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Risk factors for chronic heart failure: obesity, renal dysfunction, arteriovenous fistulas, and amyloid deposition.

The prevalence and incidence of chronic heart failure have increased over the last decades due to increasing longevity of the population, chronic and not well controlled hypertension in many, increased survival after myocardial infarction, and recently the obesity epidemic. Besides the heart and its pump function, renal function is crucially involved in this syndrome and of relevance for its management. As pointed out in a clinical review entitled ‘Renal sodium avidity in heart failure: from pathophysiology to treatment strategies’ by Wilfried Mullens and colleagues from the Ziekenhuis Oost Limburg in Genk, Belgium, increased neurohumoral stimulation results in excessive sodium avidity and extracellular volume overload in decompensated heart failure. In the presence of renal dysfunction which often is present in such patients, the kidneys fail to provide effective natriuresis. Of note, serum creatinine—a surrogate for glomerular filtration—only represents part of the nephron’s function. Alterations in tubular sodium handling are equally important in the development of volume overload and congestion. Venous congestion and neurohumoral activation in advanced heart failure further promote renal sodium and water retention. Interestingly, even before clinical signs of heart failure are evident, intrinsic renal derangements already impair natriuresis. A better understanding of cardiorenal interactions which ultimately result in sodium avidity in heart failure might help to treat and prevent congestion in chronic and acute heart failure. A recently discussed risk factor for heart failure is obesity. The obesity epidemic is of great concern not only in adults, but also in children and adolescents. However, the impact of body weight in children and adolescents on the risk of developing heart failure in the long run is not known. In an article entitled ‘Body weight in adolescence and long-term risk of early heart failure in adulthood among men in Sweden’, Annika Rosengren from the Sahlgrenska University Hospital at € Ostra in Gothenburg, Sweden studied the relationship between body mass index and risk of early hospitalization due to heart failure in a prospective cohort of 1 610 437 young men 19 years of age followed for a median of 23 years. Overall, 5492 first hospitalizations for heart failure occurred at a mean age of 47 years. Compared with men with a body mass index of 18.5–20.0 kg/m, men with a body mass index of 20.0– 22.5 kg/m had an adjusted hazard ratio of 1.22. The risk rose incrementally with increasing body mass index such that men with a body mass index of 30–35 kg/m had an adjusted hazard ratio of 6.40 and those with a body mass index of >_35 kg/m one of 9.53. The multiple-adjusted risk of heart failure per 1 unit increase in body mass index ranged from 1.06 in heart failure associated with valvular disease to 1.21 for cases associated with coronary heart disease, diabetes, or hypertension. There was a steeply rising risk of early heart failure detectable already at a normal body weight, increasing nearly 10-fold in the highest weight category. Given the current obesity epidemic, heart failure in the young may thus increase markedly in the future. The implications of these findings for weight management and prevention are reviewed in an Editorial by Pardeep Jhund from the University of Glasgow in Scotland. Heart failure may be due to ischaemia and infarction, valvular or congenital heart disease, as well as myocyte dysfunction or deposition of proteins and other molecules within the myocardial tissue. Infiltrative myocardial dysfunction is typical for different forms of amyloidosis. The diagnosis of amyloidosis is challenging, however; although typical echocardiographic findings may be leading to diagnosis, definitive confirmation requires detection of the protein in tissue. Although Congo red staining of an endomyocardial biopsy is the diagnostic gold standard in suspected cardiac amyloidosis, the procedure is invasive, and potentially associated with complications and sample bias. Thus, fat pad fine needle aspiration has been introduced for the work up of such patients. In an EHJ Brief Communication ‘Diagnostic sensitivity of abdominal fat aspiration in cardiac amyloidosis’, Julian Gillmore and colleagues from the University College London Medical School in London, UK note that although abdominal fat pad fine needle aspiration is a simple, safe, and well-established procedure