Benefits of Diagnostic Evaluation and Therapy Should Be Assessed Realistically

Letters to the Editor regarding the article Congestive Heart Failure Perioperative Risk Assessment and Therapeutic Consequences by Vera von Dossow, Giovanni Lurati Buse, Tau Hartikainen, Martin Mirus, and Johannes T. Neumann in issue 5/2026

It is self-evident and obviously not news that perioperative cardiac decompensation is associated with a poor prognosis. To deduce from this that echocardiography should be undertaken more frequently equals actionism without evidence (1). Studies have not found that the prognosis improved as a result of carrying out transthoracic echocardiography (TTE) before surgical procedures. Guidelines (2) therefore recommend TTE only for selected clinical scenarios. TTE for all patients in the constellation “cardiovascular risk factors + moderate/high procedure-related risk” (risk category B2 and B3 in Table 2 of the article) is not indicated.

Table 1a lists as the primary endpoint a significant reduction in hospital admissions for empagliflozin in congestive heart failure with preserved ejection fraction (HFpEF). In the EMPEROR-Preserved trial (3), however, what was actually reduced was merely the much weaker endpoint hospital admissions for heart failure, not hospital admissions overall. Only 20% of hospital admissions of patients with HFpEF are required because of heart failure. This population is multimorbid and has many concurring risks, which is why a relevant prognostic effect is barely achievable by treating HFpEF. In addition to diuretics, SGLT2 inhibitors are the best option, but their effectiveness should not be overestimated.

Table 1b is entitled “The main class I recommendations on drug treatment for heart failure with moderately reduced ejection fraction (HFmEF)”, but what is shown is 5 medication categories with an evidence level of only IIb.

Table 1c incorrectly lists angiotensin II receptor blockers (ARB), rather than angiotensin receptor neprilysin inhibitors (ARNI), as superior to enalapril. Among mineral corticoid receptor antagonists (MRA), only eplenerone is mentioned, not the lead compound spironolactone, which in the RALES trial (4) showed the best prognostic benefit of all therapeutics investigated in heart failure studies (30% reduction in overall mortality). Among beta-blockers, only carvedilol and nebivolol are listed, but not the equally effective bisoprolol and metoprolol succinate.

DOI: 10.3238/arztebl.m2026.0068

Dr. med. Alexander Sascha Hauber
Internist, Kardiologe
Cardiocentrum Mainz und Ingehlheim, Cardiopraxis Mainz

Conflict of interest statement
The author declares that no conflict of interest exists.

References

1. von Dossow V, Lurati Buse G, Hartikainen T, Mirus M, Neumann JT: Congestive heart failure: Perioperative risk assessment and therapeuticconsequences. Dtsch Arztebl Int 2026; 123: 138–46

2. ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: Developed by the task force forcardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). Eur Heart J 2023; 44: 4421

3. Anker SD, Butler J, Filippatos G, et al.: Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med 2021; 385: 1451–61

4. Pitt B, Zannad F, Remme WJ, et al.: The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomizedaldactone evaluation study investigators. N Engl J Med 1999; 341: 709–17.