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....................................................................................................................................................................... recommended. Because there is no evidence of harm in patients on statin treatment after the occurrence of HF, there is no need for statin discontinuation for patients already treated.

13.10 Gout and arthritis

Hyperuricemia is a common finding in patients with CHF with a prevalence up to 50%.816,817 Hyperuricemia may be caused or aggravated by diuretic treatment and it is related to symptoms, exercise capacity, severity of diastolic dysfunction and long-term prognosis.817,818 For every 1 mg/dL increase in serum uric acid levels the risk of all-cause mortality and of HF hospitalization increases by 4% and 28%, respectively.819 Both febuxostat and allopurinol reduce uric acid levels. However, allopurinol was associated with a lower rate of all-cause death and CV death, compared with febuxostat, in a prospective, multicentre, double-blind, non-inferiority trial enrolling 6190 patients with gout and CV disease, 20% with HF, with a median follow-up of 32 months.820 Allopurinol is therefore recommended as the firstchoice urate-lowering drug in HF patients with no contraindication. There is no evidence that uric acid-lowering treatment has beneficial effects on LV function, symptoms or outcomes of patients with HF.821823 With respect to treatment of acute gout attacks, non-steroidal anti-inflammatory drugs (NSAIDs) can worsen renal function and precipitate acute HF decompensation. Colchicine should be preferred as it is associated with less side effects.824 However, it, too, should be used with caution in patients with severe renal dysfunction and is contraindicated in patients on dialysis. An increase in ventricular vulnerability was shown in experimental models.825 Arthritis is a common comorbidity and is a common cause of both self-taken and prescribed NSAIDs. These agents are relatively contraindicated as they may precipitate acute decompensation in patients with HF.826 Rheumatoid arthritis is associated with a two- to threefold increase in the risk of HF and this increased risk is independent of ischaemic heart disease, suggesting a direct role in HF pathophysiology.827,828 The safety of disease-modifying drugs used for the treatment of rheumatoid arthritis has not been established in HF. High doses of anti-tumour necrosis factor alpha agents were associated with worsening HF in initial trials and should be used with caution. No adverse effects were noted with lower doses.829831

13.11 Erectile dysfunction

Erectile dysfunction is a serious problem in HF patients due to its association with CV risk factors, comorbidities (e.g. diabetes), lifestyle (e.g. inactivity), and treatment (e.g. drugs).832 In the general population, the prevalence of erectile dysfunction is estimated to be 50% in men aged >_60, but erectile dysfunction can be present in up to 81% of cardiac patients across different cultures and ethnic groups.833 Optimal assessment should include both questions assessing the presence of erectile dysfunction and factors that can be related to erectile dysfunction. Numerous classes of CV drugs, particularly diuretics and beta-blockers, have been implicated causing erectile dysfunction. However, the relationships between many contemporary CV drugs and erectile dysfunction is not clear.834 For the treatment of erectile dysfunction, phosphodiesterase type 5 inhibitors are generally safe and effective in patients with compensated HF.834,835 No studies have shown one agent to be more effective or safer than the others. However, phosphodiesterase type 5 inhibitors should not be used in patients receiving nitrates and nitrates should not be administered to patients within 24 h of sildenafil or vardenafil administration or within 48 h of tadalafil administration.834

13.12 Depression

Depression affects 20% of patients with HF and is severe in half of them. Its occurrence is higher in women and it is associated with worse clinical status and a poor prognosis.836838 Screening using a validated questionnaire is recommended when there is a clinical suspicion of depression. The Beck Depression Inventory and Cardiac Depression Scale are the tools formally validated for the assessment of depression in patients with HF. Other questionnaires (e.g. Geriatric Depression Scale, Hamilton Depression Scale, Hospital Anxiety and Depression Scale) can also be used.837,838 There is still no consensus on the best therapy for HF patients with depression. Psychosocial intervention may improve depressive symptoms but has no effect on prognosis of depressed patients with HF.839 Depressive symptoms may improve with selective serotonin reuptake inhibitors but trials specifically designed to assess the effect of these drugs in patients with HF and depression have failed to show any significant benefit over placebo on both symptoms and outcomes.840,841 Interestingly, patients improved also in the placebo arm showing the importance of better care in these patients. Both trials showed the safety of sertraline and escitalopram, respectively.840,841 Tricyclic antidepressants should be avoided for the treatment of depression in HF as they may cause hypotension, worsening HF, and arrhythmias.837,838

13.13 Cancer

HF occurs in patients with cancer as a result of the interaction among anticancer therapy, cancer itself, and patients’ CV background (risk factors and coexisting CV disease).842846 Several anticancer therapies may cause HF directly, thorough their cardiotoxic effects (Table 23), or, indirectly, through other mechanisms, such as myocarditis, ischaemia, systemic or pulmonary hypertension, arrhythmias or valve disease.844,845,847852 HF, in turn, may affect cancer outcomes by depriving patients of effective anticancer therapies.699 Some epidemiological and experimental evidence suggests a further reciprocal interaction between cancer and HF with some, though not all, studies showing a higher incidence rate of cancer in patients with HF.853858 The prevention of HF in patients with cancer undergoing potential cardiotoxic therapies requires careful patient’s assessment and management before, during, and after cancer therapy, preferably in the context of an integrated Cardio-Oncology service (Figure 18).845,859,860 A CV baseline risk assessment for all patients scheduled to receive potentially cardiotoxic cancer therapies using the HFA-ICOS risk assessment is advisable.846 Baseline CV risk assessment forms have been developed for different potentially cardiotoxic cancer therapies. History of HF or CMP characterizes patients as being at very high risk or at high risk for all cancer therapies, except anti-androgen treatments for prostate cancer. An LVEF <50% is an additional factor for high-risk patients and elevated levels Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026