Editorial articles

The 2026 European Society of Cardiology (ESC) heart failure guidelines represent an important shift in how we think about this disease.¹ Heart failure (HF) is no longer simply a syndrome treated once symptoms develop; it is a continuum from cardiovascular risk to cardiac change and overt disease. The greatest gains may come from identifying patients earlier, before irreversible changes occur. The question is no longer simply, “How should we treat HF?”, but “How early should we intervene, and can we prevent it?”

It is impossible to cover every change within such comprehensive guidelines in a single opinion piece. We, therefore, focus on four clinically important developments: the prevention-focused stages A–D, revised left ventricular ejection fraction (LVEF) classification, replacement of guideline-directed medical therapy (GDMT) with more precise terminology, and earlier referral in stage D.

Cardiovascular–kidney–metabolic (CVKM) care is increasingly recognised as a more realistic way to understand and manage chronic disease. Cardiovascular disease, chronic kidney disease (CKD), type 2 diabetes, obesity, and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently co-exist, share major risk factors, and influence one another biologically and clinically. Yet care delivery across the National Health Service (NHS) remains largely organised around separate pathways, disease-specific targets, and professional silos. This creates a practical mismatch between integrated disease biology and fragmented service delivery.^1–3

A coherent CVKM approach is, therefore, not simply a new label for existing practice. It is a shift in clinical reasoning and system design: away from isolated disease management and towards integrated risk reduction, prioritisation, and patient-centred decision-making.^4,5 The challenge is no longer only to identify effective therapies, but to deliver them in ways that are meaningful, equitable, and sustainable across real-world primary and secondary care.^6–8

To pace or not to pace? Clinical decision-making for older people with frailty and bradycardia is often challenging. For ambulatory, symptomatic patients a pacing strategy is clearly recommended, however, for those patients with severe frailty or limited mobility with an absence of clearcut symptoms, management strategies usually take a shared decision-making approach. How are clinicians expected to provide patients and carers with an objective picture of things to come in such an evidence-light space? The featured publication by Warraich et al., entitled “Outcomes of bradyarrhythmia device implantation: a single-centre retrospective cohort study”, from this issue at https://doi.org/10.5837/bjc.2026.052, is a call to arms to aid clinicians by providing some metrics around the likelihood of benefit. Bradycardia and bradyarrhythmias are common in older people reaching the end of their natural life, and patients, families and clinicians are reluctant to implant a pacemaker device when impact on quality of life is doubtful. This said, syncope can have devastating consequences, particularly hip fractures and head injuries, so there is a risk either way. Geriatricians are heavily invested in falls prevention, and the promotion of physical activity to improve health and wellbeing in the latter stages of life, so implantation is usually the preferred choice in the majority of cases, but where should we draw the line?

‘Publish or perish’. This well-known phrase, likely first mentioned over a century ago, was even once the title of a one-day course run in central London, which I attended. Thankfully, this mantra has faded from prominence in recent years, but what does it mean, why did it become so (in)famous and what have the consequences been? Oxford physician, clinical pharmacologist and writer Dr Jeffrey Aronson proposed a definition for the ‘publish or perish’ paradigm last year, suggesting the following:

“An aphorism that describes the pressure on an academic to have innovative scholarly material published in reputable journals or other forms of scholarly output, sufficiently often, in order to avoid demotion, dismissal, failure to progress in one’s scholarly career, or diminishing the status or reputation of one’s scholarly community or discipline.”¹

The burden of hypertension in the UK is profound.¹ It is the leading modifiable risk factor for cardiovascular disease, chronic kidney disease and vascular dementia, affecting approximately 30% of adults, with an estimated 4.2 million remaining undiagnosed – an alarming figure that underscores longstanding gaps between evidence and implementation in routine care.^2–5 Against this backdrop, the British and Irish Hypertension Society (BIHS), in partnership with the British Heart Foundation Clinical Research Collaborative (BHF‑CRC), has developed the first national, consensus‑driven effort to define future research priorities in hypertension.⁶ This represents a landmark initiative: a structured attempt to align research, policy, and clinical services with the realities of modern hypertension care.

Over eight million UK citizens are at unnecessary risk of the avoidable consequences of hypertension because of inadequate blood pressure (BP) control.¹ Improving this is a key objective of the Department of Health and Social Care, and is one of the five major priorities in the NHSE Core20PLUS5 approach to reducing healthcare inequalities.² The national emphasis on hypertension case finding and management requires a significant increase in the availability of specialist advice and management, which can improve control and outcomes.

“There’s a ghost in the library”

Documentation in medicine has transformed in the last 10 years: notes no longer scatter across the floor to reveal hurriedly scribbled ward rounds without signature or ownership. In the digital era, we can proudly say that ‘if it wasn’t written down it didn’t happen’. By extension, in the modern world of acute echocardiography, if it wasn’t ‘uploaded and reported’, it didn’t happen. These ‘ghost studies’ roam hospital corridors ready to interfere with patient care in maverick ways. All we are left with clinically is a rumour that a study possibly happened. There should be zero ‘ghost studies’ in our library. But, evidently, the ghosts are yet to be busted.

Cardiovascular medicine is undergoing transformation driven by machine learning (ML) technologies.¹ Algorithms now assist in imaging interpretation, electrocardiogram (ECG) analysis, and outcome prediction, with increasing sophistication.^1,2 The adoption of ML-powered diagnostic tools in cardiology is growing, yet training programmes remain largely unchanged, creating a disconnect between skills taught and those required in contemporary practice.^1–4

Despite rigorous clinical preparation, many cardiology trainees complete their education with insufficient knowledge of the ML technologies increasingly present in clinical workflows.^5,6 As these applications become more prevalent, training programmes must integrate relevant ML education to ensure cardiologists can effectively evaluate, implement, and collaborate with artificial intelligence (AI) systems, rather than merely function as passive end-users of increasingly sophisticated technology.

Every week, patients present to emergency departments (EDs) following an episode of transient loss of consciousness (TLoC) due to syncope. It is common, affecting 40% of the population, and it constitutes 1–3% of ED visits and up to 6% of all hospital admissions.^1,2 The US Society for Academic Emergency Medicine – Guidelines for Reasonable and Appropriate Care in the Emergency Department (SAEM GRACE) review found that among ED patients, up to 50% remain undiagnosed after initial evaluation, that hospitalisation rates were highly variable, and approximately one-third of admitted patients are discharged without a definite diagnosis.³ Along with this, patients are subjected to unnecessary investigations, which contribute to escalating healthcare costs.⁴

Syncope is common, disabling, and, if mismanaged, potentially dangerous, both in terms of missed diagnoses or needless and harmful stays in hospital. Yet across health systems, it continues to fall between the cracks. It is time to build bridges: connecting emergency care, cardiology, neurology, geriatrics and acute medicine, through cohesive pathways that are early, equitable, efficient, and delivered by experts.

As Sutton and de Lange remind us, syncope is a symptom, not a diagnosis, and must be taken seriously.⁵ It should no longer be the orphan condition with no home. Despite not belonging in one specialty, a coordinated approach and collaboration should be forged between specialties.

Ischaemic heart disease remains the number one cause of mortality worldwide, with chest pain being one of the most common presentations to both primary care and cardiology services. Suspected angina referral pathways have become well established within NHS practice through rapid access chest pain clinics (RACPC), allowing prompt specialist assessment. While the expansion of access to noninvasive imaging has significantly enhanced risk stratification and management of patients with obstructive coronary artery disease (CAD), questions remain about the suitability of this rule-in/rule-out approach for all individuals referred to RACPC.