Prevalence of heart failure and left ventricular dysfunction in China: the China Hypertension Survey, 2012-2015

Family Hardiness in Patients with Heart Failure: Exploring Protective Factors and Identifying the Mediator

Background

Struggling with heart failure (HF) may be a distressful experience for the entire family. As a key variable contributing to positive family functioning, family hardiness can protect against HF-related harm. Thus, recognizing factors associated with family hardiness could promote strategies that enable successful adaptation to HF. This study aimed to explore protective factors linked to family hardiness among HF patients.

Patients and Methods

A cross-sectional study was undertaken in 2020 among 167 HF patients in Nanjing, China. The study measures comprised a self-designed general information questionnaire, the Family Hardiness Index, the Mutuality Scale, the Positive and Negative Affect Scale, and the Simplified Coping Style Questionnaire. The data analysis was performed using IBM SPSS, version 25 and comprised Pearson’s correlation analysis, a multiple linear regression model, and an analysis of mediating effects.

Results

The average Family Hardiness Index score for the 167 HF patients was 57.95 ± 11.41. The multiple linear regression analysis revealed that mutuality, active coping style, and positive emotions of HF patients positively predicted family hardiness (β = 0.359, 0.308, and 0.215, respectively; all P ˂ 0.05). Mutuality between patients and family members had partial mediating effects between active coping style, positive emotions, and family hardiness.

Conclusion

Our results revealed that patients’ active coping styles, positive emotions, and mutuality were protective factors associated with family hardiness. In light of our findings, we suggest that active coping strategies, positive emotions, and, especially, closer relationships within families should be encouraged during the rehabilitation and follow-up care of HF patients.

NETosis as a Pathogenic Factor for Heart Failure

Heart failure threatens the lives of patients and reduces their quality of life. Heart failure, especially heart failure with preserved ejection fraction, is closely related to systemic and local cardiac persistent chronic low-grade aseptic inflammation, microvascular damage characterized by endothelial dysfunction, oxidative stress, myocardial remodeling, and fibrosis. However, the initiation and development of persistent chronic low-grade aseptic inflammation is unexplored. Oxidative stress-mediated neutrophil extracellular traps (NETs) are the main immune defense mechanism against external bacterial infections. Furthermore, NETs play important roles in noninfectious diseases. After the onset of myocardial infarction, atrial fibrillation, or myocarditis, neutrophils infiltrate the damaged tissue and aggravate inflammation. In tissue injury, damage-related molecular patterns (DAMPs) may induce pattern recognition receptors (PRRs) to cause NETs, but whether NETs are directly involved in the pathogenesis and development of heart failure and the mechanism is still unclear. In this review, we analyzed the markers of heart failure and heart failure-related diseases and comorbidities, such as mitochondrial DNA, high mobility box group box 1, fibronectin extra domain A, and galectin-3, to explore their role in inducing NETs and to investigate the mechanism of PRRs, such as Toll-like receptors, receptor for advanced glycation end products, cGAS-STING, and C-X-C motif chemokine receptor 2, in activating NETosis. Furthermore, we discussed oxidative stress, especially the possibility that imbalance of thiol redox and MPO-derived HOCl promotes the production of 2-chlorofatty acid and induces NETosis, and analyzed the possibility of NETs triggering coronary microvascular thrombosis. In some heart diseases, the deletion or blocking of neutrophil-specific myeloperoxidase and peptidylarginine deiminase 4 has shown effectiveness. According to the results of current pharmacological studies, MPO and PAD4 inhibitors are effective at least for myocardial infarction, atherosclerosis, and certain autoimmune diseases, whose deterioration can lead to heart failure. This is essential for understanding NETosis as a therapeutic factor of heart failure and the related new pathophysiology and therapeutics of heart failure.

Development and Validation of a Nomogram to Predict the 180-Day Readmission Risk for Chronic Heart Failure: A Multicenter Prospective Study

Background: The existing prediction models lack the generalized applicability for chronic heart failure (CHF) readmission. We aimed to develop and validate a widely applicable nomogram for the prediction of 180-day readmission to the patients. Methods: We prospectively enrolled 2,980 consecutive patients with CHF from two hospitals. A nomogram was created to predict 180-day readmission based on the selected variables. The patients were divided into three datasets for development, internal validation, and external validation (mean age: 74.2 ± 14.1, 73.8 ± 14.2, and 71.0 ± 11.7 years, respectively; sex: 50.2, 48.8, and 55.2% male, respectively). At baseline, 102 variables were submitted to the least absolute shrinkage and selection operator (Lasso) regression algorithm for variable selection. The selected variables were processed by the multivariable Cox proportional hazards regression modeling combined with univariate analysis and stepwise regression. The model was evaluated by the concordance index (C-index) and calibration plot. Finally, the nomogram was provided to visualize the results. The improvement in the regression model was calculated by the net reclassification index (NRI) (with tenfold cross-validation and 200 bootstraps). Results: Among the selected 2,980 patients, 1,696 (56.9%) were readmitted within 180 days, and 1,502 (50.4%) were men. A nomogram was established by the results of Lasso regression, univariate analysis, stepwise regression and multivariate Cox regression, as well as variables with clinical significance. The values of the C-index were 0.75 [95% confidence interval (CI): 0.72-0.79], 0.75 [95% CI: 0.69-0.81], and 0.73 [95% CI: 0.64-0.83] for the development, internal validation, and external validation datasets, respectively. Calibration plots were provided for both the internal and external validation sets. Five variables including history of acute heart failure, emergency department visit, age, blood urea nitrogen level, and beta blocker usage were considered in the final prediction model. When adding variables involving hospital discharge way, alcohol taken and left bundle branch block, the calculated values of NRI demonstrated no significant improvements. Conclusions: A nomogram for the prediction of 180-day readmission of patients with CHF was developed and validated based on five variables. The proposed methodology can improve the accurate prediction of patient readmission and have the wide applications for CHF.

Daytime Sleep as Compensation for the Effects of Reduced Nocturnal Sleep on the Incidence of Hypertension: A Cohort Study

PURPOSE

The role of sleep duration in the development of hypertension remains controversial. Little is known about the combined effects of nocturnal and daytime sleep. We assessed the association between total sleep duration and the development of hypertension in middle-aged and elderly Chinese adults.

PATIENTS AND METHODS

Data were obtained from 3 waves of China Health and Retirement Longitudinal Study surveys. Middle-aged and elderly Chinese initially without hypertension were followed biennially from 2011 to 2015. Sleep duration was self-reported. Hypertension was defined as a systolic and/or diastolic blood pressure ≥ 140/90 (mmHg), the current use of anti-hypertensive medications or self-reported hypertension.

RESULTS

Over 31,392 person-years of follow-up, 2682 of 10,176 participants developed hypertension. The multivariable adjusted hazard ratios (HR) (95% confidence intervals, 95% CI) for the development of hypertension between those with 0-30 minutes and ≥30 minutes daytime sleep vs those without daytime sleep were 0.67 (0.58, 0.77), and 0.73 (0.59, 0.92), respectively. The protective role of longer periods of daytime sleep (>30 minutes) varied between different subgroups. Compared with moderate nocturnal sleepers, long nocturnal sleepers (HR: 1.66, 95% CI=1.25-2.21) had an increased risk of hypertension. Compared with moderate nocturnal sleepers without daytime sleep, HRs (95% CI) for hypertension were 0.52 (0.45, 0.59) for short nocturnal sleep plus short daytime sleep and 0.55 (0.49, 0.62) for short nocturnal sleep plus long daytime sleep. People with extremely short (HR: 1.34, 95% CI=1.22-1.48) and long (HR: 1.28, 95% CI=1.13-1.44) combined sleep periods had an increased risk of hypertension. Consistent results were also found in subgroups stratified by age and gender.

CONCLUSION

Both extremely long and short total sleep periods were associated with an increased risk of hypertension. People with short or moderate nocturnal sleep durations, especially short nocturnal sleep duration, can benefit from habitual daytime sleep to prevent hypertension.

Matrix metalloproteinase 3 regulates angiotensin II‑induced myocardial fibrosis cell viability, migration and apoptosis

Angiotensin II (AngII) is a central signaling molecule of the renin-angiotensin system that serves a vital role in myocardial fibrosis (MF). The present study aimed to investigate the effects of matrix metalloproteinase (MMP)3 on MF progression. To induce cellular fibrosis, H9C2 rat myocardial cells were treated with AngII for 24 h. Subsequently, cells were treated with levocarnitine, or transfected with small interfering (si)RNA-negative control or siRNA-MMP3 (1/2/3). Cell viability, apoptosis and migration were assessed by performing Cell Counting Kit-8, flow cytometry and Transwell assays, respectively. Reverse transcription-quantitative PCR (RT-qPCR) and western blotting were performed to determine the expression levels of MF biomarkers, including disease-, apoptosis- and oxidative stress-related genes. Compared with the control group, AngII significantly inhibited H9C2 cell viability and migration, and significantly increased H9C2 cell apoptosis (P<0.05). However, compared with AngII-treated H9C2 cells, MMP3 knockdown significantly inhibited fibrotic H9C2 cell viability and migration, but increased fibrotic H9C2 cell apoptosis (P<0.05). The RT-qPCR results demonstrated that MMP3 knockdown significantly downregulated the expression levels of AXL receptor tyrosine kinase, AngII receptor type 1, α-smooth muscle actin and Collagen I in AngII-treated H9C2 cells (P<0.05). Moreover, compared with AngII-treated cells, MMP3 knockdown significantly decreased Bcl-2 expression levels, but significantly increased caspase-3 and p53 expression levels in AngII-treated cells (P<0.05). Additionally, compared with AngII-treated cells, MMP3 knockdown significantly decreased MMP3, MMP9, STAT3, p22Phox and p47Phox expression levels in AngII-treated cells (P<0.05). The present study indicated that MMP3 knockdown altered myocardial fibroblast cell viability, migration and apoptosis by regulating apoptosis- and oxidative stress-related genes, thus delaying MF progression.

Heart failure in the last year: progress and perspective

Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM-HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA-HF and EMPEROR-Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65-0.85; P < 0.001 and HR 0.75; 95% CI 0.65-0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82-0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.

The Correlation Between Heart Failure and Gut Microbiome Metabolites

Heart failure (HF) is a global public health problem, with morbidity and mortality increasing year by year. The gut microbiome actively affects the physiological and pathological activities of the human body in a variety of ways. More and more studies have suggested a strong correlation between HF and gut microbiome metabolites. Our review summarizes the specific alteration of these metabolites and their connection to the progression of HF, aiming at considering new approaches toward regulating the gut microbiome and using its metabolic pathways to treat HF, potentially decreasing the morbidity and mortality of HF as well as improving prognosis.

Heart failure and left ventricular dysfunction in older patients with chronic kidney disease: the China Hypertension Survey (2012-2015)

Background

Heart failure (HF) is a leading cause of hospitalization and mortality for older chronic kidney disease (CKD) patients. However, the epidemiological data is scarce. We aimed to determine the prevalence of left ventricular (LV) dysfunction and HF, and to explore the risk factors for HF among those patients.

Methods

This is a cross-sectional analysis of the China Hypertension Survey conducted between October 2012 and December 2015. A total of 5, 808 participants aged ≥ 65 years were included in the analysis. Self-reported history of HF and any other cardiovascular diseases was acquired. 2-D and Doppler echocardiography were used to assess LV dysfunction. CKD was defined as either estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m² or urinary albumin to creatinine ratio (ACR) ≥ 30 mg/g.

Results

Among CKD patients aged ≥ 65 years, the weighted prevalence of HF, heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) was 4.8%, 2.5%, 0.8%, and 1.7%, respectively. The weighted prevalence of HF was 5.0% in patients with eGFR < 60 mL/min per 1.73 m², and was 5.9% in patients with ACR ≥ 30 mg/g. The prevalence of LV systolic dysfunction was 3.1%, and while it was 8.9% for moderate/severe diastolic dysfunction. Multivariate analysis showed that smoking was significantly associated with the risk of HF. Furthermore, age, smoking, and residents in rural areas were significantly associated with a risk of LV diastolic dysfunction.

Conclusions

The prevalence of HF and LV dysfunction was high in older patients with CKD, suggesting that particular strategies will be required.

Cost-effectiveness of adding dapagliflozin to standard treatment for heart failure with reduced ejection fraction patients in China

Aims

This study was to determine the cost‐effectiveness of dapagliflozin in heart failure with reduced ejection fraction (HFrEF) patients in China from a perspective of health care payers.

Methods and results

We built a Markov model to perform a cost‐effectiveness analysis comparing standard treatment + dapagliflozin (10 mg, q.d.) with standard treatment for HFrEF. The base case in our simulation was a 65‐year‐old HFrEF patient and was modelled over 15 years. Inputs of the model were derived from the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial and other relevant data from China. Costs, quality‐adjusted life year (QALY), and incremental cost‐effectiveness ratio (ICER) were estimated for adding dapagliflozin relative to standard treatment. Costs and QALY were discounted at a 4.2% rate annually. All costs are presented in 2017 US dollars. Dapagliflozin would be considered very cost‐effective if the ICER was lower than a willingness‐to‐pay (WTP) threshold of $8573.4. Uncertainty was assessed in our model using one‐way, two‐way, and probabilistic sensitivity analysis (PSA). In our base case, compared with standard treatment, adding dapagliflozin was more expensive ($5829.4 vs. $4377.1) but more effective (4.82 vs. 4.44 QALYs). The respondent ICER was $3827.6 per QALY gained at 15‐year follow‐up. When the simulated horizon was longer than 3.5 years, the respondent ICER became lower than the WTP threshold. The inputs with the largest impact on ICER were the cost of dapagliflozin, the cardiovascular mortality in both groups, and the cost of hospitalization for heart failure. Most results of sensitivity analysis were robust. PSA showed a similar result as the base case (ICER = $4412.5 per QALY gained). In Monte Carlo simulation, at a WTP threshold of $8573.4 per QALY, dapagliflozin was considered very cost‐effective in 53.10% of the simulations.

Conclusions

Dapagliflozin was a very cost‐effective treatment option for HFrEF patients in China according to the result of our model. Our findings will help doctors and health care payers to make decisions in clinical practice. Future real‐world studies of cost‐effectiveness of dapagliflozin based on Chinese population were also needed.

Functional status mediates the association of nutritional status with depressive symptoms in patients with heart failure

AIMS

The decline of nutritional status and depressive symptoms are pandemic in heart failure patients and functional status may play a pivotal role between these. This study aimed to determine whether nutritional status is associated with depressive symptoms and whether functional status mediates this relationship in heart failure patients.

DESIGN

This was a secondary analysis of a cross-sectional study.

METHODS

The data were collected from November 2015-April 2016. Heart failure patients (N = 254) being hospitalized were included in this secondary analysis. The Depression Sub-Scale of the Hospital Anxiety and Depression Scale and the Duke Activity Status Index were used to assess patients' depressive symptoms and functional status. The nutritional status of patients was calculated using the Geriatric Nutritional Risk Index.

RESULTS

In this study, the average scores of depressive symptoms, nutritional status and functional status were 4.91 (SD 3.12), 102.38 (SD 6.57) and 20.58 (SD 8.96) respectively. Out of the 254 patients, 46 patients (18.1%) had significant depressive symptoms (the score of Depression Sub-Scale of the Hospital Anxiety and Depression Scale ≥ 8) and 55 (21.7%) suffered from malnutrition (the score of Geriatric Nutritional Risk Index ≤ 98). In the multiple regression analyses, nutritional status was negatively associated with depressive symptoms (β = -0.142, p = .02) and functional status mediated the relationship between nutritional status and depressive symptoms.

CONCLUSIONS

Many patients with heart failure have malnutrition and depressive symptoms. Functional status plays a mediating role in the relationship between nutritional status and depressive symptoms.

IMPACT

To relieve depressive symptoms in patients with heart failure, it is of importance to improve the functional status, especially for those with poor nutritional status.

Muscle Wasting and Sarcopenia in Heart Failure-The Current State of Science

Sarcopenia is primarily characterized by skeletal muscle disturbances such as loss of muscle mass, quality, strength, and physical performance. It is commonly seen in elderly patients with chronic diseases. The prevalence of sarcopenia in chronic heart failure (HF) patients amounts to up to 20% and may progress into cardiac cachexia. Muscle wasting is a strong predictor of frailty and reduced survival in HF patients. Despite many different techniques and clinical tests, there is still no broadly available gold standard for the diagnosis of sarcopenia. Resistance exercise and nutritional supplementation represent the currently most used strategies against wasting disorders. Ongoing research is investigating skeletal muscle mitochondrial dysfunction as a new possible target for pharmacological compounds. Novel agents such as synthetic ghrelin and selective androgen receptor modulators (SARMs) seem promising in counteracting muscle abnormalities but their effectiveness in HF patients has not been assessed yet. In the last decades, many advances have been accomplished but sarcopenia remains an underdiagnosed pathology and more efforts are needed to find an efficacious therapeutic plan. The purpose of this review is to illustrate the current knowledge in terms of pathogenesis, diagnosis, and treatment of sarcopenia in order to provide a better understanding of wasting disorders occurring in chronic heart failure.

Prevalence and Risk Factors of Left Ventricular Diastolic Dysfunction in Patients With Hyperthyroidism

BACKGROUND

Left ventricular (LV) diastolic dysfunction has been demonstrated to be an independent predictor of the future heart failure. Heart failure is one of the severe complications caused by overt hyperthyroidism. However, the effects of overt hyperthyroidism on diastolic dysfunction are conflicting, and little is known about the prevalence and risk factors of the diastolic dysfunction in patients with overt hyperthyroidism.

METHODS

A total of 388 patients with overt hyperthyroidism were included and compared with 388 age- and gender- matched euthyroid control subjects. LV diastolic function was evaluated by traditional and tissue-Doppler echocardiography. Routine clinical medical data and echocardiographic parameters were recorded for analysis.

RESULTS

The prevalence of LV diastolic dysfunction was 35.1% among hyperthyroid patients and significantly higher than control subjects whose prevalence was 25.5% (P = 0.003), and it increased with age and body mass index (BMI) in patients with overt hyperthyroidism. The possible risk factors for LV diastolic dysfunction, such as hypertension, diabetes, decreased estimated glomerular filtration rate (eGFR), and increased level of thyroid hormones weren't associated with LV diastolic dysfunction. However, overweight or obese were significantly associated with LV diastolic dysfunction (OR = 3.024, 95% CI = 1.517-6.027, P = 0.002) compared with normal BMI. When compared with age <40 years old group, 40-50 years old group, 50-60 years old group and age ≥60 years old group were significantly associated with LV diastolic dysfunction, with ORs of 2.976 (95% CI = 1.744-5.019), 12.424 (95% CI = 4.934-31.283), 24.966 (95% CI = 5.975-104.321), respectively.

CONCLUSION

LV diastolic dysfunction was very common, in particular, in older and overweight or obese patients with overt hyperthyroidism. Additionally, age and BMI were independent risk factors for LV diastolic dysfunction, while the level of thyroid hormones was not. Therefore, besides the LV systolic function, we also need focus on the diastolic function in patients with overt hyperthyroidism in clinical work, especially the older and overweight or obese patients.