In recent years, there has been growing interest in the risk stratification for heart failure, and the use of multiple biomarkers to identify different pathophysiological processes associated with this condition. One such biomarker is soluble suppression of tumorigenicity-2 (sST2), which has shown some potential for integration into clinical practice. sST2 is produced by both cardiac fibroblasts and cardiomyocytes in response to myocardial stress. Other sources of sST2 are endothelial cells of the aorta and coronary arteries and immune cells such as T cells. Indeed, ST2 is also associated with inflammatory and immune processes. We aimed at reviewing the prognostic value of sST2 in both chronic and acute heart failure. In this setting, we also provide a flowchart about its potential use in clinical practice.

Heart failure (HF) is a condition with a high clinical and healthcare burden. In Europe, the current incidence is approximately 5 per 1000 persons per year in the adult population, with a prevalence of 1–2%. Prognosis remains poor, with persistently high rates of mortality and hospitalization. The period immediately following hospital discharge is known as the “vulnerable phase,” marked by a heightened incidence of clinical events, including a 30% chance of rehospitalization and a 10% mortality risk. Effective patient management during this time is crucial and should incorporate a risk stratification process, which is vital for designing a personalized follow-up plan and ensuring optimal resource utilization. This review aims to outline the available tools for prognostic risk stratification and propose a structured follow-up model applicable at discharge from an HF hospitalization in patients with HF with reduced ejection fraction and in patients with mildly reduced/preserved ejection fraction.

Introduction: Heart failure with preserved or mildly reduced ejection fraction (HFmrEF/HFpEF) is a complex syndrome common in elderly patients with multiple comorbidities. Age and sex affect the clinical phenotypes and outcomes of this condition. This study aimed to identify age- and sex-specific factors influencing prognosis in elderly patients with HFmrEF/HFpEF to improve risk stratification and guide personalized treatment. Methods: This observational, ambispective study was conducted at Papa Giovanni XXIII Hospital, Bergamo, from June 2017 to August 2022, enrolling patients >65 years with HFmrEF/HFpEF [New York Heart Association (NYHA) Class II–IV] according to ESC guidelines. Data collected included demographics, medical history, echocardiograms, and lab tests. Follow-up lasted at least 1 year, with outcomes defined as a composite of all-cause death, urgent heart transplant, HF hospitalization, and emergency department referral for decompensated HF. Findings were validated using the Swedish HF registry with a similar cohort. Results: Among 2263 HF patients, 971 HFmrEF/HFpEF patients (56.8% males, mean age 79.2 years) were analysed. Males had a higher prevalence of cardiovascular risk factors (e.g. diabetes, obesity, coronary artery disease). The composite outcome occurred more frequently in males (20.6 vs 17.14 per 100 patient years; IRR = 1.20, P = .035). Multivariable analysis identified male sex (HR 1.40, 95% CI 1.13–1.73), age >80 years (HR 1.91, 95% CI 1.22–3.00), higher NYHA class, chronic kidney disease, and severe valvular heart disease as independent predictors of worse outcomes. Males had a 40% higher risk of the outcome compared with women (HR 1.40, 95% CI 1.13–1.73), while patients >80 years old had nearly double the risk compared with those aged 65–70 (HR 1.91, 95% CI 1.22–3.00). The validation analysis in the SwedeHF, adapting the same multiple Cox regression model on 20 950 selected patients, median age 79 years and 57.8% men, and observed between January 2017 and August 2022, showed similar independent risk factors for the composite outcome. Conclusion: This study highlights significant sex disparities in elderly HFmrEF/HFpEF patients, with higher age and male sex being an independent predictor for poor outcomes. These findings emphasize the need for personalized treatment strategies based on these demographic factors.

Mineralocorticoid receptor antagonism represents a therapeutic cornerstone in patients with HFrEF. However, the efficacy of MRAs in patients HFmrEF or HFpEF remains unclear. While the TOPCAT trial did not demonstrate a statistically significant reduction in cardiovascular mortality or hospitalizations for HF in this patient population, post hoc data suggested potential clinical benefits of MRAs in specific patient subgroups. More recently, the landscape has evolved with the FINEARTS-HF trial, which generated novel evidence regarding finerenone, a non-steroidal MRA, in the HFmrEF and HFpEF cohorts. This investigation established a statistically significant decrease in the primary composite endpoint, comprising cardiovascular death and worsening heart failure events. This positive outcome was principally attributable to a lower incidence of total WHF events. Key findings also highlighted the therapy’s rapid onset of action and favorable safety profile. Notably, finerenone’s benefit was consistent across the entire LVEF spectrum and was not influenced by baseline SGLT2i use, sex, or age. Finerenone’s established indication is for patients with type 2 diabetes mellitus and chronic kidney disease to reduce heart failure risk. However, based on the findings of the FINEARTS-HF trial, finerenone may represent a novel therapeutic pillar for patients with HFpEF and HFmrEF. In this review, we aim to describe the potential benefits of MRAs in the pathophysiology of HFpEF and HFmrEF and in different patient phenotypes, the results of the FINEARTS-HF trial, and the most important subanalyses of the study.

Background: Catheter ablation of right anterior, anterior–lateral, and anterior–septal accessory pathways is still challenging in children, even after seminal improvements in mapping and catheter design over the last years. The trans-jugular approach was described as an alternative to the femoral vein recently. As a direct comparison between the femoral approach and the superior approach using the axillary vein was lacking, we conducted the present study. Methods: Twenty-two pediatric patients were enrolled in this retrospective study. Patients with prior ablation attempts were excluded. Another 22 consecutive patients with the same AP localizations were selected as a control group and treated with ablation through the femoral vein. Left axillary vein cannulation was performed advancing an 18-gauge needle using fluoroscopic landmarks (the first rib below the inferior border of the clavicle). All mapping and ablations of accessory pathways were performed with a 7 F deflectable radiofrequency ablation catheter. The main outcome of this study was ablation success at 1 year. Recurrences were defined as a relapse of preexcitation on a 12-lead electrocardiogram and/or documented supraventricular tachycardia. Results: There were no significant differences in sex, age, or weight between groups. No complications occurred acutely or during follow-up. There were no significant differences in acute success rates between the two groups (19/22 vs. 22/22; p = 0.56) at 24 h ECG recordings. At the 1-year follow-up the total recurrence rate was 15.9% (7/44 patients); there was a significantly lower recurrence rate among patients in the trans-jugular group (27.2% vs. 4.5%; p = 0.039). Conclusions: The present study suggests that the trans-axillary vein approach is a safe and effective alternative to the classical femoral approach in pediatric patients.