Trends in prevalence and outcome of heart failure with preserved ejection fraction

Clinical epidemiology of heart failure

The aim of this paper is to review the clinical epidemiology of heart failure. The last paper comprehensively addressing the epidemiology of heart failure in Heart appeared in 2000. Despite an increase in manuscripts describing epidemiological aspects of heart failure since the 1990s, additional information is still needed, as indicated by various editorials.

Diastolic Heart Failure in the Elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

Response to Cardiac Resynchronization Therapy Predicts Survival in Heart Failure: A Single-Center Experience

OBJECTIVE

To determine whether survival after cardiac resynchronization therapy (CRT) is related to improvement in clinical or echocardiographic parameters.

BACKGROUND

In clinical trials, CRT improved symptoms, left ventricular (LV) structure, function, and survival. In clinical practice, response to CRT is highly variable and whether survival benefit is confined to those patients who experience improvement in clinical status or cardiac structure and function is unclear.

METHODS

This is a single-center study of patients receiving clinically indicated CRT between January 2002 and December 2004.

RESULTS

Of 309 patients (age 68 +/- 11 years, 83% male) receiving CRT at our institution during the study period, 174 returned for follow-up and 127 had repeat echocardiography. Baseline clinical characteristics and survival were similar among those who did or did not return for follow-up. In paired analyses, New York Heart Association (NYHA) class (-0.56 +/- 0.07, p < 0.0001), ejection fraction (EF, 6.3 +/- 0.7%, P < 0.0001), LV dimension (-2.7 +/- 0.6 mm, P < 0.0001), pulmonary artery systolic pressure (PASP, -4.6 +/- 1.3 mm Hg, P = 0.0007), and MR severity grade (-0.20 +/- 0.05, P = 0.0002) improved after CRT. Survival after CRT was associated with decrease in NYHA class (risk ratio [RR]= 0.43, P = 0.0004), increase in EF (RR = 0.94, P = 0.02), and decrease in PASP (RR = 0.96, P = 0.03). Change in EF and NYHA class were correlated (r = -0.46, P < 0.0001) and, adjusting for this covariance, change in NYHA (P = 0.04) but not EF (P = 0.12) was associated with improved survival.

CONCLUSION

Patients who experience improved symptoms, ventricular function, and/or hemodynamics have better survival after CRT. These data enhance understanding of the relationship between CRT clinical response and survival benefit in clinical practice.

Systolic and Diastolic Heart Failure: Differences and Similarities

BACKGROUND

Diastolic heart failure (DHF) and systolic heart failure (SHF) are 2 clinical subsets of the syndrome of chronic heart failure that are most commonly encountered in clinical practice.

METHODS AND RESULTS

The clinically overt DHF and SHF appear to be 2 separate syndromes with distinctive morphologic and functional changes although signs, symptoms, and prognosis are very similar. In DHF, the left ventricle is not dilated and the ejection fraction is preserved. In contrast in SHF, it is dilated and the ejection fraction is reduced. The neurohormonal abnormalities in DHF and SHF appear to be similar. The stimuli and the signals that ultimately produce these 2 different phenotypes of chronic heart failure remain, presently, largely unknown.

CONCLUSIONS

Although there has been considerable progress in the management of SHF, the management of DHF remains mostly empirical because of lack of knowledge of the molecular and biochemical mechanisms which produce myocardial structural and functional changes in this syndrome. Further research and investigations are urgently required.

Differences in arterial compliance, microvascular function and venous capacitance between patients with heart failure and either preserved or reduced left ventricular systolic function

BACKGROUND

Up to 50% of patients with the clinical syndrome of heart failure have preserved left ventricular systolic function (HF-PSF). These patients may have abnormalities of ventriculo-vascular coupling, due to increased vascular and ventricular stiffness.

METHODS

We compared arterial compliance, microvascular vasodilator function and venous capacitance (VC) in 3 groups of patients (n=12 each) matched for the presence of coronary heart disease: 1) HF and preserved systolic function (HF-PSF), 2) HF and reduced systolic function (HF-RSF) and 3) controls (no HF, PSF). Arterial compliance was assessed by measuring aortic pulse wave velocity (PWV) with applanation tonometry. Cutaneous microvascular function was assessed using Laser Doppler imaging (LDI) coupled with iontophoresis of endothelium-dependent (acetylcholine) and -independent (sodium nitroprusside) vasodilators. VC was measured using venous occlusion plethysmography.

RESULTS

PWV was significantly higher in HF-PSF subjects than in both HF-RSF and control groups (10.7 [1.1], 8.9 [1.7] and 8.6 [2.1] m/s respectively, p<0.05). Acetylcholine and nitroprusside induced vasodilatation were equally impaired in HF-PSF and HF-RSF, as compared to controls (p<0.01). VC was higher in HF-RSF subjects compared with HF-PSF subjects (1.75 [0.41], 1.34 [0.34] ml/100 ml forearm vol. respectively, p<0.05).

CONCLUSIONS

These findings are consistent with a more marked increase in vascular stiffness in HF-PSF than in HF-RSF and suggest that arterial stiffness, dynamic vasodilator function and venous abnormalities may be implicated in the complex pathophysiology of HF-PSF.

[Pathophysiology of heart failure]

Chronic heart failure is a clinical syndrome and the final common pathway of different cardiac diseases. Heart failure is accompanied by activation of the renin-angiotensin-aldosterone-system and the adrenergic nervous system. In addition, recent data emphasize important roles of maladaptive intracellular signaling pathways, decreased capillary density, altered calcium handling, metabolic changes, genetic polymorphisms, and programmed cell death in the failing heart. In this context, traditional pathophysiological concepts, e. g. concerning the role of cardiac hypertrophy, had to be given up. Thus, an increasingly complex scenario emerges with interdependent changes on the biochemical, molecular, metabolic, and cellular level. Novel therapeutic strategies may soon be based on these new pathophysiological concepts.

Differential prognostic importance of QRS duration in heart failure and acute myocardial infarction associated with left ventricular dysfunction

BACKGROUND/AIMS

Studies of the prognostic importance of QRS duration in patients with heart failure (HF) have shown conflicting results and few studies have estimated the importance after myocardial infarction (MI).

METHODS

The Danish Investigations and Arrhythmia ON Dofetilide (DIAMOND) study randomised 3028 patients to dofetilide (class III antiarrhythmic) or placebo. The study consisted of two almost identical trials conducted simultaneously. One trial included 1518 patients with chronic HF and the other trial 1510 patients with a recent MI. All patients had left ventricular dysfunction. Dofetilide did not influence mortality in either trial. QRS duration was systematically measured at randomisation and was available in 2972 patients.

RESULTS

Over a 10 year observation period 1037 (70%) patients in the MI study and 1324 (87%) in the HF study died. In the MI study, risk of death increased 6% for each 10 ms increase in QRS duration (HR=1.06/10 ms increase in QRS (CI=1.04-1.09), p<0.0001) whereas QRS duration had no influence in the HF study after multivariable adjustment. The difference between HF and MI was significant (p<0.0004 for interaction).

CONCLUSION

QRS duration predicts death in patients with left ventricular dysfunction who have suffered MI. In patients with HF QRS duration is not predictive of mortality.

Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry

OBJECTIVES

We sought to evaluate the characteristics, treatments, and outcomes of patients with preserved and reduced systolic function heart failure (HF).

BACKGROUND

Heart failure with preserved systolic function (PSF) is common but not well understood.

METHODS

This analysis of the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry compared 20,118 patients with left ventricular systolic dysfunction (LVSD) and 21,149 patients with PSF (left ventricular ejection fraction [EF] > or =40%). Sixty- to 90-day follow-up was obtained in a pre-specified 10% sample of patients. Analyses of patients with PSF defined as EF >50% were also performed for comparison.

RESULTS

Patients with PSF (EF > or =40%) were more likely to be older, female, and Caucasian and to have a nonischemic etiology. Although length of hospital stay was the same in both groups, risk of in-hospital mortality was lower in patients with PSF (EF > or =40%) (2.9% vs. 3.9%; p < 0.0001). During 60- to 90-day post-discharge follow-up, patients with PSF (EF > or =40%) had a similar mortality risk (9.5% vs. 9.8%; p = 0.459) and rehospitalization rates (29.2% vs. 29.9%; p = 0.591) compared with patients with LVSD. Findings were comparable with those with PSF defined as EF >50%. In a risk- and propensity-adjusted model, there were no significant relationships between discharge use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or beta-blocker and 60- to 90-day mortality and rehospitalization rates in patients with PSF.

CONCLUSIONS

Data from the OPTIMIZE-HF registry reveal a high prevalence of HF with PSF, and these patients have a similar post-discharge mortality risk and equally high rates of rehospitalization as patients with HF and LVSD. Despite the burden to patients and health care systems, data are lacking on effective management strategies for patients with HF and PSF. (Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure [OPTIMIZE-HF]); http://www.clinicaltrials.gov/ct/show/NCT00344513?order=1; NCT00344513).

Small-molecule therapies for cardiac hypertrophy: moving beneath the cell surface

Pathological stress from cardiovascular disease stimulates hypertrophy of heart cells, which increases the risk of cardiac morbidity and mortality. Recent evidence has indicated that inhibiting such hypertrophy could be beneficial, encouraging drug discovery and development efforts for agents that could achieve this goal. Most existing therapies that have antihypertrophic effects target outside-in signalling in cardiac cells, but their effectiveness seems limited, and so attention has recently turned to the potential of targeting intracellular signalling pathways. Here, we focus on new developments with small-molecule inhibitors of cardiac hypertrophy, summarizing both agents that have been in or are poised for clinical testing, and pathways that offer further promising potential therapeutic targets.

Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study

BACKGROUND

Various conventional and tissue Doppler echocardiographic indexes were compared with pressure-volume loop analysis to assess their accuracy in detecting left ventricular (LV) diastolic dysfunction in patients with heart failure with normal ejection fraction (HFNEF).

METHODS AND RESULTS

Diastolic dysfunction was confirmed by pressure-volume loop analysis obtained by conductance catheter in 43 patients (19 men) with HFNEF. Their Doppler indexes were compared with those of 12 control patients without heart failure symptoms and with normal ejection fraction. Invasively measured indexes for diastolic relaxation (tau, dP/dt(min)), LV end-diastolic pressure, and LV end-diastolic pressure-volume relationship (stiffness, b [dP/dV], and stiffness constant, beta) were correlated with several conventional mitral flow and tissue Doppler imaging indexes. Conventional Doppler indexes correlated moderately with the degree of LV relaxation index, tau (E/A: r=-0.36, P=0.013; isovolumic relaxation time: r=0.31, P=0.040) and b (deceleration time: r=0.39, P=0.012) but not with beta, in contrast to the tissue Doppler imaging indexes E'/A'(lateral) (r=-0.37, P=0.008) and E/E'(lateral) (r=0.53, P<0.001). Diastolic dysfunction was detected in 70% of the HFNEF patients by mitral flow Doppler but in 81% and 86% by E'/A'(lateral), and E/E'(lateral), respectively.

CONCLUSIONS

Of all echocardiographic parameters investigated, the LV filling index E/E'(lateral) was identified as the best index to detect diastolic dysfunction in HFNEF in which the diagnosis of diastolic dysfunction was confirmed by conductance catheter analysis. We recommend its use as an essential tool for noninvasive diagnostics of diastolic function in patients with HFNEF.

Effects of fenofibrate on cardiac remodeling in aldosterone-induced hypertension

Hypertension and cardiac remodeling are associated with myocardial fibrosis, left ventricular (LV) hypertrophy, and diastolic heart failure. Fenofibrate suppresses aldosterone-mediated increases in myocyte matrix metalloproteinase activity and extracellular signal-regulated kinase phosphorylation. It is unknown whether the peroxisome proliferator-activated receptor-alpha agonist, fenofibrate, improves cardiac remodeling in a model of aldosterone-induced hypertension and LV hypertrophy. Twelve-week-old uninephrectomized FVB mice received 1% NaCl drinking water. Miniosmotic pumps delivered saline or aldosterone for 4 weeks. Mice were either untreated (n=14) or treated with fenofibrate 100 mg/kg per day (n=12) for 1 week before and 4 weeks after surgery. Aldosterone increased systolic blood pressure in untreated mice versus saline-untreated mice (134+/-3 versus 91+/-3 mm Hg; P<0.01). This was unaffected by fenofibrate (131+/-3 mm Hg). Aldosterone increased LV end-diastolic and end-systolic dimensions, which were significantly attenuated by fenofibrate (3.8+/-0.1 versus 3.5+/-0.1 mm, and 1.5+/-0.1 versus 1.15+/-0.1 mm, respectively). Fenofibrate also decreased aldosterone-induced LV hypertrophy (LV weight/body weight, 4.1+/-0.2 versus 4.6+/-0.1 mg/g) and improved percent LV fractional shortening (67+/-7% versus 60+/-2%). Additionally, fenofibrate ameliorated the increased matrix metalloproteinase-2/tissue inhibitors of metalloproteinase-2 ratio and fibrosis seen in aldosterone-untreated hearts (P<0.05 for both). Furthermore, in aldosterone-untreated hearts, fenofibrate decreased transforming growth factor-beta, collagen type III (P<0.05 for both), and collagen type I (P<0.01) protein expression. Conversely fenofibrate increased peroxisome proliferator-activated receptor-alpha, peroxisome proliferator-activated receptor-gamma coactivator-1alpha expression, and acetyl coenzyme A carboxylase phosphorylation (P<0.05 for all) in aldosterone-infused hearts; uncoupling protein-3 and medium-chain acyl coenzyme A dehydrogenase protein expression decreased with fenofibrate (P<0.05 and P<0.01, respectively, versus aldosterone-infused), suggesting that improved myocardial remodeling is independent of fatty acid oxidation. Thus, fenofibrate improved aldosterone-induced LV hypertrophy independently of an effect on blood pressure with decreased fibrosis and altered extracellular matrix.

Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES

INTRODUCTION

Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC.

PATIENTS AND METHODS

Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables.

RESULTS

Eight hundred forty seven (847) patients were included (age 73.0 +/- 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers.

CONCLUSIONS

AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC.

Anthracycline-induced cardiotoxicity: course, pathophysiology, prevention and management

Although effective anti-neoplastic agents, anthracyclines are limited by their well recognized and pervasive cardiotoxic effects. The incidence of late progressive cardiovascular disease in long-term survivors of cancer is established and may contribute to heart failure and death. To maximize the benefits of these drugs, a high-risk population has been identified and new strategies have been investigated to minimize toxic effects, including limiting the cumulative dose, controlling the rate of administration and using liposomal preparations and novel anthracycline analogues. Dexrazoxane also shows promise as a cardioprotectant during treatment. This paper reviews these strategies, as well as medications used to manage anthracycline-induced cardiotoxicity, and functional and biochemical means of monitoring cardiotoxicity, including echocardiography, radionuclide scans and biomarker analysis. The treatment of adult cancer survivors who have had anthracycline-related cardiotoxicity has not been systematically studied. Empirically, anthracycline-associated cardiac dysfunction is treated very similarly to other forms of heart failure. These treatments include avoiding additional cardiotoxic regimens, controlling hypertension, lifestyle changes, medications and heart transplantation.

Prevalence and prognosis of asymptomatic left ventricular diastolic dysfunction in ambulatory patients with coronary heart disease

The association of asymptomatic left ventricular (LV) diastolic dysfunction with cardiovascular outcomes in ambulatory patients with coronary heart disease (CHD) and no history of heart failure (HF) was examined. LV diastolic HF predicts adverse cardiovascular outcomes. However, the prevalence and prognosis of asymptomatic LV diastolic dysfunction in patients with established CHD in the absence of clinical HF is unknown. Six hundred ninety-three patients with stable CHD, normal systolic function (LV ejection fraction>or=50%), and no history of HF were evaluated. Echocardiography was used to classify LV diastolic function, and Cox proportional hazards models were used to evaluate the association of LV diastolic dysfunction with cardiovascular outcomes during 3 years of follow-up. Of 693 subjects with normal systolic function and no history of HF, 455 (66%) had normal LV diastolic function, 166 (24%) had mild LV diastolic dysfunction, and 72 (10%) had moderate to severe LV diastolic dysfunction. After multivariable adjustment, the presence of moderate to severe LV diastolic dysfunction was strongly predictive of incident hospitalization for HF (hazard ratio 6.3, 95% confidence interval 2.4 to 16.1, p=0.0003) and death from heart disease (HR 3.9, 95% confidence interval 1.0 to 14.8, p=0.05). In conclusion, moderate to severe LV diastolic dysfunction was present in 10% of patients with stable CHD with normal ejection fraction and no history of HF and predicts subsequent hospitalization for HF and death from heart disease. Patients with asymptomatic LV diastolic dysfunction may benefit from more aggressive therapy to prevent or delay the development of HF.

Asymmetric dimethylarginine enhances cardiovascular risk prediction in patients with chronic heart failure

OBJECTIVE

The purpose of this study was to investigate whether elevated asymmetrical dimethylorginine (ADMA) concentrations are associated with increased cardiovascular risk in chronic heart failure (HF) patients.

METHODS AND RESULTS

253 patients with symptomatic chronic HF and impaired left ventricular function (median age 70 years, 202 males) were followed for a median of 14.2 months (interquartile range 6.8 to 21.2). ADMA and N-terminal pro-brain natriuretic peptide (NT-proBNP) were assessed by high performance liquid chromatography and by an enzyme-linked immunosorbent assay, respectively. Subjects with ADMA concentrations in the highest tertile had a significantly higher adjusted hazard ratio (HR; 2.00; 95% confidence interval [CI] 1.01 to 3.97) for occurrence of an end point (cardiac decompensation, major adverse cardiovascular events or all-cause mortality) compared with patients in the lowest tertile (P=0.046) during the first 6 months of follow-up. NT-proBNP also identified subjects at risk before adjustment for confounders at 6 and 12 months of follow-up. HR for patients with ADMA and NT-proBNP in the highest tertile was significantly increased (3.68, CI 1.67 to 8.14; at 6 months follow-up) compared with patients without ADMA and NT-proBNP in the highest tertile (P<0.001).

CONCLUSIONS

Elevated ADMA plasma concentrations are associated with adverse cardiovascular outcome in patients with chronic HF. Quantification of ADMA with NT-proBNP improves risk stratification in this cohort.

Diastolic heart failure in anaesthesia and critical care

Diastolic heart failure is an underestimated pathology with a high risk of acute decompensation during the perioperative period. This article reviews the epidemiology, risk factors, pathophysiology, and treatment of diastolic heart failure. Although frequently underestimated, diastolic heart failure is a common pathology. Diastolic heart failure involves heart failure with preserved left ventricular (LV) function, and LV diastolic dysfunction may account for acute heart failure occurring in critical care situations. Hypertensive crisis, sepsis, and myocardial ischaemia are frequently associated with acute diastolic heart failure. Symptomatic treatment focuses on the reduction in pulmonary congestion and the improvement in LV filling. Specific treatment is actually lacking, but encouraging data are emerging concerning the use of renin-angiotensin-aldosterone axis blockers, nitric oxide donors, or, very recently, new agents specifically targeting actin-myosin cross-bridges.

Nebivolol for heart failure in the elderly

Recent analyses in the temporal trends of mortality and hospitalization in patients with chronic heart failure showed marginal changes in the last 20 years, particularly in the elderly. According to the Euro Heart Survey program and other observational reports, only 37-50% of patients with heart failure are treated with beta-blockers, with a dosage that is approximately half the target dose of clinical trials. The most frequent reason for the limited use of beta-blockers and the suboptimal doses prescribed, is age greater than 70 years. Only two multicenter, double-blind, randomized, placebo-controlled, parallel group trials; the Effects of Nebivolol on Left Ventricular Function in Elderly Patients with Chronic Heart Failure (ENECA) and the Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization Seniors with Heart Failure (SENIORS), both with nebivolol, have been specifically aimed to assess the efficacy of beta-blockade in elderly heart failure patients. The results of such trials demonstrated that the drug is well tolerated and effective in reducing mortality and morbidity, and that the beneficial clinical effect is independent of the baseline ejection fraction.

Advances in the prevention and treatment of cardiovascular disease

Over the past thirty-five years, U.S. age-adjusted mortality from cardiovascular disease declined 50 percent. This marked reduction reflects advances in the prevention, diagnosis, and treatment of common cardiovascular conditions. Pharmaceutical agents play a major role in prevention of atherosclerosis and its consequences: heart attack, stroke, and heart failure. Additionally, novel device-based therapies contribute to the decline in cardiac morbidity and mortality. Whereas innovative strategies based on accurate imaging of the heart and blood vessels are implemented widely now, hope exists that lifestyle changes, early risk-factor screening, and more efficacious drugs will strikingly reduce cardiovascular disease in the future.

Development of congestive heart failure in Japanese patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) and congestive heart failure (CHF) are frequently coexistent, but their temporal relationship in Japanese patients is unclear.

METHODS AND RESULTS

248 AF patients (63.6+/-10.0 years old) without a history of CHF were enrolled for analysis of the development of CHF during the follow-up period of 49.7+/-29.8 months. Of them, 195 did not have structural heart disease, 22 had dilated or hypertrophic cardiomyopathy, 18 had an old myocardial infarction, and 15 had valvular heart disease. During the follow-up period, 16 patients (6.5%) developed CHF requiring hospitalization (2.0% per patient-year). Although age, gender, fractional shortening, left atrial diameter, hypertension and diabetes mellitus were not associated with CHF development, existence of structural heart disease and left ventricular hypertrophy by Cornell voltage criteria on ECG were significantly associated with CHF development. Cox-Hazard regression analysis revealed that the existence of structural heart disease was the only independent risk factor (hazard ratio 3.50, 95% confidence interval 1.21-10.1).

CONCLUSIONS

In the present group of Japanese AF patients, CHF requiring hospitalization occurred at a rate of 2% per year. The existence of structural heart disease was the only independent risk factor in this population.

VE/VCO2 Slope in Older Heart Failure Patients With Normal Versus Reduced Ejection Fraction Compared With Age-Matched Healthy Controls

BACKGROUND

Oxygen consumption (VO2) has previously been used for prognosis and risk stratification in patients with heart failure. More recent research has introduced VE/VCO2 slope as a prognostic measure. Risk of mortality is thought to increase when VE/VCO2 slope values are greater than 34. Therefore, the purpose of this study was to cross-sectionally examine VE/VCO2 slope in systolic heart failure (SHF) and diastolic heart failure (DHF) as well as age-matched healthy controls.

METHODS AND RESULTS

Maximal graded exercise tests were conducted on 147 patients (59 DHF, 60 SHF, and 28 controls) using a bicycle ergometer. Breath-by-breath expired gas analysis was performed using a commercially available system with on-line computer calculations. VE/VCO2 slope was calculated from a regression line of minute ventilation and carbon dioxide production. One-way analysis of covariance with a Bonferroni post hoc test and Pearson correlations were used for statistical analysis. VE/VCO2 slope was significantly higher in SHF when compared to both DHF (37 +/- 8 vs. 34 +/- 7, P = .03) and controls (37 +/- 8 vs. 32 +/- 5, P = .002). No significant difference was observed between DHF and healthy controls (34 +/- 7 vs. 32 +/- 5, P = .52). Additional analysis resulted in significant correlations between VO2 and VE/VCO2 slope in systolic heart failure patients (r = -0.40, P = .002); however, there was no significant relationships in diastolic heart failure patients (r = -0.09, P = .49) or in controls (r = 0.13, P = .50).

CONCLUSIONS

VE/VCO2 slope is significantly higher in patients with SHF compared with DHF and healthy controls.

Predicting survival in heart failure

Despite advances in the therapy of cardiovascular disorders, heart failure remains a challenging disease with a dismal prognosis. A plethora of variables have been shown to be related to survival in patients with heart failure. These include heart failure etiology, clinical presentation, ventricular performance, exercise capacity, neurohormones and, more recently, inflammatory and necrosis markers. In this review we briefly list established predictive markers and discuss whether survival can accurately be predicted in this condition.

Diagnosis of diastolic heart failure

Nearly half of patients with heart failure (HF) have a normal ejection fraction (EF) and have been labeled as having diastolic HF. Diastolic HF is characterized by a normal EF, a variable amount of concentric left ventricular hypertrophy, and abnormal diastolic function. Differentiating diastolic HF from HF with a reduced EF (systolic HF) is important because these two forms of HF have different pathophysiology and thus might require different therapeutic approaches. Nevertheless, patients with diastolic HF and those with systolic HF have similar clinical symptoms and signs. Thus, clinical history and physical examination do not differentiate between diastolic and systolic HF. There is accumulating evidence that diastolic dysfunction is related to the severity of HF and prognosis regardless of EF. Thus, it is important to evaluate both systolic and diastolic function not only to differentiate between diastolic and systolic HF but also to identify high-risk patients.

Predictive value of high sensitivity CRP in patients with diastolic heart failure

BACKGROUND

C-reactive protein (CRP) has been tested in patients with systolic heart failure (HF) and mixed results have been obtained with regards to its potential predictive value. However, the role of C-reactive protein (CRP) in patients with diastolic HF is not established. We studied the predictive role of high sensitivity CRP (hsCRP) in patients with diastolic HF.

METHODS

HsCRP levels were measured in a cohort of CHF outpatients, 77 patients with diastolic HF and 217 patients with systolic HF. Concentrations were compared to a large cohort of healthy population (n=7701) and associated with the HF admissions and mortality of the patients.

RESULTS

Levels of hsCRP did not differ between patients with systolic and diastolic HF and were significantly elevated compared to the cohort of healthy subjects even after adjustment to various clinical parameters (p<0.0001). In patients with diastolic HF, hsCRP levels associated with New York Heart Association functional class (NYHA-FC) (r=0.31 p=0.01). On univariate Cox regression model hsCRP levels independently predicted hospitalizations in patients with systolic but not diastolic HF (p=0.047).

CONCLUSION

HsCRP concentrations are elevated in patients with diastolic HF and correlate with disease severity; their prognostic value in this patient population should be further investigated.

Anthracycline cardiotoxicity in long-term survivors of childhood cancer

Anthracycline chemotherapy is a widely-used and effective treatment for a wide spectrum of childhood cancers. Its use is limited by associated progressive and clinically significant cardiotoxic effects. Onset can be acute, early, or late. While acute onset is rare, long-term survivors have significantly elevated rates of cardiac morbidity and mortality. Major complications include cardiomyopathy, coronary artery disease, and atherosclerosis. Means of prevention and treatment continue to be explored including limiting cumulative anthracycline dose, controlling the rate of administration, and using liposomal preparations and novel anthracycline analogues. Dexrazoxane prior to anthracycline chemotherapy has been shown to significantly lower rates of elevated serum cardiac troponin levels, a marker of myocyte injury, indicating a cardioprotective effect. Pilot studies indicate that exercise interventions may also be beneficial in long-term survivors with cardiac damage. Support and study of this population to decrease the morbidity and morality associated with anthracycline-induced cardiotoxicity is indicated in a time sensitive fashion.

Prognostic importance of pulmonary hypertension in patients with heart failure

Pulmonary hypertension is a well-known complication in heart failure, but its prognostic importance is less well established. This study assessed the risk associated with pulmonary hypertension in patients with heart failure with preserved or reduced left ventricular (LV) ejection fractions. Patients with known or presumed heart failure (n = 388) underwent the echocardiographic assessment of pulmonary systolic pressure and LV ejection fraction. Patients were followed for up to 5.5 years. Increased pulmonary pressure was associated with increased short- and long-term mortality (p <0.0001 and p = 0.003, respectively). This relation was also present when stratifying patients by reduced or preserved LV function. A Cox proportional-hazards model apportioned a 9% increase in mortality per 5 mm Hg increase in right ventricular systolic pressure (p = 0.0008), independent of age and known chronic obstructive lung disease, heart failure, and impaired renal function. In conclusion, pulmonary hypertension is associated with increased short- and long-term mortality in patients with reduced LV ejection fractions and also in patients with preserved LV ejection fractions.

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.

Cardiac structure and ventricular-vascular function in persons with heart failure and preserved ejection fraction from Olmsted County, Minnesota

BACKGROUND

Mechanisms purported to contribute to the pathophysiology of heart failure with normal ejection fraction (HFnlEF) include diastolic dysfunction, vascular and left ventricular systolic stiffening, and volume expansion. We characterized left ventricular volume, effective arterial elastance, left ventricular end-systolic elastance, and left ventricular diastolic elastance and relaxation noninvasively in consecutive HFnlEF patients and appropriate controls in the community.

METHODS AND RESULTS

Olmsted County (Minn) residents without cardiovascular disease (n=617), with hypertension but no heart failure (n=719), or with HFnlEF (n=244) were prospectively enrolled. End-diastolic volume index was determined by echo Doppler. End-systolic elastance was determined using blood pressure, stroke volume, ejection fraction, timing intervals, and estimated normalized ventricular elastance at end diastole. Tissue Doppler e' velocity was used to estimate the time constant of relaxation. End-diastolic volume (EDV) and Doppler-derived end-diastolic pressure (EDP) were used to derive the diastolic curve fitting (alpha) and stiffness (beta) constants (EDP=alphaEDVbeta). Comparisons were adjusted for age, sex, and body size. HFnlEF patients had more severe renal dysfunction, yet smaller end-diastolic volume index and cardiac output and increased EDP compared with both hypertensive and healthy controls. Arterial elastance and ventricular end-systolic elastance were similarly increased in hypertensive controls and HFnlEF patients compared with healthy controls. In contrast, HFnlEF patients had more impaired relaxation and increased diastolic stiffness compared with either control group.

CONCLUSIONS

From these cross-sectional observations, we speculate that the progression of diastolic dysfunction plays a key role in the development of heart failure symptoms in persons with hypertensive heart disease.

Impact of heart failure and left ventricular function on long-term survival--report of a community-based cohort study in Taiwan

BACKGROUND

There is little community-based information on heart failure (HF) prognosis in ethnic Chinese populations, in whom there is a low prevalence of coronary heart disease.

AIMS

To study the impact of HF and left ventricular function on long-term all-cause mortality.

METHODS AND RESULTS

This community-based prospective cohort study included 2660 subjects (1215 men, 1445 women, mean age 54.4+/-11.9 years) over a 10 year follow-up period. The prevalence of HF was 5.5%. Hypertension was the most common factor related to HF. The five and ten year all-cause mortality was higher in the HF/preserved LVEF group (14.1% and 24.4%) and the HF/impaired LVEF group (29.2% and 48.2%) than in the HF-free group (6.0% and 14.6%, p<0.0001 for both). In multivariable Cox analyses, controlling for sex, LV mass, atrial fibrillation, hypertension, coronary heart disease, HF/preserved LVEF and HF/impaired LVEF were important predictors of all-cause mortality (p=0.007).

CONCLUSIONS

Hypertension is a major heart failure related disease. HF and LV systolic dysfunction are associated with a significant increase in all-cause mortality in an ethnic Chinese population.

Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function

Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.

[Heart failure in 2006]

This article are summarizes the most relevant articles in the field of heart failure including epidemiology, diagnostic and therapeutic issues. Therapy includes drugs, cardiac resinchronization therapy, automatic implantable defibrillator, heart transplantation and cell therapy. Stem cell therapy is feasible and short term data indicates it is safe. However there are unresolved concerns on arrhythmias, restenosis and efficacy. At this point experts recommend that medium-sized randomized controlled trials, using surrogate endpoints, should be carried out to establish the efficacy and safety of this form of treatment.

Prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community

BACKGROUND

Heart failure (HF) is a progressive disorder associated with frequent morbidity and mortality. An American Heart Association/American College of Cardiology staging classification of HF has been developed to emphasize early detection and prevention. The prevalence of HF stages and their association with mortality are unknown. We sought to estimate HF stage prevalence in the community and to measure the association of HF stages with mortality.

METHODS AND RESULTS

A population-based, cross-sectional, random sample of 2029 Olmsted County, Minnesota, residents aged > or = 45 years was identified. Participants were classified by medical record review, symptom questionnaire, physical examination, and echocardiogram as follows: stage 0, healthy; stage A, HF risk factors; stage B, asymptomatic cardiac structural or functional abnormalities; stage C, HF symptoms; and stage D, severe HF. In the cohort, 32% were stage 0, 22% stage A, 34% stage B, 12% stage C, and 0.2% stage D. Mean B-type natriuretic peptide concentrations (in pg/mL) increased by stages: stage 0=26, stage A=32, stage B=53, stage C=137, and stage D=353. Survival at 5 years was 99% in stage 0, 97% in stage A, 96% in stage B, 75% in stage C, and 20% in stage D.

CONCLUSIONS

The present study provides prevalence estimates and prognostic validation for HF staging in a community cohort. Of note, 56% of adults > or = 45 years of age were classified as being in stage A (risk factors) or B (asymptomatic ventricular dysfunction). HF staging underscores the magnitude of the population at risk for progression to overt HF.

Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers

Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.

Effects of bupivacaine, levobupivacaine and ropivacaine on myocardial relaxation

PURPOSE

Ropivacaine and levobupivacaine were developed to reduce the risk of occasional toxicity reported with bupivacaine. While the effects of long-acting local anesthetics (LAAs) on myocardial contractility (inotropy) are well described, their effects on relaxation (lusitropy) remain largely unknown. The present study aimed to compare the effects of LAAs on rat myocardium.

METHODS

Left ventricular papillary muscles of male Wistar rats were used to compare the inotropic and lusitropic responses of increasing concentrations of LAAs (10(-8) to 10(-3) M) under isometric and isotonic conditions. Data are mean % (SD) of baseline value.

RESULTS

Long-acting local anesthetics induced a significant impairment of relaxation in isotonic and isometric conditions. As compared to ropivacaine, bupivacaine and levobupivacaine induced greater negative lusitropic effects in isotony [at 10(-3) M, maximum unloaded shortening velocity ((max)Vr) = 27 +/- 11 vs 13 +/- 6 and 8 +/- 5%] and isometry (at 10(-3) M, time-to-half-relaxation: 106 +/- 10 vs 127 +/- 17 and 133 +/- 17%). When the comparison was made with equipotent concentrations, the negative lusitropic effects induced with levobupivacaine were significantly greater than those of bupivacaine and ropivacaine in isometric and isotonic conditions (at 10(-3) M, (max)Vr = 7 +/- 4 vs 13 +/- 6 and 17 +/- 4 %). As previously described, LAAs also induced concentration-dependent negative inotropic effects that were greater for levobupivacaine compared to equivalent or equipotent concentrations of bupivacaine and ropivacaine.

CONCLUSIONS

Long-acting local anesthetics induce marked negative inotropic and lusitropic effects. Among LAAs, levobupivacaine exerts the greater depressant effects. Impairment of calcium handling and sarcoplasmic reticulum could explain the differential responses to local anesthetics.

Management of atrial fibrillation in patients with heart failure

Atrial fibrillation is a marker for worse outcomes in patients with heart failure and requires careful, individualized management. Anticoagulation and rate control are important. Routine use of antiarrhythmic drug therapy for maintenance of sinus rhythm carries concerns of risk and limited efficacy. Catheter ablation for maintaining sinus rhythm is feasible for some patients, but further studies are needed to define the risks and benefits. A role remains for AV junction ablation and pacing, with consideration of biventricular pacing to prevent dyssynchrony induced by chronic right ventricular pacing. Ongoing trials will continue to define the risks and benefits as these therapies evolve.

Epidemiology, pathophysiology, and prognosis of heart failure in the elderly

Heart failure (HF) represents the quintessential disorder of cardio-vascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality,morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis re-mains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.

Diastolic heart failure in the elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

Diastolic heart failure: a separate disease or selection bias?

Chronic heart failure (CHF) is often subdivided based on left ventricular ejection fraction (LVEF) in 2 distinct forms, usually specified as "diastolic heart failure" and "systolic heart failure." In this review, arguments are provided against an LVEF-based bimodal view, and CHF is presented as one pathophysiological identity encompassing a continuous spectrum of closely related phenotypes. Most importantly, there is currently no pathophysiological basis to support a bimodal view. As a result, conceptual presentations of CHF, such as the vicious circle paradigm of CHF, become obsolete. Furthermore, the binary view of CHF is the unfortunate result of selection biases that has confounded practically all clinical trials of CHF. Unfortunately, current investigations still introduce selection bias when studying heart failure at preserved or reduced LVEF. Future investigations should analyze CHF as one disease and focus on the mechanisms through which disease modifiers such as sex, diabetes, and hypertension induce phenotypic diversity.

Stiffness- and relaxation-based quantitation of radial left ventricular oscillations: elucidation of regional diastolic function mechanisms

Traditionally, global and longitudinal (i.e., regional) left ventricular (LV) diastolic function (DF) assessment has utilized features of transmitral Doppler E and A waves or Doppler tissue imaging (DTI)-derived mitral annular E' and A' waves, respectively. Quantitation of regional DF has included M-mode echocardiography-based approaches and strain and strain rate imaging (in selected imaging planes), while analysis of mitral annular "oscillations" has recently provided a new window into longitudinal (long-axis) function. The remaining major spatial degree of kinematic freedom during diastole, radial (short-axis) motion, has not been fully characterized, nor has it been exploited for its potential to provide radial LV stiffness (k'(rad)) and relaxation/damping (c'(rad)) indexes. Prior characterization of regional (longitudinal) DF used only annular E'- and A'-wave peak velocities or, alternatively, myocardial strain and strain rate. By kinematically modeling short-axis tissue motion as damped radial oscillation, we present a novel method of estimating k'(rad) and c'(rad) during early filling. As required by the (near) constant-volume property of the heart and tissue/blood incompressibility, in subjects (n = 10) with normal DF, we show that oscillation duration-determined longitudinal (k'(long) and c'(long)) and radial (k'(long) and c'(rad)) parameters are highly correlated (R = 0.69 and 0.92, respectively). Selected examples of diabetic and LV hypertrophic subjects yield radial (k'(long) and c'(rad)) parameters that differ substantially from controls. Results underscore the utility of the incompressibility-based causal relation between DTI-determined mitral annular long-axis (longitudinal mode) and short-axis (radial mode) oscillations in healthy subjects. Selected pathological examples provide mechanistic insight and illustrate the value and potential role of regional (longitudinal and radial) DF indexes in fully characterizing normal vs. impaired DF states.