Bidirectional impact between cardiovascular comorbidities and heart failure: an updated position paper from the Italian society of cardiology (SIC) working group on heart failure.

Heart failure (HF) and cardiovascular (CV) diseases (CVD) are closely interconnected through a complex and bidirectional relationship. HF frequently represents the final common pathway of several CV conditions; in contrast, CV comorbidities often act as key drivers of disease progression along the HF continuum, from stage A (individuals at risk) to overt symptomatic HF (stages C-D). The coexistence of multiple CV comorbidities-including arterial hypertension, atrial fibrillation, coronary artery disease, peripheral artery disease, and valvular heart disease-is associated with a more severe clinical profile, reduced functional capacity, impaired quality of life, and increased risk of hospitalization and mortality. Importantly, CV comorbidities may significantly influence the implementation and optimization of guideline-directed medical therapy (GDMT), frequently limiting appropriate up-titration due to haemodynamic instability, drug intolerance, or increased susceptibility to adverse events. The prevalence, pathophysiological interactions, and prognostic impact of CV comorbidities vary across HF phenotypes, contributing to the heterogeneity of disease presentation and clinical outcomes. An integrated and phenotype-oriented approach is therefore essential to optimize risk stratification and personalize therapeutic strategies. Since the publication of the 2019 manifesto on HF comorbidities from the Working Group on Heart Failure of the Italian Society of Cardiology (SIC), substantial new evidence has emerged regarding the epidemiology, pathophysiology, and management of CV comorbidities in HF. In this updated position paper, the SIC Working Group on Heart Failure provides a comprehensive and clinically oriented overview of the current evidence on major CV comorbidities in HF, with the aim of supporting clinicians in improving diagnostic pathways, optimizing therapeutic strategies, and ultimately enhancing clinical outcomes.