Neurovascular Coupling Impairment in Heart Failure with Reduction Ejection Fraction

The hemodynamic consequences of a persistent reduced ejection fraction and unknown cardiac output on the brain have not been thoroughly studied. We sought to explore the status of the mechanisms of cerebrovascular regulation in patients with heart failure with reduced (HFrEF) and recovered (HFrecEF) ejection fraction. We monitored cerebral blood flow velocity (CBFV) with transcranial Doppler and blood pressure. Cerebral autoregulation, assessed by transfer function from the spontaneous oscillations of blood pressure to CBFV and neurovascular coupling (NVC) with visual stimulation were compared between groups of HFrEF, HFrecEF and healthy controls. NVC was significantly impaired in HFrEF patients with reduced augmentation of CBFV during stimulation (overshoot systolic CBFV 19.11 ± 6.92 vs. 22.61 ± 7.78 vs. 27.92 ± 6.84, p = 0.04), slower upright of CBFV (rate time to overshoot: 1.19 ± 3.0 vs. 3.06 (4.30) vs. 2.90 ± 3.84, p = 0.02); p = 0.023) and reduced arterial oscillatory properties (natural frequency 0.17 ± 0.06 vs. 0.20 ± 0.09 vs. 0.24 ± 0.07, p = 0.03; attenuation 0.34 ± 0.24 vs. 0.48 ± 0.35 vs. 0.50 ± 0.23, p = 0.05). Cerebral autoregulation was preserved. The neurovascular unit of subjects with chronically reduced heart pumping capability is severely dysfunctional. Dynamic testing with transcranial Doppler could be useful in these patients, but whether it helps in predicting cognitive impairment must be addressed in future prospective studies.

Role of Vitamin D Supplementation in Heart Failure Patients With Vitamin D Deficiency and Its Effects on Clinical Outcomes: A Literature Review

Vitamin D deficiency has become a global pandemic affecting approximately one billion people worldwide. Much attention has been paid to the association of low serum 25-hydroxyvitamin D (25(OH)D) levels and various chronic diseases, especially heart failure (HF). A clear role of vitamin D deficiency has been established, with increased mortality and morbidity in heart failures. However, previous randomized control trials have failed to show improvement in clinical outcomes with calciferol supplementation in these patients. Therefore, it is still unclear whether calciferol therapy can be added to the standard care in congestive heart failure (CHF) patients with deficiency. Hence, to evaluate the role of vitamin D supplementation in CHF patients with low serum 25(OH)D, we conducted an extensive search in the PubMed and Google Scholar databases using various combinations of keywords. All potentially eligible studies that evaluated the effects of vitamin D supplementation on clinical outcomes in HF patients were retrieved and extensively studied. We also checked the references of all eligible studies to identify additional relevant publications. In this study, we reviewed various mechanisms of vitamin D affecting the cardiovascular system and examined the impact of deficiency on heart failures in terms of mortality and hospitalizations. In conclusion, vitamin D supplementation has failed to improve the clinical outcomes in HF patients. The possible long-term benefits of supplementation cannot be excluded. Therefore, for future clinical trials, we recommend considering large sample sizes, longer follow-up durations, along with optimal dosage and appropriate dosing frequency.

Targeting cardiac fibrosis in heart failure with preserved ejection fraction: mirage or miracle?

Cardiac fibrosis is central to the pathology of heart failure, particularly heart failure with preserved ejection fraction (HFpEF). Irrespective of the underlying profibrotic condition (e.g. ageing, diabetes, hypertension), maladaptive cardiac fibrosis is defined by the transformation of resident fibroblasts to matrix-secreting myofibroblasts. Numerous profibrotic factors have been identified at the molecular level (e.g. TGFβ, IL11, AngII), which activate gene expression programs for myofibroblast activation. A number of existing HF therapies indirectly target fibrotic pathways; however, despite multiple clinical trials in HFpEF, a specific clinically effective antifibrotic therapy remains elusive. Therapeutic inhibition of TGFβ, the master-regulator of fibrosis, has unfortunately proven toxic and ineffective in clinical trials to date, and new approaches are needed. In this review, we discuss the pathophysiology and clinical implications of interstitial fibrosis in HFpEF. We provide an overview of trials targeting fibrosis in HFpEF to date and discuss the promise of potential new therapeutic approaches and targets in the context of underlying molecular mechanisms.

Evaluation of a Heart Failure Telemonitoring Program Through a Microsimulation Model: Cost-Utility Analysis

BACKGROUND

Heart failure (HF) is a major public health issue in Canada that is associated with high prevalence, morbidity, and mortality rates and high financial and social burdens. Telemonitoring (TM) has been shown to improve all-cause mortality and hospitalization rates in patients with HF. The Medly program is a TM intervention integrated as standard of care at a large Canadian academic hospital for ambulatory patients with HF that has been found to improve patient outcomes. However, the cost-effectiveness of the Medly program is yet to be determined.

OBJECTIVE

This study aims to conduct a cost-utility analysis of the Medly program compared with the standard of care for HF in Ontario, Canada, from the perspective of the public health care payer.

METHODS

Using a microsimulation model, individual patient data were simulated over a 25-year time horizon to compare the costs and quality-adjusted life years (QALYs) between the Medly program and standard care for patients with HF treated in the ambulatory care setting. Data were sourced from a Medly Program Evaluation study and literature to inform model parameters, such as Medly's effectiveness in reducing mortality and hospitalizations, health care and intervention costs, and model transition probabilities. Scenario analyses were conducted in relation to HF severity and TM deployment models. One-way deterministic effectiveness analysis and probabilistic sensitivity analysis were performed to explore the impact on the results of uncertainty in model parameters.

RESULTS

The Medly program was associated with an average total cost of Can $102,508 (US $77,626) per patient and total QALYs of 5.51 per patient compared with the average cost of Can $97,497 (US $73,831) and QALYs of 4.95 per patient in the Standard Care Group. This led to an incremental cost of Can $5011 (US $3794) and incremental QALY of 0.566, resulting in an incremental cost-effectiveness ratio of Can $8850 (US $6701)/QALY. Cost-effectiveness improved in relation to patients with advanced HF and with deployment models in which patients used their own equipment. Baseline and alternative scenarios consistently showed probabilities of cost-effectiveness greater than 85% at a willingness-to-pay threshold of Can $50,000 (US $37,718). Although the results showed some sensitivity to assumptions about effectiveness parameters, the intervention was found to remain cost-effective.

CONCLUSIONS

The Medly program for patients with HF is cost-effective compared with standard care using commonly reported willingness-to-pay thresholds. This study provides evidence for decision makers on the use of TM for HF, supports the use of a nurse-led model of TM that embeds clinically validated algorithms, and informs the use of economic modeling for future evaluations of early-stage health informatics technology.

Palliative Care Consultation Affects How and Where Heart Failure Patients Die

OBJECTIVE

Determine the role of palliative care on terminal code status and setting of death for those with heart failure.

BACKGROUND

Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis.

METHODS

Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate.

RESULTS

334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient's chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001).

CONCLUSION

Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.

Non-coding RNAs in Cardiac Intercellular Communication

Intercellular communication allows for molecular information to be transferred from cell to cell, in order to maintain tissue or organ homeostasis. Alteration in the process due to changes, either on the vehicle or the cargo information, may contribute to pathological events, such as cardiac pathological remodeling. Extracellular vesicles (EVs), namely exosomes, are double-layer vesicles secreted by cells to mediate intercellular communication, both locally and systemically. EVs can carry different types of cargo, including non-coding RNAs (ncRNAs), which, are major regulators of physiological and pathological processes. ncRNAs transported in EVs are functionally active and trigger a cascade of processes in the recipient cells. Upon cardiac injury, exosomal ncRNAs can derive from and target different cardiac cell types to initiate cellular and molecular remodeling events such as hypertrophic growth, cardiac fibrosis, endothelial dysfunction, and inflammation, all contributing to cardiac dysfunction and, eventually, heart failure. Exosomal ncRNAs are currently accepted as crucial players in the process of cardiac pathological remodeling and alterations in their presence profile in EVs may attenuate cardiac dysfunction, suggesting that exosomal ncRNAs are potential new therapeutic targets. Here, we review the current research on the role of ncRNAs in intercellular communication, in the context of cardiac pathological remodeling.

Clinical and Genetic Investigations of 109 Index Patients With Dilated Cardiomyopathy and 445 of Their Relatives

BACKGROUND

It was the aim to investigate the frequency and genetic basis of dilated cardiomyopathy (DCM) among relatives of index patients with unexplained heart failure at a tertiary referral center.

METHODS

Clinical investigations were performed in 109 DCM index patients and 445 of their relatives. All index patients underwent genetic investigations of 76 disease-associated DCM genes. A family history of DCM occurred in 11% (n=12) while clinical investigations identified familial DCM in a total of 32% (n=35). One-fifth of all relatives (n=95) had DCM of whom 60% (n=57) had symptoms of heart failure at diagnosis, whereas 40% (n=38) were asymptomatic. Symptomatic relatives had a shorter event-free survival than asymptomatic DCM relatives (P<0.001).

RESULTS

Genetic investigations identified 43 pathogenic (n=27) or likely pathogenic (n=16) variants according to the American College of Medical Genetics and Genomics and the Association for Molecular Pathology criteria. Forty-four percent (n=48/109) of index patients carried a pathogenic/likely pathogenic variant of whom 36% (n=27/74) had sporadic DCM, whereas 60% (21/35) were familial cases. Thirteen of the pathogenic/likely pathogenic variants were also present in ≥7 affected individuals and thereby considered to be of sufficient high confidence for use in predictive genetic testing.

CONCLUSIONS

A family history of DCM identified only 34% (n=12/35) of hereditary DCM, whereas systematic clinical screening identified the remaining 66% (n=23) of DCM families. This emphasized the importance of clinical investigations to identify familial DCM. The high number of pathogenic/likely pathogenic variants identified in familial DCM provides a firm basis for offering genetic investigations in affected families. This should also be considered in sporadic cases since adequate family evaluation may not always be possible and the results of the genetic investigations may carry prognostic information with an impact on individual management.

Relationship between resting heart rate and incident heart failure in patients with hypertension: The Kailuan Cohort Study in China

An elevated heart rate increases the risk of cardiovascular disease, but the relationship between resting heart rate (RHR) and the risk of heart failure (HF) in hypertensive patients is unclear. This study was performed to assess the relationship between elevated RHR and incident HF in hypertensive patients. In total, 16 286 hypertensive patients from the Kailuan cohort were enrolled and underwent three physical examinations. According to mean RHR based on quartile, the hypertensive patients were divided into four groups: Q1 (mean RHR ≤ 69 bpm), Q2 (69 bpm < mean RHR ≤ 74 bpm), Q3 (74 bpm < mean RHR ≤ 79 bpm), and Q4 (mean RHR > 79 bpm). The cumulative mortality rate was analyzed by using the Kaplan-Meier method, with comparisons among RHR quartiles. Cox proportional hazards regression models and restricted cubic spline models were established to evaluate the association between RHR and risk of incident HF. After adjustment for confounders, the hazard ratio (HR) for HF was 1.97(95% CI: 1.28-3.04, P < .001) in the fourth quartile compared to the first quartile. Each 1-standard deviation [10 (beats/min)] increase in RHR was associated with a 40% increase in the risk of incident HF. Restricted cubic spline models presented a linear relationship between RHR and incident HF. Our study suggests that elevated RHR is associated with an enhanced risk of HF in hypertensive patients.

Risk of Acute Myocardial Infarction, Heart Failure, and Death in Migraine Patients Treated with Triptans

OBJECTIVE

The goal of this study is to determine the strength of association between treatment with triptans and acute myocardial infarction, heart failure, and death.

BACKGROUND

Case reports in the literature have raised concerns over an association between treatment of migraine headaches with triptans and cardiovascular events. This study aims to systematically evaluate this association in a contemporary population-based cohort. We hypothesized that triptan exposure is not associated with increased cardiovascular events.

METHODS

A retrospective cohort study was conducted within an integrated healthcare delivery system in Southern California. From January 2009 to December 2018, 189,684 patients age ≥18 years had a diagnosis of migraine. In this group, 130,656 were exposed to triptans. Patients treated with triptans were matched 1:1 to those not exposed to triptans by using a propensity score. The primary outcome was acute myocardial infarction; secondary outcomes were heart failure, all-cause death, and combined acute myocardial infarction, heart failure, and death.

RESULTS

The incidence rate of acute myocardial infarction was 0.67 per 1000 person-year in triptan-exposed vs 1.44 per 1000 person-year in not exposed patients. In propensity-matched analyses, the adjusted hazard ratio for triptan exposure was 0.95 (95% confidence interval [CI] 0.84-1.08) for acute myocardial infarction; 1.00 (95% CI 0.93-1.08) for all-cause death; 0.93 (95% CI 0.81-1.08) for heart failure; and 0.99 (95% CI 0.93-1.06) for a composite of acute myocardial infarction, heart failure, or death. Sensitivity analyses focusing on stratified subgroups based on age, gender, ethnicity, and several cardiac risk factors also revealed no significant association between triptan exposure and cardiovascular events.

CONCLUSIONS

No association was found between exposure to triptans and an increased risk of cardiovascular events. These data provide reassurance regarding the cardiovascular safety of utilizing triptans for the medical management of migraine headaches.

Progress Toward Cardiac Xenotransplantation

Consistent survival of life-supporting pig heart xenograft recipients beyond 90 days was recently reported using genetically modified pigs and a clinically applicable drug treatment regimen. If this remarkable achievement proves reproducible, published benchmarks for clinical translation of cardiac xenografts appear to be within reach. Key mechanistic insights are summarized here that informed recent pig design and therapeutic choices, which together appear likely to enable early clinical translation.

Evaluation of dapagliflozin in the treatment of heart failure

The European Society of Cardiology recently addressed the use of SGLT2 inhibitor use in the treatment of heart failure (HF). Dapagliflozin is a SGLT2 inhibitor recently approved by the US FDA for treatment of patients with HF with a reduced ejection fraction with a New York Heart Association classification of II-IV. Dapagliflozin significantly decreases the risk of worsening HF or death from cardiovascular cause compared with placebo and this risk does not differ based on the presence or absence of Type 2 diabetes. This paper aims to summarize the chemistry, pharmacodynamics and pharmacokinetics of dapagliflozin; and evaluates the clinical efficacy of dapagliflozin in the treatment of HF.

Clinical and echocardiographic outcomes in heart failure associated with methamphetamine use and cessation

OBJECTIVE

Methamphetamine use is associated with systolic dysfunction, pulmonary arterial hypertension and may also be associated with diastolic dysfunction. The impact of methamphetamine cessation on methamphetamine-associated heart failure (MethHF) remains poorly characterised. We aimed to longitudinally characterise methamphetamine-associated heart failure patients with reduced (METHrEF) and preserved (METHpEF) left ventricular ejection fraction (EF), and evaluate the relationship between methamphetamine cessation and clinical outcomes.

METHODS

We performed a retrospective cohort study, and reviewed medical records of patients with METHrEF, METHpEF and heart failure controls without methamphetamine use. Echocardiographic variables were recorded for up to 12 months, with clinical follow-up extending to 24 months.

RESULTS

Among METHrEF patients (n=28, mean age 51±9 years, 82.1% male), cessation was associated with improvement in EF (+10.6±13.1%, p=0.009) and fewer heart failure admissions per year compared with continued use (median 0.0, IQR 0.0-1.0 vs median 2.0, IQR 1.0-3.0, p=0.039). METHpEF patients (n=28, mean age 50±8 years, 60.7% male) had higher baseline right ventricular systolic pressure (median 53.44, IQR 43.70-84.00 vs median 36.64, IQR 29.44-45.95, p=0.011), and lower lateral E/E' ratio (8.1±3.6 vs 11.2±4., p<0.01) compared with controls (n=32). Significant improvements in echocardiographic parameters and clinical outcomes were not observed following cessation in this group.

CONCLUSIONS

METHrEF patients who cease methamphetamine use have significant improvement in left ventricular systolic function and fewer heart failure admissions, suggesting that METHrEF may be reversible. Echocardiographic parameters suggest that some patients with METHpEF may have pulmonary hypertension in the absence of overt signs of left ventricular diastolic dysfunction, but additional study is needed to characterise this patient cohort.

Pronounced haemodynamic changes during and after robotic-assisted laparoscopic prostatectomy: a prospective observational study

OBJECTIVES

Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). This study investigated the influence of permanent 45° STP and capnoperitoneum on haemodynamic parameters during and after RALP.

DESIGN

Prospective observational study.

SETTING

Haemodynamic changes were recorded with transpulmonary thermodilution and pulse contour analysis in men undergoing RALP under standardised anaesthesia.

PARTICIPANTS

Informed consent was obtained from 51 patients scheduled for elective RALP in a University Medical Centre in Germany.

INTERVENTIONS

Heart rate, mean arterial pressure, central venous pressure (CVP), Cardiac Index (CI), systemic vascular resistance (SVR), Global End-Diastolic Volume Index (GEDI), global ejection fraction (GEF), Cardiac Power Index (CPI) and stroke volume variation (SVV) were recorded at six time points: 20 min after induction of anaesthesia (T1), after insufflation of capnoperitoneum in supine position (T2), after 30 min in STP (T3), when controlling Santorini's plexus in STP (T4), before awakening in supine position (T5) and after 45 min in the recovery room (T6). Adverse cardiac events were registered intraoperatively and postoperatively.

RESULTS

All haemodynamic parameters were significantly changed by capnoperitoneum and STP during RALP and partly normalised at T6. CI, GEF and CPI were highest at T6 (CI: 3.9 vs 2.2 L/min/m²; GEF: 26 vs 22%; CPI: 0.80 vs 0.39 W/m²; p<0.001). CVP was highest at T4 (31 vs 7 mm Hg, p<0.001) and GEDI at T6 (819 vs 724 mL/m², p=0.005). Mean SVR initially increased (T2) but had decreased by 24% at T6 (p<0.001). SVV was highest at T5 (12 vs 9%, p<0.001). Two of the patients developed cardiac arrhythmia during RALP and one patient suffered postoperative cardiac ischaemia.

CONCLUSIONS

RALP led to pronounced perioperative haemodynamic changes. The combination of increased cardiac contractility and heart rate reflects a hyperdynamic situation during and after RALP. Anaesthesiologists should be aware of unnoticed pre-existing heart failure to worsen during STP in patients undergoing RALP.

Relation between Hemoconcentration Status and Readmission Plus Mortality Rate Among Iranian Individuals with Decompensated Heart Failure

BACKGROUND

Hemoconcentration (HC) has been suggested to be a useful biomarker for determination of optimum diuretic therapy in acute heart failure (HF), but role of this factor in rehospitalization and death was still controversial. In this study, we aimed to define relation between HC and readmission and mortality rate among Iranian patients with acute HF.

METHODS

This was a prospective cohort study done from March 2017 to March 2018 using data of a HF section of Persian Registry Of cardioVascular diseasE. From a total number of 390 registered HF individuals aged 18 years or older, 69 ones showed alterations in hemoglobin (Hb) levels. Hb levels were measured at admission and discharge time. HC was defined as any increased level in Hb during hospitalization. The relation of HC with readmission and death rate was done using multiple logistic regression and Cox proportional hazard model, respectively.

RESULTS

The mean age of study population was 70.5 ± 11.9 years with the dominant percentage of male participants (66.9%). Patients showing HC during admission did not reveal any significant decreased likelihood of rehospitalization compared to negative ones. In comparison to HC negative patients, those showing increments in Hb levels had a borderline significant lower likelihood of mortality (hazard ratio: 0.82, 95% confidence interval, CI = 0.07-1.18, P = 0.08).

CONCLUSIONS

Our data suggested that HC was associated marginally with reduced mortality rate 6 months post HF attack and could be utilized as a useful biomarker for risk stratification of HF patients. Several prospective longitudinal population-based studies are necessary proving these associations.

Value of combined cardiopulmonary and echocardiography stress test to characterize the haemodynamic and metabolic responses of patients with heart failure and mid-range ejection fraction

AIMS

To characterize heart failure (HF) with mid-range ejection fraction (HFmrEF), combining cardiopulmonary exercise test, and exercise stress echocardiography.

METHODS AND RESULTS

We studied 169 consecutive subjects (age 62.3 ± 11 years; 74% male): 30 healthy controls, 45 patients with HF and preserved EF (HFpEF), 40 HFmrEF, and 54 with HF and reduced EF (HFrEF). Left ventricular (LV) stroke volume (SV), EF, elastance, global longitudinal strain, E/E', oxygen consumption (VO2), and arterial-venous oxygen content difference (AVO2diff) were measured in all exercise stages. HFmrEF revealed baseline features intermediate between HFrEF and HFpEF, except for B-type natriuretic peptide levels, which was similar to HFpEF and significantly lower than HFrEF. Peak VO2 was not significantly different between HF groups. HFrEF exhibited a significantly lower peak SV as compared to either HFpEF or HFmrEF (74.3 ± 21.8 mL vs. 88.0 ± 17.4 mL and 96.5 ± 25.1 mL; P < 0.01), whereas peak heart rate was not significantly different between HF groups. A significantly reduced AVO2diff at peak exercise was apparent in HFpEF and HFmrEF (15.2 ± 3.3 mL/dL and 13.3 ± 4.2 mL/dL) vs. HFrEF (17.±6.6 mL/dL; P < 0.01), whereas no significant difference was reported between HFpEF and HFmrEF. Multivariate analysis in the overall population and all groups revealed peak parameters as independent predictors of peak VO2 (R2 = 0.90, P < 0.0001); AVO2diff showed the largest standardized regression coefficient.

CONCLUSION

In HFpEF and HFmrEF, effort intolerance is predominantly due to peripheral factors (AVO2diff), whereas in HFrEF peak VO2 is restricted by low increases in SV. Individual therapy according to which component of VO2 is more impaired is advisable.

Basal Takotsubo syndrome induced by pheochromocytoma rupture

Takotsubo syndrome (TTS), characterised by transient left ventricular systolic dysfunction, is divided into five types: (1) apical ballooning, (2) mid-ventricular, (3) basal or inverted, (4) and focal wall-motion patterns, and (5) other types, including biventricular type, isolated right ventricular and global type. The common clinical features of TTS are similar to acute coronary syndrome, which makes them indistinguishable in the early stages. TTS has a wide spectrum of emotional or physical triggers. Pheochromocytoma has been widely recognised as a distinct physical trigger of TTS. Although reports of pheochromocytoma causing TTS are not uncommon, spontaneous rupture of pheochromocytoma causing TTS is extremely rare because of the low incidence of tumour rupture. Here we report on a case of a 31-year-old man with adrenal pheochromocytoma rupture developing basal TTS.

microRNA-221 Inhibits Latent TGF-β1 Activation through Targeting Thrombospondin-1 to Attenuate Kidney Failure-Induced Cardiac Fibrosis

Kidney failure (KF) is associated with cardiac fibrosis and significantly increased mortality in heart failure. Thrombospondin-1 (TSP1), a key regulator of latent transforming growth factor-β1 (L-TGF-β1) activation, is a predicted target of miR-221. We hypothesized miR-221 attenuates severe KF-associated cardiac fibrosis via targeting of Thbs1 with subsequent inhibition of L-TGF-β1 activation. Rat cardiac fibroblasts (cFB) were isolated and transfected with microRNA-221 (miR-221) mimics or mimic control (miR-221 and MC) with or without exposure to L-TGF-β1. We demonstrate miR-221 downregulates Thbs1 via direct 3′ untranslated region (3′ UTR) targeting with consequent inhibition of L-TGF-β1 activation in cFB as proven by the significant reduction of myofibroblast activation, collagen secretion, TGF-β1 signaling, TSP1 secretion, and TGF-β1 bioactivity measured by Pai1 promoter reporter. The 5/6 nephrectomy (Nx) model of cardiac fibrosis was used to test the in vivo therapeutic efficacy of miR-221 (i.v. 1 mg/kg ×3). miR-221 significantly inhibited Nx-induced upregulation of TSP1 and p-SMAD3 in the heart at day-7 and reduced cardiac fibrosis (picro-sirius), improved cardiac function (±dP/dt), and improved 8-week survival rate (60% versus 36%; p = 0.038). miR-221 mimic treatment improved survival and reduced cardiac fibrosis in a model of severe KF. miR-221 is a therapeutic target to address cardiac fibrosis originating from renal disease and other causes.

Racial and Ethnic Differences in Biomarkers, Health Status, and Cardiac Remodeling in Patients With Heart Failure With Reduced Ejection Fraction Treated With Sacubitril/Valsartan

Supplemental Digital Content is available in the text.

Among patients with heart failure and reduced ejection fraction (left ventricular (LV) ejection fraction ≤40%), sacubitril/valsartan (S/V) treatment is associated with improved health status and reverse cardiac remodeling. Data regarding racial and ethnic differences in response to S/V are lacking.

Mechanical Considerations of Electrospun Scaffolds for Myocardial Tissue and Regenerative Engineering

Biomaterials to facilitate the restoration of cardiac tissue is of emerging importance. While there are many aspects to consider in the design of biomaterials, mechanical properties can be of particular importance in this dynamically remodeling tissue. This review focuses on one specific processing method, electrospinning, that is employed to generate materials with a fibrous microstructure that can be combined with material properties to achieve the desired mechanical behavior. Current methods used to fabricate mechanically relevant micro-/nanofibrous scaffolds, in vivo studies using these scaffolds as therapeutics, and common techniques to characterize the mechanical properties of the scaffolds are covered. We also discuss the discrepancies in the reported elastic modulus for physiological and pathological myocardium in the literature, as well as the emerging area of in vitro mechanobiology studies to investigate the mechanical regulation in cardiac tissue engineering. Lastly, future perspectives and recommendations are offered in order to enhance the understanding of cardiac mechanobiology and foster therapeutic development in myocardial regenerative medicine.

Dynamic right ventricular function response to incremental exercise in pulmonary hypertension

Pulmonary hypertension is a progressive disease whose survival is linked to adequate right ventricle adaptation to its afterload. In the current study, we performed an in-depth characterization of right ventricle function during maximum incremental exercise in patients with pulmonary hypertension and how it relates to exercise capacity. A total of 377 pulmonary hypertension patients who completed a maximum symptom-limited invasive cardiopulmonary exercise testing were evaluated to identify 45 patients with heart failure with preserved ejection fraction, 48 with exercise pulmonary hypertension, and 47 with established pulmonary arterial hypertension. These patients were compared to 17 age- and gender-matched normal controls. Load-adjusted right ventricle function was quantified as the ratio of right ventricle stroke work index to pulmonary arterial elastance. All patients with pulmonary hypertension had reduced peak VO₂ %predicted compared to controls. Right ventricle function deteriorated for all pulmonary hypertension groups by 50% of peak VO₂. Worsening of right ventricle function during freewheeling exercise was associated with greater reduction in peak VO₂ compared to those whose right ventricle function deteriorated at later exercise stages (i.e. min 1, 2, and 3). On multivariate analysis, reduced ratio of right ventricle stroke work index to arterial elastance was an independent predictor of peak VO₂ %predicted (β-Coefficient –5.46, 95% CI: –9.47 to –1.47, p = 0.01). Right ventricle function deteriorates early during incremental exercise in pulmonary hypertension, occurring by 50% of peak oxygen uptake. The current study demonstrates that right ventricle dysfunction is an early phenomenon during incremental exercise in pulmonary hypertension, occurring by 50% of peak oxygen uptake. The threshold at which right ventricle function is compromised during incremental exercise in pulmonary hypertension influences aerobic capacity and may help guide exercise strategies to mitigate dynamic worsening of right ventricle function during exercise training.

The association of non-alcoholic fatty liver disease and cardiac structure and function-Framingham Heart Study

BACKGROUND & AIMS

Non-alcoholic fatty liver disease confers increased risk for cardiovascular disease, including heart failure (HF), for reasons that remain unclear. Possible pathways could involve an association of liver fat with cardiac structural or functional abnormalities even after accounting for body size.

METHODS

We analysed N = 2356 Framingham Heart Study participants (age 52 ± 12 years, 52% women) who underwent echocardiography and standardized computed tomography measures of liver fat.

RESULTS

In cross-sectional multivariable regression models adjusted for age, gender, cohort and cardiovascular risk factors, liver fat was positively associated with left ventricular (LV) mass (β = 1.45; 95% confidence interval (CI): 0.01, 2.88), LV wall thickness (β = 0.01; 95% CI: 0.00, 0.02), mass volume ratio (β = 0.02; 95% CI 0.01, 0.03), mitral peak velocity (E) (β = 0.83; 95% CI 0.31, 1.36) and LV filling pressure (E/e' ratio) (β = 0.16; 95% CI 0.09, 0.23); and inversely associated with global systolic longitudinal strain (β = 0.20, 95% CI 0.07, 0.33), diastolic annular velocity (e') (β = -0.12; 95% CI - 0.22, -0.03), and E/A ratio (β = -0.01; 95% CI - 0.02, -0.00). After additional adjustment for body mass index (BMI), statistical significance was attenuated for all associations except for that of greater liver fat with increased LV filling pressure, a possible precursor to HF (β = 0.11; 95% CI 0.03, 0.18).

CONCLUSION

Increased liver fat was associated with multiple subclinical cardiac dysfunction measures, with most of associations mediated by obesity. Interestingly, the association of liver fat and LV filling pressure was only partially mediated by BMI, suggesting a possible direct effect of liver fat on LV filling pressure. Further confirmatory studies are needed.

Birthweight predicts adult cardiovascular disorders: Population based cross sectional survey

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of death in the developed-countries and mostly in the poorer areas of the country, and in lower income-groups.

HYPOTHESIS

Birthweight predicts adult development of angina, coronary heart disease, stroke, and combination of all CVD.

METHODS

The AusDiab is a cross-sectional study of Australians aged 25 years or over. Data on age, sex, previous-CVD, smoking-status, alcohol-intake, time-spent on watching television and physical-activity, total house-income, dwelling-type and education-level were collected by interviewer- administered-questionnaires.

RESULTS

Four thousand five hundred and two had birthweights (mean (SD) of 3.4(0.7) kg). Females in the lowest birthweight-quintile were at least 1.23, 1.48, 1.65, and 1.23 times more likely to have angina, CAD, stroke, and CVS compared to the referent group ≥3.72 kg with P = .123, .09, .099, and 0.176, respectively. Similarly, males in the lowest-birthweight-quintile were 1.23, 1.30, 1.39, and 1.26 times more likely to have angina, CAD, stroke, and CVS compared to the referent-group ≥4.05 kg with P = .231, .087, .102, and .123, respectively. Females with low birth weight (LBW) were at least 1.39, 1.40, 2.30, and 1.47 times more likely to have angina, CAD, stroke and CVS compared to those ≥2.5 kg with P = .06, .19, .03, and .13, respectively. Similarly, males with LBW were 1.76, 1.48, 3.34, and 1.70 times more likely to have angina, CAD, stroke, and CVS compared to those ≥2.5 kg with P = .14, .13, .03, and .08, respectively.

CONCLUSION

there was a negative relationship between birth weight and angina, CAD, stroke, and the overall CVS. It would be prudent, to adopt policies of intensified whole of life surveillance of lower-birthweight people, anticipating this risk.