Hormonal changes and catabolic/anabolic imbalance in chronic heart failure and their importance for cardiac cachexia

Skeletal muscle alterations in HFrEF vs. HFpEF

PURPOSE OF REVIEW

Severe exercise intolerance and early fatigue are hallmarks of heart failure patients either with a reduced (HFrEF) or a still preserved (HFpEF) ejection fraction. This review, therefore, will provide a contemporary summary of the alterations currently known to occur in the skeletal muscles of both HFrEF and HFpEF, and provide some further directions that will be required if we want to improve our current understanding of this area.

RECENT FINDINGS

Skeletal muscle alterations are well documented for over 20 years in HFrEF, and during the recent years also data are presented that in HFpEF muscular alterations are present. Alterations are ranging from a shift in fiber type and capillarization to an induction of atrophy and modulation of mitochondrial energy supply. In general, the molecular alterations are more severe in the skeletal muscle of HFrEF when compared to HFpEF. The alterations occurring in the skeletal muscle at the molecular level may contribute to exercise intolerance in HFrEF and HFpEF. Nevertheless, the knowledge of changes in the skeletal muscle of HFpEF is still sparsely available and more studies in this HF cohort are clearly warranted.

Androgen status in non-diabetic elderly men with heart failure

PURPOSE

We aimed at evaluating androgen status (serum testosterone [TT] and estimated free testosterone [eFT]) and its determinants in non-diabetic elderly men with heart failure (HF). Additionally, we investigated its associations with body composition and long-term survival.

METHODS

Seventy three non-diabetic men with HF and 20 healthy men aged over 55 years were studied. Echocardiography, 6-min walk test, grip strength, body composition measurement by DEXA method were performed. TT, sex hormone binding globulin, NT-proBNP, and adipokines (adiponectin and leptin) were measured. All-cause mortality was evaluated at six years of follow-up.

RESULTS

Androgen status (TT, eFT) was similar in elderly men with HF compared to healthy controls (4.79 ± 1.65 vs. 4.45 ± 1.68 ng/ml and 0.409 ± 0.277 vs. 0.350 ± 0.204 nmol/l, respectively). In HF patients, TT was positively associated with NT-proBNP (r= 0.371, p = 0.001) and adiponectin levels (r = 0.349, p = 0.002), while inverse association was noted with fat mass (r = -0.413, p < 0.001). TT and eFT were independently determined by age, total fat mass and adiponectin levels in elderly men with HF (p < 0.05 for all). Androgen status was not predictor for all-cause mortality at six years of follow-up.

CONCLUSIONS

In non-diabetic men with HF, androgen status is not altered and is not predictive of long-term outcome.

Comparison of In-Hospital Outcomes After Percutaneous Revascularization for Peripheral Arterial Disease in Patients With a Body Mass Index of >30 kg/m2 Versus ≤30 kg/m2 (from the National Inpatient Sample)

Obesity is an independent risk factor for cardiovascular disease and mortality which may affect the outcomes of patients with peripheral arterial disease (PAD). However, the exact role of obesity in patients with PAD who underwent percutaneous revascularization is not well defined. We sought to analyze in-hospital outcomes and characteristics in obese patients who underwent percutaneous treatment for PAD. We identified study cohorts who underwent percutaneous treatment for PAD from 2012 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedures codes specific for PAD and endovascular treatment. Endovascular treatment included a drug-eluting stent, a bare metal stent, and an atherectomy or angioplasty in the lower extremities. Obesity was defined as a body mass index of >30 kg/m². Patients below 18 years of age were excluded. A total of 62,445 (weighted 312,225) patients were identified. The mean age was higher in the nonobese group (64.2 vs 69.0 years, p ≤0.001). No difference existed in the primary outcome, in-hospital mortality, with the propensity score matched (1:10) analysis. Renal failure and the composite of complications were increased in obese patients. Percutaneous treatment of PAD was associated with increased length of stay (7.7 vs 7.0 days, p ≤0.001) and median cost of hospitalization ($30,602 vs $28,692, p ≤0.001) in obese patients. In conclusion, obesity did not impact in-hospital mortality in patients who underwent peripheral percutaneous revascularization. Increased adverse events, however, were seen in the obese population. The increased cost associated with the hospitalization of obese patients may be attributed to longer length of stay and greater complication.

Left atrial volume index in patients with heart failure and severely impaired left ventricular systolic function: the role of established echocardiographic parameters, circulating cystatin C and galectin-3

Backround: Left atrial (LA) enlargement plays an important role in the development of heart failure (HF) and is a robust prognostic factor. Fibrotic processes have also been advocated to evoke HF through finite signalling proteins.

METHODS

We examined the association of two such proteins, cystatin C (CysC) and galectin-3 (Gal-3), and other clinical, echocardiographic and biochemical parameters with LA volume index (LAVi) in patients with HF with severely impaired left ventricular ejection fraction (LVEF). Severe renal, liver, autoimmune disease and cancer were exclusion criteria.

RESULTS

A total of 40 patients with HF (31 men, age 66.6 ± 1.7) with LVEF = 25.4 ± 0.9% were divided into two groups according to the mean LAVi (51.03 ± 2.9 ml/m2) calculated by two-dimensional transthoracic echocardiography. Greater LAVi was positively associated with LV end-diastolic volume ( p = 0.017), LV end-systolic volume ( p = 0.025), mitral regurgitant volume (MRV) ( p = 0.001), right ventricular systolic pressure (RVSP) ( p < 0.001), restrictive diastolic filling pattern ( p = 0.003) and atrial fibrillation ( p = 0.005). Plasma CysC was positively correlated with LAVi ( R2 = 0.135, p = 0.019) and log-transformed plasma Gal-3 ( R2 = 0.109, p = 0.042) by simple linear regression analysis. Stepwise multiple linear regression analysis showed that only MRV ( t = 2.236, p = 0.032), CysC ( t = 2.467, p = 0.019) and RVSP ( t = 2.155, p = 0.038) were significant predictors of LAVi.

CONCLUSIONS

Apart from known determinants of LAVi, circulating CysC and Gal-3 were associated with greater LA dilatation in patients with HF with reduced LVEF. Interestingly, the correlation between these two fibrotic proteins was positive.

Glucose Homeostasis, Pancreatic Endocrine Function, and Outcomes in Advanced Heart Failure

Background

The mechanisms and relevance of impaired glucose homeostasis in advanced heart failure (HF) are poorly understood. The study goals were to examine glucose regulation, pancreatic endocrine function, and metabolic factors related to prognosis in patients with nondiabetic advanced HF.

Methods and Results

In total, 140 advanced HF patients without known diabetes mellitus and 21 sex‐, age‐, and body mass index–matched controls underwent body composition assessment, oral glucose tolerance testing, and measurement of glucose‐regulating hormones to model pancreatic β‐cell secretory response. Compared with controls, HF patients had similar fasting glucose and insulin levels but higher levels after oral glucose tolerance testing. Insulin secretion was not impaired, but with increasing HF severity, there was a reduction in glucose, insulin, and insulin/glucagon ratio—a signature of starvation. The insulin/C‐peptide ratio was decreased in HF, indicating enhanced insulin clearance, and this was correlated with lower cardiac output, hepatic insufficiency, right ventricular dysfunction, and body wasting. After a median of 449 days, 41% of patients experienced an adverse event (death, urgent transplant, or assist device). Increased glucagon and, paradoxically, low fasting plasma glucose displayed the strongest relations to outcome (P=0.01). Patients in the lowest quartile of fasting plasma glucose (3.8–5.1 mmol·L⁻¹, 68–101 mg·dL⁻¹) had 3‐times higher event risk than in the top quartile (6.0–7.9 mmol·L⁻¹, 108–142 mg·dL⁻¹; relative risk: 3.05 [95% confidence interval, 1.46–6.77]; P=0.002).

Conclusions

Low fasting plasma glucose and increased glucagon are robust metabolic predictors of adverse events in advanced HF. Pancreatic insulin secretion is preserved in advanced HF, but levels decrease with increasing HF severity due to enhanced insulin clearance that is coupled with right heart failure and cardiac cachexia.

Centella asiatica modulates cancer cachexia associated inflammatory cytokines and cell death in leukaemic THP-1 cells and peripheral blood mononuclear cells (PBMC's)

Background

Cancer cachexia is associated with increased pro-inflammatory cytokine levels. Centella asiatica (C. asiatica) possesses antioxidant, anti-inflammatory and anti-tumour potential. We investigated the modulation of antioxidants, cytokines and cell death by C. asiatica ethanolic leaf extract (C_LE) in leukaemic THP-1 cells and normal peripheral blood mononuclear cells (PBMC’s).

Methods

Cytotoxcity of C_LE was determined at 24 and 72 h (h). Oxidant scavenging activity of C_LE was evaluated using the 2, 2-diphenyl-1 picrylhydrazyl (DPPH) assay. Glutathione (GSH) levels, caspase (−8, −9, −3/7) activities and adenosine triphosphate (ATP) levels (Luminometry) were then assayed. The levels of tumour necrosis factor-α (TNF-α), interleukin (IL)-6, IL-1β and IL-10 were also assessed using enzyme-linked immunosorbant assay.

Results

C_LE decreased PBMC viability between 33.25–74.55% (24 h: 0.2–0.8 mg/ml C_LE and 72 h: 0.4–0.8 mg/ml C_LE) and THP-1 viability by 28.404% (72 h: 0.8 mg/ml C_LE) (p < 0.0001). Oxidant scavenging activity was increased by C_LE (0.05–0.8 mg/ml) (p < 0.0001). PBMC TNF-α and IL-10 levels were decreased by C_LE (0.05–0.8 mg/ml) (p < 0.0001). However, PBMC IL-6 and IL-1β concentrations were increased at 0.05–0.2 mg/ml C_LE but decreased at 0.4 mg/ml C_LE (p < 0.0001). In THP-1 cells, C_LE (0.2–0.8 mg/ml) decreased IL-1β and IL-6 whereas increased IL-10 levels (p < 0.0001). In both cell lines, C_LE (0.05–0.2 mg/ml, 24 and 72 h) increased GSH concentrations (p < 0.0001). At 24 h, caspase (−9, −3/7) activities was increased by C_LE (0.05–0.8 mg/ml) in PBMC’s whereas decreased by C_LE (0.2–0.4 mg/ml) in THP-1 cells (p < 0.0001). At 72 h, C_LE (0.05–0.8 mg/ml) decreased caspase (−9, −3/7) activities and ATP levels in both cell lines (p < 0.0001).

Conclusion

In PBMC’s and THP-1 cells, C_LE proved to effectively modulate antioxidant activity, inflammatory cytokines and cell death. In THP-1 cells, C_LE decreased pro-inflammatory cytokine levels whereas it increased anti-inflammatory cytokine levels which may alleviate cancer cachexia.

Aldosterone breakthrough in dogs with naturally occurring myxomatous mitral valve disease

INTRODUCTION

Aldosterone breakthrough (ABT) is the condition in which angiotensin converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers fail to effectively suppress the activity of the renin angiotensin aldosterone system. The objective of this study was to determine if ABT occurs in dogs with naturally occurring myxomatous mitral valve disease receiving an ACEI, using the urine aldosterone to creatinine ratio (UAldo:C) as a measure of renin angiotensin aldosterone system activation.

ANIMALS, MATERIALS AND METHODS

This study includes 39 dogs with myxomatous mitral valve disease. A UAldo:C cut-off definition (derived from a normal population of healthy, adult, and client-owned dogs) was used to determine the prevalence of ABT in this population. Spearman analysis and univariate logistic regression were used to evaluate the relationship between UAldo:C and ABT (yes/no) and eight variables (age, serum K⁺ concentration, serum creatinine concentration, ACEI therapy duration and ACEI dosage, furosemide therapy duration and furosemide dosage, and urine sample storage time). Finally, the UAldo:C in dogs receiving spironolactone, as part congestive heart failure (CHF) therapy, was compared to dogs with CHF that were not receiving spironolactone.

RESULTS

The prevalence of ABT was 32% in dogs with CHF and 30% in dogs without CHF. There was no relationship between either the UAldo:C or the likelihood of ABT and the eight variables. Therapy with spironolactone lead to a significant elevation of the UAldo:C.

DISCUSSION

Using the UAldo:C and a relatively stringent definition of ABT, it appears that incomplete RAAS blockade is common in dogs with MMVD receiving an ACEI. The prevalence of ABT in this canine population mirrors that reported in humans. While the mechanism of ABT is likely multifactorial and still poorly understood, the proven existence of ABT in dogs offers the potential to improve the prognosis for MMVD with the addition of a mineralocorticoid receptor blocker to current therapeutic regimens.

CONCLUSIONS

Approximately 30% of dogs being treated for heart disease and CHF satisfied the definition of ABT. Identifying patient subpopulations experiencing ABT may help guide future study design and clinical decision-making.

In vivo ameliorative effect of cerium oxide nanoparticles in isoproterenol-induced cardiac toxicity

BACKGROUND

Cerium oxide nanoparticles have gained much more attention especially in the field of nanomedicine. This work represents cerium oxide nanoparticles as a new prophylactic model for heart failure progression.

OBJECTIVE

To investigate the potential protective effect of cerium oxide nanoparticles on Isoproterenol (ISO)-induced cardiac toxicity in rats.

METHODS

Cerium oxide nanoparticles (5±1nm) were synthesized by reverse micelle method and characterized using High Resolution Transmission Electron Microscopy, X-Ray Diffraction and particle size analyzer. The experiments were performed on 96 male Wistar rats. The rats were randomly allocated into eight groups. Namely; two Negative and positive control groups, captopril administered group, Nano-ceria (low dose) group, Nano-ceria (high dose) group, Captopril- Isoproterenol group, Nano-ceria (low dose)-Isoproterenol group and Nano-ceria (high dose)-Isoproterenol group. Cardio toxic rat model was induced by subcutaneous administration of Isoproterenol (ISO) (30mg/kg) for two consecutive days in adult male rats. Two doses (0.5 and 5μg/kg/week) of cerium oxide nanoparticles were applied for five weeks and 50mg/kg/day of Captopril was used as a reference drug. Cardiac marker enzymes, Cortisol and Aldosterone hormones were assessed in serum. Oxidant-antioxidant parameters and histopathological examination in heart tissues were also determined.

RESULTS

These dose of nano-ceria, showed a promising ameliorative and prophylactic effect against cardiac toxicity compared to Captopril reference drug. Serum cardiac markers were decreased by noticeable percentage, CK-MB (50% and 57%), LDH (47% and 57.7%), AST (38% and 36.5%) and ALT (33.5% and 30.6%) for both doses respectively, while increased tissues level of the antioxidant enzymes, catalase (48% - 26%) and superoxide dismutase (64%, 143%).

CONCLUSION

These consistent biochemical and histopathological results suggest that, nano-ceria could be used as effective antioxidant in prophylactic protocols for management of cardiac disorders associated with oxidative stress.

Exercise training decreases NADPH oxidase activity and restores skeletal muscle mass in heart failure rats

We have recently demonstrated that NADPH oxidase hyperactivity, NF-κB activation, and increased p38 phosphorylation lead to atrophy of glycolytic muscle in heart failure (HF). Aerobic exercise training (AET) is an efficient strategy to counteract skeletal muscle atrophy in this syndrome. Therefore, we tested whether AET would regulate muscle redox balance and protein degradation by decreasing NADPH oxidase hyperactivity and reestablishing NF-κB signaling, p38 phosphorylation, and proteasome activity in plantaris muscle of myocardial infarcted-induced HF (MI) rats. Thirty-two male Wistar rats underwent MI or fictitious surgery (SHAM) and were randomly assigned into untrained (UNT) and trained (T; 8 wk of AET on treadmill) groups. AET prevented HF signals and skeletal muscle atrophy in MI-T, which showed an improved exercise tolerance, attenuated cardiac dysfunction and increased plantaris fiber cross-sectional area. To verify the role of inflammation and redox imbalance in triggering protein degradation, circulating TNF-α levels, NADPH oxidase profile, NF-κB signaling, p38 protein levels, and proteasome activity were assessed. MI-T showed a reduced TNF-α levels, NADPH oxidase activity, and Nox2 mRNA expression toward SHAM-UNT levels. The rescue of NADPH oxidase activity induced by AET in MI rats was paralleled by reducing nuclear binding activity of the NF-κB, p38 phosphorylation, atrogin-1, mRNA levels, and 26S chymotrypsin-like proteasome activity. Taken together our data provide evidence for AET improving plantaris redox homeostasis in HF associated with a decreased NADPH oxidase, redox-sensitive proteins activation, and proteasome hyperactivity further preventing atrophy. These data reinforce the role of AET as an efficient therapy for muscle wasting in HF.

NEW & NOTEWORTHY This study demonstrates, for the first time, the contribution of aerobic exercise training (AET) in decreasing muscle NADPH oxidase activity associated with reduced reactive oxygen species production and systemic inflammation, which diminish NF-κB overactivation, p38 phosphorylation, and ubiquitin proteasome system hyperactivity. These molecular changes counteract plantaris atrophy in trained myocardial infarction-induced heart failure rats. Our data provide new evidence into how AET may regulate protein degradation and thus prevent skeletal muscle atrophy.

Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction

BACKGROUND

Frailty and malnutrition are common in patients with heart failure (HF), and are associated with adverse outcomes. We studied the prognostic value of three malnutrition and three frailty indices in patients admitted acutely to hospital with HF.

METHODS

265 consecutive patients [62% males, median age 80 (interquartile range (IQR): 72-86) years, median NTproBNP 3633 (IQR: 2025-6407) ng/l] admitted with HF between 2013 and 2014 were enrolled. Patients were screened for frailty using the Derby frailty index (DFI), acute frailty network (AFN) frailty criteria, and clinical frailty scale (CFS) and for malnutrition using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score and prognostic nutritional index (PNI).

RESULTS

According to the CFS (> 4), DFI, and AFN, 53, 50, and 53% were frail, respectively. According to the GNRI (≤ 98), CONUT score (> 4), and PNI (≤ 38), 46, 46, and 42% patients were malnourished, respectively. During a median follow-up of 598 days (IQR 319-807 days), 113 patients died. One year mortality was 1% for those who were neither frail nor malnourished; 15% for those who were either malnourished or frail; and 65% for those who were both malnourished and frail. Amongst the malnutrition scores, PNI, and amongst the frailty scores, CFS increased model performance most compared with base model. A final model, including CFS and PNI, increased c-statistic for mortality prediction from 0.68 to 0.84.

CONCLUSION

Worsening frailty and malnutrition indices are strongly related to worse outcome in patients hospitalised with HF.

Whole-Body Protein Metabolism in Chronic Heart Failure: Relationship to Anabolic and Catabolic Hormones

BACKGROUND

Patients with chronic heart failure frequently experience profound wasting during the course of the disease, a condition termed cardiac cachexia. Although protein is the primary structural and functional component of most tissues, few studies have examined the effect of heart failure on protein metabolism. Moreover, no study has assessed the relationship of protein turnover to hormonal alterations thought to promote cachexia. Thus, our goal was to determine if whole-body protein metabolism is altered in heart failure patients and to assess the relationship of protein kinetics to circulating levels of anabolic and catabolic hormones.

METHODS

We measured whole-body protein metabolism using 13C-leucine, body composition, and circulating anabolic and catabolic hormone levels in 10 patients with chronic heart failure and 11 elderly controls.

RESULTS

No differences in leucine rate of appearance, oxidation, or nonoxidative disposal were noted between heart failure patients and controls. However, in a subgroup of patients characterized by increased resting energy expenditure for their metabolic body size (n = 4; > or = 20% above that predicted from fat-free mass), leucine rate of appearance (mean +/- SE; 146 +/- 6 micromol/min), an index of protein breakdown, tended to be higher compared with patients with normal resting energy expenditure (n = 5; 120 +/- 8 micromol/min) and controls (127 +/- 4 micromol/min; p = .06). Alterations in anabolic/catabolic hormone balance did not explain increased protein breakdown in this subgroup, and no correlations were found between hormone levels and protein breakdown in the heart failure group as a whole. In contrast, increased circulating interleukin-6 soluble receptor (r = 0.829; p < .01) and reduced insulin-like growth factor-I (r =-.751; p < .05) levels were related to greater rates of leucine oxidation in heart failure patients.

CONCLUSION

Our results demonstrate that, although increased protein turnover is not a generalized feature of heart failure, there is a subgroup of patients characterized by resting hypermetabolism and increased protein breakdown. Moreover, hormonal alterations related to the heart failure syndrome were related to increased protein oxidation.

Role of Testosterone in the Treatment of Cardiovascular Disease

Cardiovascular disease (CVD) is the most prevalent non-communicable cause of death worldwide. Testosterone is a sex hormone that is predominant in males but also occurs in lower concentrations in females. It has effects directly on the blood vessels of the cardiovascular system and on the heart, as well as effects on risk factors for CVD. Serum testosterone concentrations are known to decrease with age and reduced testosterone levels are linked to premature coronary artery disease, unfavourable effects on CVD risk factors and increased risk of cardiovascular mortality independent of age. A significant number of men with heart failure demonstrate reduced serum testosterone concentrations and there is early evidence suggesting that low testosterone levels affect cardiac repolarisation. Any association between endogenous testosterone concentrations and CVD in women has yet to be established. Testosterone replacement is used to treat men with hypogonadism but also has cardiovascular effects. This review will present the current evidence, expert opinion and controversies around the role of testosterone in the pathophysiology of CVD and surrounding the use of testosterone treatment and its effects on the cardiovascular system and CVD.

Association of body mass index and visceral fat with aortic valve calcification and mortality after transcatheter aortic valve replacement: the obesity paradox in severe aortic stenosis

BACKGROUND

Previous studies showed that metabolic syndrome is associated with aortic valve calcification (AVC) and poor outcomes in aortic stenosis (AS). However, if these associations change and how body fat impacts the prognosis of patients in late stage of the disease have been not yet explored.

AIMS

To determine the association of body mass index (BMI) and visceral fat with AVC and mortality after transcatheter aortic valve replacement (TAVR).

METHODS

This was a prospective cohort of 170 severe AS patients referred to TAVR. We quantified AVC mass score and fat depots including epicardial adipose tissue, intrathoracic fat, and abdominal visceral (VAF) and subcutaneous fats by computed tomography. Fat depots were indexed to body surface area. All-cause and cardiovascular-related deaths after TAVR were recorded over a median follow-up of 1.2 years.

RESULTS

Higher AVC mass was independently associated with low BMI and low VAF. All-cause mortality risk increased with the decrease of BMI and increment of VAF. A stratified analysis by obesity showed that in non-obese, VAF was inversely associated with mortality, whereas in obese, high VAF was associated with higher mortality (p value for interaction < 0.05). At long-term, hazard ratio [HR] with non-obese/low VAF was 2.3 (95% confidence interval [CI] 1.1-4.9; p = 0.021) and HR with obese/high VAF was 2.5 (95% CI 1.1-5.8; p = 0.031) compared with obese/low VAF patients.

CONCLUSIONS

In AS patients submitted to TAVR, BMI and VAF were inversely associated with AVC. Pre-intervention assessment of VAF by computed tomography may provide a better discrimination of mortality than BMI alone.

Prognostic value of malnutrition assessed by Controlling Nutritional Status score for long-term mortality in patients with acute heart failure

BACKGROUND

The prognostic value of nutritional status is poorly understood and evidence-based nutritional assessment indices are required in acute heart failure (AHF). We investigated the prognostic value of malnutrition assessed by the Controlling Nutritional Status (CONUT) score (range 0-12, higher=worse, consisting of serum albumin, cholesterol and lymphocytes) in AHF patients.

METHODS

The CONUT score was measured on admission in 635 consecutive AHF patients. The primary outcome was all-cause death.

RESULTS

Median CONUT score was 3 (interquartile range 2 to 5). During the median follow-up of 324days, CONUT score was independently associated with death (HR 1.26, 95% CI 1.11-1.42, P<0.001) after adjustment for confounders in a multivariate Cox model. The CONUT score demonstrated the best C-statistic for predicting death (0.71) among other common nutritional markers in HF. Furthermore, addition of the CONUT score to an established risk prediction model from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure study significantly increased the C-statistic from 0.75 to 0.77 (P=0.02). The net reclassification improvement afforded by CONUT score was 21% for all-cause death, 27% for survival and 49% overall (P<0.001).

CONCLUSION

Malnutrition assessed by the CONUT score on admission was an independent determinant of long-term death in AHF, and its prognostic value outweighed that of other nutritional indices. Moreover, addition of the score to the existing risk prediction model significantly increased the predictive ability for death, indicating beneficial clinical application of the CONUT score in AHF patients.

Could gonadal and adrenal androgen deficiencies contribute to the depressive symptoms in men with systolic heart failure?

BACKGROUND

Testosterone (TT) and dehydroepiandrosterone sulphate (DHEAS) are neurosteroids and their deficiencies constitute the hormone risk factors promoting the development of depression in elderly otherwise healthy men. We investigated the link between hypogonadism and depression in accordance with age and concomitant diseases in men with systolic HF using the novel scale previously dedicated for elderly population.

METHODS

We analysed the prevalence of depression and severity of depressive symptoms in population of 226 men with systolic HF (40-80 years) compared to 379 healthy peers. The severity of depression was assessed using the Polish long version of Geriatric Depression Scale (GDS).

RESULTS

In men aged 40-59 years the severity of depressive symptoms was greater in NYHA classes III-IV compared to NYHA classes I-II and reference group. In men aged 60-80 years depressive symptoms were more severe in NYHA class III-IV compared to controls (all p ≤ 0.001). In multivariate logistic regression model in men aged 40-59 years advanced NYHA class was associated with higher prevalence of mild depression (OR = 2.14, 95%CI: 1.07-4.29) and chronic obstructive pulmonary disease (COPD) with higher prevalence of severe depression (OR = 69.1, 95%CI: 2.11-2264.3). In men aged 60-80 years advanced NYHA class and TT deficiency were related to higher prevalence of mild depression (respectively: OR = 2.9, 95%CI: 1.3-6.4; OR = 3.6, 95%CI: 1.2-10.63).

CONCLUSION

TT deficiency, COPD and advanced NYHA class were associated with higher prevalence of depression in men with systolic HF.

Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

Serum Concentrations of Leptin and Adiponectin in Dogs with Myxomatous Mitral Valve Disease

Background

The concentrations of circulating adipokines in dogs with myxomatous mitral valve disease (MMVD) have not been investigated in detail.

Objectives

To determine whether serum concentrations of adipokines differ between healthy dogs and dogs with MMVD and whether circulating concentrations depend on the severity of heart failure resulting from MMVD.

Animals

In the preliminary study, 30 healthy dogs and 17 client‐owned dogs with MMVD, and in the subsequent study, 30 healthy dogs and 46 client‐owned dogs with MMVD.

Methods

Prospective case‐controlled observational study. In the preliminary study, serum concentrations of leptin, adiponectin, resistin, visfatin, interleukin (IL)‐1β, IL‐6, IL‐10, IL‐18, and tumor necrosis factor‐α were measured. In the subsequent study, MMVD dogs were divided into three groups according to the International Small Animal Cardiac Health Council (ISACHC) classification, and serum concentrations of leptin and adiponectin were measured.

Results

In the preliminary study, serum leptin and adiponectin concentrations differed significantly between dogs with MMVD and healthy dogs. Serum leptin (P = .0013) concentrations were significantly higher in dogs with MMVD than in healthy dogs, whereas adiponectin (P = .0009) concentrations were significantly lower in dogs with MMVD. However, we observed no significant differences in the other variables. In the subsequent study, dogs classified as ISACHC class 3 had higher serum concentrations of leptin (P = .0022) than healthy dogs but ISACHC class 1 or 2 dogs did not. Serum adiponectin concentrations were significantly lower in ISACHC class 1 (P < .0001) dogs than in healthy dogs, whereas adiponectin concentrations in ISACHC class 3 dogs were significantly higher than in ISACHC class 1 dogs (P = .0081).

Conclusions and Clinical Importance

Circulating concentrations of leptin and adiponectin might be altered in dogs with MMVD.

Effects of exercise training on insulin-like growth factor-I expression in the skeletal muscle of non-cachectic patients with chronic heart failure

Background Chronic heart failure (CHF) is associated with progressive muscle atrophy and reduced local expression of insulin-like growth factor I (IGF-I).

Design The present study was designed to test the hypothesis that the local deficiency of IGF-I in the skeletal muscle of patients with CHF would respond to a 6-months aerobic training intervention. Therefore, 18 patients [mean age 52.4 (SD 4.8) years, left ventricular ejection function (LVEF) 27 (SD 6)%] were prospectively randomized to either 6 months of training or sedentary lifestyle.

Methods Serum levels of growth hormone (GH) were measured by immunofluorometric assay, IGF-I by competitive solid phase immunoassay. IGF-I expression was assessed in vastus lateralis biopsies by real-time PCR.

Results Exercise training led to a significant increase in peak oxygen uptake by 26% [from 20.3 (SD 3.3) ml/kg per min to 25.5 (SD 5.7) ml/kg per min, P=0.003 versus control]. Local expression of IGF-I increased significantly after exercise training by 81% [from 6.3 (SE 0.8) to 11.4 (SE 1.4) relative units, P=0.007 versus control] while IGF-I receptor expression was reduced by 33% [from 20.0 (SE 2.1) to 13.8 (SE 1.7) relative units, P=0.008 versus control]. Serum growth hormone (GH) rose modestly from 0.12 (SE 0.07) to 0.65 (SE 0.37) ng/ml in the training group ( P=0.043 versus baseline), however, this change was not significant compared to the control group ( P=0.848). IGF-I serum levels remained virtually unchanged.

Conclusions Exercise training improves local IGF-I expression without significant changes of systemic parameters of the GH/IGF-I axis. These findings indicate that exercise training has the therapeutic potential to attenuate peripheral skeletal muscle alterations in particular with respect to local IGF-I expression in patients with moderate CHF.

Usefulness of Geriatric Nutritional Risk Index for Assessing Nutritional Status and Its Prognostic Impact in Patients Aged ≥65 Years With Acute Heart Failure

Malnutrition is becoming one of the most important determinants of worse clinical outcomes in patients with acute heart failure (AHF). However, appropriate tools for evaluating the nutritional status in patients aged ≥65 years with AHF remain unclear. We examined 490 consecutive patients aged ≥65 years with AHF. They were divided into 2 groups according to Geriatric Nutritional Risk Index (GNRI; cut-off value = 92). During a median period of 189 days, the mortality rate was significantly higher in the lower GNRI group than the higher GNRI group (p <0.001). In multivariate analyses, lower GNRI was an independent determinant of adverse events (HR 0.92, 95% CI 0.88 to 0.95, p <0.001). The GNRI showed the best prognostic value (C-statistic: 0.70) among other nutritional indexes. Adding GNRI to an existing outcome prediction model for mortality in AHF significantly increased the C-statistic from 0.68 to 0.74 (p = 0.017). The net reclassification improvement afforded by GNRI was 60% overall, 27% for events, and 33% for nonevents (p <0.001). In conclusion, lower GNRI on admission was independently associated with worse clinical outcomes in patients aged ≥65 years with AHF, and it was superior to other nutritional parameters. Furthermore, the assessment of nutritional status using GNRI is very helpful for risk stratification.

Insulin Signaling and Heart Failure

Heart failure is associated with generalized insulin resistance. Moreover, insulin-resistant states such as type 2 diabetes mellitus and obesity increases the risk of heart failure even after adjusting for traditional risk factors. Insulin resistance or type 2 diabetes mellitus alters the systemic and neurohumoral milieu, leading to changes in metabolism and signaling pathways in the heart that may contribute to myocardial dysfunction. In addition, changes in insulin signaling within cardiomyocytes develop in the failing heart. The changes range from activation of proximal insulin signaling pathways that may contribute to adverse left ventricular remodeling and mitochondrial dysfunction to repression of distal elements of insulin signaling pathways such as forkhead box O transcriptional signaling or glucose transport, which may also impair cardiac metabolism, structure, and function. This article will review the complexities of insulin signaling within the myocardium and ways in which these pathways are altered in heart failure or in conditions associated with generalized insulin resistance. The implications of these changes for therapeutic approaches to treating or preventing heart failure will be discussed.

Toward a broader understanding of aldosterone in congestive heart failure

Discovered some 50 years ago, aldosterone (ALDO) has come to be recognised as a mineralocorticoid hormone with well-known endocrine properties in epithelial cells that contribute to the pathophysiology of congestive heart failure. This includes Na + resorption at the expense of K+ excretion in classic target tissues: kidneys, colon, sweat and salivary glands. Though less well known, Mg2+ excretion is likewise enhanced by ALDO, while adrenal ALDO secretion is regulated by extracellular Mg2+ ([Mg2+ ]o). An emerging body of information has and continues to identify other endocrine actions of ALDO receptor-ligand binding. They include: promoting an efflux of cytosolic free Mg2+, or [Mg2+]i, in exchange for Na+ in such non-epithelial cells as peripheral blood mononuclear cells; its influence on endothelial cell function; and its central actions that involve regulation of cerebrospinal fluid composition produced by epithelial cells of the choroid plexus, activity of the hypothalamic paraventricular nucleus involved in Na+ appetite, Na+ and H2O excretion and sympathetic nerve activity, and the regulation of TNF-α production from central and/or peripheral sources. Extra-adrenal steroidogenesi and auto/paracrine properties of ALDO generated de novo in the cardiovasculature are now under investigation and preliminary findings suggest they contribute to tissue repair. The past decade has witnessed a revival of interest in this steroid molecule. In years to come, an even broader understanding of ALDO's contribution to the pathophysiology of congestive heart failure will undoubtedly emerge.

Aldosterone and cardiovascular remodelling: focus on myocardial failure

Heart failure is a clinical syndrome that may result from different disease states or conditions that injure the myocardium. The activation of circulating neurohormones, particularly aldosterone, may play a pivotal role in left ventricular (LV) remodelling. The Randomized Aldactone Evaluation Study and Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival trial have emphasised the clinical importance of aldosterone. This review addresses some of the proposed mechanisms of LV remodelling in heart failure.

Cardiac cachexia: hic et nunc

Cardiac cachexia (CC) is the clinical entity at the end of the chronic natural course of heart failure (HF). Despite the efforts, even the most recent definition of cardiac cachexia has been challenged, more precisely, the addition of new criteria on top of obligatory weight loss. The pathophysiology of CC is complex and multifactorial. A better understanding of pathophysiological pathways in body wasting will contribute to establish potentially novel treatment strategies. The complex biochemical network related with CC and HF pathophysiology underlines that a single biomarker cannot reflect all of the features of the disease. Biomarkers that could pick up the changes in body composition before they convey into clinical manifestations of CC would be of great importance. The development of preventive and therapeutic strategies against cachexia, sarcopenia, and wasting disorders is perceived as an urgent need by healthcare professionals. The treatment of body wasting remains an unresolved challenge to this day. As CC is a multifactorial disorder, it is unlikely that any single agent will be completely effective in treating this condition. Among all investigated therapeutic strategies, aerobic exercise training in HF patients is the most proved to counteract skeletal muscle wasting and is recommended by treatment guidelines for HF.

A New Transgenic Mouse Model of Heart Failure and Cardiac Cachexia Raised by Sustained Activation of Met Tyrosine Kinase in the Heart

Among other diseases characterized by the onset of cachexia, congestive heart failure takes a place of relevance, considering the high prevalence of this pathology in most European countries and in the United States, and is undergoing a rapid increase in developing countries. Actually, only few models of cardiac cachexia exist. Difficulties in the recruitment and follow-up of clinical trials implicate that new reproducible and well-characterized animal models are pivotal in developing therapeutic strategies for cachexia. We generated a new model of cardiac cachexia: a transgenic mouse expressing Tpr-Met receptor, the activated form of c-Met receptor of hepatocyte growth factor, specifically in the heart. We showed that the cardiac-specific induction of Tpr-Met raises a cardiac hypertrophic remodelling, which progresses into concentric hypertrophy with concomitant increase in Gdf15 mRNA levels. Hypertrophy progresses to congestive heart failure with preserved ejection fraction, characterized by reduced body weight gain and food intake and skeletal muscle wasting. Prevention trial by suppressing Tpr-Met showed that loss of body weight could be prevented. Skeletal muscle wasting was also associated with altered gene expression profiling. We propose transgenic Tpr-Met mice as a new model of cardiac cachexia, which will constitute a powerful tool to understand such complex pathology and test new drugs/approaches at the preclinical level.

Effect of Exercise Training and Testosterone Replacement on Skeletal Muscle Wasting in Patients With Heart Failure With Testosterone Deficiency

OBJECTIVE

To examine whether combined testosterone replacement and exercise training (ET) therapies would potentiate the beneficial effects of isolated therapies on neurovascular control and muscle wasting in patients with heart failure (HF) with testosterone deficiency.

PATIENTS AND METHODS

From January 10, 2010, through July 25, 2013, 39 male patients with HF, New York Heart Association functional class III, total testosterone level less than 249 ng/dL (to convert to nmol/L, multiply by .03467), and free testosterone level less than 131 pmol/L were randomized to training (4-month cycloergometer training), testosterone (intramuscular injection of testosterone undecylate for 4 months), and training + testosterone groups. Muscle sympathetic nerve activity was measured using microneurography, forearm blood flow using plethysmography, body composition using dual X-ray absorptiometry, and functional capacity using cardiopulmonary test. Skeletal muscle biopsy was performed in the vastus lateralis.

RESULTS

Muscle sympathetic nerve activity decreased in ET groups (training, P<.01; training + testosterone, P<.01), whereas no changes were observed in the testosterone group (P=.89). Forearm blood flow was similar in all groups. Lean mass increased in ET groups (training, P<.01; training + testosterone, P<.01), whereas lean mass decreased in the testosterone group (P<.01). The response of cross-sectional area of type I (P<.01) and type II (P<.05) fibers increased in the training + testosterone group as compared with the isolated testosterone group.

CONCLUSION

Our findings provide evidence for a superior effect of combined ET and testosterone replacement therapies on muscle sympathetic nerve activity, muscle wasting, and functional capacity in patients with HF with testosterone deficiency.

Impact of Protein Nutritional Status on Plasma BNP in Elderly Patients

BACKGROUND

Previous studies have demonstrated that the levels of B-type natriuretic peptide (BNP) in plasma are negatively correlated with Body Mass Index (BMI) whereas lean body mass is also closely related to plasma BNP. The purpose of this study is to determine the effect of protein nutritional status on plasma BNP in aged patients.

METHODS AND RESULTS

The cross-sectional study was applied and the anthropometric measurement and nutritional biochemical test was performed in 1118 elderly inpatients in a stable condition were enrolled in the study (mean age, 75 years; 54% women). The partial correlation and multivariate regression analysis were conducted to analyze the relation of plasma BNP with covariates. After adjustment for confounding factors such as age, smoking and coexisting diseases, we found that the concentrations of BNP were independently associated with serum albumin (β=-0.065, P<0.001), serum total cholesterol (β=-0.097, P<0.012) and calf circumference (β=-0.032, P<0.014) in female patients, and associated with the serum albumin (β=-0.051, P<0.001), prealbumin (β=-2.177, P<0.026), mid-arm circumference (β=-0.062, P<0.001) and grip strength (β=-0.100, P<0.048) in male patients. Every 1 gram per liter of increased serum albumin corresponded to the reduced plasma BNP in male patients by 13.9% (OR 0.861, 95% CI 0.817, 0.909) and in female patients by 13.4% (OR 0.866, 95% CI 0.819, 0.916).

CONCLUSIONS

Our study suggests that plasma BNP is negatively correlated with muscle mass, and it is also related to muscle force in male patients. The serum albumin is an independent determinant factor of BNP in both men and women. These findings suggest that good protein nutritional status could be beneficial in maintaining the cardiac function in elder population.

Cardiac cachexia: hic et nunc: "hic et nunc" - here and now

Cardiac cachexia (CC) is the clinical entity at the end of chronic natural course of heart failure (HF). Despite the efforts, even the most recent definition of cardiac cachexia has been challenged, more precisely the addition of new criteria on top of obligatory weight loss. The pathophysiology of CC is complex and multifactorial. Better understanding of pathophysiological pathways in body wasting will contribute to establish potentially novel treatment strategies. The complex biochemical network related with CC and HF pathophysiology underlines that a single biomarker cannot reflect all of the features of the disease. Biomarkers that could pick-up the changes in body composition before they convey into clinical manifestations of CC would be of great importance. The development of preventive and therapeutic strategies against cachexia, sarcopenia and wasting disorders is perceived as an urgent need by healthcare professionals. The treatment of body wasting remains an unresolved challenge to this day. As CC is a multifactorial disorder, it is unlikely that any single agent will be completely effective in treating this condition. Among all investigated therapeutic strategies, aerobic exercise training in HF patients is the most proved to counteract skeletal muscle wasting and is recommended by treatment guidelines for HF.

Amino acids and derivatives, a new treatment of chronic heart failure?

Amino acids play a key role in multiple cellular processes. Amino acids availability is reduced in patients with heart failure (HF) with deleterious consequences on cardiac and whole-body metabolism. Several metabolic abnormalities have been identified in the failing heart, and many of them lead to an increased need of amino acids. Recently, several clinical trials have been conducted to demonstrate the benefits of amino acids supplementation in patients with HF. Although they have shown an improvement of exercise tolerance and, in some cases, of left ventricular function, they have many limitations, namely small sample size, differences in patients' characteristics and nutritional supplementations, and lack of data regarding outcomes. Moreover recent data suggest that a multi-nutritional approach, including also antioxidants, vitamins, and metals, may be more effective. Larger trials are needed to ascertain safety, efficacy, and impact on prognosis of such an approach in HF.

Hormonal Profile in Patients With Dilated Cardiomyopathy

BACKGROUND

There is increasing evidence that endocrine system may be dysfunctional in patients with heart failure.

OBJECTIVES

In the present study, we investigated hormonal abnormalities in heart failure and the effect of disturbed hormonal balance on prognostic outcomes of patients with systolic heart failure.

PATIENTS AND METHODS

Among patients followed in Heart Failure and Transplantation Clinic, 33 men with a diagnosis of idiopathic dilated cardiomyopathy receiving guidelines-directed medical therapies and with New York Heart Association Class II-III were enrolled. Serum concentrations of growth hormone (GH), insulin-like growth factor 1 (IGF-1), thyroid hormones, free testosterone, high-sensitive C-reactive protein (hs-CRP), and N-terminal pro-brain natriuretic peptide (NT Pro-BNP) were measured in all the patients. The physical performance of patients was assessed by six-minute walk test (6MWT). The patients were subsequently followed for a year and the data regarding their death, transplantation, or hospitalizations due to acute heart failure were recorded.

RESULTS

Except for testosterone level, the levels of GH, IGF-1, T3, and T4 concentrations in the patients were significantly lower than the normal values (P < 0.05). Among different hormone, only GH had correlation with NT Pro-BNP, hs-CRP, and 6MWT. There was no association between the occurrence of the combined events and different hormonal levels in multivariate analysis.

CONCLUSIONS

The hormonal levels were low in patients with idiopathic dilated cardiomyopathy. However, the prognostic significance of different hormonal deficiencies was not clear in our study populations who were receiving standard therapies for heart failure and had a relatively stable clinical condition.