The pathophysiology of heart failure

Bioimpedance vector analysis in stable chronic heart failure patients: Level of agreement between single and multiple frequency devices

BACKGROUND & AIMS

The accuracy of estimating body composition compartments is critical in the clinical setting. Currently, there are different bioelectrical impedance analysis (BIA) devices available for obtaining raw BIA parameters. The aim of this study was to determine the level of agreement between multiple frequency (MF)-BIA and single frequency (SF)-BIA devices in obtaining raw BIA measurements (resistance (R), reactance (Xc), and phase angle (PhA)), as well as the agreement on the classification of hydration status and body cell mass by the bioelectrical impedance vector analysis (BIVA) method.

METHODS

This cross-sectional study included 406 outpatients with stable chronic heart failure (HF). The raw BIA measurements at 50 kHz obtained by tetrapolar MF-BIA (Bodystat QuadScan 4000) were compared with those obtained by tetrapolar SF-BIA (RJL Quantum X). In addition, the patients were classified by their hydration status and body cell mass according to the BIVA method.

RESULTS

Strong and significant correlations were observed between the two methods in all raw BIA variables (r ≥ 0.90). Lin's concordance correlation coefficient (CCC) values were almost perfect for R (CCC = 0.99; 95% CI 0.997 to 0.998), moderate for Xc (CCC = 0.93; 95% CI 0.92 to 0.94), and poor for PhA (CCC = 0.88; 95% CI 0.85 to 0.90). The agreement obtained in the two classifications (quadrants and hydration status) was >0.81.

CONCLUSIONS

MF-BIA and SF-BIA demonstrated good agreement for measurement of the R parameter; however, the Xc and PhA parameters must be used carefully due to the previously reported variability. Likewise, the agreement in all classifications by the BIVA method was almost perfect.

Novel technologies in the management of heart failure with preserved ejection fraction: a promise during the time of disappointment from pharmacological approaches?

PURPOSE OF REVIEW

Despite numerous attempts, none of a wide variety of tested drugs achieved meaningful improvement in the outcomes of heart failure with preserved ejection fraction (HFpEF), making new therapeutic strategies a major unmet medical need. The medical device industry embraced the challenge, developing novel technologies directed to face specific aspects of the pathophysiology of HFpEF. This review focuses on some of the most promising technologies attaining meaningful clinical progress recently in the field of HFpEF therapy.

RECENT FINDINGS

Implantable pulmonary artery pressure, monitoring for optimization of medical therapy, proved to be beneficial in heart failure admissions in a large postmarketing clinical study. Investigational devices, such as inter-atrial shunts and transvenous phrenic nerve stimulators for the treatment of central sleep apnea with Cheyne-Stokes breathing, are currently being evaluated in HFpEF cohorts in recent trials.

SUMMARY

Device-based therapies for HFpEF demonstrated encouraging safety and efficacy results in various stages of the disease. Further efforts are needed to ensure that these devices will reach clinical use and contribute to the management of HFpEF patients.

Cardiac cAMP-PKA Signaling Compartmentalization in Myocardial Infarction

Under physiological conditions, cAMP signaling plays a key role in the regulation of cardiac function. Activation of this intracellular signaling pathway mirrors cardiomyocyte adaptation to various extracellular stimuli. Extracellular ligand binding to seven-transmembrane receptors (also known as GPCRs) with G proteins and adenylyl cyclases (ACs) modulate the intracellular cAMP content. Subsequently, this second messenger triggers activation of specific intracellular downstream effectors that ensure a proper cellular response. Therefore, it is essential for the cell to keep the cAMP signaling highly regulated in space and time. The temporal regulation depends on the activity of ACs and phosphodiesterases. By scaffolding key components of the cAMP signaling machinery, A-kinase anchoring proteins (AKAPs) coordinate both the spatial and temporal regulation. Myocardial infarction is one of the major causes of death in industrialized countries and is characterized by a prolonged cardiac ischemia. This leads to irreversible cardiomyocyte death and impairs cardiac function. Regardless of its causes, a chronic activation of cardiac cAMP signaling is established to compensate this loss. While this adaptation is primarily beneficial for contractile function, it turns out, in the long run, to be deleterious. This review compiles current knowledge about cardiac cAMP compartmentalization under physiological conditions and post-myocardial infarction when it appears to be profoundly impaired.

Sixteen Years of Heart Transplant in an Open Cohort in Brazil: Analysis of Graft Survival of Patients using Immunosuppressants

BACKGROUND

Heart transplant is the main therapeutic alternative for advanced heart failure patients. Several risk factors affect these patients' survival; however, few studies about the topic are available in Brazil.

OBJECTIVES

To review the survival rates of heart transplant patients in the Brazilian Public Health System (Sistema Único de Saúde - SUS) between 2000 and 2015.

METHODS

This is a non-concurrent, open cohort study, involving cardiac transplant patients in Brazil. The cumulative survival probability was estimated by the Kaplan-Meier curve, and the curve comparison was done using the Log-Rank test. The Cox model was used to calculate the Hazard-Ratio (HR). Analyses were conducted at the 95% confidence level.

RESULTS

The heart transplant survival rate median in Brazil, during the period, was 8.3 years. Each additional year in the recipient's age, the occurrence of infections, and the performance of the surgical procedure in the South Region were associated with a higher risk of graft loss. A higher use ratio of immunosuppressants mycophenolate and azathioprine acted as a protection factor.

CONCLUSIONS

The analyses conducted provide the first information about the median survival time in heart transplant patients in Brazil. The difference noticed among the geographical regions may be related to the different treatment protocols adopted in the country, especially in the early 2000s. The rate of mycophenolate and azathioprine use as a protection factor suggests that, despite the absence of differences among therapeutic strategies, use of these drugs may favor survival of certain patients. The study provides robust epidemiological data, which are relevant for public health.

Cardiac Fibrosis: Key Role of Integrins in Cardiac Homeostasis and Remodeling

Cardiac fibrosis is a common finding that is associated with the progression of heart failure (HF) and impacts all chambers of the heart. Despite intense research, the treatment of HF has primarily focused upon strategies to prevent cardiomyocyte remodeling, and there are no targeted antifibrotic strategies available to reverse cardiac fibrosis. Cardiac fibrosis is defined as an accumulation of extracellular matrix (ECM) proteins which stiffen the myocardium resulting in the deterioration cardiac function. This occurs in response to a wide range of mechanical and biochemical signals. Integrins are transmembrane cell adhesion receptors, that integrate signaling between cardiac fibroblasts and cardiomyocytes with the ECM by the communication of mechanical stress signals. Integrins play an important role in the development of pathological ECM deposition. This review will discuss the role of integrins in mechano-transduced cardiac fibrosis in response to disease throughout the myocardium. This review will also demonstrate the important role of integrins as both initiators of the fibrotic response, and modulators of fibrosis through their effect on cardiac fibroblast physiology across the various heart chambers.

Prediction of short-term mortality in acute heart failure patients using minimal electronic health record data

Background

Acute heart failure (AHF) is associated with significant morbidity and mortality. Effective patient risk stratification is essential to guiding hospitalization decisions and the clinical management of AHF. Clinical decision support systems can be used to improve predictions of mortality made in emergency care settings for the purpose of AHF risk stratification. In this study, several models for the prediction of seven-day mortality among AHF patients were developed by applying machine learning techniques to retrospective patient data from 236,275 total emergency department (ED) encounters, 1881 of which were considered positive for AHF and were used for model training and testing. The models used varying subsets of age, sex, vital signs, and laboratory values. Model performance was compared to the Emergency Heart Failure Mortality Risk Grade (EHMRG) model, a commonly used system for prediction of seven-day mortality in the ED with similar (or, in some cases, more extensive) inputs. Model performance was assessed in terms of area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity.

Results

When trained and tested on a large academic dataset, the best-performing model and EHMRG demonstrated test set AUROCs of 0.84 and 0.78, respectively, for prediction of seven-day mortality. Given only measurements of respiratory rate, temperature, mean arterial pressure, and FiO₂, one model produced a test set AUROC of 0.83. Neither a logistic regression comparator nor a simple decision tree outperformed EHMRG.

Conclusions

A model using only the measurements of four clinical variables outperforms EHMRG in the prediction of seven-day mortality in AHF. With these inputs, the model could not be replaced by logistic regression or reduced to a simple decision tree without significant performance loss. In ED settings, this minimal-input risk stratification tool may assist clinicians in making critical decisions about patient disposition by providing early and accurate insights into individual patient’s risk profiles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13040-021-00255-w.

Detection and Quantification of Myocardial Fibrosis Using Stain-Free Infrared Spectroscopic Imaging

CONTEXT.—

Myocardial fibrosis underpins a number of cardiovascular conditions and is difficult to identify with standard histologic techniques. Challenges include imaging, defining an objective threshold for classifying fibrosis as mild or severe, as well as understanding the molecular basis for these changes.

OBJECTIVE.—

To develop a novel, rapid, label-free approach to accurately measure and quantify the extent of fibrosis in cardiac tissue using infrared spectroscopic imaging.

DESIGN.—

We performed infrared spectroscopic imaging and combined that with advanced machine learning-based algorithms to assess fibrosis in 15 samples from patients belonging to the following 3 classes: (1) nonpathologic (control) donor hearts; (2) patients receiving transplant; and (3) tissue from patients undergoing implantation of ventricular assist device.

RESULTS.—

Our results show excellent sensitivity and accuracy for detecting myocardial fibrosis as demonstrated by high area under the curve of 0.998 in the receiver-operating characteristic curve measured from infrared imaging. Fibrosis of various morphologic subtypes are then demonstrated with virtually generated picrosirius red images, which show good visual and quantitative agreement (correlation coefficient = 0.92, ρ = 7.76 × 10-15) with stained images of the same sections. Underlying molecular composition of the different subtypes were investigated with infrared spectra showing reproducible differences presumably arising from differences in collagen subtypes and/or crosslinking.

CONCLUSIONS.—

Infrared imaging can be a powerful tool in studying myocardial fibrosis and gleaning insights into the underlying chemical changes that accompany it. Emerging methods suggest that the proposed approach is compatible with conventional optical microscopy and its consistency makes it translatable to the clinical setting for real-time diagnoses as well as for objective and quantitative research.

Correlation of Vitamin D Deficiency With Severity of Chronic Heart Failure as Assessed by Functional Class and N-Terminal Pro-Brain Natriuretic Peptide Levels

Introduction Chronic heart failure (CHF) is a major cause of mortality and morbidity in spite of tremendous advances in medical therapies. Vitamin D deficiency has been increasingly recognised in heart failure and its therapeutic as well as prognostic implications are debated. This study was carried out to examine the relationship of Vitamin D levels with severity of heart failure as assessed by NYHA functional class and serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels in vitamin D deficient patients with CHF. Methodology and results In this cross-sectional analysis, 119 patients of symptomatic CHF presenting to the outpatient/inpatient department of cardiology in a tertiary care institute in North India were screened. Patients were categorised according to their functional class as New York Heart Association (NYHA) class II, III, IV and their serum levels of vitamin D and NT-pro-BNP were measured. Out of 119 patients, 107 (90%) were found to have low vitamin D levels which were classified as insufficient (20-30 ng/ml) (n=25, 23%) or deficient (<20 ng/ml) (n=82,77%). The mean NT-pro-BNP levels increased significantly across functional class as 3783±6132 pg/ml, 7866±4383 pg/ml, 21115±11905 pg/ml in NYHA class II, III and IV respectively (p=0.000). The respective mean serum Vitamin D3 levels of 11.6±5.8ng/ml, 12.2±7.9 ng/ml, 14.4±8.9 ng/ml were not significantly different between classes (p=0.234). We found no correlation between serum NT-pro-BNP and serum vitamin D levels in the study cohort across various NYHA classes. In multivariate regression model, after adjusting for various co-variates, vitamin D levels were not significantly associated with NT-pro-BNP or functional class in patients with CHF. Conclusion Patients with CHF have a high prevalence (90%) of vitamin D deficiency. Although NT-pro-BNP levels increase significantly, vitamin D levels do not vary significantly with worsening NYHA classes. Further, no consistent significant correlation of vitamin D deficiency with NT-pro-BNP across different NYHA classes was observed. Thus, low levels of vitamin D didn't predict the severity and prognosis of patients with heart failure. .

Sex differences in heart failure medications targeting the renin-angiotensin-aldosterone system

Heart failure (HF) is a major healthcare problem. Sex-related differences in clinical manifestations, outcomes, risk factors and symptoms in HF have been described in the literature. Sex-related differences have also been described in the regulation of the renin-angiotensin-aldosterone system (RAAS), which is at the core of the pathophysiology of HF. Considering that drugs targeting RAAS are cornerstones in the treatment of HF, it is important to determine whether sex-related differences exist in the use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs) and ARB/neprilysin inhibitors (ARNIs). In regards to the relative efficacy of RAAS drugs in men vs. women in HF, there are conflicting results, which may stem from the fact that a lot of clinical trials were not specifically designed to investigate sex differences, with many of them having an underrepresentation of women. With respect to optimal dosage of RAAS drugs, even though, current HF guidelines, recommend up-titration to the same target dose in both men and women, evidence suggests that lower doses could be used in women. Furthermore, several studies have reported underutilization of guideline-directed medical therapy in women, including ACEIs, ARBs and MRAs, which may be at least partially attributed to increased prevalence of HF with a preserved ejection fraction and increased propensity for adverse effects in women. Overall, these investigations have shed some light on sex-related differences but there is scope for conducting further studies to determine the optimal use of RAAS drugs in men and women with failing hearts.

AT1 receptor blocker, but not an ACE inhibitor, prevents kidneys from hypoperfusion during congestive heart failure in normotensive and hypertensive rats

To provide novel insights into the pathogenesis of heart failure-induced renal dysfunction, we compared the effects of ACE inhibitor (ACEi) and AT₁ receptor blocker (ARB) on systemic and kidney hemodynamics during heart failure in normotensive HanSD and hypertensive transgenic (TGR) rats. High-output heart failure was induced by creating an aorto-caval fistula (ACF). After five weeks, rats were either left untreated or treatment with ACEi or ARB was started for 15 weeks. Subsequently, echocardiographic, renal hemodynamic and biochemical measurements were assessed. Untreated ACF rats with ACF displayed significantly reduced renal blood flow (RBF) (HanSD: 8.9 ± 1.0 vs. 4.7 ± 1.6; TGR: 10.2 ± 1.9 vs. 5.9 ± 1.2 ml/min, both P < .001), ACEi had no major RBF effect, whereas ARB completely restored RBF (HanSD: 5.6 ± 1.1 vs. 9.0 ± 1.5; TGR: 7.0 ± 1.2 vs. 10.9 ± 1.9 ml/min, both P < .001). RBF reduction in untreated and ACEi-treated rats was accompanied by renal hypoxia as measured by renal lactate dehydrogenase activity, which was ameliorated with ARB treatment (HanSD: 40 ± 4 vs. 42 ± 3 vs. 29 ± 5; TGR: 88 ± 4 vs. 76 ± 4 vs. 58 ± 4 milliunits/mL, all P < .01). Unlike improvement seen in ARB-treated rats, ACE inhibition didn’t affect urinary nitrates compared to untreated ACF TGR rats (50 ± 14 vs. 22 ± 13 vs. 30 ± 13 μmol/mmol Cr, both P < .05). ARB was more effective than ACEi in reducing elevated renal oxidative stress following ACF placement. A marker of ACEi efficacy, the angiotensin I/angiotensin II ratio, was more than ten times lower in renal tissue than in plasma. Our study shows that ARB treatment, in contrast to ACEi administration, prevents renal hypoperfusion and hypoxia in ACF rats with concomitant improvement in NO bioavailability and oxidative stress reduction. The inability of ACE inhibition to improve renal hypoperfusion in ACF rats may result from incomplete intrarenal RAS suppression in the face of depleted compensatory mechanisms.

Mimicking cardiac tissue complexity through physical cues: A review on cardiac tissue engineering approaches

Cardiovascular diseases are the number one killer in the world.^1,2 Currently, there are no clinical treatments to regenerate damaged cardiac tissue, leaving patients to develop further life-threatening cardiac complications. Cardiac tissue has multiple functional demands including vascularization, contraction, and conduction that require many synergic components to properly work. Most of these functions are a direct result of the cardiac tissue structure and composition, and, for this reason, tissue engineering strongly proposed to develop substitute engineered heart tissues (EHTs). EHTs usually have combined pluripotent stem cells and supporting scaffolds with the final aim to repair or replace the damaged native tissue. However, as simple as this idea is, indeed, it resulted, after many attempts in the field, to be very challenging. Without design complexity, EHTs remain unable to mature fully and integrate into surrounding heart tissue resulting in minimal in vivo effects.³ Lately, there has been a growing body of evidence that a complex, multifunctional approach through implementing scaffold designs, cellularization, and molecular release appears to be essential in the development of a functional cardiac EHTs.^4-6 This review covers the advancements in EHTs developments focusing on how to integrate contraction, conduction, and vascularization mimics and how combinations have resulted in improved designs thus warranting further investigation to develop a clinically applicable treatment.

Targeting the Endothelium to Achieve Cardioprotection

Despite considerable improvements in the treatment of myocardial infarction, it is still a highly prevalent disease worldwide. Novel therapeutic strategies to limit infarct size are required to protect myocardial function and thus, avoid heart failure progression. Cardioprotection is a research topic with significant achievements in the context of basic science. However, translation of the beneficial effects of protective approaches from bench to bedside has proven difficult. Therefore, there is still an unmet need to study new avenues leading to protecting the myocardium against infarction. In line with this, the endothelium is an essential component of the cardiovascular system with multiple therapeutic targets with cardioprotective potential. Endothelial cells are the most abundant non-myocyte cell type in the heart and are key players in cardiovascular physiology and pathophysiology. These cells can regulate vascular tone, angiogenesis, hemostasis, and inflammation. Accordingly, endothelial dysfunction plays a fundamental role in cardiovascular diseases, which may ultimately lead to myocardial infarction. The endothelium is of paramount importance to protect the myocardium from ischemia/reperfusion injury via conditioning strategies or cardioprotective drugs. This review will provide updated information on the most promising therapeutic agents and protective approaches targeting endothelial cells in the context of myocardial infarction.

The interplay between gastrointestinal and cardiovascular diseases: a narrative review focusing on the clinical perspective

Both cardiovascular and gastrointestinal disorders represent considerable health burden on community clinics and hospitals with overwhelming economic cost. An overlap in the occurrence of these disorders is encountered in daily practice. Both affect each other in bidirectional manner through several mechanisms including altered hemodynamics, systemic inflammation, bacterial overgrowth and interactions and adverse effects of medications. In addition, to the known overlap in the symptoms occurrence of upper gastrointestinal tract diseases and cardiovascular diseases (CVDs). Awareness of this interplay and its clinical manifestations optimizes patient management, and could prevent catastrophic consequences and even save lives. In this review, we highlighted the clinical aspects of this bidirectional association between gastrointestinal and CVDs aiming to shed light on this topic and improve patients' care.

BGP-15 Protects against Heart Failure by Enhanced Mitochondrial Biogenesis and Decreased Fibrotic Remodelling in Spontaneously Hypertensive Rats

Heart failure (HF) is a complex clinical syndrome with poor clinical outcomes despite the growing number of therapeutic approaches. It is characterized by interstitial fibrosis, cardiomyocyte hypertrophy, activation of various intracellular signalling pathways, and damage of the mitochondrial network. Mitochondria are responsible for supplying the energy demand of cardiomyocytes; therefore, the damage of the mitochondrial network causes cellular dysfunction and finally leads to cell death. BGP-15, a hydroxylamine derivative, is an insulin-sensitizer molecule and has a wide range of cytoprotective effects in animal as well as in human studies. Our recent work was aimed at examining the effects of BGP-15 in a chronic hypertension-induced heart failure model. 15-month-old male SHRs were used in our experiment. The SHR-Baseline group represented the starting point (n = 7). Animals received BGP-15 (SHR-B, n = 7) or placebo (SHR-C, n = 7) for 18 weeks. WKY rats were used as age-matched normotensive controls (n = 7). The heart function was monitored by echocardiography. Histological preparations were made from cardiac tissue. The levels of signalling proteins were determined by Western blot. At the end of the study, systolic and diastolic cardiac function was preserved in the BGP-treated animals. BGP-15 decreased the interstitial collagen deposition via decreasing the activity of TGFβ/Smad signalling factors and prevented the cardiomyocyte hypertrophy in hypertensive animals. BGP-15 enhanced the prosurvival signalling pathways (Akt/Gsk3β). The treatment increased the activity of MKP1 and decreased the activity of p38 and JNK signalling routes. The mitochondrial mass of cardiomyocytes was also increased in BGP-15-treated SHR animals due to the activation of mitochondrial biogenesis. The mitigation of remodelling processes and the preserved systolic cardiac function in hypertension-induced heart failure can be a result-at least partly-of the enhanced mitochondrial biogenesis caused by BGP-15.

Exercise Training Stabilizes RyR2-Dependent Ca2+ Release in Post-infarction Heart Failure

Aim: Dysfunction of the cardiac ryanodine receptor (RyR2) is an almost ubiquitous finding in animal models of heart failure (HF) and results in abnormal Ca²⁺ release in cardiomyocytes that contributes to contractile impairment and arrhythmias. We tested whether exercise training (ET), as recommended by current guidelines, had the potential to stabilize RyR2-dependent Ca²⁺ release in rats with post-myocardial infarction HF.

Materials and Methods: We subjected male Wistar rats to left coronary artery ligation or sham operations. After 1 week, animals were characterized by echocardiography and randomized to high-intensity interval ET on treadmills or to sedentary behavior (SED). Running speed was adjusted based on a weekly VO_2max test. We repeated echocardiography after 5 weeks of ET and harvested left ventricular cardiomyocytes for analysis of RyR2-dependent systolic and spontaneous Ca²⁺ release. Phosphoproteins were analyzed by Western blotting, and beta-adrenoceptor density was quantified by radioligand binding.

Results: ET increased VO_2max in HF-ET rats to 127% of HF-SED (P < 0.05). This coincided with attenuated spontaneous SR Ca²⁺ release in left ventricular cardiomyocytes from HF-ET but also reduced Ca²⁺ transient amplitude and slowed Ca²⁺ reuptake during adrenoceptor activation. However, ventricular diameter and fractional shortening were unaffected by ET. Analysis of Ca²⁺ homeostasis and major proteins involved in the regulation of SR Ca²⁺ release and reuptake could not explain the attenuated spontaneous SR Ca²⁺ release or reduced Ca²⁺ transient amplitude. Importantly, measurements of beta-adrenoceptors showed a normalization of beta₁-adrenoceptor density and beta₁:beta₂-adrenoceptor ratio in HF-ET.

Conclusion: ET increased aerobic capacity in post-myocardial infarction HF rats and stabilized RyR2-dependent Ca²⁺ release. Our data show that these effects of ET can be gained without major alterations in SR Ca²⁺ regulatory proteins and indicate that future studies should include upstream parts of the sympathetic signaling pathway.

Emerging physiological and pathological roles of MeCP2 in non-neurological systems

Numerous neurological and non-neurological disorders are associated with dysfunction of epigenetic modulators, and methyl CpG binding protein 2 (MeCP2) is one of such proteins. Initially identified as a transcriptional repressor, MeCP2 specifically binds to methylated DNA, and mutations of MeCP2 have been shown to cause Rett syndrome (RTT), a severe neurological disorder. Recently, accumulating evidence suggests that ubiquitously expressed MeCP2 also plays a central role in non-neurological disorders including cardiac dysfunction, liver injury, respiratory disorders, urological dysfunction, adipose tissue metabolism disorders, movement abnormality and inflammatory responses in a DNA methylation dependent or independent manner. Despite significant progresses in our understanding of MeCP2 over the last few decades, there is still a considerable knowledge gap to translate the in vitro and in vivo experimental findings into therapeutic interventions. In this review, we provide a synopsis of the role of MeCP2 in the pathophysiology of non-neurological disorders, MeCP2-based research directions and therapeutic strategies for non-neurological disorders are also discussed.

Neuropsychological Assessment and Screening in Heart Failure: a Meta-Analysis and Systematic Review

A variety of neuropsychological changes secondary to heart failure have been documented in the literature. However, what remains unclear are which neuropsychological abilities are the most impacted by heart failure and what tests have the sensitivity to measure that impact. Eight databases were searched for articles that examined the neuropsychological functioning of patients with heart failure. Some of the inclusion criteria were articles had to have a heart failure group with a demographically comparable control group and standardized neuropsychological testing. Exclusion criteria included articles with a heart failure group with any other type of major organ failure, or comparisons that were between different classes of heart failure rather than between a heart failure and non-heart failure group. A total of 33 articles met the inclusion criteria (total heart failure sample n = 8900) and provided effect size data for 20 neuropsychological domains. All observed domain-level differences between heart failure and non-heart failure groups were statistically significant, except for simple motor functioning and confrontation naming. The greatest differences in performance were in executive functioning, global cognition, complex psychomotor speed, and verbal memory. The highest effect sizes came from Trail-Making Test-Part B, CAMCOG, Symbol Digit Modality Test, and California Verbal Learning Test. The neuropsychological patterns of heart failure suggested diffuse cognitive involvement, with higher-level processes being most affected. It is important to track neurocognition in this clinical population since neuropsychological impairment is prevalent, and screening measures appear to be reliable. Such screening and further assessment would inform future medical treatment and may improve patient care management.

Cognition and Frailty in Patients With Heart Failure: A Systematic Review of the Association Between Frailty and Cognitive Impairment

Background/Aim: Pathological processes associated with aging increase the risk of cognitive deficits. Frailty syndrome may significantly accelerate these pathological processes in elderly patients with heart failure. The objective of this review was to better understand the association between frailty syndrome and co-occurring cognitive decline in patients with heart failure. Methods: We conducted a systematic review based on PubMed/MEDLINE, Scopus, EMBASE, and CINAHL as databases. The search followed the method described by Webb and Roe. For inclusions, the studies were selected employing cross-sectional and longitudinal designs. The included studies had to evaluate frailty syndrome and cognitive impairments among participants with heart failure. As we were interested in older adults, the search was limited to individuals >65 years of age. The search was limited to primary research articles written in English published since the year 2000. Results: Of the 1,245 studies retrieved by the systematic review, 8 relevant studies were enclosed for the full-text review. Our review revealed that most studies of patients with HF demonstrated evidence of an association between greater frailty and cognitive impairment. In particular, six studies reported evidence for the significant association between higher levels of frailty and cognitive impairment in patients with heart failure. The remaining two studies failed to find an association between frailty and cognitive impairment. Conclusions: The development of frailty and cognitive impairment in heart failure is particularly important because this cardiovascular disease is a common cause of both morbidity and mortality in the world. The results of this review fill the existing gap in the literature related to the identification of clinical factors linked with frailty syndrome that contribute to cognitive impairment in patients with a diagnosis of heart failure. The prevalence of overlapping frailty and cognitive impairment in patients with heart failure, therefore, necessitates a routine assessment of these components in the care of patients with cardiovascular disease.

Case Report: Low Dose of Valsartan/Sacubitril Leads to Successful Reversal of Acute Heart Failure in Chemotherapy-Induced Cardiomyopathy

Valsartan/sacubitril is a new agent approved for the treatment of chronic heart failure in adults, with a combination of angiotensin receptor inhibitor and neprilysin inhibitor. However, the benefit of valsartan/sacubitril in pediatric patients is unknown. We herein report its clinical benefit in a case of acute decompensated heart failure in chemotherapy-induced cardiomyopathy. This case suggests that in children with acute heart failure refractory to conventional medications, low dose of sacubitril/valsartan may be an effective therapy.

Citri Reticulatae Pericarpium protects against isoproterenol-induced chronic heart failure via activation of PPARγ

Background

Accumulated clinical trials and animal studies showed that Qiliqiangxin (QLQX), a traditional Chinese medicine formula containing extracts of 11 herbs, exerts beneficial effects on chronic heart failure (HF). Citri Reticulatae Pericarpium (CRP), one herbal medicine in QLQX, has been widely used in treatment against digestive, respiratory and cardiovascular diseases (CVDs) in China. However, the cardiac protective effects and mechanisms of CRP are still unclear.

Methods

The effects of CRP were investigated in isoproterenol (ISO)-induced chronic HF mice model and neonatal rat ventricular cardiomyocytes (NRVMs) treated with ISO. Echocardiography was used to determine cardiac function. Hematoxylin-eosin (HE) staining and α-actinin immunofluorescent staining were used to measure cardiomyocyte size. Cardiac fibrosis was evaluated by Masson’s trichrome staining. The expression of atrial natriuretic polypeptide (ANP) and brain natriuretic polypeptide (BNP) were determined by quantitative real time PCR (qRT-PCR). Western blot was applied to examine the expression of peroxisome proliferator-activated receptor gamma (PPARγ), PPARγ coactivator-1α (PGC-1α), fibrosis-related and apoptosis-related proteins.

Results

We found that CRP could significantly attenuate ISO-induced cardiac dysfunction, inhibit cardiac pathological hypertrophy and alleviate myocardial fibrosis and apoptosis. Mechanistically, the downregulation of PPARγ and PGC-1α in ISO-injected mice hearts and ISO-treated NRVMs could be reversed by CRP treatment. The beneficial effects of CRP against ISO-induced HF were abolished by PPARγ inhibitor (T0070907), suggesting that CRP-mediated PPARγ upregulation was essential for the preventive effect of CRP on ISO-induced cardiac dysfunction.

Conclusions

In conclusion, our study demonstrated that CRP attenuates ISO-induced cardiac remodeling via PPARγ activation, which represents a new application for CRP in the prevention of chronic HF.

Peptidic vaccines: The new cure for heart diseases?

Cardiovascular disease continues to be the most common cause of death worldwide. The global burden is so high that numerous organizations are providing counseling recommendations and annual revisions of current pharmacological and non-pharmacological treatments as well as risk prediction for disease prevention and further progression. Although primary preventive interventions targeting risk factors such as obesity, hypertension, smoking, and sedentarism have led to a global decline in hospitalization rates, the aging population has overwhelmed these efforts on a global scale. This review focuses on peptidic vaccines, with the known and not well-known autoantigens in atheroma formation or acquired cardiac diseases, as novel potential immunotherapy approaches to counteract harmful heart disease continuance. We summarize how cancer immunomodulatory strategies started novel approaches to modulate the innate and adaptive immune responses, and how they can be targeted for therapeutic purposes in the cardiovascular system. Brief descriptions focused on the processes that start as either immunologic or non-immunologic, and the ultimate loss of cardiac muscle cell contractility as the outcome, are discussed. We conclude debating how novel strategies with nanoparticles and nanovaccines open a promising therapeutic option to reduce or prevent cardiovascular diseases.

Balloon pulmonary angioplasty reverse right ventricular remodelling and dysfunction in patients with inoperable chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis

OBJECTIVES

Right ventricular (RV) function is considered the major determinant of prognosis in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this meta-analysis was to evaluate RV remodelling and function following balloon pulmonary angioplasty (BPA) in patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension (PH) after pulmonary endarterectomy (PEA).

METHODS

We reviewed all studies evaluating RV function by cardiac magnetic resonance (CMR) and/or echocardiography pre- and post-BPA from PubMed/Medline prior to 15 December 2019. Ten (299 patients) of the 29 studies retrieved met the inclusion criteria: 5 CMR and 5 echocardiography studies. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines.

RESULTS

Pooled data from CMR studies revealed BPA resulted in a significantly decreased RV end-diastolic volume index (weighted mean difference (WMD) - 28.33 ml/m², p < 0.00001) and RV end-systolic volume index (WMD - 29.06 ml/m², p < 0.00001) accompanied by an increased RV ejection fraction (RVEF, WMD 8.97%, p < 0.00001). Data from the echocardiography studies showed BPA resulted in decreased RV basal diameter (WMD - 0.37 cm, p = 0.0009) and an increase of RV fractional area change (WMD 5.97 %, p = 0.003), but improvements of tricuspid annular plane systolic excursion (TAPSE) and S' were not significant.

CONCLUSIONS

BPA improves RVEF and decreases RV volumes in patients with inoperable CTEPH or persistent/recurrent PH after PEA.

KEY POINTS

• Balloon pulmonary angioplasty improves RVEF and decreases RV volumes in patients with inoperable CTEPH or persistent/recurrent PH after PEA.

A Modern View of the Interstitial Space in Health and Disease

Increases in the volume of the interstitial space are readily recognized clinically as interstitial edema formation in the loose connective tissue of skin, mucosa, and lung. However, the contents and the hydrostatic pressure of this interstitial fluid can be very difficult to determine even in experimental settings. These difficulties have long obscured what we are beginning to appreciate is a dynamic milieu that is subject to both intrinsic and extrinsic regulation. This review examines current concepts regarding regulation of interstitial volume, pressure, and flow and utilizes that background to address three major topics of interest that impact IV fluid administration. The first of these started with the discovery that excess dietary salt can be stored non-osmotically in the interstitial space with minimal impact on vascular volume and pressures. This led to the hypothesis that, along with the kidney, the interstitial space plays an active role in the long-term regulation of blood pressure. Second, it now appears that hypovolemic shock leads to systemic inflammatory response syndrome principally through the entry of digestive enzymes into the intestinal interstitial space and the subsequent progression of enzymes and inflammatory agents through the mesenteric lymphatic system to the general circulation. Lastly, current evidence strongly supports the non-intuitive view that the primary factor leading to inflammatory edema formation is a decrease in interstitial hydrostatic pressure that dramatically increases microvascular filtration.

Congestion occurrence and evaluation in acute heart failure scenario: time to reconsider different pathways of volume overload

Although congestion is considered to be the main reason for hospital admission in patients with acute heart failure, a simplistic view considering idro saline retention and total body volume accumulation did not provide convincing data. Clinical congestion occurrence is often the tip of the iceberg of several different mechanisms ranging from increased filling pressure to extravascular fluid accumulation and blood flow redistribution. Therefore, the clinical evaluation is often restricted to a simple physical examination including few and inaccurate signs and symptoms. This superficial approach has led to contradictory data and patients have not been evaluated according to a more realistic clinical scenario. The integration with new diagnostic ultrasonographic and laboratory tools would substantially improve these weaknesses. Indeed, congestion could be assessed by following the most recognized HF subtypes including primitive cardiac defect, presence of right ventricular dysfunction, and organ perfusion. Moreover, there is a tremendous gap regarding the interchangeable concept of fluid retention and redistribution used with a univocal meaning. Overall, congestion assessment should be revised, considering it as either central, peripheral, or both. In this review, we aim to provide different evidence regarding the concept of congestion starting from the most recognized pathophysiological mechanisms of AHF decompensation. We highlight the fact that a better knowledge of congestion is a challenge for future investigation and it could lead to significant advances in HF treatment.

Multiplicity of Nitric Oxide and Natriuretic Peptide Signaling in Heart Failure

Heart failure (HF) is a common consequence of several cardiovascular diseases and is understood as a vicious cycle of cardiac and hemodynamic decline. The current inventory of treatments either alleviates the pathophysiological features (eg, cardiac dysfunction, neurohumoral activation, and ventricular remodeling) and/or targets any underlying pathologies (eg, hypertension and myocardial infarction). Yet, since these do not provide a cure, the morbidity and mortality associated with HF remains high. Therefore, the disease constitutes an unmet medical need, and novel therapies are desperately needed. Cyclic guanosine-3',5'-monophosphate (cGMP), synthesized by nitric oxide (NO)- and natriuretic peptide (NP)-responsive guanylyl cyclase (GC) enzymes, exerts numerous protective effects on cardiac contractility, hypertrophy, fibrosis, and apoptosis. Impaired cGMP signaling, which can occur after GC deactivation and the upregulation of cyclic nucleotide-hydrolyzing phosphodiesterases (PDEs), promotes cardiac dysfunction. In this study, we review the role that NO/cGMP and NP/cGMP signaling plays in HF. After considering disease etiology, the physiological effects of cGMP in the heart are discussed. We then assess the evidence from preclinical models and patients that compromised cGMP signaling contributes to the HF phenotype. Finally, the potential of pharmacologically harnessing cardioprotective cGMP to rectify the present paucity of effective HF treatments is examined.

Finding a Needle in a Haystack: Proteomics in Heart Failure

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Proteomics has aided HF biomarker discovery, which allows for greater disease insights.

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Experiment design can be tailored to HF research to discover novel biomarkers.

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Primary methods include MS, protein microarray, aptamer, and PEA-based technologies.

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Proteomics can detect unique low abundance proteins and detect protein modifications.

Circulating protein biomarkers provide information regarding pathways in heart failure (HF) and can add important value to clinicians. Advancements in proteomics allow researchers to measure a multitude of proteins simultaneously with excellent sensitivity and selectivity to detect low abundance proteins. This helps identify previously unrecognized pathways in HF and discover biomarkers and potential targets for HF therapies. Although several proteomic methods exist, including mass spectrometry, protein microarray, aptamer, and proximity extension assay−based techniques, each have their unique advantages. This paper provides an overview of the various proteomic methods, with examples of how each has contributed to understanding the pathways in HF.

Effects of Quercetin on Cardiac Function in Pressure Overload and Postischemic Cardiac Injury in Rodents: a Systematic Review and Meta-Analysis

PURPOSE

Cardiac dysfunction can occur as a sequela of a state of prolonged pressure overload and postischemic injury. Flavonoids such as quercetin may be protective against cardiovascular disease. This study aimed to systematically assess the effects of quercetin on cardiac function in pressure overload and postischemia-reperfusion injury in rodents.

METHODS

A systematic search of the literature up to May 2020 was conducted in PubMed, Ovid Medline, EBSCOhost, Scopus, and the Cochrane Library to identify relevant published studies on quercetin and cardiac function using standardized criteria. Meta-analyses were performed on animal studies of pressure overload and ischemia-reperfusion (I/R) injury.

RESULTS

The effects of quercetin on cardiac function in both models were qualitatively reported in 14 studies. The effects of quercetin in four pressure-overload model studies involving 73 rodents and eight I/R-injury model studies involving 120 rodents were quantitatively assessed by meta-analysis. Quercetin improved the overall cardiac function in both pressure overload (n = 4 studies, n = 73 rodents; SMD = - 1.50; 95% CI: - 2.66 to - 0.33; P < 0.05; I² = 74.05%) and I/R injury (n = 8 studies, n = 120 rodents; SMD = - 1.81; 95% CI: - 3.05 to - 0.56; P < 0.01; I² = 84.93%) models. The improvement was associated with amelioration in cardiac structure in the pressure-overload model and both systolic and diastolic functioning in the I/R-injury model.

CONCLUSION

The present meta-analysis suggested that quercetin has beneficial effects for improving cardiac left ventricular dysfunction in both pressure-overload and I/R-injury models.

Fumonisin B1 Production by Fusarium Species and Mycotoxigenic Effect on Larval Zebrafish

Fumonisin B₁ (FB₁) is a common mycotoxin produced by Fusarium species particularly F. proliferatum and F. verticillioides. The toxin produced can cause adverse effects on humans and animals. The objectives of this study were to detect the production of FB₁ based on the amplification of FUM1 gene, to quantify FB₁ produced by the isolates using Ultra-fast Liquid Chromatography (UFLC) analysis, to examine the embryotoxicity effect of FB₁ and to determine EC₅₀ toward the larvae of zebrafish (Danio rerio). Fifty isolates of Fusarium species were isolated from different hosts throughout Malaysia. Successful amplification of the FUM1 gene showed the presence of this gene (800 bp) in the genome of 48 out of 50 isolates. The highest level of FB₁ produced by F. proliferatum isolate B2433 was 6677.32 ppm meanwhile F. verticillioides isolate J1363 was 954.01 ppm. From the assessment of embryotoxicity test of FB₁ on larvae of zebrafish, five concentrations of FB₁ (0.43 ppm, 0.58 ppm, 0.72 ppm, 0.87 ppm and 1.00 ppm) were tested. Morphological changes of the FB₁ exposed-larvae were observed at 24 to 168 hpf. The mortality rate and abnormality of zebrafish larvae were significantly increased at 144 hpf exposure. Meanwhile, the spontaneous tail coiling showed a significant difference. There were no significant differences in the heartbeat rate. As a conclusion, the presence of FUM1 in every isolate can be detected by FUM1 gene analysis and both of the species produced different concentrations of FB₁. This is the first report of FB₁ produced by Fusarium species gave a significant effect on zebrafish development.

Hit-to-lead optimization and discovery of a potent, and orally bioavailable G protein coupled receptor kinase 2 (GRK2) inhibitor

G-protein coupled receptor kinase 2 (GRK2), which is upregulated in the failing heart, appears to play a critical role in heart failure (HF) progression in part because enhanced GRK2 activity promotes dysfunction of β-adrenergic signaling and myocyte death. An orally bioavailable GRK2 inhibitor could offer unique therapeutic outcomes that cannot be attained by current heart failure treatments that directly target GPCRs or angiotensin-converting enzyme. Herein, we describe the discovery of a potent, selective, and orally bioavailable GRK2 inhibitor, 8h, through high-throughput screening, hit-to-lead optimization, structure-based design, molecular modelling, synthesis, and biological evaluation. In the cellular target engagement assays, 8h enhances isoproterenol-mediated cyclic adenosine 3',5'-monophosphate (cAMP) production in HEK293 cells overexpressing GRK2. Compound 8h was further evaluated in a human stem cell-derived cardiomyocyte (HSC-CM) contractility assay and potentiated isoproterenol-induced beating rate in HSC-CMs.

Pathophysiology and molecular signalling in pediatric heart failure and VAD therapy

Heart Failure (HF) is a progressive clinical syndrome characterized by molecular and structural abnormalities that result in impaired ventricular filling and a reduced blood ejection. In pediatric patients, HF represents an important cause of morbidity and mortality, but underlying cause, presentation and disease course remains unclear in many cases. It is evident that a child is not a "small adult" and findings are not comparable. The adoption of a standardized clinical and surgical tools as well as increased biomolecular research and therapeutic trials targeting pediatric patients with HF would greatly improve the management of this special class of patients. This review examines the most current information about the pathophysiology and molecular mechanisms related to HF in children to identify gaps in our knowledge base to further improve clinical care and outcomes.

Icariside II protects cardiomyocytes from hypoxia‑induced injury by upregulating the miR‑7‑5p/BTG2 axis and activating the PI3K/Akt signaling pathway

Icariside II (ICS II) has been reported to have protective effects against oxidative stress. However, whether ICS II protects cardiomyocytes from myocardial infarction (MI), and the associated underlying mechanisms, remain to be elucidated. Therefore, the current study investigated the effects of ICS II on hypoxia‑injured H9c2 cells, as well as the associated molecular mechanisms. A hypoxic injury model was established to emulate the effects of MI. The effects of ICS II on the proliferation of rat cardiomyocyte H9c2 cells were assessed with cell counting kit‑8 assays. The apoptotic status of the cells was assessed by flow cytometry, and the expression of apoptosis‑related proteins was analyzed by western blotting. A microRNA (miRNA/miR) microarray was used to quantify the differential expression of miRNAs after ICS II treatment, and the levels of miR‑7‑5p were further quantified by reverse transcription‑quantitative PCR. Whether ICS II affected hypoxia‑injured cells via miR‑7‑5p was subsequently examined, and the target of miR‑7‑5p was also investigated by bioinformatics analysis and luciferase reporter assays. The effects of ICS II on the PI3K/Akt pathway were then evaluated by western blot analysis. Hypoxia treatment decreased viability and the migration and invasion abilities of H9c2 cells, and also induced apoptosis. ICS II significantly increased viability and reduced hypoxia‑associated apoptosis. Moreover, ICS II treatment led to the upregulation of miR‑7‑5p, and the protective effects of ICS II were found to rely on miR‑7‑5p. Moreover, BTG anti‑proliferation factor (BTG2) was identified as a direct target of miR‑7‑5p, and overexpression of BTG2 inhibited the protective effects of miR‑7‑5p. Finally, ICS II treatment resulted in the activation of the PI3K/Akt signaling pathway, which is essential for the survival of H9c2 cells under hypoxic conditions. In summary, ICS II reduces hypoxic injury in H9c2 cells via the miR‑7‑5p/BTG2 axis and activation of the PI3K/Akt signaling pathway.

Knockdown of circular RNA circMAT2B reduces oxygen-glucose deprivation-induced inflammatory injury in H9c2 cells through up-regulating miR-133

Myocardial infarction (MI) is the main cause of morbidity and mortality. Reperfusion ways can cause damage to cardiomyocytes. CircMAT2B, a novel circRNA, takes positive roles in regulating glucose metabolism under hypoxia. Therefore, we aimed to explore the effects of circMAT2B on MI. Oxygen-glucose deprivation (OGD)-induced H9c2 cell model was employed to stimulate MI. Ex-circMAT2B, si-circMAT2B, miR-133 inhibitor and relative control were transfected into H9c2 cells. qRT-PCR was employed to examine levels of circMAT2B and miR-133. Cell activity, apoptosis, ROS generation and release of inflammatory factors were assessed by CCK-8, flow cytometry, ROS species assay kit and ELISA, respectively. Moreover, the expression of apoptosis-related and pathway-related factors was detected through western blot analysis. The results showed that circMAT2B expression was notably up-regulated by OGD treatment. Moreover, circMAT2B knockdown could effectively decrease OGD-induced the increasing of apoptosis, ROS generation and the expression of IL-1β, IL-6 and TNF-α. Besides, miR-133 was positively regulated by si-circMAT2B. CircMAT2B knockdown attenuated OGD-induced H9c2 cell damage and alleviated OGD-induced the inhibition of PI3K/AKT and Raf/MEK/ERK pathways through up-regulating miR-133. In brief, circMAT2B knockdown works as an inflammatory inhibitor in OGD-induced H9c2 cells inflammatory injury through up-regulating miR-133.

Relationships of diabetes self-care behaviours to glycaemic control in adults with type 2 diabetes and comorbid heart failure

Aim

To describe the relationship between diabetes self-care behaviours and glycaemic control in patients with type 2 diabetes and comorbid heart failure.

Design

A cross-sectional, correlational study.

Method

A secondary analysis of 180 participants' baseline data from a clinical trial that tested a 6-month integrated self-care intervention was performed. Correlational and hierarchical linear regression analysis was used to assess the relationships between diabetes self-care behaviours and glycaemic control.

Result

The Summary of Diabetes Self-Care Activities general diet and Summary of Diabetes Self-Care Activities exercise were negatively associated with glycated haemoglobin (HbA1c), while Summary of Diabetes Self-Care Activities specific diet was positively associated. Diabetic end-organ failure, taking insulin only and taking both oral antiglycaemic and insulin, predicted higher HbA1c and fasting blood glucose. African American race and dyslipidaemia predicted higher HbA1c while taking higher total daily medication predicted higher fasting blood glucose. Longer years lived with heart failure, lower ventricular ejection fraction and exposure to chemotherapy predicted lower fasting blood glucose.

Sympathetic nervous system activation and heart failure: Current state of evidence and the pathophysiology in the light of novel biomarkers

Heart failure (HF) is a complex clinical syndrome characterized by the activation of at least several neurohumoral pathways that have a common role in maintaining cardiac output and adequate perfusion pressure of target organs and tissues. The sympathetic nervous system (SNS) is upregulated in HF as evident in dysfunctional baroreceptor and chemoreceptor reflexes, circulating and neuronal catecholamine spillover, attenuated parasympathetic response, and augmented sympathetic outflow to the heart, kidneys and skeletal muscles. When these sympathoexcitatory effects on the cardiovascular system are sustained chronically they initiate the vicious circle of HF progression and become associated with cardiomyocyte apoptosis, maladaptive ventricular and vascular remodeling, arrhythmogenesis, and poor prognosis in patients with HF. These detrimental effects of SNS activity on outcomes in HF warrant adequate diagnostic and treatment modalities. Therefore, this review summarizes basic physiological concepts about the interaction of SNS with the cardiovascular system and highlights key pathophysiological mechanisms of SNS derangement in HF. Finally, special emphasis in this review is placed on the integrative and up-to-date overview of diagnostic modalities such as SNS imaging methods and novel laboratory biomarkers that could aid in the assessment of the degree of SNS activation and provide reliable prognostic information among patients with HF.

Comparative effects of furosemide and other diuretics in the treatment of heart failure: a systematic review and combined meta-analysis of randomized controlled trials

Diuretics have an essential role in the management of heart failure (HF). However, each drug has its own benefit and side effect. Side effects include fluid, electrolyte abnormalities, and acid-base disturbance. These adverse effects of diuretics predispose patients to serious cardiac arrhythmias and may increase the risk of arrhythmic mortality. Herein, we aim to summarize the relative efficacy and safety of all available diuretics used in the treatment of patients with HF. In June 2017, a systematic electronic database search was conducted in nine databases. All randomized controlled trials (RCTs) comparing the different diuretics used in HF were included for meta-analysis. The protocol was registered in Prospero with CRD42018084819. Among the included 54 studies (10,740 patients), 34 RCTs were eligible for quantitative network meta-analysis (NMA) and traditional meta-analysis while the other 20 studies were qualitatively analyzed. Our results showed that azosemide and torasemide caused a significant reduction in brain natriuretic peptide (BNP) level. Torasemide also caused a significant decrease in collagen volume fraction (CVF) and edema. No significant difference between the agents concerning glomerular filtration rate (GFR), water extraction, and sodium excretion was demonstrated. Regarding side effects, no significant difference among diuretics was observed in terms of hospital readmission and mortality rates. Diuretics are the main treatment of hypervolemia in HF patients. The choice of appropriate diuretic is essential for successful management and is mainly guided by patient clinical situations and the presence of other co-morbidities.

Exendin-4 inhibits atrial arrhythmogenesis in a model of myocardial infarction-induced heart failure via the GLP-1 receptor signaling pathway

Glucagon-like peptide-1 receptor (GLP-1 receptor) agonists are considered to exert cardioprotective effects in models of acute and chronic heart disease. The present study aimed to investigate the role of exendin-4 (a GLP-1 receptor agonist) in atrial arrhythmogenesis in a model of myocardial infarction (MI)-induced heart failure and to elucidate the mechanisms underlying its effects. For this purpose, male Sprague-Dawley rats underwent sham surgery or left anterior descending artery ligation prior to being treated with saline/exendin-4/exendin-4 plus exendin9-39 (an antagonist of GLP-1 receptor) for 4 weeks. The effects of exendin-4 on atrial electrophysiology, atrial fibrosis and PI3K/AKT signaling were assessed. Rats with MI exhibited depressed left ventricular function, an enlarged left atrium volume, prolonged action potential duration, elevated atrial tachyarrhythmia inducibility, decreased conduction velocity and an increased total activation time, as well as total activation time dispersion and atrial fibrosis. However, these abnormalities were attenuated by treatment with the GLP-1 receptor agonist, exendin-4. Moreover, the expression levels of collagen I, collagen III, transforming growth factor-β1, phosphorylated PI3K and AKT levels in atrial tissues were upregulated in rats with MI. These changes were also attenuated by exendin-4. It was also found that these exedin-4-mediated attenutations were mitigated by the co-administration of exendin9-39 with exendin-4. Overall, the findings of the present study suggested that exendin-4 decreases susceptibility to atrial arrhythmogenesis, improves conduction properties and exerts antifibrotic effects via the GLP-1 receptor signaling pathway. These findings provide evidence for the potential use of GLP-1R in the treatment of atrial fibrillation.

Short-term exposure to noise on stroke volume and left ventricular contractility: A repeated-measure study

Prolonged exposure to noise has been associated with cardiovascular disease, but the possible mechanism for its influence on cardiac activity is unknown. This study investigated the acute effects of noise exposure on 24-h ambulatory cardiac parameters among male workers. We recruited 75 volunteers in an aviation-industry cohort in 2009. Personal noise-exposure levels and individual cardiac parameters, including stroke volume (SV) and left ventricular contractility (LVC), were measured simultaneously over 24 h on working and nonworking days. Linear mixed-effects regression models were used to estimate transient and sustained effects on ambulatory SV and LVC among high-noise-exposure (≥80 A-weighted decibels [dBA]), low-noise-exposure (<80 dBA) and office workers. Every 1-dBA increase in noise exposure was significantly associated with transient changes of -1.50 (95% confidence interval [CI]: -2.18, -1.03) ml/beat in SV and -1.76 (-2.99, -1.03) L/sec in LVC at work on working days only among high-exposure workers. The 1-dBA increase in nocturnal noise exposure was also significantly associated with transiently decreased SV among high-exposure (-1.62 [-2.15, -1.22] ml/beat), low-exposure (-1.27 [-1.57, -1.03] ml/beat) and office workers (-1.09 [-1.18, -1.00] ml/beat), but only the high-exposure group had the transiently reduced LVC (-1.70, [-2.37, -1.22] L/sec) after the current noise exposure on nonworking days. Such decreasing effects persisted to become sustained decreases in 24-h ambulatory SV in high-exposure (-1.10 [-1.20, -1.01] ml/beat) and office workers (-1.13 [-1.22, -1.05] ml/beat) on working days and in all three groups (-1.19 [-1.36, -1.04]; -1.15 [-1.31, -1.02]; -1.08 [-1.13, -1.02] ml/beat, respectively) on nonworking days. No significant effect on 24-h ambulatory LVC was found in any group on working or nonworking days. Occupational and nocturnal noise exposure may have acute effects on 24-h ambulatory SV among male workers, directly influencing the cardiac function related to cardiovascular disease.

Cardiac and renal function interactions in heart failure with reduced ejection fraction: A mathematical modeling analysis

Congestive heart failure is characterized by suppressed cardiac output and arterial filling pressure, leading to renal retention of salt and water, contributing to further volume overload. Mathematical modeling provides a means to investigate the integrated function and dysfunction of heart and kidney in heart failure. This study updates our previously reported integrated model of cardiac and renal functions to account for the fluid exchange between the blood and interstitium across the capillary membrane, allowing the simulation of edema. A state of heart failure with reduced ejection fraction (HF-rEF) was then produced by altering cardiac parameters reflecting cardiac injury and cardiovascular disease, including heart contractility, myocyte hypertrophy, arterial stiffness, and systemic resistance. After matching baseline characteristics of the SOLVD clinical study, parameters governing rates of cardiac remodeling were calibrated to describe the progression of cardiac hemodynamic variables observed over one year in the placebo arm of the SOLVD clinical study. The model was then validated by reproducing improvements in cardiac function in the enalapril arm of SOLVD. The model was then applied to prospectively predict the response to the sodium-glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin, which has been shown to reduce heart failure events in HF-rEF patients in the recent DAPAHF clinical trial by incompletely understood mechanisms. The simulations predict that dapagliflozin slows cardiac remodeling by reducing preload on the heart, and relieves congestion by clearing interstitial fluid without excessively reducing blood volume. This provides a quantitative mechanistic explanation for the observed benefits of SGLT2i in HF-rEF. The model also provides a tool for further investigation of heart failure drug therapies.

Suppression of Netrin-1 attenuates angiotension II-induced cardiac remodeling through the PKC/MAPK signaling pathway

BACKGROUND

Myocardial remodeling caused by angiotensin II (Ang II) is essential for the pathological process of heart failure. Netrin-1, which is an axonal guidance cue, has been shown to be involved in the inflammatory response, tumorigenesis, and angiogenesis in non-neuronal tissues. However, the role of Netrin-1 in cardiac remodeling has not been fully elucidated.

METHODS

The rat cardiomyocyte cell line H9c2 and primary neonatal rat cardiomyocytes were treated with Ang II. Cells were transfected with siRNA to silence Netrin-1 expression. Real-time polymerase chain reaction and Western blot analysis were used to detect the markers for fibrosis, apoptosis, and hypertrophy in cardiomyocytes. An Annexin V-EGFP/PI cell apoptosis detection kit was used to measure the level of apoptosis caused by angiotensin II.

RESULTS

We found that Netrin-1 expression was upregulated in the H9c2 cells and the neonatal rat cardiomyocytes stimulated by Ang II. The increased Netrin-1 expression was decreased by valsartan to block AT1R. Importantly, the application of Netrin-1 siRNA significantly alleviated the degrees of myocardial hypertrophy, fibrosis (reflected by Myhc, collagen I, and TGF-β) and apoptosis (reflected by the level of Caspase 3, Bax, and Bcl-2) induced by Ang II. In addition, the silencing of Netrin-1 substantially decreased the phosphorylation of PKCα, JNK, and P38. We treated H9c2 cells with LY317615, SP600125, and SB203580, inhibitors of PKCα, JNK, and P38, respectively, thereby resulting in a substantial decrease in hypertrophy, fibrosis, and apoptosis.

CONCLUSIONS

Ang II produces cardiac hypertrophy, fibrosis, and apoptosis through the upregulation of Netrin-1 and the activation of the AT1R/PKCα/MAPK (JNK, P38) pathway. Suppression of Netrin-1 can relieve Ang II-induced cardiac remodeling via inhibition of the PKCα/MAPK (JNK and P38) signaling pathway. Thus, Netrin-1 may be a novel therapeutic target for Ang II-mediated cardiac remodeling.

Safety and efficacy of cell therapies in pediatric heart disease: a systematic review and meta-analysis

BACKGROUND

Adult clinical trials have reported safety and the therapeutic potential of stem cells for cardiac disease. These observations have now translated to the pediatric arena. We conducted a meta-analysis to assess safety and efficacy of cell-based therapies in animal and human studies of pediatric heart disease.

METHODS AND RESULTS

A literature search was conducted to examine the effects of cell-based therapies on: (i) safety and (ii) cardiac function. In total, 18 pre-clinical and 13 human studies were included. Pre-clinical: right ventricular dysfunction was the most common animal model (80%). Cardiac-derived (28%) and umbilical cord blood (24%) cells were delivered intravenously (36%) or intramyocardially (35%). Mortality was similar between cell-based and control groups (OR 0.94; 95% CI 0.05, 17.41). Cell-based treatments preserved ejection fraction by 6.9% (p < 0.01), while intramyocardial at a dose of 1-10 M cells/kg optimized ejection fraction. Clinical: single ventricle physiology was the most common cardiac disease (n = 9). Cardiac tissue was a frequent cell source, dosed from 3.0 × 105 to 2.4 × 107 cells/kg. A decrease in adverse events occurred in the cell-based cohort (OR 0.17, p < 0.01). Administration of cell-based therapies improved ejection fraction (MD 4.84; 95% CI 1.62, 8.07; p < 0.01).

CONCLUSIONS

In this meta-analysis, cell-based therapies were safe and improved specific measures of cardiac function. Implications from this review may provide methodologic recommendations (source, dose, route, timing) for future clinical trials. Of note, many of the results described in this study pattern those seen in adult stem cell reviews and meta-analyses.

Insomnia and Insomnia Symptoms in Persons With Heart Failure: An Integrative Review

BACKGROUND/OBJECTIVE

Insomnia and insomnia symptoms are highly prevalent in persons with heart failure (HF), and they are associated with several untoward outcomes. The purpose of this integrative review is to describe the correlates, predictors, and outcomes of insomnia and insomnia symptoms in persons with HF.

METHODS

Using integrative review methods, an extensive electronic search of 5 databases was conducted for the period of 2000-2019. Sixteen studies were identified that met the inclusion criteria for review and investigated insomnia or insomnia symptoms in HF.

RESULTS

Various sociodemographic factors, chronic comorbidities, clinical factors, and cognitive-behavioral factors are correlates and predictors of insomnia and insomnia symptoms in persons with HF. Depression, fatigue, daytime sleepiness, poor self-reported physical functioning, decreased exercise capacity, cardiac events, and poor health-related quality of life are significant outcomes of insomnia and insomnia symptoms in persons with HF. The associations of insomnia and insomnia symptoms with age, sex, sleep-disordered breathing, and cognition were not consistent across all studies.

CONCLUSION

Larger studies with diverse age and race groups as well as longitudinal studies and designs that test mediation effects are needed to disentangle complex relationships between insomnia and insomnia symptoms and several of their potential predictors and correlates in HF.

Neprilysin: A Potential Therapeutic Target of Arterial Hypertension?

Arterial hypertension is the most prevalent chronic disease in the adult population of developed countries and it constitutes a significant risk factor in the development of cardiovascular disease, contributing to the emergence of many comorbidities, among which heart failure excels, a clinical syndrome that nowadays represents a major health problem with uncountable hospitalizations and the indolent course of which progressively worsens until quality of life decreases and lastly death occurs prematurely. In the light of this growing menace, each day more efforts are invested in the field of cardiovascular pharmacology, searching for new therapeutic options that allow us to modulate the physiological systems that appear among these pathologies. Therefore, in the later years, the study of natriuretic peptides has become so relevant, which mediate beneficial effects at the cardiovascular level such as diuresis, natriuresis, and decreasing cardiac remodeling; their metabolism is mediated by neprilysin, a metalloproteinase, widely expressed in the human and capable of catalyzing many substrates. The modulation of these functions has been studied by decades, giving room to Sacubitril, the first neprilysin inhibitor, which in conjunction with an angiotensin receptor blocker has provided a high efficacy and tolerability among patients with heart failure, for whom it has already been approved and recommended. Nonetheless, in the matter of arterial hypertension, significant findings have arisen that demonstrate the potential role that it will play among the pharmacological alternatives in the upcoming years.

Pathogenesis and pathophysiology of heart failure with reduced ejection fraction: translation to human studies

Heart failure represents the end result of different pathophysiologic processes, which culminate in functional impairment. Regardless of its aetiology, the presentation of heart failure usually involves symptoms of pump failure and congestion, which forms the basis for clinical diagnosis. Pathophysiologic descriptions of heart failure with reduced ejection fraction (HFrEF) are being established. Most commonly, HFrEF is centred on a reactive model where a significant initial insult leads to reduced cardiac output, further triggering a cascade of maladaptive processes. Predisposing factors include myocardial injury of any cause, chronically abnormal loading due to hypertension, valvular disease, or tachyarrhythmias. The pathophysiologic processes behind remodelling in heart failure are complex and reflect systemic neurohormonal activation, peripheral vascular effects and localised changes affecting the cardiac substrate. These abnormalities have been the subject of intense research. Much of the translational successes in HFrEF have come from targeting neurohormonal responses to reduced cardiac output, with blockade of the renin-angiotensin-aldosterone system (RAAS) and beta-adrenergic blockade being particularly fruitful. However, mortality and morbidity associated with heart failure remains high. Although systemic neurohormonal blockade slows disease progression, localised ventricular remodelling still adversely affects contractile function. Novel therapy targeted at improving cardiac contractile mechanics in HFrEF hold the promise of alleviating heart failure at its source, yet so far none has found success. Nevertheless, there are increasing calls for a proximal, 'cardiocentric' approach to therapy. In this review, we examine HFrEF therapy aimed at improving cardiac function with a focus on recent trials and emerging targets.