101
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Tsilika M, Mitrou J, Antonakos N, Tseti IK, Damoraki G, Leventogiannis K, Giamarellos-Bourboulis EJ. An active new formulation of iron carried by aspartyl casein for iron-deficiency anemia: results of the ACCESS trial. Ann Hematol 2023; 102:1341-1349. [PMID: 37022473 PMCID: PMC10182142 DOI: 10.1007/s00277-023-05197-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Abstract
Oral iron supplementation is the cornerstone for the management of iron-deficiency anemia. A new oral formulation of iron conjugated with N-aspartyl-casein (Fe-ASP) (Omalin®, Uni-Pharma) is studied in the ACCESS double-blind, double-dummy randomized clinical trial; 60 patients were randomized to 12-week oral treatment twice every day either with oral ferrous sulfate (FeSO4) delivering 47 mg elementary iron or oral Fe-ASP delivering 40 mg elementary iron. Participants had hemoglobin less than 10 g/dl, decreased red blood cell (RBC) count, and ferritin lower than 30 ng/ml; patients with a medical history of malignancy were excluded. The primary endpoint was the increase of Hb in the first 4 weeks of treatment, and the study was powered for non-inferiority. A new score of global improvement was introduced where all participants were given one point for any at least 10% increase of Hb, RBC, and reticulocytes. At week 4, the mean (SE) change of Hb was 0.76 g/dl in the FeSO4 group and 0.83 g/dl in the Fe-ASP group (p: 0.876). The odds for worse allocation of the global score were 0.35 in the Fe-ASP group compared to the FeSO4 group. Patients in the Fe-ASP group experienced a significant decrease in the number of IDA-related physical signs by week 4. No differences were found between the two groups in any of the patient-reported outcomes of fatigue and of gastrointestinal adverse events either at week 4 or at week 12. ACCESS is the most recent clinical trial showing the non-inferiority of Fe-ASP to FeSO4 for the primary endpoint of the Hb change.
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Affiliation(s)
- Maria Tsilika
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - John Mitrou
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Antonakos
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Georgia Damoraki
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Leventogiannis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
- 4th Department of Internal Medicine, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece.
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Kawanami S, Egami Y, Sugae H, Ukita K, Kawamura A, Nakamura H, Matsuhiro Y, Yasumoto K, Tsuda M, Okamoto N, Matsunaga‐Lee Y, Yano M, Nishino M, Tanouchi J. Predictors of bleeding events in acute decompensated heart failure patients with antithrombotic therapy: AURORA study. ESC Heart Fail 2023; 10:1114-1121. [PMID: 36585753 PMCID: PMC10053354 DOI: 10.1002/ehf2.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/18/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Heart failure (HF) is reported to be one of the major risks of bleeding events. On the other hand, HF patients frequently receive anticoagulants or antiplatelet therapy to manage various co-morbidities. However, predictors of bleeding events in patients with HF have rarely been reported. This study aimed to evaluate the predictors of bleeding events and relationship between bleeding events and HF re-hospitalizations. METHODS AND RESULTS We included 1660 acute decompensated heart failure (ADHF) patients from the AURORA registry between January 2015 and December 2020. A total of 1429 patients were excluded because of history of HF admission, missing echocardiographic data at discharge, lost to follow-up, haemodialysis and no antithrombotic drugs. Finally, we evaluated 231 patients from AURORA registry. The bleeding events were defined as Type 2 to 5 bleeding according to the Bleeding Academic Research Consortium definition. We divided our patients into the bleeding group and non-bleeding group. We compared the baseline characteristics, medications, laboratory data, and echocardiographic data between the two groups. Median age was 78 (IQR 71-82) years old and male accounted for 59%. Approximately half of the patients had an antiplatelet therapy and 70% had an anticoagulant therapy. During a median follow-up of 651 (IQR 357-1139) days, 32 patients (13.8%) suffered from bleeding events. The major driver of the registered events was gastrointestinal bleeding (n = 21, 65.6%), and the other events were cerebral bleeding (n = 4, 12.5%), intraarticular bleeding (n = 2, 6.3%), urogenital bleeding (n = 2, 6.3%), haemorrhagic pericardial effusions (n = 1, 3.1%), subcutaneous hematomas (n = 1, 3.1%), and haemothorax (n = 1, 3.1%). There was a significantly lower haemoglobin level (P < 0.01), higher proportion of inferior vena cava (IVC) diameter ≥21 mm (P < 0.01), and higher furosemide equivalent doses per kilogram (P < 0.01) in the bleeding group than non-bleeding group. A multivariate analysis revealed an equivalent dose of furosemide per kilogram ≥0.66 mg/kg (hazard ratios (HR) of 2.64, 95% confidence interval (CI) 1.26-5.68, P = 0.01), haemoglobin ≤10.3 g/dL (HR of 2.43, 95% CI 1.14-5.03, P = 0.02), and IVC diameter ≥21 mm (HR of 2.79, 95% CI 1.16-6.29, P = 0.02) were independently associated with bleeding events. The Kaplan-Meier analysis showed that HF re-hospitalization rates were higher in the bleeding group than non-bleeding group (P = 0.04). CONCLUSIONS High doses of oral loop diuretics, IVC dilatation, and anaemia were predictors of bleeding events in patients hospitalized with ADHF patients. In addition, bleeding events were associated with HF re-hospitalizations.
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Affiliation(s)
- Shodai Kawanami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuyuki Egami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hiroki Sugae
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Kohei Ukita
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Akito Kawamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hitoshi Nakamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yutaka Matsuhiro
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Koji Yasumoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masaki Tsuda
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Naotaka Okamoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuharu Matsunaga‐Lee
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masamichi Yano
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masami Nishino
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Jun Tanouchi
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
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103
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Scicchitano P, Iacoviello M, Massari A, De Palo M, Potenza A, Landriscina R, Abruzzese S, Tangorra M, Guida P, Ciccone MM, Caldarola P, Massari F. Anaemia and Congestion in Heart Failure: Correlations and Prognostic Role. Biomedicines 2023; 11:biomedicines11030972. [PMID: 36979951 PMCID: PMC10046168 DOI: 10.3390/biomedicines11030972] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
The aim of this study was to evaluate the relationship between anaemia and biomarkers of central/peripheral congestion in heart failure (HF) and the impact on mortality. We retrospectively evaluated 434 acute/chronic HF (AHF/CHF) patients. Anaemia was defined as haemoglobin levels <12 g/dL (women) or <13 g/dL (men). The brain natriuretic peptide (BNP) and hydration index (HI) were measured. The endpoint of the study was all-cause mortality. Anaemia occurred in 59% of patients with AHF and in 35% with CHF (p < 0.001) and showed a significant correlation with the NYHA functional class and renal function. BNP and HI were significantly higher in patients with anaemia than in those without anaemia. Independent predictors of anaemia included BNP, estimated creatinine clearance (eCrCL), and HI. The all-cause mortality rate was 21%, which was significantly higher in patients with anaemia than in those without anaemia (30% vs. 14%, p < 0.001; hazard ratio: 2.6). At multivariate Cox regression analysis, BNP, eCrCL, and HI were independent predictors for mortality (Hazard ratios: 1.0002, 0.97, and 1.05, respectively), while anaemia was not. Anaemia correlates with HF status, functional class, renal function, BNP, and HI. Anaemia was not an independent predictor for mortality, acting as a disease severity marker in congestive patients rather than as a predictor of death.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | | | - Micaela De Palo
- Cardiac Surgery Unit, Policlinic University Hospital, 70124 Bari, Italy
| | - Angela Potenza
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | | | - Silvia Abruzzese
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Maria Tangorra
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Piero Guida
- Ospedale Generale Regionale "F. Miulli", 70021 Acquaviva delle Fonti, Italy
| | - Marco Matteo Ciccone
- Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Francesco Massari
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
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Sezai A, Sekino H, Taoka M, Osaka S, Tanaka M. A Single Arm Clinical Study on the Effects of Continuous Erythropoietin Receptor Activator Treatment in Non-Dialysis Patients with Chronic Heart Failure and Renal Anemia. Biomedicines 2023; 11:biomedicines11030946. [PMID: 36979925 PMCID: PMC10046271 DOI: 10.3390/biomedicines11030946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Erythropoiesis-stimulating agents improve the NYHA functional class and decrease the hospital readmission rates for heart failure; however, little is known about the influence of continuous erythropoietin receptor activator (CERA) on the heart. Therefore, a prospective study was conducted to investigate the effects of CERA on cardiac and renal function and oxidative stress in chronic heart failure with renal anemia. Sixty patients with chronic heart failure and renal anemia were enrolled and received CERA for 12 months. The primary endpoints were hemoglobin (Hb) and hematocrit, and the secondary endpoints were: (1) atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP); (2) NYHA class; (3) echocardiography; (4) blood urea nitrogen, creatinine, cystatin C, and urinary albumin; (5) high-sensitivity C-reactive protein; (6) oxidized low-density lipoprotein (Ox-LDL); and (7) renin, angiotensin-II, and aldosterone. There was a significant difference in the Hb levels measured before and after CERA administration. The BNP, ANP, NYHA, left ventricular mass index, renal function, and Ox-LDL decreased significantly after CERA administration. This study shows that CERA improves anemia and reduces renal impairment, as well as cardiac and oxidative stress. The result of this study is useful for a study in which switching from CERA to a new renal anemia drug, hypoxia-inducible factor prolyl-hydroxylase inhibitor, is investigated.
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Affiliation(s)
- Akira Sezai
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | | | - Makoto Taoka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Shunji Osaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
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Fujii H, Hamano T, Tsuchiya K, Kuragano T, Joki N, Tsuruya K, Honda H, Uemura Y, Nitta K. Not baseline but time-dependent erythropoiesis-stimulating agent responsiveness predicts cardiovascular disease in hemodialysis patients receiving epoetin beta pegol: A multicenter prospective PARAMOUNT-HD Study. Int J Cardiol 2023; 375:110-118. [PMID: 36592827 DOI: 10.1016/j.ijcard.2022.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Responsiveness to erythropoiesis-stimulating agents (ESAs) has been reported to be associated with increased cardiovascular disease (CVD) and mortality in patients undergoing hemodialysis (HD). However, the association between hyporesponsiveness to the long-acting ESA, epoetin beta pegol (CERA), and CVD remains unknown. METHODS This multicenter prospective study included 4034 patients undergoing maintenance HD. After shifting from prior ESA to CERA, we studied the association between erythropoietin resistance index (ERI) at six months and outcomes, including cardiac events, major adverse cardiovascular events (MACE), and all-cause mortality, using Cox proportional hazards models (Landmark analyses) and marginal structural models to adjust for time-dependent confounding factors, including iron-containing medications and hemodiafiltration (HDF). RESULTS The median dialysis vintage and the observational period were 5.0 years and 22.1 months, respectively. The landmark analyses revealed that the highest tertile of baseline ERI (T3) was associated with a significantly higher all-cause mortality than the lowest tertile (T1) (hazard ratio [HR]: 1.48, 95% CI: 1.03-2.13). Furthermore, marginal structural models revealed that time-dependent ERI T3 was significantly associated with increased cardiac events (HR: 1.59, 95% CI: 1.14-2.23), MACE (HR: 1.60, 95% CI: 1.19-2.15), all-cause mortality (HR: 1.97, 95% CI: 1.40-2.77), and heart failure (HF) (HR: 2.05, 95% CI: 1.23-3.40) compared to T1. A linear mixed effects model showed that iron-containing medications and HDF are negatively associated with time-dependent ERI. CONCLUSIONS Baseline ERI at six months predicted only all-cause mortality; however, time-dependent ERI was a predictor of cardiac events, all-cause mortality, MACE, and HF. The widespread use of iron-containing medications and HDF would ameliorate ESA hyporesponsiveness.
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Affiliation(s)
- Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Takayuki Hamano
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiro Kuragano
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | | | - Hirokazu Honda
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
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106
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Bigorra Mir M, Charlebois E, Tsyplenkova S, Fillebeen C, Pantopoulos K. Cardiac Hamp mRNA Is Predominantly Expressed in the Right Atrium and Does Not Respond to Iron. Int J Mol Sci 2023; 24:ijms24065163. [PMID: 36982241 PMCID: PMC10049151 DOI: 10.3390/ijms24065163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/10/2023] Open
Abstract
Hepcidin is a liver-derived hormone that controls systemic iron traffic. It is also expressed in the heart, where it acts locally. We utilized cell and mouse models to study the regulation, expression, and function of cardiac hepcidin. Hepcidin-encoding Hamp mRNA was induced upon differentiation of C2C12 cells to a cardiomyocyte-like phenotype and was not further stimulated by BMP6, BMP2, or IL-6, the major inducers of hepatic hepcidin. The mRNAs encoding hepcidin and its upstream regulator hemojuvelin (Hjv) are primarily expressed in the atria of the heart, with ~20-fold higher Hamp mRNA levels in the right vs. left atrium and negligible expression in the ventricles and apex. Hjv−/− mice, a model of hemochromatosis due to suppression of liver hepcidin, exhibit only modest cardiac Hamp deficiency and minor cardiac dysfunction. Dietary iron manipulations did not significantly affect cardiac Hamp mRNA in the atria of wild-type or Hjv−/− mice. Two weeks following myocardial infarction, Hamp was robustly induced in the liver and heart apex but not atria, possibly in response to inflammation. We conclude that cardiac Hamp is predominantly expressed in the right atrium and is partially regulated by Hjv; however, it does not respond to iron and other inducers of hepatic hepcidin.
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Affiliation(s)
- Maria Bigorra Mir
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Edouard Charlebois
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Sofiya Tsyplenkova
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Carine Fillebeen
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Kostas Pantopoulos
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Department of Medicine, McGill University, Montreal, QC H4A 3J1, Canada
- Correspondence: ; Tel.: +1-514-340-8260 (ext. 25293)
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107
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Yasui Y, Nakamura K, Omote K, Ishizaka S, Takenaka S, Mizuguchi Y, Shimono Y, Kazui S, Takahashi Y, Saiin K, Naito S, Tada A, Kobayashi Y, Sato T, Kamiya K, Nagai T, Anzai T. Prognostic Significance of Peak Workload-to-Weight Ratio by Cardiopulmonary Exercise Testing in Chronic Heart Failure. Am J Cardiol 2023; 193:37-43. [PMID: 36867917 DOI: 10.1016/j.amjcard.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
The prognostic impact of peak workload-to-weight ratio (PWR) during cardiopulmonary exercise testing (CPET) and its determinants in patients with chronic heart failure (CHF) are not well understood. Consecutive 514 patients with CHF referred for CPET at the Hokkaido University Hospital between 2013 and 2018 were identified. The primary outcome was a composite of hospitalization because of worsening heart failure and death. PWR was calculated as peak workload normalized to body weight (W/kg) by CPET. Patients with low PWR (cut-off median 1.38 [W/kg], n = 257) were older and more anemic than those with high PWR (n = 257). In CPET, patients with low PWR displayed reduced peak oxygen consumption and impaired ventilatory efficiency compared with those with high PWR, whereas the peak respiratory exchange ratio was not significantly different between the 2 groups. There were 89 patients with events over a median follow-up period of 3.3 (interquartile range 0.8 to 5.5) years. The incidence of composite events was significantly higher in patients with low PWR than in those with high PWR (log-rank p <0.0001). In the multivariable Cox regression, lower PWR was associated with adverse events (hazard ratio 0.31, 95% confidence interval 0.13 to 0.73, p = 0.008). Low hemoglobin concentration was strongly related to impaired PWR (β coefficient = 0.43, per 1 g/100 ml increased, p <0.0001). In conclusion, PWR was associated with worse clinical outcomes, where blood hemoglobin was strongly related to PWR. Further study is required to identify therapies targeting peak workload achievements in exercise stress tests to improve the outcome in patients with CHF.
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Affiliation(s)
- Yutaro Yasui
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kosuke Nakamura
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sakae Takenaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yui Shimono
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sho Kazui
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Takahashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kohei Saiin
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Seiichiro Naito
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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O’Mahony D, Mabunda SA, Mntonintshi M, Iruedo J, Kaswa R, Blanco-Blanco E, Ogunsanwo B, Namugenyi KAF, Vasaikar S, Yogeswaran P. Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3584. [PMID: 36834279 PMCID: PMC9966846 DOI: 10.3390/ijerph20043584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting. METHODS A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests. RESULTS Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively. CONCLUSIONS HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.
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Affiliation(s)
- Don O’Mahony
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Sikhumbuzo A. Mabunda
- School of Population Health, University of New South Wales, Sydney 2052, Australia
- George Institute for Global Health, University of New South Wales, Sydney 2042, Australia
- Department of Public Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Mbulelo Mntonintshi
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Joshua Iruedo
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Ramprakash Kaswa
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
| | - Ernesto Blanco-Blanco
- Department of Laboratory Medicine and Pathology, Walter Sisulu University, Mthatha 5100, South Africa
| | - Basil Ogunsanwo
- Department of Surgery, Walter Sisulu University, Mthatha 5117, South Africa
| | | | - Sandeep Vasaikar
- Department of Microbiology, Walter Sisulu University, Mthatha 5117, South Africa
| | - Parimalaranie Yogeswaran
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha 5117, South Africa
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Wongsalap Y, Poolpun D, Keawhai K, Kitpluem N, Pansiri P, Malaimat S, Senthong V, Kengkla K. Pharmacotherapy treatment patterns at hospital discharge and clinical outcomes among patients with heart failure with reduced ejection fraction. Chronic Dis Transl Med 2023. [DOI: 10.1002/cdt3.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Affiliation(s)
- Yuttana Wongsalap
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
- Unit of Excellence on Pharmacogenomic Pharmacokinetic and Pharmacotherapeutic Researches (UP‐PER), School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | | | - Konrapee Keawhai
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Napusson Kitpluem
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Parichat Pansiri
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Siriluck Malaimat
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Vichai Senthong
- Cardiovascular Unit, Department of Medicine, Faculty of Medicine Khon Kaen University Khon Kaen Thailand
| | - Kirati Kengkla
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences University of Phayao Phayao Thailand
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Yousaf M, iIlahi M, Bibi A, Elhassan H, Sharif M, Abid AR, Omran MA, Hassan A, Haroon KH. Chronic anemia complicated by cardiac failure, pulmonary hypertension, and pericardial effusion: a case report. J Med Case Rep 2023; 17:44. [PMID: 36750883 PMCID: PMC9906880 DOI: 10.1186/s13256-022-03686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/20/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Worldwide, iron deficiency anaemia (IDA) is the most common cause of anaemia. Iron deficiency alone has an association with heart failure and pulmonary hypertension. Chronic iron deficiency anemia triggers various physiologic adjustments, leading to hyperdynamic circulation and enhanced hypoxic pulmonary vasoconstriction. Those mechanisms may result in the development of high output cardiac failure and pulmonary hypertension; however, pericardial effusion remains a rare association. CASE PRESENTATION A 44-year-old Nepalese man presented with fatigability and swollen ankles. Except for a hemorrhoidectomy 4 years ago, he had no comorbidities. Labs confirmed severe iron deficiency anemia (hemoglobin 1.8 grams per deciliter) likely secondary to hemorrhoids. An echocardiogram revealed high output cardiac failure, pericardial effusion, and severe pulmonary hypertension. He responded well to the correction of anemia and diuretics with the resolution of vascular complications. CONCLUSION We report a unique presentation of chronic severe iron deficiency anemia complicated by heart failure, pulmonary hypertension, and pericardial effusion. We believe it to be the first-ever such case reported in the literature. These cardiovascular complications seem to result from internal homeostatic mechanisms against the chronic tissue hypoxemia observed in severe anemia. Furthermore, iron deficiency alone has an association with heart failure and pulmonary hypertension. After excluding other potential causes, we confirmed iron deficiency anaemia as the cause of those complications. The correction of anemia led to an excellent recovery without any sequelae. Our case report highlights the fact that management of such a case should be focused on underlying etiology rather than the complications.
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Affiliation(s)
- Muhammad Yousaf
- Hazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar. .,Weill Cornell Medicine Qatar, Cornell University, Doha, Qatar.
| | - Memon iIlahi
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar ,grid.416973.e0000 0004 0582 4340Weill Cornell Medicine Qatar, Cornell University, Doha, Qatar
| | - Aisha Bibi
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hadeel Elhassan
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Sharif
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar ,grid.416973.e0000 0004 0582 4340Weill Cornell Medicine Qatar, Cornell University, Doha, Qatar
| | - Abdul Rehman Abid
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Maya Ali Omran
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Arwa Hassan
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Khawaja Hassan Haroon
- grid.413548.f0000 0004 0571 546XHazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar
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Pugliese NR, Pellicori P, Filidei F, De Biase N, Maffia P, Guzik TJ, Masi S, Taddei S, Cleland JGF. Inflammatory pathways in heart failure with preserved left ventricular ejection fraction: implications for future interventions. Cardiovasc Res 2023; 118:3536-3555. [PMID: 36004819 PMCID: PMC9897694 DOI: 10.1093/cvr/cvac133] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/26/2022] [Accepted: 08/10/2022] [Indexed: 02/07/2023] Open
Abstract
Many patients with symptoms and signs of heart failure have a left ventricular ejection fraction ≥50%, termed heart failure with preserved ejection fraction (HFpEF). HFpEF is a heterogeneous syndrome mainly affecting older people who have many other cardiac and non-cardiac conditions that often cast doubt on the origin of symptoms, such as breathlessness, or signs, such as peripheral oedema, rendering them neither sensitive nor specific to the diagnosis of HFpEF. Currently, management of HFpEF is mainly directed at controlling symptoms and treating comorbid conditions such as hypertension, atrial fibrillation, anaemia, and coronary artery disease. HFpEF is also characterized by a persistent increase in inflammatory biomarkers. Inflammation may be a key driver of the development and progression of HFpEF and many of its associated comorbidities. Detailed characterization of specific inflammatory pathways may provide insights into the pathophysiology of HFpEF and guide its future management. There is growing interest in novel therapies specifically designed to target deregulated inflammation in many therapeutic areas, including cardiovascular disease. However, large-scale clinical trials investigating the effectiveness of anti-inflammatory treatments in HFpEF are still lacking. In this manuscript, we review the role of inflammation in HFpEF and the possible implications for future trials.
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Affiliation(s)
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow G12 8QQ, UK
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Pasquale Maffia
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, UK
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples 80138, Italy
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Department of Internal and Agricultural Medicine, Jagiellonian University, Collegium Medicum, Krakow 31-008, Poland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow G12 8QQ, UK
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Abstract
The cardiovascular system requires iron to maintain its high energy demands and metabolic activity. Iron plays a critical role in oxygen transport and storage, mitochondrial function, and enzyme activity. However, excess iron is also cardiotoxic due to its ability to catalyze the formation of reactive oxygen species and promote oxidative damage. While mammalian cells have several redundant iron import mechanisms, they are equipped with a single iron-exporting protein, which makes the cardiovascular system particularly sensitive to iron overload. As a result, iron levels are tightly regulated at many levels to maintain homeostasis. Iron dysregulation ranges from iron deficiency to iron overload and is seen in many types of cardiovascular disease, including heart failure, myocardial infarction, anthracycline-induced cardiotoxicity, and Friedreich's ataxia. Recently, the use of intravenous iron therapy has been advocated in patients with heart failure and certain criteria for iron deficiency. Here, we provide an overview of systemic and cellular iron homeostasis in the context of cardiovascular physiology, iron deficiency, and iron overload in cardiovascular disease, current therapeutic strategies, and future perspectives.
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Affiliation(s)
- Konrad Teodor Sawicki
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Adam De Jesus
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
| | - Hossein Ardehali
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
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Rosenblum SL. Inflammation, dysregulated iron metabolism, and cardiovascular disease. FRONTIERS IN AGING 2023; 4:1124178. [PMID: 36816471 PMCID: PMC9935942 DOI: 10.3389/fragi.2023.1124178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
Iron is an essential trace element associated with both pathologic deficiency and toxic overload. Thus, systemic and cell iron metabolism are highly controlled processes regulated by protein expression and localization, as well as turnover, through the action of cytokines and iron status. Iron metabolism in the heart is challenging because both iron overload and deficiency are associated with cardiac disease. Also associated with cardiovascular disease is inflammation, as many cardiac diseases are caused by or include an inflammatory component. In addition, iron metabolism and inflammation are closely linked. Hepcidin, the master regulator of systemic iron metabolism, is induced by the cytokine IL-6 and as such is among the acute phase proteins secreted by the liver as part of the inflammatory response. In an inflammatory state, systemic iron homeostasis is dysregulated, commonly resulting in hypoferremia, or low serum iron. Less well characterized is cardiac iron metabolism in general, and even less is known about how inflammation impacts heart iron handling. This review highlights what is known with respect to iron metabolism in the heart. Expression of iron metabolism-related proteins and processes of iron uptake and efflux in these cell types are outlined. Evidence for the strong co-morbid relationship between inflammation and cardiac disease is also reviewed. Known connections between inflammatory processes and iron metabolism in the heart are discussed with the goal of linking inflammation and iron metabolism in this tissue, a connection that has been relatively under-appreciated as a component of heart function in an inflammatory state. Therapeutic options connecting inflammation and iron balance are emphasized, with the main goal of this review being to bring attention to alterations in iron balance as a component of inflammatory diseases of the cardiovascular system.
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Massaiu I, Campodonico J, Mapelli M, Salvioni E, Valerio V, Moschetta D, Myasoedova VA, Cappellini MD, Pompilio G, Poggio P, Agostoni P. Dysregulation of Iron Metabolism-Linked Genes at Myocardial Tissue and Cell Levels in Dilated Cardiomyopathy. Int J Mol Sci 2023; 24:ijms24032887. [PMID: 36769209 PMCID: PMC9918212 DOI: 10.3390/ijms24032887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
In heart failure, the biological and clinical connection between abnormal iron homeostasis, myocardial function, and prognosis is known; however, the expression profiles of iron-linked genes both at myocardial tissue and single-cell level are not well defined. Through publicly available bulk and single-nucleus RNA sequencing (RNA-seq) datasets of left ventricle samples from adult non-failed (NF) and dilated cardiomyopathy (DCM) subjects, we aim to evaluate the altered iron metabolism in a diseased condition, at the whole cardiac tissue and single-cell level. From the bulk RNA-seq data, we found 223 iron-linked genes expressed at the myocardial tissue level and 44 differentially expressed between DCM and NF subjects. At the single-cell level, at least 18 iron-linked expressed genes were significantly regulated in DCM when compared to NF subjects. Specifically, the iron metabolism in DCM cardiomyocytes is altered at several levels, including: (1) imbalance of Fe3+ internalization (SCARA5 down-regulation) and reduction of internal conversion from Fe3+ to Fe2+ (STEAP3 down-regulation), (2) increase of iron consumption to produce hemoglobin (HBA1/2 up-regulation), (3) higher heme synthesis and externalization (ALAS2 and ABCG2 up-regulation), (4) lower cleavage of heme to Fe2+, biliverdin and carbon monoxide (HMOX2 down-regulation), and (5) positive regulation of hepcidin (BMP6 up-regulation).
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Affiliation(s)
| | | | | | | | | | - Donato Moschetta
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20122 Milan, Italy
| | | | - Maria Domenica Cappellini
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Paolo Poggio
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Correspondence: (P.P.); (P.A.); Tel.: +39-02-5800-2853 (P.P.); +39-02-5800-2488 (P.A.)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Correspondence: (P.P.); (P.A.); Tel.: +39-02-5800-2853 (P.P.); +39-02-5800-2488 (P.A.)
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115
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Kloeser R, Buser A, Bolliger D. Treatment Strategies in Anemic Patients Before Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:266-275. [PMID: 36328926 DOI: 10.1053/j.jvca.2022.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.
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Affiliation(s)
- Raphael Kloeser
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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Fuchs Andersen C, Omar M, Glenthøj A, El Fassi D, Møller HJ, Lindholm Kurtzhals JA, Styrishave B, Kistorp C, Tuxen C, Poulsen MK, Faber J, Køber L, Gustafsson F, Møller JE, Schou M, Jensen J. Effects of empagliflozin on erythropoiesis in heart failure: data from the Empire HF trial. Eur J Heart Fail 2023; 25:226-234. [PMID: 36377106 DOI: 10.1002/ejhf.2735] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS It remains unknown whether the consistently observed increase in haematocrit with sodium-glucose cotransporter 2 inhibitors is caused by diuresis-associated haemoconcentration or increased erythropoiesis. We aimed to investigate the early effect of empagliflozin on erythropoiesis and iron metabolism in patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS The Empire HF was a double-blind, randomized, placebo-controlled trial. Patients with a left ventricular ejection fraction (LVEF) ≤40%, New York Heart Association (NYHA) class I-III symptoms, and on stable guideline-directed HFrEF therapy were randomly assigned (1:1) to empagliflozin or matching placebo once daily for 12 weeks. Exploratory outcomes reflecting changes in erythropoiesis and iron metabolism were analysed. In total, 190 patients were randomized. Baseline characteristics were well-balanced between the groups (age: mean 64 [± 11] years; male: 85%; LVEF: mean 29 [± 8)%; NYHA class II: 78%; type 2 diabetes: 13%; anaemia: 28%; chronic kidney disease: 13%). In this post hoc analysis, erythropoietin was increased with empagliflozin compared to placebo from baseline to 12 weeks (adjusted mean difference 2.6 IU/L, 95% confidence interval [CI] 0.8-4.4; p = 0.0046). Moreover, hepcidin was reduced (adjusted ratio of change 0.76, 95% CI 0.59-0.97; p = 0.031), with no change observed for erythroferrone (adjusted ratio of change 1.17, 95% CI 0.86-1.60; p = 0.31) compared to placebo. No significant treatment-by-subgroup interactions were observed regarding baseline type 2 diabetes, anaemia, or chronic kidney disease (pinteraction >0.05). CONCLUSION These findings suggest that empagliflozin increases erythropoiesis and augments early iron utilization in patients with HFrEF. These mechanisms may contribute to the cardioprotective properties of empagliflozin.
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Affiliation(s)
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
| | - Andreas Glenthøj
- Department of Haematology, Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel El Fassi
- Department of Haematology, Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Holger J Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jørgen A Lindholm Kurtzhals
- Department of Clinical Microbiology, Centre of Medical Parasitology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bjarne Styrishave
- Toxicology and Drug Metabolism Group, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Kistorp
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Christian Tuxen
- Department of Cardiology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Mikael K Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jens Faber
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, Centre of Endocrinology and Metabolism, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Lars Køber
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, Centre of Endocrinology and Metabolism, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
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Initial experience of hypoxia-inducible factor prolyl hydroxylase inhibitors in patients with heart failure and renal anemia. Heart Vessels 2023; 38:284-290. [PMID: 36205772 DOI: 10.1007/s00380-022-02181-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/22/2022] [Indexed: 01/10/2023]
Abstract
Hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitors might improve renal anemia maintaining fewer cardiovascular complications. However, its safety and efficacy, as well as its impact on inflammatory biomarkers, in heart failure patients remain unknown. We initiated HIF-PH inhibitors in 13 patients with chronic heart failure and renal anemia (median age 77 years, median estimated glomerular filtration rate 24.9 mL/min/1.73m2) between September 2021 and February 2022. There were no drug-related complications, except for a patient who had a headache and hot flash, resulting in discontinuation of HIF-PH inhibitor at 3 months. Among 10 patients who continued HIF-PH inhibitors for over 3 months, hemoglobin levels increased significantly (median from 9.6 g/dL to 10.7 g/dL, p = 0.004) and hepcidin-25 levels tended to decrease (median from 11.5 ng/mL to 3.0 ng/mL, p = 0.294) at 3-month follow-up. In conclusion, HIF-PH inhibitors might be safe and effective for the treatment of renal anemia in patients with chronic heart failure.
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118
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Trends and Predictors of Poor Outcomes in Patients With Right Heart Failure: Insights From the National Readmission Database. Curr Probl Cardiol 2023; 48:101625. [PMID: 36724819 DOI: 10.1016/j.cpcardiol.2023.101625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
Right heart failure (RHF) is a complex clinical syndrome that confers high risk of morbidity and mortality. We sought to study RHF using large national database. The study is a retrospective analysis of the National Readmission Database (NRD) of years 2017-2019. Admissions with a primary diagnosis of RHF were included. Study outcomes were temporal trends of RHF diagnosis and predictors of in-hospital mortality and 30-day readmission. Subgroup analysis according to co-presence of reduced or preserved left ventricular ejection fraction (LVEF). Multivariate logistic regression was utilized to detect predictors of poor outcome and difference between subgroups. A total of 127,503 admissions were identified from the database of which 4,717 primary RHF admissions were included in our cohort. There was a trend of increasing RHF diagnosis from 2017 4th Quarter to 2019 4th Quarter. Age, liver disease and reduced LVEF were amongst predictors of in-hospital mortality while iron deficiency anemia and a Charlson Comorbidity Score ≥ 3 were predictors of 30-day readmission. The study of real-world data contributes to a better understanding of RHF outcomes. Further studies are needed to investigate the association between RHF and different types of heart failure and its implications on clinical practice.
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Song J, Yu T, Yan Q, Zhang Q, Wang L. Association of Hemoglobin to Red Blood Cell Distribution Width-Standard Deviation (RDW-SD) Ratio and 3-Month Readmission in Elderly Chinese Patients with Heart Failure: A Retrospective Cohort Study. Int J Gen Med 2023; 16:303-315. [PMID: 36718147 PMCID: PMC9883988 DOI: 10.2147/ijgm.s396805] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
Purpose Hemoglobin (Hb) and red blood cell distribution width-standard deviation (RDW-SD) have clinical significance in the prognosis of heart failure (HF). Little is known regarding the prognostic value of the Hb/RDW-SD ratio in patients with HF. This study sought to investigate the association between Hb/RDW-SD ratio and HF 3-month readmission in Chinese elderly patients. Patients and Methods The present study was a retrospective cohort study. A total of 1816 HF patients were extracted from the Chinese HF database. A generalized linear model was used to explore the association between Hb/RDW-SD and 3-month readmission in HF. The generalized additive model was used to explore the nonlinear relationship, and a two-piecewise linear regression model was used to find the inflection point. Subgroup analysis explored interactions and whether each subgroup was consistent with the primary outcome direction. Results Result showed Hb/RDW-SD was negatively associated with HF 3-month readmission (OR = 0.70, 95% CI: 0.55 to 0.89, P = 0.0031). A non-linear relationship was detected between Hb/RDW-SD and HF 3-month readmission with two inflection points (1.78 and 2.17). Both Hb/RDW-SD < 1.78 and Hb/RDW-SD > 2.17 showed a significant correlation between them, with corresponding effect values of (OR = 0.38, 95% CI: 0.17 to 0.87, P = 0.0209) and (OR = 0.44, 95% CI: 0.27 to 0.71, P = 0.0007), respectively. Conclusion Hb/RDW-SD is negatively associated with HF 3-month readmission. The relationship between Hb/RDW-SD and HF 3-month readmission is also non-linear. Both Hb/RDW-SD < 1.78 and Hb/RDW-SD > 2.17 were strong negatively associated with HF 3-month readmission.
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Affiliation(s)
- Jikai Song
- Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Tianhang Yu
- North China University of Science and Technology, Tangshan, Hebei Province, People’s Republic of China
| | - Qiqi Yan
- Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Qinggang Zhang
- Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Lihong Wang
- Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province, People’s Republic of China,Correspondence: Lihong Wang, Zhejiang Provincial People’s Hospital, Hangzhou, People’s Republic of China, Tel +86 13666690598, Email
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Chen Y, Li X, Wang S, Miao R, Zhong J. Targeting Iron Metabolism and Ferroptosis as Novel Therapeutic Approaches in Cardiovascular Diseases. Nutrients 2023; 15:nu15030591. [PMID: 36771298 PMCID: PMC9921472 DOI: 10.3390/nu15030591] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Iron functions as an essential micronutrient and participates in normal physiological and biochemical processes in the cardiovascular system. Ferroptosis is a novel type of iron-dependent cell death driven by iron accumulation and lipid peroxidation, characterized by depletion of glutathione and suppression of glutathione peroxidase 4 (GPX4). Dysregulation of iron metabolism and ferroptosis have been implicated in the occurrence and development of cardiovascular diseases (CVDs), including hypertension, atherosclerosis, pulmonary hypertension, myocardial ischemia/reperfusion injury, cardiomyopathy, and heart failure. Iron chelators deferoxamine and dexrazoxane, and lipophilic antioxidants ferrostatin-1 and liproxstatin-1 have been revealed to abolish ferroptosis and suppress lipid peroxidation in atherosclerosis, cardiomyopathy, hypertension, and other CVDs. Notably, inhibition of ferroptosis by ferrostatin-1 has been demonstrated to alleviate cardiac impairments, fibrosis and pathological remodeling during hypertension by potentiating GPX4 signaling. Administration of deferoxamine improved myocardial ischemia/reperfusion injury by inhibiting lipid peroxidation. Several novel small molecules may be effective in the treatment of ferroptosis-mediated CVDs. In this article, we summarize the regulatory roles and underlying mechanisms of iron metabolism dysregulation and ferroptosis in the occurrence and development of CVDs. Targeting iron metabolism and ferroptosis are potential therapeutic strategies in the prevention and treatment of hypertension and other CVDs.
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Affiliation(s)
- Yufei Chen
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xueting Li
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Siyuan Wang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Ran Miao
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Correspondence: (R.M.); (J.Z.)
| | - Jiuchang Zhong
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Correspondence: (R.M.); (J.Z.)
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Role of Iron Deficiency in Heart Failure-Clinical and Treatment Approach: An Overview. Diagnostics (Basel) 2023; 13:diagnostics13020304. [PMID: 36673114 PMCID: PMC9857585 DOI: 10.3390/diagnostics13020304] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The association of chronic heart failure (CHF) and iron deficiency (ID) with or without anemia is frequently encountered in current medical practice and has a negative prognostic impact, worsening patients' exercise capacity and increasing hospitalization costs. Moreover, anemia is common in patients with chronic kidney disease (CKD) and CHF, an association known as cardio-renal anemia syndrome (CRAS) possessing a significantly increased risk of death. AIM This review aims to provide an illustrative survey on the impact of ID in CHF patients-based on physiopathological traits, clinical features, and the correlation between functional and absolute ID with CHF-and the benefit of iron supplementation in CHF. METHOD We selected the most recent publications with important scientific content covering the association of CHF and ID with or without anemia. DISCUSSIONS An intricate physiopathological interplay is described in these patients-decrease in erythropoietin levels, activation of the renin-angiotensin-aldosterone system, systemic inflammation, and increases in hepcidin levels. These mechanisms amplify anemia, CHF, and CKD severity and worsen patients' outcomes. CONCLUSIONS Anemia is frequently encountered in CHF and represents a negative prognostic factor. Data from randomized controlled trials have underlined the administration of intravenous iron therapy (ferric carboxymaltose) as the only viable treatment option, with beneficial effects on quality of life and exercise capacity in patients with ID and systolic heart failure.
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Gurkina AA, Stuklov NI, Kisly ND, Gimadiev RR, Kovalchuk MS. Characteristics of anemia in heart failure: iron metabolism, erythropoietic activity and markers of inflammation. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2023-3332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Aim. To determine the characteristics of erythrocyte parameters, iron metabolism, erythropoiesis, inflammation markers in patients with heart failure (CHF) and anemia.Material and methods. The study included 68 patients with HF to describe the characteristics of anemia (general group). Patients of the general group were divided into 3 subgroups depending on the serum ferritin (SF) and transferrin saturation (TS).Results. Anemia in HF is not always associated with iron deficiency (ID), characterized by inadequate production of erythropoietin, increased levels of C-reactive protein and hepcidin. From the general group of patients, the following were distinguished: absolute ID (43%), functional ID (19%), and non-ID anemia (38%).Conclusion. In the general group of patients with HF, anemia is normochromic, normocytic, characterized by high levels of C-reactive protein, hepcidin, and inadequate production of erythropoietin. Patients with absolute and functional ID do not differ in the main iron metabolism parameters and in general account for 62% (p=0,01). In these two subgroups, iron supplements should be prescribed at further stages.
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Affiliation(s)
| | - N. I. Stuklov
- Peoples’ Friendship University of Russia; National Medical Research Center of Radiology
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Fan C, Wang X, Song X, Sun R, Liu R, Sui W, Jin Y, Wu T, Zhang M. Identification of a Novel Walnut Iron Chelating Peptide with Potential High Antioxidant Activity and Analysis of Its Possible Binding Sites. Foods 2023; 12:foods12010226. [PMID: 36613440 PMCID: PMC9818316 DOI: 10.3390/foods12010226] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Peptide iron chelate is widely regarded as one of the best iron supplements for relieving iron deficiency. In this study, a new type of walnut peptide iron (WP-Fe) chelate was prepared using low molecular weight walnut peptides (WP) as raw materials. Under the conditions of this study, the chelation rate and iron content of the WP-Fe chelate were 71.87 ± 1.60% and 113.11 ± 2.52 mg/g, respectively. Fourier transform infrared spectroscopy (FTIR), zeta potential, amino acid composition, and other structural analysis showed that WP-Fe is formed by the combination of carboxyl, amino and carbonyl with Fe2+. The WP-Fe chelate exhibits a honeycomb-like bulk structure different from that of WP. In addition, we predicted and established the binding model of ferrous ion and WP by molecular docking technology. After chelation, the free radical scavenging ability of the WP-Fe chelate was significantly higher than that of the WP. Overall, the WP-Fe chelate has high iron-binding capacity and antioxidant activity. We believe that peptides from different sources also have better iron binding capacity, and peptide iron chelates are expected to become a promising source of iron supplement and antioxidant activities.
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Affiliation(s)
- Chaozhong Fan
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Xintong Wang
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Xiwang Song
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Ronghao Sun
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Rui Liu
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Wenjie Sui
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Yan Jin
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
| | - Tao Wu
- State Key Laboratory of Food Nutrition and Safety, Food Biotechnology Engineering Research Center of Ministry of Education, College of Food Science and Engineering, Tianjin University of Science & Technology, Tianjin 300457, China
- Correspondence: (T.W.); (M.Z.)
| | - Min Zhang
- China-Russia Agricultural Processing Joint Laboratory, Tianjin Agricultural University, Tianjin 300384, China
- Correspondence: (T.W.); (M.Z.)
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Pistelli L, Parisi F, Correale M, Cocuzza F, Campanella F, de Ferrari T, Crea P, De Sarro R, La Cognata O, Ceratti S, Recupero T, Ruocco G, Palazzuoli A, Imbalzano E, Dattilo G. Gliflozins: From Antidiabetic Drugs to Cornerstone in Heart Failure Therapy-A Boost to Their Utilization and Multidisciplinary Approach in the Management of Heart Failure. J Clin Med 2023; 12:jcm12010379. [PMID: 36615178 PMCID: PMC9820867 DOI: 10.3390/jcm12010379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/11/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
Heart failure (HF) is a complex, multifactorial, progressive clinical condition affecting 64.3 million people worldwide, with a strong impact in terms of morbidity, mortality and public health costs. In the last 50 years, along with a better understanding of HF physiopathology and in agreement with the four main models of HF, many therapeutic options have been developed. Recently, the European Society of Cardiology (ESC) HF guidelines enthusiastically introduced inhibitors of the sodium-glucose cotransporter (SGLT2i) as first line therapy for HF with reduced ejection fraction (HFrEF) in order to reduce hospitalizations and mortality. Despite drugs developed as hypoglycemic agents, data from the EMPA-REG OUTCOME trial encouraged the evaluation of the possible cardiovascular effects, showing SGLT2i beneficial effects on loading conditions, neurohormonal axes, heart cells' biochemistry and vascular stiffness, determining an improvement of each HF model. We want to give a boost to their use by increasing the knowledge of SGLT2-I and understanding the probable mechanisms of this new class of drugs, highlighting strengths and weaknesses, and providing a brief comment on major trials that made Gliflozins a cornerstone in HF therapy. Finally, aspects that may hinder SGLT2-i widespread utilization among different types of specialists, despite the guidelines' indications, will be discussed.
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Affiliation(s)
- Lorenzo Pistelli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Francesca Parisi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Michele Correale
- Cardiothoracic Department, University Hospital Policlinico Riuniti, 71100 Foggia, Italy
- Correspondence: ; Tel.: +39-3282918518
| | - Federica Cocuzza
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Francesca Campanella
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Tommaso de Ferrari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Pasquale Crea
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Rosalba De Sarro
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Olga La Cognata
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Simona Ceratti
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Tonino Recupero
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Gaetano Ruocco
- Cardiology Unit, Riuniti of Valdichiana Hospitals, USL-SUD-EST Toscana, 53045 Montepulciano, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte Hospital, University of Siena, 53018 Siena, Italy
| | - Egidio Imbalzano
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy
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Packer M. Potential Interactions When Prescribing SGLT2 Inhibitors and Intravenous Iron in Combination in Heart Failure. JACC. HEART FAILURE 2023; 11:106-114. [PMID: 36396554 DOI: 10.1016/j.jchf.2022.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Abstract
In patients with heart failure, sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to decrease hepcidin and ferritin and increase transferrin receptor protein, changes that are typically indicative of worsening absolute iron deficiency, as would be seen with poor dietary intake or gastrointestinal bleeding, neither of which is provoked by SGLT2 inhibitors. Therefore, 2 alternative conceptual frameworks may explain the observed pattern of changes in iron homeostasis proteins. According to the "cytosolic iron depletion hypothesis," the effect of SGLT2 inhibitors to decrease hepcidin and ferritin and increase transferrin receptor is related to a decline in cytosolic Fe2+ that occurs after drug-induced erythropoietin-related increase in iron use. Erythropoietin-mimetics (eg, darbepoietin) elicit this type of iron-deficiency pattern of response, and it is typically accompanied by erythropoietin resistance that is alleviated by intravenous iron supplementation. In contrast, according to the "cytosolic iron repletion hypothesis," the effect of SGLT2 inhibitors to decrease hepcidin and ferritin and increase transferrin receptor represents a direct action of these drugs: 1) to reverse inflammation-related increases in hepcidin and ferritin, and, thus, alleviate functional blocks on iron utilization; and 2) to increase in sirtuin-1 signaling, which suppresses hepcidin, accelerates the degradation of ferritin, and up-regulates transferrin receptor protein. Through either or both mechanisms, direct suppression of hepcidin and ferritin would be expected to increase cytosolic Fe2+, thus allowing an unattenuated erythrocytic response to erythropoietin without the need for intravenous iron supplementation. The totality of clinical evidence supports the "cytosolic iron repletion hypothesis" because SGLT2 inhibitors elicit a full and sustained erythrocytosis in response to erythropoietin, even in overtly iron-deficient patients and in the absence of intravenous iron therapy. Therefore, the emergence of an iron-deficiency pattern of response during SGLT2 inhibition does not reflect worsening iron stores that are in need of replenishment, but instead, represents potential alleviation of a state of inflammation-related functional iron deficiency that is commonly seen in patients with chronic heart failure. Treatment with intravenous iron may be unnecessary and theoretically deleterious.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, Texas, USA; Imperial College, London, United Kingdom.
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126
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Yan C, Li R, Zhang J, Zhang L, Yang M, Zhang Q, Li H. Association of myocardial iron deficiency based on T2* CMR with the risk of mild left ventricular dysfunction in HIV-1-infected patients. Front Cardiovasc Med 2023; 10:1132893. [PMID: 37123480 PMCID: PMC10130653 DOI: 10.3389/fcvm.2023.1132893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
Objectives This study sought to noninvasively determine myocardial iron levels in HIV-1-infected patients using CMR and explore the association between T2* values and mild left ventricular systolic dysfunction (LVSD). Methods This prospective study was conducted from June 2019 to July 2021. HIV-1-infected adults and healthy controls were consecutively enrolled for CMR exam. CMR exam included the assessment of myocardium iron content (T2*), cardiac function (cine), inflammation (T2), and fibrosis (through extracellular volume fraction [ECV] and late gadolinium enhancement [LGE]) measurements. Mild LVSD is defined as a left ventricular ejection fraction (LVEF) between 40% and 49%. Results Of 47 HIV-1-infected patients enrolled, 12 were diagnosed with mild LVSD (HIV-1+/LEVF+) and 35 were diagnosed with preserved LV function (HIV-1+/LEVF-). Compared with healthy controls, HIV-1-infected patients displayed higher T2*, T1, T2, ECV values and lower global circumferential strain (GCS) and global radial strain (GRS) (all P < 0.05). However, between patients with and without mild LVSD, only the T2* values and ECV (all P <0.05) were different. The association between increased T2* values (>26 ms) and mild LVSD remained significant after adjusting for the established univariate predictors (ECV >32.9%, T1 values >1336 ms) of mild LVSD (odds ratio [OR], 10.153; 95% confidence interval [CI] 1.565-65.878, P = 0.015). Conclusions Myocardial T2* values were elevated in HIV-1-infected patients, supporting the notion that ID was associated with mild LVSD. Our findings highlight the potential for ID in HIV-1-infected patients as an auxiliary biomarker to monitor the course of LVSD.
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Affiliation(s)
- Chengxi Yan
- Department of Radiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ruili Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Radiology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jiannan Zhang
- Department of Radiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Li Zhang
- Department of Radiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Minglei Yang
- Department of Algorithm, Artificial Intelligene Innovation Center (AIIC), Midea Group, Beijing, China
| | - Qiujuan Zhang
- Department of Radiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Correspondence: Hongjun Li Qiujuan Zhang
| | - Hongjun Li
- Department of Radiology, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Correspondence: Hongjun Li Qiujuan Zhang
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McEwan P, Ponikowski P, Shiri T, Rosano GMC, Coats AJS, Dorigotti F, Ramirez de Arellano A, Jankowska EA. Clinical and economic impact of ferric carboxymaltose treatment for iron deficiency in patients stabilized following acute heart failure: a multinational study. J Med Econ 2023; 26:51-60. [PMID: 36476095 DOI: 10.1080/13696998.2022.2155375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To estimate clinical events and evaluate the financial implications of introducing ferric carboxymaltose (FCM) to treat iron deficiency (ID) at discharge in patients hospitalized for acute heart failure (AHF) with left ventricular ejection fraction (LVEF) <50% in the UK, Switzerland and Italy. METHODS A decision analytic cost-offset model was developed to evaluate the costs associated with introducing FCM for all eligible patients in three countries compared to a world without FCM, over a five-year time horizon. Data from AFFIRM-AHF clinical trial were used to model clinical outcomes, using an established cohort state-transition Markov model. Country-specific prevalence estimates were derived using data from real-world studies to extrapolate number of events and consequent cost totals to the population at risk on a national scale. RESULTS The cost-offset modeling demonstrated that FCM is projected to be a cost-saving intervention in all three country settings over a five-year time horizon. Savings were driven primarily by reduced hospitalizations and avoided cardiovascular deaths, with net cost savings of -£14,008,238, -CHF25,456,455 and -€105,295,146 incurred to the UK, Switzerland and Italy, respectively. LIMITATIONS Although AFFIRM-AHF was a multinational trial, efficacy data per country was not sufficiently large to enable country-specific analysis, therefore overall clinical parameters have been assumed to apply to all countries. CONCLUSIONS This study provides further evidence of the potential cost savings achievable by treating ID with FCM at discharge in patients hospitalized for AHF with LVEF <50%. The value of FCM treatment within the healthcare systems of the UK, Switzerland and Italy was demonstrated even within a limited time frame of one year, with consistent cost savings indicated over a longer term.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Giuseppe M C Rosano
- Cardiovascular and Cell Sciences Research Institute, St George's University, London, UK
| | | | | | | | - Ewa A Jankowska
- Institute of Heart Diseases, University Hospital, Wrocław, Poland
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Machida T, Iizuka K. [Consideration of the Characteristics of Oral Iron Preparations from the Viewpoint of the Mechanism of Nausea and Vomiting]. YAKUGAKU ZASSHI 2023; 143:599-606. [PMID: 37394455 DOI: 10.1248/yakushi.23-00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
The nausea and vomiting that occur as a result of oral iron administration for the treatment of iron-deficiency anemia (IDA) can cause significant physical and emotional stress in patients. Because iron is absorbed from the intestine as ferrous iron, the most widely used treatment for IDA is oral ferrous agents. However, ferrous forms are more toxic than ferric forms because ferrous forms readily generate free radicals. A randomized, double-blind, active-controlled, multicenter non-inferiority study conducted in Japan showed that ferric citrate hydrate (FC) was just as effective as sodium ferrous citrate (SF) in the treatment of IDA, with a lower incidence of adverse reactions such as nausea and vomiting compared with SF. Animal studies have shown that chemotherapy-induced nausea and vomiting (CINV) involves the release of 5-hydroxytryptamine from enterochromaffin cells by free radicals, and that some chemotherapeutic agents cause hyperplasia of these cells. Enterochromaffin cells also contain substance P, which is known to be also closely related to CINV. We found that administration of SF to rats causes hyperplasia of enterochromaffin cells in the small intestine, whereas FC has no effect on enterochromaffin cells. Oral iron agents may induce nausea and vomiting via the effect of ferrous iron on reactive oxygen species production in the intestine and subsequent enterochromaffin cell hyperplasia. Further research to elucidate the detailed mechanism of enterochromaffin cell hyperplasia induced by ferrous iron preparations is needed to develop a treatment for iron deficiency anemia that causes less gastrointestinal damage.
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Affiliation(s)
- Takuji Machida
- Department of Pharmacological Sciences, School of Pharmaceutical Sciences, Health Sciences University of Hokkaido
| | - Kenji Iizuka
- Department of Pharmacological Sciences, School of Pharmaceutical Sciences, Health Sciences University of Hokkaido
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The complex pathophysiology of cardiac cachexia: A review of current pathophysiology and implications for clinical practice. Am J Med Sci 2023; 365:9-18. [PMID: 36055378 DOI: 10.1016/j.amjms.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 04/09/2022] [Accepted: 08/24/2022] [Indexed: 01/04/2023]
Abstract
Cardiac cachexia is a muscle wasting process that often develops in those with chronic heart failure resulting in weight loss, low levels of physical activity, reduced quality of life, and is associated with a poor prognosis. The pathology of cardiac cachexia is complex with new evidence emerging that implicates several body systems. This review describes the pathophysiology associated with cardiac cachexia and addresses: 1) hormonal changes- neurohormonal abnormalities and metabolic hormone imbalance; 2) mechanisms of muscle wasting in cardiac cachexia, and the integral mechanisms between changed hormones due to cardiac cachexia and muscle wasting processes, and 3) associated abnormalities of gastrointestinal system that contribute to cardiac cachexia. These pleiotropic mechanisms demonstrate the intricate interplay between the affected systems and account for why cardiac cachexia is difficult to manage clinically. This review summarises current pathophysiology of cardiac cachexia and highlights symptoms of cardiac cachexia, implications for clinical practice and research gaps.
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de Oliveira ABM, Luchiari B, Bonilha I, Barreto J, Nogueira ACC, Ceniccola GD, Polanczyk CA, Sposito AC, de Carvalho LSF. Aspirin in primary prevention and the risk of heart failure: a systematic review and meta‐analysis of controlled trials. ESC Heart Fail 2022; 10:1488-1491. [PMID: 36572648 PMCID: PMC10053165 DOI: 10.1002/ehf2.14269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Ana Beatrice Magalhães de Oliveira
- Laboratory of Data for Quality of Care and Outcomes Research (LaDa:QCOR) Universidade Católica de Brasília QS 07, Lote 01, Taguatinga Sul Brasília DF 71966‐700 Brazil
- Escola Superior de Ciências da Saúde (ESCS) Brasilia Brazil
| | - Beatriz Luchiari
- Laboratory of Atherosclerosis and Vascular Biology UNICAMP Campinas Brazil
| | - Isabella Bonilha
- Laboratory of Atherosclerosis and Vascular Biology UNICAMP Campinas Brazil
| | | | - Ana Claudia Cavalcante Nogueira
- Laboratory of Data for Quality of Care and Outcomes Research (LaDa:QCOR) Universidade Católica de Brasília QS 07, Lote 01, Taguatinga Sul Brasília DF 71966‐700 Brazil
- Escola Superior de Ciências da Saúde (ESCS) Brasilia Brazil
- Aramari Apo Institute for Education and Clinical Research SCN Quadra 02 Bloco D, Entrada B Sala 1107 Brasília DF 70.712‐903 Brazil
| | | | | | - Andrei Carvalho Sposito
- Escola Superior de Ciências da Saúde (ESCS) Brasilia Brazil
- Laboratory of Atherosclerosis and Vascular Biology UNICAMP Campinas Brazil
| | - Luiz Sérgio Fernandes de Carvalho
- Laboratory of Data for Quality of Care and Outcomes Research (LaDa:QCOR) Universidade Católica de Brasília QS 07, Lote 01, Taguatinga Sul Brasília DF 71966‐700 Brazil
- Escola Superior de Ciências da Saúde (ESCS) Brasilia Brazil
- Laboratory of Atherosclerosis and Vascular Biology UNICAMP Campinas Brazil
- Aramari Apo Institute for Education and Clinical Research SCN Quadra 02 Bloco D, Entrada B Sala 1107 Brasília DF 70.712‐903 Brazil
- Clarity Healthcare Intelligence Marginal da Av Anhanguera, n 480 Jundiai SP 13087‐460 Brazil
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Nakagawa S, Takahama H, Hoshino K, Yanagi Y, Irie Y, Moriuchi K, Amano M, Okada A, Amaki M, Kanzaki H, Kusano K, Noguchi T, Yasuda S, Izumi C. Prevalence and predictive factors for clinical outcomes of isolated functional tricuspid regurgitation. J Cardiol 2022:S0914-5087(22)00325-2. [PMID: 36565994 DOI: 10.1016/j.jjcc.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/23/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND A substantial number of patients have functional tricuspid regurgitation (TR). Isolated functional TR has been undertreated and may be a next target for transcatheter intervention. However, the prevalence, patient characteristics, and predictive factors for prognosis remain unclear. METHODS From patients in our echocardiographic database (N = 64,242), we extracted those with severe TR and examined prognosis according to etiologies of TR. Thereafter, we focused on two types of isolated functional TR; progressive TR after left-sided valve surgery (postoperative TR) and TR associated with annular dilatation (atrial TR). Composite adverse events were defined as all-cause death or hospitalization for heart failure (HF). RESULTS Of 1001 patients with severe TR (median age, 77 years; female, 58 %), 71 (7 %) patients were classified as postoperative TR, and 149 (15 %) as atrial TR. During the follow-up period (median, 1.6 years), 30 composite adverse events were observed (postoperative TR, n = 14; atrial TR, n = 16). Composite adverse events were less frequent in these two types of functional TR than TR of other etiologies. Multivariate analysis adjusted for age and sex showed that a history of hospitalization for HF, history of cardiac surgery >2 times, loop diuretics, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, platelet level, left ventricular ejection fraction, and right ventricular dimension were associated with clinical adverse events (p < 0.05), while B-type natriuretic peptide level was not. CONCLUSIONS A considerable number of patients had isolated functional TR. Extracardiac factors such as renal function, hemoglobin and platelet are important in determining clinical outcomes.
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Affiliation(s)
- Shoko Nakagawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Keiji Hoshino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshiki Yanagi
- Department of Clinical Physiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Irie
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenji Moriuchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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McDonagh TA, Bromage DI, Cannata A. Intravenous iron passes another endurance test in heart failure. Lancet 2022; 400:2158-2159. [PMID: 36347266 DOI: 10.1016/s0140-6736(22)02180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Theresa A McDonagh
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK.
| | - Daniel I Bromage
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK
| | - Antonio Cannata
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK
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133
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Kim M, Lee CJ, Kang H, Son N, Bae S, Seo J, Oh J, Rim S, Jung IH, Choi E, Kang S. Red cell distribution width as a prognosticator in patients with heart failure. ESC Heart Fail 2022; 10:834-845. [PMID: 36460487 PMCID: PMC10053156 DOI: 10.1002/ehf2.14231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS Increased red cell distribution width (RDW) is a poor prognostic factor in patients with heart failure (HF). However, only a few large-scale studies have identified the clinical utility of RDW after adjusting for covariates affecting RDW. METHODS AND RESULTS From January 2010 to April 2021, we retrospectively enrolled patients diagnosed with HF from three referral hospitals with available RDW data (taken within 3 months of HF diagnosis) using an integrated clinical data system. Patients with an ejection fraction (EF) < 50% or HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology) score ≥ 2 without severe valvular heart disease or coronary revascularization were enrolled. The primary endpoint was all-cause mortality, and cardiovascular mortality was also collected. Multivariable Cox regression analysis and stabilized inverse probability of treatment weighting (IPTW) were used to identify any association between RDW and all-cause death by balancing covariates or compounding factors. The global χ2 score was calculated and discrimination analysis was performed to evaluate the incremental value of RDW in predicting prognosis. Among the 6599 participants enrolled in this study, 1256 (19.0%) cases of all-cause death occurred, and the median duration of follow-up was 887 (interquartile range 351-1589) days. Elevated RDW at the initial diagnosis was associated with poor prognosis [cumulative incidence: 819 (30.2%) vs. 437 (11.2%), relative risk 1.58, 95% confidence interval (CI) 1.51-1.67, log-rank P < 0.001]. Multivariable Cox analysis showed that elevated RDW was a poor prognostic factor for the primary endpoint [hazard ratio (HR) 1.11, 95% CI 1.06-1.16, P < 0.001], independent of clinical risk factors, N-terminal pro-brain natriuretic peptide (NT-proBNP), and EF, which was concordant with the stabilized IPTW (HR 1.29, 95% CI 1.10-1.49, P < 0.001). Adding RDW to model composed of traditional risk factors, NT-proBNP, and echocardiographic parameters showed incremental prognostic value for predicting poor prognosis (area under the receiver operating characteristic curve, 0.799-0.826; P < 0.001). CONCLUSIONS Increased RDW at the time of diagnosis is associated with poor prognosis in patients with HF, independent of clinical risk factors, such as NT-proBNP, and echocardiographic parameters. Therefore, RDW may aid in the management of these patients beyond traditional risk factors.
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Affiliation(s)
- Minkwan Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Yongin Severance Hospital Yonsei University College of Medicine 363 Dongbaekjukjeon‐daero, Giheung‐gu Yongin‐si Gyeonggi‐do 16995 Republic of Korea
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Severance Hospital Yonsei University College of Medicine Seoul Republic of Korea
| | - Hye‐Jin Kang
- Department of Internal Medicine, Yongin Severance Hospital Yonsei University College of Medicine Yongin‐si Gyeonggi‐do Republic of Korea
| | - Nak‐Hoon Son
- Department of Statistics Keimyung University Daegu Republic of Korea
| | - SungA Bae
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Yongin Severance Hospital Yonsei University College of Medicine 363 Dongbaekjukjeon‐daero, Giheung‐gu Yongin‐si Gyeonggi‐do 16995 Republic of Korea
| | - Jiwon Seo
- Division of Cardiology, Department of Internal Medicine, Heart Center, Gangnam Severance Hospital Yonsei University College of Medicine 211 Eonju‐ro, Gangnam‐gu Seoul 06273 Republic of Korea
| | - Jaewon Oh
- Division of Cardiology, Department of Internal Medicine, Severance Hospital Yonsei University College of Medicine Seoul Republic of Korea
| | - Se‐Joong Rim
- Division of Cardiology, Department of Internal Medicine, Heart Center, Gangnam Severance Hospital Yonsei University College of Medicine 211 Eonju‐ro, Gangnam‐gu Seoul 06273 Republic of Korea
| | - In Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Yongin Severance Hospital Yonsei University College of Medicine 363 Dongbaekjukjeon‐daero, Giheung‐gu Yongin‐si Gyeonggi‐do 16995 Republic of Korea
| | - Eui‐Young Choi
- Division of Cardiology, Department of Internal Medicine, Heart Center, Gangnam Severance Hospital Yonsei University College of Medicine 211 Eonju‐ro, Gangnam‐gu Seoul 06273 Republic of Korea
| | - Seok‐Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital Yonsei University College of Medicine Seoul Republic of Korea
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134
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Management of Iron Deficiency in Heart Failure: A Review of Evidence. J Cardiovasc Pharmacol 2022; 80:755-768. [PMID: 36027595 DOI: 10.1097/fjc.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
ABSTRACT Iron deficiency is common in patients with heart failure and has been associated with worse outcomes, including increases in mortality, disease progression, and hospitalizations. As such, several studies have evaluated the role of iron supplementation in mitigating these risks. Evidence for the role of intravenous iron in improving exercise capacity, quality of life, and hospitalizations is promising, although the benefits of oral iron remain less clear. This review will evaluate the literature surrounding iron supplementation in heart failure and provide practical recommendations for its management.
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135
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Kim WD, Kim BS, Shin JH. Association of anaemia with long-term mortality among patients with hypertensive crisis in the emergency department. Ann Med 2022; 54:2752-2759. [PMID: 36205691 PMCID: PMC9553135 DOI: 10.1080/07853890.2022.2128209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Anaemia is frequent in patients with cardiovascular disease and is significantly associated with poor prognosis. However, the prognostic significance of anaemia in hypertensive crisis remains unknown. We conducted this study to determine whether anaemia is a risk factor for all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED). METHODS This retrospective study included patients who visited the ED between 2016 and 2019 for hypertensive crisis, which was defined as systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg. A total of 5,512 patients whose serum haemoglobin levels were checked were included in this study and were classified into three groups according to their serum haemoglobin levels at admission to the ED: moderate/severe anaemia (haemoglobin <11 g/dL), mild anaemia (haemoglobin 11 to <13 g/dL in men and 11 to <12 g/dL in women), and non-anaemia (haemoglobin ≥13 g/dL in men and ≥12 g/dL in women). RESULTS Among 5,512 patients, 665 (12.1%) and 668 (12.1%) were classified into the moderate/severe anaemia and mild anaemia groups, respectively. The three-year all-cause mortality rates in the moderate/severe anaemia, mild anaemia, and non-anaemia groups were 46.0, 29.2, and 12.0%, respectively. After accounting for relevant covariates, patients with moderate/severe anaemia group (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.75-2.64) and mild anaemia group (HR, 1.32; 95% CI, 1.07-1.63) had a higher risk of 3-year all-cause mortality than the non-anaemia group. CONCLUSION Anaemia is independently associated with 3-year all-cause mortality in patients with hypertensive crisis. A comprehensive therapeutic approach through more in-depth examination and close follow up are required for patients with hypertensive crisis with anaemia.KEY MESSAGESAnaemia is independently associated with 3-year all-cause mortality in patients with hypertensive crisis.A comprehensive therapeutic approach through more in-depth examination and close follow up are required for patients with hypertensive crisis with anaemia.
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Affiliation(s)
- Wook-Dong Kim
- Department of Internal Medicine, Division of Cardiology, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Byung Sik Kim
- Department of Internal Medicine, Division of Cardiology, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Jeong-Hun Shin
- Department of Internal Medicine, Division of Cardiology, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
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136
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Packer M. How can sodium-glucose cotransporter 2 inhibitors stimulate erythrocytosis in patients who are iron-deficient? Implications for understanding iron homeostasis in heart failure. Eur J Heart Fail 2022; 24:2287-2296. [PMID: 36377108 PMCID: PMC10100235 DOI: 10.1002/ejhf.2731] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022] Open
Abstract
Many patients with heart failure have an iron-deficient state, which can limit erythropoiesis in erythroid precursors and ATP production in cardiomyocytes. Yet, treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitors produces consistent increases in haemoglobin and haematocrit, even in patients who are iron-deficient before treatment, and this effect remains unattenuated throughout treatment even though SGLT2 inhibitors further aggravate biomarkers of iron deficiency. Heart failure is often accompanied by systemic inflammation, which activates hepcidin, thus impairing the duodenal absorption of iron and the release of iron from macrophages and hepatocytes, leading to a decline in circulating iron. Inflammation and oxidative stress also promote the synthesis of ferritin and suppress ferritinophagy, thus impairing the release of intracellular iron stores and leading to the depletion of bioreactive cytosolic Fe2+ . By alleviating inflammation and oxidative stress, SGLT2 inhibitors down-regulate hepcidin, upregulate transferrin receptor protein 1 and reduce ferritin; the net result is to increase the levels of cytosolic Fe2+ available to mitochondria, thus enabling the synthesis of heme (in erythroid precursors) and ATP (in cardiomyocytes). The finding that SGLT2 inhibitors can induce erythrocytosis without iron supplementation suggests that the abnormalities in iron diagnostic tests in patients with mild-to-moderate heart failure are likely to be functional, rather than absolute, that is, they are related to inflammation-mediated trapping of iron by hepcidin and ferritin, which is reversed by treatment with SGLT2 inhibitors. An increase in bioreactive cytosolic Fe2+ is also likely to augment mitochondrial production of ATP in cardiomyocytes, thus retarding the progression of heart failure. These effects on iron metabolism are consistent with (i) proteomics analyses of placebo-controlled trials, which have shown that biomarkers of iron homeostasis represent the most consistent effect of SGLT2 inhibitors; and (ii) statistical mediation analyses, which have reported striking parallelism of the effect of SGLT2 inhibitors to promote erythrocytosis and reduce heart failure events.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular InstituteDallasTXUSA
- Imperial CollegeLondonUK
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137
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Kaur G, Lau E. Sex differences in heart failure with preserved ejection fraction: From traditional risk factors to sex-specific risk factors. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221140209. [PMID: 36448661 PMCID: PMC9720805 DOI: 10.1177/17455057221140209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Heart failure with preserved ejection fraction has a higher prevalence in women versus men. There are several proposed mechanisms to explain this sex discrepancy including differences in cardiovascular adaptation to comorbidities and potential underlying etiologic mechanisms. In this review, we summarize sex differences in traditional risk factors, such as obesity, diabetes, hypertension, and coronary artery disease, which contribute to the development of heart failure with preserved ejection fraction in women. Furthermore, we explore female-specific risk factors, such as sex hormones, adverse pregnancy outcomes, and other reproductive factors, which may explain the predominance of heart failure with preserved ejection fraction in women. Beyond sex differences in risk factors, there are also significant sex differences in outcomes with women reporting lower quality of life but overall better survival versus men. Finally, while treatment options for patients with heart failure with preserved ejection fraction are still limited, sex differences have also been reported for the available therapies, with suggestion of preferential benefit of specific heart failure with preserved ejection fraction therapies in women. Further work is required to better understand sex differences in heart failure with preserved ejection fraction, including deeper understanding of pathophysiological mechanisms, derivation of more accurate risk stratification models, and increased representation of women in clinical trials.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Emily Lau
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA,Emily Lau, Division of Cardiology, Massachusetts General Hospital, 185 Cambridge Street, CPZN #3206, Boston, MA 02114, USA.
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138
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Effect of Ferric Carboxymaltose Supplementation in Patients with Heart Failure with Preserved Ejection Fraction: Role of Attenuated Oxidative Stress and Improved Endothelial Function. Nutrients 2022; 14:nu14235057. [PMID: 36501086 PMCID: PMC9740330 DOI: 10.3390/nu14235057] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Both clinical and experimental evidence shows that iron deficiency (ID) correlates with an increased incidence of heart failure (HF). Moreover, data on iron supplementation demonstrating a beneficial effect in subjects with HF have mostly been collected in patients undergoing HF with reduced ejection fraction (HFrEF). Relatively poor data, however, exist on the potential of iron supplementation in patients with HF with preserved ejection fraction (HFpEF). Here, we report on data emerging from a multicentric, double-blind, randomized, placebo-controlled study investigating the effect of IV supplementation with a placebo or ferric carboxymaltose (FCM) on 64 subjects with HFpEF. ID was detected by the measurement of ferritin levels. These data were correlated with cardiac performance measurements derived from a 6 min walking test (6MWT) and with echocardiographic determinations of diastolic function. Moreover, an EndoPAT analysis was performed to correlate cardiac functionality with endothelial dysfunction. Finally, the determination of serum malondialdehyde (MDA) was performed to study oxidative stress biomarkers. These measurements were carried out before and 8 weeks after starting treatment with a placebo (100 mL of saline given i.v. in 10 min; n = 32) or FCM at a dose of 500 mg IV infusion (n = 32), which was given at time 0 and repeated after 4 weeks. Our data showed that a condition of ID was more frequently associated with impaired diastolic function, worse 6MWT and endothelial dysfunction, an effect that was accompanied by elevated MDA serum levels. Treatment with FCM, compared to the placebo, improved ferritin levels being associated with an improved 6MWT, enhanced cardiac diastolic function and endothelial reactivity associated with a significant reduction in MDA levels. In conclusion, this study confirmed that ID is a frequent comorbidity in patients with HFpEF and is associated with reduced exercise capacity and oxidative stress-related endothelial dysfunction. Supplementation with FCM determines a significant improvement in diastolic function and the exercise capacity of patients with HFpEF and is associated with an enhanced endothelial function and a reduced production of oxygen radical species.
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139
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Nakamaru R, Shiraishi Y, Sandhu AT, Heidenreich PA, Shoji S, Kohno T, Takei M, Nagatomo Y, Nakano S, Kohsaka S, Yoshikawa T. Cardiovascular vs. non-cardiovascular deaths after heart failure hospitalization in young, older, and very old patients. ESC Heart Fail 2022; 10:673-684. [PMID: 36436825 PMCID: PMC9871708 DOI: 10.1002/ehf2.14245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS The long-term outcome in patients with heart failure (HF) after hospitalization may vary substantially depending on their age and left ventricular ejection fraction (LVEF). We aimed to assess the relative rates of cardiovascular death (CVD) and non-CVD based on the age and how the rates differ under the updated LVEF classification system. METHODS AND RESULTS Consecutively registered hospitalized patients with HF (N = 3558; 39.7% women with a mean age of 73.9 ± 13.3 years) were followed for a median of 2 (interquartile range, 0.8-3.1) years. The CVDs and non-CVDs were evaluated based on age [young (<65 years), older (65-84 years), and very old (≥85 years)] and LVEF classification [HF with preserved EF (HFpEF; LVEF ≥50%) and non-HFpEF (LVEF <50%)]. The adverse clinical events were adjudicated independently by a central committee. Overall, 1505 (42.3%) had HFpEF [young: n = 182 (12.1%), older: n = 894 (59.4%), very old: n = 429 (28.5%)], and 2053 (57.7%) had non-HFpEF [young: n = 575 (28.0%), older: n = 1159 (56.5%), very old: n = 319 (15.5%)]. During the follow-up, the crude incidence of all-cause death was higher in non-HFpEF than in HFpEF across all age groups (non-HFpEF vs. HFpEF, young: 10.4% vs. 5.5%, log-rank P = 0.10; older: 26.6% vs. 20.9%, log-rank P = 0.002; very old: 36.7% vs. 31.7%, log-rank P = 0.043). CVDs accounted for more than half of all deaths in non-HFpEF (young 65.0%, older 64.2%, and very old 55.6%), whereas the proportion of CVDs remained less than half in HFpEF (young 50.0%, older 41.2%, very old 38.2%). HF readmission was associated with subsequent all-cause death in non-HFpEF [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.41-2.09, P < 0.001], but not in HFpEF (HR: 1.12, 95% CI: 0.87-1.43, P = 0.39). CONCLUSIONS The probability of a non-CVD increases in both LVEF categories with advancing age, but that it is greater in the HFpEF category. The findings indicate that mitigating CV-related outcomes alone may be insufficient for treating HF in older population, particularly in the HFpEF category.
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Affiliation(s)
- Ryo Nakamaru
- Department of CardiologyKeio University School of MedicineTokyoJapan,Department of Healthcare Quality AssessmentThe University of TokyoTokyoJapan
| | | | - Alexander T. Sandhu
- Division of Cardiology, Department of MedicineStanford UniversityStanfordCAUSA
| | - Paul A. Heidenreich
- Division of Cardiology, Department of MedicineStanford UniversityStanfordCAUSA
| | - Satoshi Shoji
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Takashi Kohno
- Department of Cardiovascular MedicineKyorin University Faculty of MedicineTokyoJapan
| | - Makoto Takei
- Department of CardiologySaiseikai Central HospitalTokyoJapan
| | - Yuji Nagatomo
- Department of CardiologyNational Defense Medical CollegeTokorozawaJapan
| | - Shintaro Nakano
- Department of CardiologySaitama Medical University, International Medical CenterSaitamaJapan
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
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140
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Del Pinto R, Ferri C. Iron deficiency in heart failure: diagnosis and clinical implications. Eur Heart J Suppl 2022; 24:I96-I99. [PMID: 36380788 PMCID: PMC9653155 DOI: 10.1093/eurheartjsupp/suac080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Iron deficiency is a widely prevalent finding in patients with heart failure, observed on average in 50% of outpatients and up to 80% of acute patients, regardless of the ejection fraction and the presence of anaemia, being an independent predictor of worst functional capacity and reduced survival. The definition of iron deficiency in heart failure considers the state of chronic inflammation that characterizes the pathology, recognizing a discriminating role for transferrin saturation. The studies conducted so far, which focused on the patient with heart failure with at least moderately reduced ejection fraction, have shown clinical benefit with intravenous supplementation of ferric carboxymaltose in terms of functional capacity, quality of life, laboratory markers of disease and inflammation, and possible reduction of re-hospitalizations, but not in terms of mortality. Based on this evidence, guidelines recommend intravenous ferric carboxymaltose in decompensated and iron-deficient patients, while research is at work to investigate the clinical impact of supplementation in contexts not yet examined, such as that of decompensation in patients with heart failure and preserved ejection fraction.
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Affiliation(s)
- Rita Del Pinto
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L’Aquila
| | - Claudio Ferri
- UOC Internal Medicine and Nephrology and ESH Center of Excellence for Arterial Hypertension and Cardiovascular Prevention—S. Salvatore Regional Hospital , L’Aquila
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141
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The role of iron in chronic inflammatory diseases: from mechanisms to treatment options in anemia of inflammation. Blood 2022; 140:2011-2023. [PMID: 35994752 DOI: 10.1182/blood.2021013472] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
Anemia of inflammation (AI) is a highly prevalent comorbidity in patients affected by chronic inflammatory disorders, such as chronic kidney disease, inflammatory bowel disease, or cancer, that negatively affect disease outcome and quality of life. The pathophysiology of AI is multifactorial, with inflammatory hypoferremia and iron-restricted erythropoiesis playing a major role in the context of disease-specific factors. Here, we review the recent progress in our understanding of the molecular mechanisms contributing to iron dysregulation in AI, the impact of hypoferremia and anemia on the course of the underlying disease, and (novel) therapeutic strategies applied to treat AI.
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142
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Zhou J, Zhao R, Wang D, Gao Q, Zhao D, Ouyang B, Hao L, Peng X. Sex-Specific Association Between Iron Status and the Predicted 10-Year Risk for Atherosclerotic Cardiovascular Disease in Hypertensive Patients. Biol Trace Elem Res 2022; 200:4594-4607. [PMID: 35067842 PMCID: PMC9492579 DOI: 10.1007/s12011-021-03060-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/10/2021] [Indexed: 12/20/2022]
Abstract
Serum ferritin (SF) and haemoglobin (Hb) are widely used in clinical practice to assess iron status. Studies exploring the relationship of SF and Hb with atherosclerotic cardiovascular disease (ASCVD) risk have yielded conflicting results, and some indicated sex specificity. Hypertensive patients have abnormal iron status. However, research on patients with hypertension is limited. We aim to investigate the sex-specific links of SF and Hb with the predicted 10-year ASCVD risk in hypertensive patients. This cross-sectional study included 718 hypertensive men and 708 hypertensive women. The predicted 10-year ASCVD risk was calculated based on the China-PAR equation. The dose-response curves were illustrated by fitting linear and quadratic models. In hypertensive men, the iron status fits for a quadratic model for ASCVD risk, showing a U-shape. After adjusting for potential confounding factors, the regression coefficients and 95% confidence intervals (95% CI) across tertile of SF were 0.0 (reference), - 0.99 (- 1.65, - 0.33) and - 0.22 (- 0.88, 0.44), and of Hb were 0.0 (reference), - 0.74 (- 1.41, - 0.08) and - 0.77 (- 1.46, - 0.08). In hypertensive women, iron status was linearly and positively associated with ASCVD risk. Per one unit increment of log-transformed SF as well as Hb was associated with a 1.22 (95% CI: 0.97, 1.48) and 0.04 (95% CI: 0.02, 0.07) increased in ASCVD risk score, respectively. A significant interaction between iron status and inflammation on ASCVD risk was observed in hypertensive women. SF and Hb showed a U-shape with ASCVD risk in hypertensive men; however, a positive linear relationship was observed in hypertensive women.
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Affiliation(s)
- Juan Zhou
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, 518051, China
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Rui Zhao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dongxia Wang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qin Gao
- Department of Public Health, Jining Medical University, Jining, 272067, China
| | - Dan Zhao
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, 518051, China
| | - Binfa Ouyang
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, 518051, China
| | - Liping Hao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaolin Peng
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, 518051, China.
- Department of Oncology, Injury Prevention and Nutrition, Shenzhen Nanshan Center for Chronic Disease Control, 7 Huaming Road, Shenzhen, 518051, China.
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143
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Skeletal muscle mitochondrial remodeling in heart failure: An update on mechanisms and therapeutic opportunities. Biomed Pharmacother 2022; 155:113833. [DOI: 10.1016/j.biopha.2022.113833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/22/2022] Open
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144
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Bakosova M, Krejci J, Godava J, Ozabalova E, Poloczkova H, Honek T, Hude P, Machal J, Bedanova H, Nemec P, Spinarova L. Iron Deficiency in Patients with Advanced Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1569. [PMID: 36363528 PMCID: PMC9697608 DOI: 10.3390/medicina58111569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
Background and Objectives: Iron deficiency (ID) is a common comorbidity in patients with heart failure. It is associated with reduced physical performance, frequent hospitalisations for heart failure decompensation, and high cardiovascular and overall mortality. The aim was to determine the prevalence of ID in patients with advanced heart failure on the waiting list for heart transplantation. Methods and Materials: We included 52 patients placed on the waiting list for heart transplantation in 2021 at our centre. The cohort included seven patients with LVAD (left ventricle assist device) as a bridge to transplantation implanted before the time of results collection. In addition to standard tests, the parameters of iron metabolism were monitored. ID was defined as a ferritin value <100 µg/L, or 100−299 µg/L if transferrin saturation (T-sat) is <20%. Results: ID was present in 79% of all subjects, but only in 35% of these patients anaemia was expressed. In the group without LVAD, ID was present in 82%, a median (lower−upper quartile) of ferritin level was 95.4 (62.2−152.1) µg/mL and mean T-sat was 0.18 ± 0.09. In LVAD group, ID was present in 57%, ferritin level was 268 (106−368) µg/mL and mean T-sat was 0.14 ± 0.04. Haemoglobin concentration was the same in patients with or without ID (133 ± 16) vs. (133 ± 23). ID was not associated with anaemia defined with regard to patient’s gender. In 40.5% of cases, iron deficiency was accompanied by chronic renal insufficiency, compared to 12.5% of the patients without ID. In the patients with LVAD, ID was present in four out of seven patients, but the group was too small for reliable statistical testing due to low statistical power. Conclusions: ID was present in the majority of patients with advanced heart failure and was not always accompanied by anaemia and renal insufficiency. Research on optimal markers for the diagnosis of iron deficiency, especially for specific groups of patients with heart failure, is still ongoing.
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Affiliation(s)
- Maria Bakosova
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
| | - Jan Krejci
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
| | - Julius Godava
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
| | - Eva Ozabalova
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
| | - Hana Poloczkova
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
| | - Tomas Honek
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
| | - Peter Hude
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
| | - Jan Machal
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
- International Clinical Research Center, St Anne's University Hospital, 60200 Brno, Czech Republic
| | - Helena Bedanova
- Center for Cardiovascular and Transplant Surgery, 65691 Brno, Czech Republic
| | - Petr Nemec
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
- Center for Cardiovascular and Transplant Surgery, 65691 Brno, Czech Republic
| | - Lenka Spinarova
- 1st Department of Internal Medicine-Cardioangiology, St. Anne's University Hospital, 60200 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, 60200 Brno, Czech Republic
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145
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Yesil E, Uyar H, Orscelik O, Ozkan B, Demir M, Yesildas C, Ozcan IT, Celik A. The effect of ferric carboxymaltose treatment on the Tp-e interval and the Tp-e/QT and Tp-e/QTc ratios in heart failure patients with iron deficiency. KARDIOLOGIIA 2022; 62:42-48. [DOI: 10.18087/cardio.2022.10.n2211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/26/2022] [Indexed: 11/18/2022]
Abstract
Aim In heart failure (HF) patients with iron deficiency, cardiac electrical irregularity is a cause of arrhythmias. The aim of our study was to evaluate the effect of ferric carboxymaltose (FCM) treatment on T wave peak to end (Tp-e) interval and the Tp-e / QT and Tp-e / corrected QT (QTc) ratios that reflect the transmural dispersion of repolarization in HF patients with iron deficiency.Material and methods Forty HF patients with iron deficiency that were treated with FCM were included in our single center, observational study. Repolarization parameters on electrocardiograms recorded before and 12 wks after FCM treatment were compared. Additionally, these parameters were compared with ventricular repolarization parameters of 40 healthy age and gender matched individuals and with another group of 40 HF patients without iron deficiency.Results In the HF patients with iron deficiency, the Tp-e interval and the Tp-e / QT and Tp-e / QTc ratios before FCM treatment were 103.7±19.1 ms, 0.25± 0.04, 0.23±0.04, respectively. These values were higher compared to the healthy the group and HF group without iron deficiency (p<0.001). In the HF patients with iron deficiency, the Tp-e interval and the Tp-e / QT and Tp-e / QTc ratios after FCM treatment were lower compared to pre-treatment and similar to the HF patients without iron deficiency (89.4±18.6 ms, 0.22±0.04, 0.20±0.04, respectively; p<0.001).Conclusion FCM treatment of HF patients with iron deficiency corrects prolonged Tp-e interval and high Tp-e / QT and Tp-e / QTc ratios, which are risk factors for ventricular arrhythmias.
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Affiliation(s)
| | - Hakan Uyar
- Mersin City Training and Research Hospital
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146
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Requena-Ibáñez JA, Santos-Gallego CG, Badimón JJ. SGLT2i in heart failure: can their benefits be expanded across the entire spectrum of ejection fraction? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:833-841. [PMID: 35817327 DOI: 10.1016/j.rec.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/04/2022] [Indexed: 06/15/2023]
Abstract
The publication of the EMPEROR-Preserved trial and data on the benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with heart failure (HF) with ejection fraction (EF)> 40% represent a significant step forward in the treatment of HF with preserved EF. Given these results, in February 2022 the US Food and Drug Administration approved the use of empaglifozin in adults with HF with reduced or preserved EF. However, more detailed analysis of the EMPEROR-Preserved trial led to doubts about the effect of empagliflozin in patients with an EF of> 60% this patient group is widely heterogeneous and, probably, a single phenotype cannot be considered in treatment goals or the clinical approach. Moreover, EF occurs on a continuum and classifications of HF according to arbitrary cut-points in EF do not appear consistent with recent evidence, which points to a gradual shift and considerable overlap in underlying mechanisms, phenotypes and treatment response over the spectrum of EF. Enhanced knowledge of pathophysiological mechanisms is essential to establish new therapeutic targets, interpret the results of clinical trials, and develop targeted and effective therapies.
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Affiliation(s)
- Juan Antonio Requena-Ibáñez
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York City, United States.
| | - Carlos G Santos-Gallego
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York City, United States
| | - Juan José Badimón
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York City, United States
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147
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Huang J, McDonnell BJ, Lawley JS, Byrd J, Stöhr EJ, Cornwell WK. Impact of Mechanical Circulatory Support on Exercise Capacity in Patients With Advanced Heart Failure. Exerc Sport Sci Rev 2022; 50:222-229. [PMID: 36095073 PMCID: PMC9475848 DOI: 10.1249/jes.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Approximately 6 million individuals have heart failure in the United States alone and 15 million in Europe. Left ventricular assist devices (LVAD) improve survival in these patients, but functional capacity may not fully improve. This article examines the hypothesis that patients supported by LVAD experience persistent reductions in functional capacity and explores mechanisms accounting for abnormalities in exercise tolerance.
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Affiliation(s)
- Janice Huang
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Barry J. McDonnell
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff UK
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck Austria
| | - Jessica Byrd
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Eric J. Stöhr
- Faculty of Philosophical Sciences, Institute of Sport Science, Leibniz University Hannover, Hannover, Germany
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - William K. Cornwell
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
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148
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Cacoub P, Choukroun G, Cohen-Solal A, Luporsi E, Peyrin-Biroulet L, Peoc'h K, Andrieu V, Lasocki S, Puy H, Trochu JN. Iron deficiency screening is a key issue in chronic inflammatory diseases: A call to action. J Intern Med 2022; 292:542-556. [PMID: 35466452 PMCID: PMC9544998 DOI: 10.1111/joim.13503] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Iron deficiency is frequent in patients with chronic inflammatory conditions (e.g., chronic heart failure, chronic kidney disease, cancers, and bowel inflammatory diseases). Indeed, high concentrations of inflammatory cytokines increase hepcidin concentrations that lead to the sequestration of iron in cells of the reticuloendothelial system (functional iron deficiency). Iron parameters are often assessed only in the context of anemia, but iron deficiency, even without anemia, is present in about half of patients with inflammatory conditions. Iron deficiency worsens underlying chronic diseases and is an independent factor of morbidity and mortality. In daily practice, the most effective biomarkers of iron status are serum ferritin, which reflects iron storage, and transferrin saturation, which reflects the transport of iron. Serum ferritin is increased in an inflammatory context, and there is still no consensus on the threshold to be used in chronic inflammatory conditions. Nevertheless, recent recommendations of international guidelines agreed to define iron deficiency by serum ferritin <100 µg/L and/or transferrin saturation <20%. Iron parameters remain, however, insufficiently assessed in patients with chronic inflammatory conditions. Indeed, clinical symptoms of iron deficiency, such as fatigue, are not specific and often confused with those of the primary disease. Iron repletion, preferably by the intravenous route to bypass tissue sequestration, improves clinical signs and quality of life. Because of the negative impact of iron deficiency on chronic inflammatory diseases and the efficacy of intravenous iron repletion, screening of iron parameters should be part of the routine examination of all patients with chronic inflammatory diseases.
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Affiliation(s)
- Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,UPMC Univ Paris 06, INSERM, UMR S 959, Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, Paris, France.,Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Gabriel Choukroun
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France.,Division of Nephrology, Amiens University Hospital, Amiens, France
| | - Alain Cohen-Solal
- Cardiology Department, Lariboisière Hospital, AP-HP, Paris, France.,Université de Paris, Paris, France
| | | | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Katell Peoc'h
- APHP, Department of Clinical Biochemistry, Beaujon Hospital, Clichy, France.,Centre de Recherche sur l'Inflammation (CRI), INSERM UMR 1149, Université de Paris, Paris, France
| | - Valérie Andrieu
- APHP, Department of Hematology, Bichat-Claude Bernard Hospital, Paris, France
| | - Sigismond Lasocki
- Département d'Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Hervé Puy
- Centre de Recherche Biomedicale Bichat-Beaujon, Universite Paris Diderot, Paris, France
| | - Jean-Noël Trochu
- Inserm, Institut du Thorax, CNRS, CHU de Nantes, Université Nantes, Nantes, France
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149
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Myint PT, Nandar PP, Thet AM, Orasanu G. Cost-effective heart failure management: Meta-analysis of IV iron therapy in iron-deficient heart failure patients. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100204. [PMID: 38558909 PMCID: PMC10978398 DOI: 10.1016/j.ahjo.2022.100204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 09/06/2022] [Indexed: 04/04/2024]
Abstract
Background Iron deficiency is an important co-morbidity in heart failure patients. IV iron may improve quality of life and reduce heart failure hospitalizations, but the results of the clinical trials are varied. Objective The purpose of this meta-analysis is to assess not only the effect of IV iron in iron-deficient heart failure patients but also the quality of evidence. Methods PubMed and Cochrane databases were searched from inception to Oct 2021. Randomized clinical trials in iron-deficient, heart failure patients assessing the effect of IV iron versus placebo and with at least 12 weeks of follow-up were included. The outcomes were pooled and analyzed using a random-effect model. The quality of evidence was assessed using the GRADE approach. Results Seven studies were included in our meta-analysis. IV iron was associated with a 13.8 % decreased risk of HF hospitalizations (OR 0.59; 0.35-0.98, p = 0.040, GRADE = Low). All-cause mortality and CV mortality were not different between IV iron and placebo. But a composite outcome of HF hospitalizations or CV mortality was 17.5 % lower with IV iron (OR 0.51;0.31-0.84, p = 0.008, GRADE = Moderate). Conclusions Among heart failure patients with iron deficiency, IV iron is associated with lower HF hospitalizations. It is a relatively inexpensive regimen that can potentially improve quality of life and decrease healthcare expenditure.
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Affiliation(s)
- Phyo Thazin Myint
- Department of Hospital Medicine, Baystate Medical Center, Springfield, MA, USA
| | | | - Aye M. Thet
- Department of Hematology & Oncology, Ascension Macomb-Oakland Hospital, Warren, MI, USA
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150
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Caravita S, Faini A, Vignati C, Pelucchi S, Salvioni E, Cattadori G, Baratto C, Torlasco C, Contini M, Villani A, Malfatto G, Perger E, Lombardi C, Piperno A, Agostoni P, Parati G. Intravenous iron therapy improves the hypercapnic ventilatory response and sleep disordered breathing in chronic heart failure. Eur J Heart Fail 2022; 24:1940-1949. [PMID: 35867685 PMCID: PMC9804720 DOI: 10.1002/ejhf.2628] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 01/09/2023] Open
Abstract
AIMS Intravenous iron therapy can improve symptoms in patients with heart failure, anaemia and iron deficiency. The mechanisms underlying such an improvement might involve chemoreflex sensing and nocturnal breathing patterns. METHODS AND RESULTS Patients with heart failure, reduced left ventricular ejection fraction, anaemia (haemoglobin <13 g/dl in men; <12 g/dl in women) and iron deficiency (ferritin <100 or 100-299 μg/L with transferrin saturation <20%) were 2:1 randomized to patient-tailored intravenous ferric carboxymaltose dose or placebo. Chemoreflex sensitivity cardiorespiratory sleep study, symptom assessment and cardiopulmonary exercise test were performed before and 2 weeks after the last treatment dose. Fifty-eight patients (38 active arm/20 placebo arm) completed the study. Intravenous iron was associated with less severe symptoms, higher haemoglobin (12.5 ± 1.4 vs. 11.7 ± 1.0 mg/dl, p < 0.05) and improved haematinic parameters. Ferric carboxymaltose improved the central hypercapnic ventilatory response (-25.8%, p < 0.05 vs. placebo), without changes in peripheral chemosensitivity. In particular, the central hypercapnic ventilatory responses passed from 4.6 ± 6.5 to 2.9 ± 2.9 L/min/mmHg after ferric carboxymaltose and from 4.4 ± 4.6 to 4.6 ± 3.9 L/min/mmHg after placebo (ptreatment*condition = 0.046). In patients presenting with sleep-related breathing disorder, apnoea-hypopnoea index was reduced with active treatment as compared to placebo (12 ± 11 vs. 19 ± 13 events/h, p < 0.05). After ferric carboxymaltose, but not after placebo, both peak oxygen uptake (VO2 ) increased (Δ1.1 ± 2.0 ml/kg/min, p < 0.05) and VO2 /workload slope was steeper (Δ0.67 ± 1.7 L/min/W, p < 0.01). CONCLUSIONS Intravenous ferric carboxymaltose improves the hypercapnic ventilatory response and sleep-related breathing disorders in patients with heart failure, anaemia and iron deficiency. These newly described findings, along with improved oxygen delivery to exercising muscles, likely contribute to the favourable effects of ferric carboxymaltose in anaemic patients with heart failure.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Management, Information and Production EngineeringUniversity of BergamoDalmineItaly
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | | | - Sara Pelucchi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | | | | | - Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Camilla Torlasco
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | | | - Alessandra Villani
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Gabriella Malfatto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Elisa Perger
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Carolina Lombardi
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Alberto Piperno
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCSMilanItaly,Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
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