enhancing patient survival and overall quality of life. Moreover, advancements in diverse imaging modalities facilitate precise diagnosis and comprehensive investigation into the fundamental etiology, enabling the development of more precise therapeutic approaches. Nonetheless, discernible gaps persist in comprehending specific facets of this condition, albeit persistent research endeavors seek to elucidate these inquiries.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca es una patología con una prevalencia y mortalidad significativa, sobre todo en el mundo occidental. En las últimas décadas han surgido terapias, farmacológicas y no farmacológicas, que han contribuido en aumentar la supervivencia y la calidad de vida de estos pacientes. Además, el avance en las diferentes técnicas de imagen hace posible establecer un diagnóstico certero y ahondar sobre causa fundamental, permitiendo así adquirir estrategias terapéuticas más dirigidas. Sin embargo, aún existen lagunas sobre algunos aspectos de esta entidad, aunque continuamente se están realizando estudios que tratan de resolver estos interrogantes.</p></span>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1423 "Ancho" => 2508 "Tamanyo" => 212361 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of diastolic dysfunction.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LA: left atrium; LVEF: left ventricular ejection fraction; TR: tricuspid regurgitation.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1235 "Ancho" => 2925 "Tamanyo" => 279429 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estimation of LV pressures.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LA: left atrium; E/A: ratio of early ventricular filling wave to atrial contraction; TR: tricuspid regurgitation; LV: left ventricle.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1562 "Ancho" => 3341 "Tamanyo" => 366724 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of cardiac amyloidosis. The Perugini scale is based on visual quantification of cardiac radiotracer uptake and four grades are established. Grade 0: no uptake in cardiac area; grade 1: mild uptake, lower than bone; grade 2: moderate uptake, equal to bone; grade 3: high uptake, greater than bone.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ATTR, transthyretin amyloidosis; HF, heart failure; CMR, cardiac magnetic resonance imaging; SPECT, single photon emission computed tomography.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">HF, heart failure; LVEF, left ventricular ejection fraction; LV, left ventricle; mrEF-HF, heart failure with mildly reduced ejection fraction; pEF-HF, heart failure with preserved ejection fraction.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">rEF-HF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">mrEF-HF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pEF-HF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms ± signs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms ± signs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms ± signs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVEF ≤ 40%. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVEF 41%−49%. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVEF ≥ 50% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">__ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">__ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence of structural or functional cardiac abnormalities (diastolic dysfunction, increased LV filling pressures, increased natriuretic peptide levels). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3590094.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Classification of HF according to LVEF.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ARBs, angiotensin II receptor blockers; HF, heart failure; LVEF, left ventricular ejection fraction; MRAs, mineralocorticoid receptor antagonists; mrEF-HF, heart failure with mildly reduced ejection fraction; SGLT2i, sodium-glucose cotransporter type 2 inhibitors.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Class \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diuretic treatment is recommended to alleviate symptoms and signs for patients with mrEF-HF and congestion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">An SGLT2i (empagliflozin or dapagliflozin) is recommended in patients with mrEF-HF to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with mrEF-HF, ACE inhibitors may be considered to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with mrEF-HF, ARBs may be considered to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beta-blockers may be considered in patients with mrEF-HF to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with mrEF-HF, MRA may be considered to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with mrEF-HF, sacubitril/valsartan may be considered to reduce the risk of HF hospitalisations or death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3590093.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Recommendations in the management of HF with mildly reduced LVEF.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comments to the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "SEC Working Group for the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure and SEC Guidelines Committee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rec.2021.11.023" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol (Engl Ed)." 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Advances in heart failure management
Avances en insuficiencia cardiaca
José Luis Zamorano
, Alejandra González Leal
Autor para correspondencia
Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain