We report from the 19th Annual Scientific Meeting of the Cardiorenal Forum held in London on 4th October 2024, which served as a dynamic platform for experts in cardiology, diabetes, and renal medicine to converge and exchange the latest insights on managing heart and kidney failure. The meeting centred on the intricate relationship between cardiac and renal health, with sessions aimed at bridging gaps between specialties to improve patient outcomes in cardiorenal syndromes. Drs Kaushika Rautray and Sarah Birkhoelzer share some of the meeting highlights.
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HFpEF on the rise: navigating the heterogeneity
In an engaging opening talk, Professor Christopher Miller (University of Manchester) revealed heart failure with preserved ejection fraction (HFpEF) as the dominant form of heart failure (HF), rising by 10% every decade. Over 70% of patients with HF have HFpEF, most of whom are over 65 years of age experiencing complex comorbidities. The diagnostic challenges in heterogeneous groups were discussed against the background of the diagnostic criteria provided by European Society of Cardiology (ESC)1 as some patients with clinical signs of HFpEF show normal left atrial size and only mildly elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) levels.
Professor Miller emphasised the need for deeper exploration of the different phenotype and genotype of HFpEF to improve diagnostic accuracy. Clinicians were encouraged to enrol patients in the UK HFpEF programme, enhancing clinical trials and unravelling the syndrome’s molecular mysteries. This initiative stands to revolutionise treatment strategies and heighten understanding of HFpEF.
Innovative approaches in lipid treatment for cardiometabolic diseases
Dr Tina Mazaheri (Imperial College London) highlighted developments in lipid-lowering treatment and its role in cardiometabolic diseases and progression. Statin therapy is advised for high-risk adults based on their QRISK score,2 even without established cardiovascular disease (CVD). For primary prevention, a 40% reduction in non-high-density lipoprotein cholesterol (non-HDL-C) is recommended. Secondary prevention targets are low-density lipoprotein cholesterol (LDL-C) levels below 2 mmol/L or non-HDL-C levels below 2.6 mmol/L.3 Around 80% of atherosclerotic CVD patients do not meet LDL-C goals,4 stressing the need for improved post-myocardial infarction management. Undertreatment is mainly due to inadequate follow-up and underutilisation of combination therapies. New options offer promising solutions for enhanced lipid management (see table 1).
Table 1. New therapy options for lipid management
| Treatment | Key points |
| PCSK 9 inhibitors |
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| Inclisiran |
|
| Bempedoic acid |
|
| Icosapent ethyl (IPE) |
|
| Key: CKD = chronic kidney disease; eGFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; LDL-C = low-density lipoprotein cholesterol | |
Untangling resistant hypertension: differentiation and innovations
The management of resistant hypertension was explored by Dr David New (Salford Royal Foundation Trust) who emphasised the need to differentiate from pseudo resistant hypertension. Resistant hypertension is defined as uncontrolled blood pressure despite using three different antihypertensive classes, including diuretics, renin-angiotensin-aldosterone (RAAS) inhibitors and calcium channel blockers. Intriguingly, up to 50% of supposed cases of resistant hypertension are pseudo resistant hypertension,8 highlighting the need for precise assessment, such as urine drug checks of antihypertensives which often highlight lack of medication adherence.
Roughly 20% of resistant hypertension is due to primary aldosteronism9 showcasing the value of spironolactone as an effective add-on drug.10 Lifestyle interventions, such as physical exercise, have been shown to reduce blood pressure by an average of 9.5 (systolic)/5 (diastolic) mmHg.11 Emerging treatments, such as renal denervation, remain a last resort.12,13 Recent trials indicate promising results for new drugs to treat resistant hypertension. Aprocitentan14 and baxdrostat15 seem to effectively lower blood pressure in contrast to firibastat,16 which did not. These findings underscore the importance of accurate diagnosis and innovative treatments for managing renal hypertension.
Unravelling the cardiorenal anaemia cycle: new frontiers in treatment
Cardiorenal anaemia syndrome (CRAS) is a vicious cycle involving HF, chronic kidney disease (CKD), and anaemia.17 Dr Noémi Roy (Oxford University Hospitals Foundation Trust) explained how CRAS significantly impacts HF prognosis. Insights into the disease pathogenesis have led to new targeted treatments, such as hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs), a novel class of anti-anaemia agents.18 Over three months, HIF-PHI treatment improved haemoglobin, total iron binding capacity, and haematocrit levels while reducing ferritin, transferrin saturation, hepcidin, and lipid levels. NTproBNP levels, however, which are indicative of HF, saw limited decrease.19 Dr Roy noted the cardiovascular safety of HIF-PHIs is comparable to that of erythropoiesis-stimulating agents.
Current management options for the treatment of iron deficiency in heart failure patients are summarised in table 2.20
Table 2. Summary of iron supplementation studies in heart failure patients with iron deficiency
| Study | Primary end point |
| IRONOUT HF:21 use of oral iron supplementation in patients with HF and a reduced ejection fraction | Does not affect peak VO2 or increase serum ferritin levels |
| CONFIRM-HF:22 effects of intravenous iron administration in patients with HF complicated by anaemia | Reduced hospitalisation rate |
| FAIR HF:23 effects of intravenous iron administration in patients with iron deficient HF | Improved symptoms and quality of life |
| EFFECT HF:24 effects of intravenous iron administration in patients with iron deficient HF | Improvement in peak oxygen consumption at CPET |
| AFFIRM AHF:25 ferric carboxymaltose in patients hospitalised for acute HF | Significantly fewer hospital readmission due to HF |
| Key: CPET = cardiopulmonary exercise test; HF = heart failure | |
Interactive cases
Heart failure before the end-of-life
A case exploring HF from a palliative perspective, emphasising psychosocial support and communication was presented by Dr Alexandra Abel (Hull York Medical School). In patients with advanced HF, a high symptom burden and poor prognosis, palliative care prioritises comfort over refractory treatments. Hospitalisations in these patients often stem from non-cardiac causes, regardless of HF phenotype.26 Dr Abel highlighted the importance of psychosocial support, including counselling, mental health care, and discussions about patients’ goals and values with the focus on comfort and dignity. This case highlighted the role of early referral for palliative care, suggesting a potential for better advanced care planning in HF management.
IgA nephropathy
A case on IgA nephropathy, the commonest autoimmune primary glomerular disease worldwide, was presented by Dr Kaitlin Mayne (Glasgow Renal & Transplant Unit, University of Glasgow). She highlighted proteinuria as a key prognostic toll and albuminuria for early detection in people with diabetes and hypertension. Most patients may progress to kidney failure within one to 15 years if proteinuria is high. Treatment options, validated by clinical trials, include ACE inhibitors/angiotensin II receptor blockers, SGLT2 inhibitors, sparsentan, and nefecon for disease management, marking an evolution beyond steroid dependency.27–8
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Cardiology clinical trials update
Dr Geraint Morton (Portsmouth Hospitals NHS Trust) gave his personal take home messages from some of the latest clinical trials in cardiology over the past year. These are summarised in table 3.
Table 3. Cardiology trials clinical update
| Trial name | Take home message |
| SELECT29 | Once weekly semaglutide reduced CV events in patients with overweight/obesity in absence of diabetes |
| SENOR-RITA30 | Routine invasive therapy for NSTEMI in elderly does not reduce CV death or MI compared to medical treatment |
POST MI beta blockers31
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It is safe to withhold beta blockers post-MI if left ventricular ejection fraction is preserved. No improvement in quality of life is seen on deprescription |
| FINEARTS-HF32 | Finerenone in patients with HF and ejection fraction >40% reduced first or recurrent heart failure events |
| Exercise: weekend warrior vs. regular exercise | Exercise reduced the adverse CV events regardless of exercise pattern |
| Key: CV = cardiovascular; MI = myocardial infarction; NSTEMI = non-ST segment elevation MI | |
Amyloidosis alert: spot the red flags for early diagnosis
Professor Julian Gilmore (UCL London and UK National Amyloidosis Centre) discussed the challenges diagnosing cardiac amyloidosis due to clinicians missing early clues. Non- specific symptoms such as nausea, vomiting, diarrhoea, gastrointestinal symptoms, renal failure with albuminuria, and macroglossia are red flag symptoms. When combined with bilateral carpal tunnel syndrome, unexplained neuropathy, and lumbar stenosis, amyloidosis should be considered. Such symptoms often predate cardiomyopathy. Improved diagnosis with bone scintigraphy means 70% of ATTR amyloidosis cases are now non-invasively identified.33 Awareness among clinicians is essential, especially in patients over 50 years of age, to ensure earlier diagnosis and intervention for better outcomes.
Addressing cardiotoxicity in leukaemia survivors
As cancer survival rates improve with 75% of survivors now being over 65 years’ old, the spotlight is now on treatment-related side effects, such as cardiotoxicity. The 2022 ESC guidelines in cardio-oncology34 provide expert consensus in an area with limited trials. Dr Renata Walewska (Royal Bournemouth Hospital) emphasised baseline risk stratification, urging clinicians to adopt systematic approaches promptly. By considering CV risk during cancer treatment decisions, educating patients, and tailoring CV surveillance, clinicians can refer high-risk patients appropriately to cardio-oncology services, reducing CV risk and enhancing cancer treatment adherence and survival rates. Anthracycline chemotherapy, despite its efficacy, poses significant cardiotoxicity risks, highlighting the necessity of integrating cardio-oncology to manage these challenges effectively. Early multidisciplinary team consultations involving cardiologists, oncologists, and haematologists, with active patient involvement, are essential for optimal care coordination.
UKKA addressing diabetes kidney disease: the role of primary care
The rise in type 2 diabetes mellitus (T2DM) has led to increased diabetes kidney disease (DKD) rates, a major cause of chronic and end-stage kidney disease. DKD patients face heightened cardiovascular risks. Dr Stuart Stewart (Northern Care Alliance and University of Manchester) stressed the need for incentivising general practitioners (GPs) in DKD management, as financial de-incentivisation has reduced urine albumin-creatinine ratio (ACR) testing by 40%. This trend weakens primary care’s ability to detect and manage kidney disease effectively. Reinstating GP support and resources is crucial for proper diagnostic coding, essential for patient alerts and managing conditions like hypertension and cardiovascular disease. Dr Stewart calls for re-establishing incentives and educating providers on the ‘Detect → Diagnose → Disclose and Code → Manage’ framework to bridge these gaps.35
Revolution
Integrated healthcare models aim to improve patient care by bridging gaps between primary and secondary care, especially for prevalent conditions like diabetes mellitus (DM) and hypertension in the UK. These conditions greatly contribute to kidney disease, affecting patient quality of life and increasing mortality risks. Managing kidney disease faces funding challenges, underscoring the need for integrated care approaches.
Dr Pierina Kapur (Chapel Group Medical Centre, Salford) spoke about the Revoce CKD study which is looking at collaborative multidisciplinary team working between the nephrology department at the Salford Royal Foundation Trust, Salford Integrated Care Board and two primary care networks to improve care in CKD.
Key findings so far include notable reductions in disease progression, with a 7.4 mg/mmol decrease in ACR during the study. Over 50% of patients achieved an ACR of less than 3 mg/mmol at discharge, showcasing significant improvements. Patients also averaged a weight loss of 2.6 kg, benefiting DM and hypertension control and further supporting kidney health. These outcomes highlight the effectiveness of integrated care in improving patient health and addressing systemic barriers. Dr Kapur’s advocacy emphasises the need for funding, education, and collaboration to tackle chronic conditions, inspiring similar care models to enhance patient quality of life and reduce healthcare burdens.
Acknowledgements
The Cardiorenal Forum would like to thank the following companies for their support of this independent meeting: A Menarini Farmaceutica Internazionale SRL, AstraZeneca, Beigene UK Limited, the alliance of Boehringer-Ingelheim and Eli Lilly & Company, Medice UK, Novartis Pharmaceuticals UK Limited, Novo Nordisk, and Vifor Pharma UK Limited, as well as the following societies for their endorsement of the meeting: the British Society for Heart Failure, the Irish Nephrology Society, Kidney Disease Improving Global Outcomes, the UK Kidney Association, and the UK Renal Pharmacy Group.
Conflicts of interest
SB received funding from AstraZeneca, Bayer and Daiichi-Sankyo. KR: none declared.
Diary date
Contact [email protected] for more information and to sign up for updates. The website www.cardiorenalforum.com will also carry full details of the next meeting.
Kaushika Rautray
Internal medicine trainee
Sheffield University Teaching Hospitals
[email protected]
Sarah M Birkhoelzer
Clinical Research Fellow
Oxford Centre of Clinical Magnetic Resonance Research, Oxford University
[email protected]
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