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Zhou L, Filiberti A, Humphrey MB, Fleming CD, Scherlag BJ, Po SS, Stavrakis S. Low-level transcutaneous vagus nerve stimulation attenuates cardiac remodelling in a rat model of heart failure with preserved ejection fraction. Exp Physiol 2018; 104:28-38. [PMID: 30398289 DOI: 10.1113/ep087351] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/02/2018] [Indexed: 12/17/2022]
Abstract
NEW FINDINGS What is the central question of this study? What is the effect of chronic intermittent low-level transcutaneous vagus nerve stimulation on cardiac inflammation, fibrosis and diastolic dysfunction in a rat model of heart failure with preserved ejection fraction? What is the main finding and its importance? In salt-sensitive rats fed with high salt diet, low-level transcutaneous vagus nerve stimulation significantly attenuated blood pressure elevation, ameliorated diastolic function, and attenuated left ventricular inflammation and fibrosis compared to the sham group. Further studies to examine the efficacy of this novel treatment in humans are warranted. ABSTRACT Inflammation and fibrosis play a central role in the development of heart failure with preserved ejection fraction (HFpEF). We previously showed that low-level, transcutaneous stimulation of the vagus nerve at the tragus (LLTS) is anti-inflammatory. We investigated the effect of chronic intermittent LLTS on cardiac inflammation, fibrosis and diastolic dysfunction in a rat model of HFpEF. Dahl salt-sensitive (DS) rats were randomized in three groups: low salt (LS, 0.3% NaCl; n = 12; control group without stimulation) and high salt (HS, 4% NaCl) with either active (n = 18) or sham (n = 18) LLTS at 7 weeks of age. After 6 weeks of diet (baseline), sham or active LLTS (20 Hz, 2 mA, 0.2 ms) was implemented for 30 min daily for 4 weeks. Echocardiography was performed at baseline and 4 weeks after treatment (endpoint). At endpoint, left ventricle (LV) histology and gene expression were examined. After 6 weeks of diets, HS rats developed hypertension and LV hypertrophy compared to LS rats. At endpoint, LLTS significantly attenuated blood pressure elevation, prevented the deterioration of diastolic function and improved LV circumferential strain, compared to the HS sham group. LV inflammatory cell infiltration and fibrosis were attenuated in the HS active compared to the HS sham group. Pro-inflammatory and pro-fibrotic genes (tumour necrosis factor, osteopontin, interleukin (IL)-11, IL-18 and IL-23A) were differentially altered in the two groups. Chronic intermittent LLTS ameliorates diastolic dysfunction, and attenuates cardiac inflammation and fibrosis in a rat model of HFpEF, suggesting that LLTS may be used clinically as a novel non-invasive neuromodulation therapy in HFpEF.
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Affiliation(s)
- Liping Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Adrian Filiberti
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mary Beth Humphrey
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Christian D Fleming
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Benjamin J Scherlag
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sunny S Po
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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302
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Gori M, D'Elia E, Senni M. Sacubitril/valsartan therapeutic strategy in HFpEF: Clinical insights and perspectives. Int J Cardiol 2018; 281:158-165. [PMID: 30420146 DOI: 10.1016/j.ijcard.2018.06.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/06/2018] [Accepted: 06/13/2018] [Indexed: 01/09/2023]
Abstract
Sacubitril/valsartan represents the first of a new class of drugs able to act as a neprilysin inhibitor and as an angiotensin receptor blocker. This double inhibition has the advantage of concomitantly blocking a pro-fibrotic/pro-hypertrophic mechanism (angiotensin receptor blocker component) while stimulating an anti-fibrotic/anti-hypertrophic mechanism (neprilysin inhibitor component). Furthermore, the novel drug has natriuretic and diuretic properties, better preserves renal function, provides better blood pressure control as compared to renin angiotensin system inhibitors, and improves ventricular-arterial coupling. Consequently, sacubitril/valsartan provides greater target organ protection than angiotensin receptor blocker therapy alone, including cardiac, vascular, and renal protection. Up to now, this drug does not have an indication in patients with heart failure with preserved ejection fraction (HFpEF). However, its complex mechanism of action and previous experimental and clinical data seem to suggest its possible success in HFpEF. In this review we highlight and discuss the rationale, clinical insights, and perspectives behind the use of sacubitril/valsartan in HFpEF, specifically referring to its possible efficacy in pathophysiologic mechanisms, such as myocardial hypertrophy, fibrosis, and ischemia, renal dysfunction, impaired ventricular-arterial coupling, which are all tightly related to elevated left ventricular end diastolic pressure, a common hallmark for this multifaceted syndrome.
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Affiliation(s)
- Mauro Gori
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Emilia D'Elia
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy.
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303
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Pabel S, Wagner S, Bollenberg H, Bengel P, Kovács Á, Schach C, Tirilomis P, Mustroph J, Renner A, Gummert J, Fischer T, Van Linthout S, Tschöpe C, Streckfuss-Bömeke K, Hasenfuss G, Maier LS, Hamdani N, Sossalla S. Empagliflozin directly improves diastolic function in human heart failure. Eur J Heart Fail 2018; 20:1690-1700. [PMID: 30328645 DOI: 10.1002/ejhf.1328] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 12/19/2022] Open
Abstract
AIMS Empagliflozin, a clinically used oral antidiabetic drug that inhibits the sodium-dependent glucose co-transporter 2, has recently been evaluated for its cardiovascular safety. Surprisingly, empagliflozin reduced mortality and hospitalization for heart failure (HF) compared to placebo. However, the underlying mechanisms remain unclear. Therefore, our study aims to investigate whether empagliflozin may cause direct pleiotropic effects on the myocardium. METHODS AND RESULTS In order to assess possible direct myocardial effects of empagliflozin, we performed contractility experiments with in toto-isolated human systolic end-stage HF ventricular trabeculae. Empagliflozin significantly reduced diastolic tension, whereas systolic force was not changed. These results were confirmed in murine myocardium from diabetic and non-diabetic mice, suggesting independent effects from diabetic conditions. In human HF cardiomyocytes, empagliflozin did not influence calcium transient amplitude or diastolic calcium level. The mechanisms underlying the improved diastolic function were further elucidated by studying myocardial fibres from patients and rats with diastolic HF (HF with preserved ejection fraction, HFpEF). Empagliflozin beneficially reduced myofilament passive stiffness by enhancing phosphorylation levels of myofilament regulatory proteins. Intravenous injection of empagliflozin in anaesthetized HFpEF rats significantly improved diastolic function measured by echocardiography, while systolic contractility was unaffected. CONCLUSION Empagliflozin causes direct pleiotropic effects on the myocardium by improving diastolic stiffness and hence diastolic function. These effects were independent of diabetic conditions. Since pharmacological therapy of diastolic dysfunction and HF is an unmet need, our results provide a rationale for new translational studies and might also contribute to the understanding of the EMPA-REG OUTCOME trial.
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Affiliation(s)
- Steffen Pabel
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany.,Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Stefan Wagner
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hannah Bollenberg
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Philipp Bengel
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Árpád Kovács
- Department of Systems Physiology, Ruhr University Bochum, Bochum, Germany
| | - Christian Schach
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Petros Tirilomis
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Julian Mustroph
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - André Renner
- Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Center), North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Jan Gummert
- Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Center), North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Thomas Fischer
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Sophie Van Linthout
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin-Brandenburg Center for Regenerative Therapies and German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin-Brandenburg Center for Regenerative Therapies and German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Katrin Streckfuss-Bömeke
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Gerd Hasenfuss
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Nazha Hamdani
- Department of Systems Physiology, Ruhr University Bochum, Bochum, Germany
| | - Samuel Sossalla
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany.,Clinic for Cardiology & Pneumology, Georg-August University Goettingen, and German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
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304
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Favorable outcomes of metformin on coronary microvasculature in experimental diabetic cardiomyopathy. J Mol Histol 2018; 49:639-649. [PMID: 30317407 DOI: 10.1007/s10735-018-9801-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
Although metformin is widely prescribed in diabetes, its use with associated cardiac dysfunction remains debatable. In the current study, we investigated the effect of metformin on coronary microvasculature in experimental diabetic cardiomyopathy (DCM) induced by streptozotocin. Administration of metformin after induction of DCM, reversed almost all cardiomyocyte degenerative changes induced by DCM. Metformin diminished the significantly increased (p < 0.05) collagen deposited in the DCM. In addition metformin had improved the density of the significantly decreased arteriolar (αSMA+) and capillary (CD31+) coronary microvasculature compared to that of the DCM and non-diabetics (ND) with downregulation of the significantly increased expression (p < 0.05) of COL-I, III, TGF-β, CTGF, ICAM and VCAM genes. Therefore metformin may be beneficial in limiting the fibrotic and the vascular remodeling occurring in DCM at the genetic as well as the structural levels.
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305
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Barandiarán Aizpurua A, Schroen B, van Bilsen M, van Empel V. Targeted HFpEF therapy based on matchmaking of human and animal models. Am J Physiol Heart Circ Physiol 2018; 315:H1670-H1683. [PMID: 30239232 DOI: 10.1152/ajpheart.00024.2018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The diversity in clinical phenotypes and poor understanding of the underlying pathophysiology of heart failure with preserved ejection fraction (HFpEF) is the main reason why no effective treatments have been found yet. Targeted, instead of one size fits all, treatment seems the only promising approach for treating HFpEF. To be able to design a targeted, phenotype-specific HFpEF treatment, the matrix relating clinical phenotypes and underlying pathophysiological mechanisms has to be clarified. This review discusses the opportunities for additional evaluation of the underlying pathophysiological processes, e.g., to evaluate biological phenotypes on top of clinical routine, to guide us toward a phenotype-specific HFpEF treatment. Moreover, a translational approach with matchmaking of animal models to biological HFpEF phenotypes will be a valuable step to test the effectiveness of novel, targeted interventions in HFpEF. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/personalized-medicine-in-hfpef/ .
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Affiliation(s)
- Arantxa Barandiarán Aizpurua
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Blanche Schroen
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Marc van Bilsen
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Department of Physiology, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University , Maastricht , The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
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306
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Poller W, Dimmeler S, Heymans S, Zeller T, Haas J, Karakas M, Leistner DM, Jakob P, Nakagawa S, Blankenberg S, Engelhardt S, Thum T, Weber C, Meder B, Hajjar R, Landmesser U. Non-coding RNAs in cardiovascular diseases: diagnostic and therapeutic perspectives. Eur Heart J 2018; 39:2704-2716. [PMID: 28430919 PMCID: PMC6454570 DOI: 10.1093/eurheartj/ehx165] [Citation(s) in RCA: 273] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/14/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
Recent research has demonstrated that the non-coding genome plays a key role in genetic programming and gene regulation during development as well as in health and cardiovascular disease. About 99% of the human genome do not encode proteins, but are transcriptionally active representing a broad spectrum of non-coding RNAs (ncRNAs) with important regulatory and structural functions. Non-coding RNAs have been identified as critical novel regulators of cardiovascular risk factors and cell functions and are thus important candidates to improve diagnostics and prognosis assessment. Beyond this, ncRNAs are rapidly emgerging as fundamentally novel therapeutics. On a first level, ncRNAs provide novel therapeutic targets some of which are entering assessment in clinical trials. On a second level, new therapeutic tools were developed from endogenous ncRNAs serving as blueprints. Particularly advanced is the development of RNA interference (RNAi) drugs which use recently discovered pathways of endogenous short interfering RNAs and are becoming versatile tools for efficient silencing of protein expression. Pioneering clinical studies include RNAi drugs targeting liver synthesis of PCSK9 resulting in highly significant lowering of LDL cholesterol or targeting liver transthyretin (TTR) synthesis for treatment of cardiac TTR amyloidosis. Further novel drugs mimicking actions of endogenous ncRNAs may arise from exploitation of molecular interactions not accessible to conventional pharmacology. We provide an update on recent developments and perspectives for diagnostic and therapeutic use of ncRNAs in cardiovascular diseases, including atherosclerosis/coronary disease, post-myocardial infarction remodelling, and heart failure.
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Affiliation(s)
- Wolfgang Poller
- Department of Cardiology, CBF, CC11, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Charite Centrum 11 (Cardiovascular Medicine), Hindenburgdamm 20, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Site Berlin, Berlin, Germany
| | - Stefanie Dimmeler
- Institute for Cardiovascular Regeneration, Center of Molecular Medicine, Johann Wolfgang Goethe Universität, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
- DZHK, Site Rhein-Main, Frankfurt, Germany
| | - Stephane Heymans
- Center for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Tanja Zeller
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, Hamburg, Germany
- DZHK, Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jan Haas
- Institute for Cardiomyopathies Heidelberg (ICH), Universitätsklinikum Heidelberg, Im Neuenheimer Feld 669, Heidelberg, Germany
- DZHK, Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Mahir Karakas
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, Hamburg, Germany
- DZHK, Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - David-Manuel Leistner
- Department of Cardiology, CBF, CC11, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Charite Centrum 11 (Cardiovascular Medicine), Hindenburgdamm 20, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Site Berlin, Berlin, Germany
| | - Philipp Jakob
- Department of Cardiology, CBF, CC11, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Charite Centrum 11 (Cardiovascular Medicine), Hindenburgdamm 20, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Site Berlin, Berlin, Germany
| | - Shinichi Nakagawa
- RNA Biology Laboratory, RIKEN Advanced Research Institute, Wako, Saitama, Japan
- RNA Biology Laboratory, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita 12-jo Nishi 6-chome, Kita-ku, Sapporo, Japan
| | - Stefan Blankenberg
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, Hamburg, Germany
- DZHK, Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Engelhardt
- Institute for Pharmacology and Toxikology, Technische Universität München, Biedersteiner Strasse 29, München, Germany
- DZHK, Site Munich, Munich, Germany
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Christian Weber
- DZHK, Site Munich, Munich, Germany
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-Universität, Pettenkoferstrasse 8a/9, Munich, Germany
| | - Benjamin Meder
- Institute for Cardiomyopathies Heidelberg (ICH), Universitätsklinikum Heidelberg, Im Neuenheimer Feld 669, Heidelberg, Germany
- DZHK, Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Roger Hajjar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ulf Landmesser
- Department of Cardiology, CBF, CC11, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Charite Centrum 11 (Cardiovascular Medicine), Hindenburgdamm 20, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Site Berlin, Berlin, Germany
- Berlin Institute of Health, Kapelle-Ufer 2, Berlin, Germany
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307
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Plitt GD, Spring JT, Moulton MJ, Agrawal DK. Mechanisms, diagnosis, and treatment of heart failure with preserved ejection fraction and diastolic dysfunction. Expert Rev Cardiovasc Ther 2018; 16:579-589. [PMID: 29976104 PMCID: PMC6287909 DOI: 10.1080/14779072.2018.1497485] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) continues to be a major challenge for clinicians. Many crucial aspects of the syndrome remain unclear, including the exact pathophysiology, early diagnosis, and treatment. Patients with HFpEF are often asymptomatic late into the disease process, and treatment with medications commonly used in heart failure with reduced ejection fraction (HFrEF) has not been proven to be beneficial. In addition, the confusion of similar terms with HFpEF, such as diastolic heart failure, and diastolic dysfunction (DD), has led to a misunderstanding of the true scope of HFpEF. Areas covered: In this review, authors highlight the differences in terminology and critically review the current knowledge on the underlying mechanisms, diagnosis, and latest treatment strategies of HFpEF. Expert commentary: While significant advances have been made in the understanding of HFpEF, the definitive diagnosis of HFpEF continues to be difficult. The development of improved and standardized methods for detecting DD has shown promise in identifying early HFpEF. However, even with early detection, there are few treatment options shown to provide mortality benefit warranting further investigation.
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Affiliation(s)
- Gilman D. Plitt
- Department of Clinical & Translational Science, Creighton University School of Medicine, Omaha, NE
| | - Jordan T. Spring
- Department of Clinical & Translational Science, Creighton University School of Medicine, Omaha, NE
| | - Michael J. Moulton
- Department of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Devendra K. Agrawal
- Department of Clinical & Translational Science, Creighton University School of Medicine, Omaha, NE
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308
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Obokata M, Reddy YNV, Melenovsky V, Kane GC, Olson TP, Jarolim P, Borlaug BA. Myocardial Injury and Cardiac Reserve in Patients With Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2018; 72:29-40. [PMID: 29957229 PMCID: PMC6034112 DOI: 10.1016/j.jacc.2018.04.039] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/05/2018] [Accepted: 04/12/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiac reserve is depressed in patients with heart failure and preserved ejection fraction (HFpEF). The mechanisms causing this are poorly understood. OBJECTIVES The authors hypothesized that myocardial injury might contribute to the hemodynamic derangements and cardiac reserve limitations that are present in HFpEF. Markers of cardiomyocyte injury, central hemodynamics, ventricular function, and determinants of cardiac oxygen supply-demand balance were measured. METHODS Subjects with HFpEF (n = 38) and control subjects without heart failure (n = 20) underwent cardiac catheterization, echocardiography, and expired gas analysis at rest and during exercise. Central venous blood was sampled to measure plasma high-sensitivity troponin T levels as an index of cardiomyocyte injury. RESULTS Compared with control subjects, troponins were more than 2-fold higher in subjects with HFpEF at rest and during exercise (p < 0.0001). Troponin levels were directly correlated with left ventricular (LV) filling pressures (r = 0.52; p < 0.0001) and diastolic dysfunction (r = -0.43; p = 0.002). Although myocardial oxygen demand was similar, myocardial oxygen supply was depressed in HFpEF, particularly during exercise (coronary perfusion pressure-time integral; 44 ± 9 mm Hg × s × min-1 × l × dl-1 vs. 30 ± 9 mm Hg × s × min-1 × l × dl-1; p < 0.0001), and reduced indices of supply were correlated with greater myocyte injury during exercise (r = -0.44; p = 0.0008). Elevation in troponin with exercise was directly correlated with an inability to augment LV diastolic (r = -0.40; p = 0.02) and systolic reserve (r = -0.57; p = 0.0003), greater increases in LV filling pressures (r = 0.55; p < 0.0001), blunted cardiac output response (r = -0.44; p = 0.002), and more severely depressed aerobic capacity in HFpEF. CONCLUSIONS Limitations in LV functional reserve and the hemodynamic derangements that develop secondary to these limitations during exercise in HFpEF are correlated with the severity of cardiac injury, assessed by plasma levels of troponin T. Further study is warranted to determine the mechanisms causing myocyte injury in HFpEF and the potential role of ischemia, and to identify and test novel interventions targeted to these mechanisms. (EXEC [Study of Exercise and Heart Function in Patients With Heart Failure and Pulmonary Vascular Disease]; NCT01418248).
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Yogesh N V Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Garvan C Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Petr Jarolim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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309
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Bimodal Function of Anti-TNF Treatment: Shall We Be Concerned about Anti-TNF Treatment in Patients with Rheumatoid Arthritis and Heart Failure? Int J Mol Sci 2018; 19:ijms19061739. [PMID: 29895751 PMCID: PMC6032136 DOI: 10.3390/ijms19061739] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/26/2018] [Accepted: 06/04/2018] [Indexed: 12/24/2022] Open
Abstract
Treatment with anti-TNF-α (tumor necrosis factor), one of the pivotal cytokines, was introduced to clinical practice at the end of last century and revolutionized the treatment of rheumatoid arthritis (RA) as well as many other inflammatory conditions. Such a treatment may however bring many safety issues regarding infections, tuberculosis, as well as cardiovascular diseases, including heart failure. Given the central role of proinflammatory cytokines in RA, atherosclerosis, and congestive heart failure (CHF), such a treatment might result in better control of the RA process on the one side and improvement of heart function on the other. Unfortunately, at the beginning of this century two randomized controlled trials failed to show any benefit of anti-TNF treatment in patients with heart failure (HF), suggesting direct negative impact of the treatment on morbidity and mortality in HF patients. As a result the anti-TNF treatment is contraindicated in all patients with heart failure and a substantial portion of patients with RA and impaired heart function are not able to benefit from the treatment. The role of TNF in CHF and RA differs substantially with regard to the source and pathophysiological function of the cytokine in both conditions, therefore negative data from CHF studies should be interpreted with caution. At least some of RA patients with heart failure may benefit from anti-TNF treatment, as it results not only in the reduction of inflammation but also contributes significantly to the improvement of cardiac function. The paper addresses the epidemiological data of safety of anti-TNF treatment in RA patients with the special emphasis to basic pathophysiological mechanisms via which TNF may act differently in both diseases.
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310
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Bokslag A, Franssen C, Alma LJ, Kovacevic I, van Kesteren F, Teunissen PW, Kamp O, Ganzevoort W, Hordijk PL, de Groot CJM, Paulus WJ. Early-onset preeclampsia predisposes to preclinical diastolic left ventricular dysfunction in the fifth decade of life: An observational study. PLoS One 2018; 13:e0198908. [PMID: 29894501 PMCID: PMC5997308 DOI: 10.1371/journal.pone.0198908] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022] Open
Abstract
Background Systemic inflammation, endothelial dysfunction and deficient vascularization of either uterus or myocardium are mechanistic hallmarks of early-onset preeclampsia and heart failure with preserved ejection fraction (HFpEF). HFpEF is especially prevalent in elderly women and preceded in middle age by preclinical left ventricular (LV) diastolic dysfunction. To detect if preeclampsia predisposes to HFpEF at later age, echocardiographic indices of LV function and of LV structure and biomarkers of systemic inflammation and of endothelial dysfunction were compared in middle-aged women with a history of early-onset preeclampsia or uncomplicated pregnancy. Methods and findings Middle-aged women with a history of early-onset preeclampsia (n = 131) or uncomplicated pregnancy (n = 56) were prospectively recruited 9 to 16 years after pregnancy. Women with a history of preeclampsia had higher body mass index (p = 0.006), blood pressure (p<0.001) and plasma levels of interleukin-6 (p = 0.005) and soluble intercellular adhesion molecule-1 (sICAM-1) (p = 0.014). They had thicker septal (p = 0.001) and posterior (p = 0.003) LV walls and worse diastolic LV function evident from reduced mean mitral annular lengthening velocity (E’mean; p = 0.007) and higher ratio of early diastolic mitral flow velocity (E) over E’mean (E/E’mean; p<0.001). Differences of sICAM-1, E’mean and E/E’mean remained significant after accounting for BMI and blood pressure. Conclusions History of preeclampsia predisposes in middle age to worse LV diastolic function, which could increase the likelihood of later HFpEF development. This predisposition derives not only from persistent cardiovascular risk but may also be caused by persistent endothelial dysfunction hindering adequate vascularization in the uterus during pregnancy and in the myocardium in middle age.
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Affiliation(s)
- Anouk Bokslag
- Department of Obstetrics and Gynaecology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Constantijn Franssen
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Lisa J. Alma
- Department of Obstetrics and Gynaecology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Igor Kovacevic
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Floortje van Kesteren
- Department of Obstetrics and Gynaecology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Pim W. Teunissen
- Department of Obstetrics and Gynaecology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Otto Kamp
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Peter L. Hordijk
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Christianne J. M. de Groot
- Department of Obstetrics and Gynaecology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Walter J. Paulus
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
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311
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Soni M, Birati EY. Recognition, Diagnosis, and Management of Heart Failure with Preserved Ejection Fraction. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:21:1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The clinical syndrome of heart failure with preserved ejection fraction (HFpEF) is unique in terms of etiologies, diagnostic criteria, costs, and treatment modalities when compared to heart failure with reduced ejection fraction. There is an emerging paradigm shift that recognizes the clinical syndrome of HFpEF and its various phenotypes. Understanding these HFpEF phenotypes is crucial to understanding the pathophysiology of HFpEF, which in turn can further guide our management strategies. This review outlines the diagnostic criteria, introduces the common clinical phenotypes, and discusses treatments currently utilized in practice for the management of HFpEF.
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312
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Meagher P, Adam M, Civitarese R, Bugyei-Twum A, Connelly KA. Heart Failure With Preserved Ejection Fraction in Diabetes: Mechanisms and Management. Can J Cardiol 2018; 34:632-643. [PMID: 29731023 DOI: 10.1016/j.cjca.2018.02.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/25/2018] [Accepted: 02/25/2018] [Indexed: 12/20/2022] Open
Abstract
Diabetes mellitus (DM) is a major cause of heart failure in the Western world, either secondary to coronary artery disease or from a distinct entity known as "diabetic cardiomyopathy." Furthermore, heart failure with preserved ejection fraction (HFpEF) is emerging as a significant clinical problem for patients with DM. Current clinical data suggest that between 30% and 40% of patients with HFpEF suffer from DM. The typical structural phenotype of the HFpEF heart consists of endothelial dysfunction, increased interstitial and perivascular fibrosis, cardiomyocyte stiffness, and hypertrophy along with advanced glycation end products deposition. There is a myriad of mechanisms that result in the phenotypical HFpEF heart including impaired cardiac metabolism and substrate utilization, altered insulin signalling leading to protein kinase C activation, advanced glycated end products deposition, prosclerotic cytokine activation (eg, transforming growth factor-β activation), along with impaired nitric oxide production from the endothelium. Moreover, recent investigations have focused on the role of endothelial-myocyte interactions. Despite intense research, current therapeutic strategies have had little effect on improving morbidity and mortality in patients with DM and HFpEF. Possible explanations for this include a limited understanding of the role that direct cell-cell communication or indirect cell-cell paracrine signalling plays in the pathogenesis of DM and HFpEF. Additionally, integrins remain another important mediator of signals from the extracellular matrix to cells within the failing heart and might play a significant role in cell-cell cross-talk. In this review we discuss the characteristics and mechanisms of DM and HFpEF to stimulate potential future research for patients with this common, and morbid condition.
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Affiliation(s)
- Patrick Meagher
- Keenan Research Centre for Biomedical Science, St Michael's Hospital; Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Adam
- Keenan Research Centre for Biomedical Science, St Michael's Hospital; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Robert Civitarese
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Antoinette Bugyei-Twum
- Keenan Research Centre for Biomedical Science, St Michael's Hospital; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Science, St Michael's Hospital; Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada.
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313
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Konerman MC, Greenberg JC, Kolias TJ, Corbett JR, Shah RV, Murthy VL, Hummel SL. Reduced Myocardial Flow Reserve Is Associated With Diastolic Dysfunction and Decreased Left Atrial Strain in Patients With Normal Ejection Fraction and Epicardial Perfusion. J Card Fail 2018; 24:90-100. [PMID: 29051079 PMCID: PMC5811315 DOI: 10.1016/j.cardfail.2017.10.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/16/2017] [Accepted: 10/10/2017] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Coronary microvascular dysfunction (MVD) may contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Using myocardial flow reserve (MFR) measured by positron emission tomography (PET) as an assessment of microvascular function, we hypothesized that abnormal MFR is associated with LV diastolic dysfunction (DD) and reduced LV and LA strain in patients with risk factors for HFpEF and normal epicardial perfusion on cardiac PET. METHODS AND RESULTS Retrospective study of patients without heart failure who underwent cardiac rubidium-82 PET and echocardiography. Global MFR was calculated as the ratio of global stress to rest myocardial blood flow. Echocardiographic measures of diastolic function were recorded. Global longitudinal LA and LV strain were measured with a 2-dimensional speckle-tracking technique. Relationships among MFR and echocardiographic measures were assessed with linear regression, analysis of variance, and test for trend. Seventy-three patients (age 64 ± 11 years, 52% male) were identified with no epicardial perfusion defect on cardiac PET and an ejection fraction ≥50%. Decreased MFR was associated with LV DD (P = .02) and increased E/e', an estimation of LV filling pressure (low E/e' [<8] vs. high E/e' [>15], P < .001). MFR was associated with LA strain independent of age, gender, and common comorbidities (adjusted β = 2.6% per unit MFR, P = 0.046); however, MFR was only marginally related to LV strain. CONCLUSIONS In patients with risk factors for HFpEF, MVD assessed with MFR was associated with DD, increased estimated LV filling pressure, and abnormal LA strain.
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Affiliation(s)
- Matthew C Konerman
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
| | | | - Theodore J Kolias
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - James R Corbett
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Ravi V Shah
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Venkatesh L Murthy
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Scott L Hummel
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
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314
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Faita F, Di Lascio N, Rossi C, Kusmic C, Solini A. Ultrasonographic Characterization of the db/db Mouse: An Animal Model of Metabolic Abnormalities. J Diabetes Res 2018; 2018:4561309. [PMID: 29707583 PMCID: PMC5863337 DOI: 10.1155/2018/4561309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/13/2017] [Accepted: 01/04/2018] [Indexed: 12/18/2022] Open
Abstract
The availability of an animal model able to reliably mirror organ damage occurring in metabolic diseases is an urgent need. These models, mostly rodents, have not been fully characterized in terms of cardiovascular, renal, and hepatic ultrasound parameters, and only sparse values can be found in literature. Aim of this paper is to provide a detailed, noninvasive description of the heart, vessels, liver, and kidneys of the db/db mouse by ultrasound imaging. Sixteen wild type and thirty-four db/db male mice (11-week-old) were studied. State-of-the-art ultrasound technology was used to acquire images of cardiovascular, renal, and hepatic districts. A set of parameters describing function of the selected organs was evaluated. db/db mice are characterized by systolic and diastolic dysfunction, confirmed by strain analysis. Abdominal aortic and carotid stiffness do not seem to be increased in diabetic rodents; furthermore, they are characterized by a smaller mean diameter for both vessels. Renal microcirculation is significantly compromised, while liver steatosis is only slightly higher in db/db mice than in controls. We offer here for the first time an in vivo detailed ultrasonographic characterization of the db/db mouse, providing a useful tool for a thoughtful choice of the right rodent model for any experimental design.
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MESH Headings
- Animals
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/physiopathology
- Blood Glucose/metabolism
- Carotid Artery, Common/diagnostic imaging
- Carotid Artery, Common/physiopathology
- Diabetes Mellitus/blood
- Diabetes Mellitus/diagnostic imaging
- Diabetes Mellitus/genetics
- Diabetes Mellitus/physiopathology
- Disease Models, Animal
- Echocardiography, Doppler, Pulsed
- Genetic Predisposition to Disease
- Heart/diagnostic imaging
- Heart/physiopathology
- Lipids/blood
- Liver/diagnostic imaging
- Liver/physiopathology
- Male
- Mice, Inbred C57BL
- Microcirculation
- Perfusion Imaging/methods
- Phenotype
- Predictive Value of Tests
- Renal Artery/diagnostic imaging
- Renal Artery/physiopathology
- Renal Circulation
- Ultrasonography, Doppler, Pulsed
- Vascular Stiffness
- Ventricular Function, Left
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Affiliation(s)
- Francesco Faita
- Institute of Clinical Physiology, Italian National Research Council, Pisa, Italy
| | - Nicole Di Lascio
- Institute of Clinical Physiology, Italian National Research Council, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Chiara Rossi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudia Kusmic
- Institute of Clinical Physiology, Italian National Research Council, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular, and Critical Area Pathology, University of Pisa, Pisa, Italy
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315
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Jia G, Whaley-Connell A, Sowers JR. Diabetic cardiomyopathy: a hyperglycaemia- and insulin-resistance-induced heart disease. Diabetologia 2018; 61:21-28. [PMID: 28776083 PMCID: PMC5720913 DOI: 10.1007/s00125-017-4390-4] [Citation(s) in RCA: 488] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 06/13/2017] [Indexed: 12/19/2022]
Abstract
Diabetic cardiomyopathy is characterised in its early stages by diastolic relaxation abnormalities and later by clinical heart failure in the absence of dyslipidaemia, hypertension and coronary artery disease. Insulin resistance, hyperinsulinaemia and hyperglycaemia are each independent risk factors for the development of diabetic cardiomyopathy. The pathophysiological factors in diabetes that drive the development of cardiomyopathy include systemic metabolic disorders, inappropriate activation of the renin-angiotensin-aldosterone system, subcellular component abnormalities, oxidative stress, inflammation and dysfunctional immune modulation. These abnormalities collectively promote cardiac tissue interstitial fibrosis, cardiac stiffness/diastolic dysfunction and, later, systolic dysfunction, precipitating the syndrome of clinical heart failure. Recent evidence has revealed that dysregulation of coronary endothelial cells and exosomes also contributes to the pathology behind diabetic cardiomyopathy. Herein, we review the relationships among insulin resistance/hyperinsulinaemia, hyperglycaemia and the development of cardiac dysfunction. We summarise the current understanding of the pathophysiological mechanisms in diabetic cardiomyopathy and explore potential preventative and therapeutic strategies.
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Affiliation(s)
- Guanghong Jia
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO, 65212, USA.
- Research Service, Harry S Truman Memorial Veterans Hospital, Research Service, Columbia, MO, USA.
| | - Adam Whaley-Connell
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO, 65212, USA
- Research Service, Harry S Truman Memorial Veterans Hospital, Research Service, Columbia, MO, USA
- Division of Nephrology and Hypertension, Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - James R Sowers
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO, 65212, USA.
- Research Service, Harry S Truman Memorial Veterans Hospital, Research Service, Columbia, MO, USA.
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO, USA.
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA.
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316
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Abstract
Heart failure (HF) represents a global pandemic health problem with a high impact on health-care costs, affecting about 26 million adults worldwide. The overall HF prevalence and incidence are ~2% and ~0.2% per year, respectively, in Western countries, with half of the HF population with reduced ejection fraction (HFpEF) and half with preserved (HFpEF) or mid-range ejection fraction (HFmrEF). Sex differences may exist in HF. More males have HFrEF or HFmrEF and an ischemic etiology, whereas more females have HFpEF and hypertension, diastolic dysfunction, and valvular pathologies as HF etiologies. Females are generally older, have a higher EF, higher frequency of HF-related symptoms, and lower NYHA functional status. Generally, it is observed that female HF patients tend to have more comorbidities such as atrial fibrillation, diabetes, hypertension, anemia, iron deficiency, renal disease, arthritis, frailty, depression, and thyroid abnormalities. However, overall, females have better prognosis in terms of mortality and hospitalization risk compared with men, regardless of EF. Potential sex differences in HF characteristics may be underestimated because of the underrepresentation of females in cardiovascular research and, in particular, the sex imbalance in clinical trial enrollment may avoid to identify sex-specific differences in treatments' benefit.
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317
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Jia G, Habibi J, Aroor AR, Hill MA, DeMarco VG, Lee LE, Ma L, Barron BJ, Whaley-Connell A, Sowers JR. Enhanced endothelium epithelial sodium channel signaling prompts left ventricular diastolic dysfunction in obese female mice. Metabolism 2018; 78:69-79. [PMID: 28920862 DOI: 10.1016/j.metabol.2017.08.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/21/2017] [Accepted: 08/25/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Enhanced activation of cell specific mineralocorticoid receptors (MRs) in obesity plays a key role in the development of cardiovascular disease including cardiac diastolic dysfunction as a critical prognosticator. Our previous investigations demonstrated that selective endothelium MR activation promotes a maladaptive inflammatory response and fibrosis in cardiovascular tissue in female mice fed a western diet (WD), and this was associated with expression and activation of the epithelial sodium channel on the surface of endothelial cells (EnNaC). However, the specific role of EnNaC signaling in the development of cardiac stiffness and diastolic dysfunction has not been examined. We hypothesized that targeted inhibition of EnNaC with low dose amiloride would prevent WD-induced diastolic dysfunction by suppressing abnormal endothelial permeability, inflammation and oxidative stress, and myocardial fibrosis. MATERIALS/METHODS Four week-old female C57BL6/J mice were fed a WD with or without a low dose of amiloride (1mg/kg/day) for 16weeks. Left ventricular cardiac function was evaluated by magnetic resonance imaging. In addition, we examined coronary vessel and cardiac remodeling, fibrosis, macrophage infiltration using immunohistochemistry, western blot and real time PCR. RESULTS Amiloride, an antagonist of EnNaC, attenuated WD-induced impairment of left ventricular initial filling rate and relaxation time. Cardiac diastolic dysfunction was associated with increases in coronary endothelium remodeling and permeability that paralleled WD-induced increases in F-actin and fibronectin, decreased expression of claudin-5 and occludin, and increased macrophage recruitment, M1 polarization, cardiac oxidative stress, fibrosis and maladaptive remodeling. CONCLUSION Our data support the concept that EnNaC activation mediates endothelium permeability which, in turn, promotes macrophage infiltration, M1 polarization, and oxidative stress, resulting in cardiac fibrosis and diastolic dysfunction in females with diet induced obesity.
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Affiliation(s)
- Guanghong Jia
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA.
| | - Javad Habibi
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA
| | - Annayya R Aroor
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA
| | - Michael A Hill
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO 65212, USA; Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65212, USA
| | - Vincent G DeMarco
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA; Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Li E Lee
- Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA; Department of Radiology, University of Missouri school of Medicine, Columbia, MO 65212, USA
| | - Lixin Ma
- Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA; Department of Radiology, University of Missouri school of Medicine, Columbia, MO 65212, USA
| | - Brady J Barron
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA
| | - Adam Whaley-Connell
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA
| | - James R Sowers
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO 65212, USA; Research Service, Harry S Truman Memorial Veterans Hospital, 800 Hospital Dr, Columbia, MO 65201, USA; Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO 65212, USA; Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65212, USA.
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318
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Prenner SB, Mather PJ. Obesity and heart failure with preserved ejection fraction: A growing problem. Trends Cardiovasc Med 2017; 28:322-327. [PMID: 29305040 DOI: 10.1016/j.tcm.2017.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023]
Abstract
Heart Failure with Preserved Ejection Fraction (HFpEF) is increasing in prevalence due to the aging of the United States population as well as the current obesity epidemic. While obesity is very common in patients with HFpEF, obesity may represent a specific phenotype of HFpEF characterized by unique hemodynamics and structural abnormalities. Obesity induces a systemic inflammatory response that may contribute to myocardial fibrosis and endothelial dysfunction. The most obese patients continue to be excluded from HFpEF clinical trials, and thus ongoing research is needed to determine the role of pharmacologic and interventional approaches in this growing population.
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Affiliation(s)
- Stuart B Prenner
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul J Mather
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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319
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Adams PS, Zahid M, Khalifa O, Feingold B, Lo CW. Low Nasal NO in Congenital Heart Disease With Systemic Right Ventricle and Postcardiac Transplantation. J Am Heart Assoc 2017; 6:JAHA.117.007447. [PMID: 29212650 PMCID: PMC5779050 DOI: 10.1161/jaha.117.007447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background NO bioavailability has not been systematically examined in congenital heart disease (CHD). To assess NO in patients with CHD, we measured nasal NO (nNO) generated by the nasal epithelia, given blood NO is difficult to measure (half‐life, <2 ms). Given NO's role in hemodynamic regulation and the association of NO bioavailability with heart failure risk, we hypothesized NO levels may differ with varying severity of CHD physiologic characteristics. Methods and Results Six‐hundred eighteen subjects, 483 with CHD and 135 controls, had nNO measured noninvasively via the nares using American Thoracic Society/European Respiratory Society guidelines. Subjects were dichotomized as having low or normal nNO based on age‐specific cutoff values. Prevalence of low nNO was examined by various CHD physiologic feature types. Low nNO was more prevalent with CHD than controls (odds ratio, 2.28; P=0.001). A logistic regression model showed overall significance (P=0.035) for single ventricle, systemic right ventricle, ventricular dysfunction, oxygen desaturation, and heterotaxy predicting low nNO, with systemic right ventricle independently having twice the odds of low nNO (odds ratio, 2.04; P=0.014). Patients with low nNO had a higher risk of experiencing heart transplant or death (hazard ratio, 2.75; P=0.048), and heart transplant recipients (N=16) exhibited 5 times the odds of low nNO (69% versus 30%; odds ratio, 5.1; P=0.001). Conclusions Patients with CHD have increased prevalence of low nNO, with highest odds seen with systemic right ventricle and heart transplant. Further studies are needed to investigate heart failure risks in patients with CHD with left versus right systemic ventricle physiologic characteristics and utility of low nNO for predicting heart failure risk.
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Affiliation(s)
- Phillip S Adams
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maliha Zahid
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Omar Khalifa
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brian Feingold
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cecilia W Lo
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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320
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Upadhya B, Pisani B, Kitzman DW. Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure with Preserved Ejection Fraction. J Am Geriatr Soc 2017; 65:2431-2440. [PMID: 29124734 DOI: 10.1111/jgs.15141] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The majority of older adults who develop heart failure (HF), particularly older women, have a preserved left ventricular ejection fraction (HFpEF). The prevalence of this syndrome is increasing, and the prognosis is not improving, unlike that of HF with reduced ejection fraction (HFrEF). Individuals with HFpEF have severe symptoms of effort intolerance, poor quality of life, frequent hospitalizations, and greater likelihood of death. Despite the importance of HFpEF, there are numerous major gaps in our understanding of its pathophysiology and management. Although it was originally viewed as a disorder due solely to abnormalities in left ventricular diastolic function, our understanding has evolved such that HFpEF is now understood as a systemic syndrome involving multiple organ systems, and it is likely that it is triggered by inflammation and other as-yet-unidentified circulating factors, with important contributions of aging and multiple comorbidities, features generally typical of other geriatric syndromes. We present an update on the pathophysiology, diagnosis, management, and future directions in this disorder in older persons.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Barbara Pisani
- Cardiovascular Medicine Section, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Dalane W Kitzman
- Cardiovascular Medicine Section, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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321
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Florijn BW, Bijkerk R, van der Veer EP, van Zonneveld AJ. Gender and cardiovascular disease: are sex-biased microRNA networks a driving force behind heart failure with preserved ejection fraction in women? Cardiovasc Res 2017; 114:210-225. [DOI: 10.1093/cvr/cvx223] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/23/2017] [Indexed: 01/08/2023] Open
Abstract
AbstractCardiovascular disease (CVD) is the primary cause of death among men and women worldwide. Nevertheless, our comprehension of how CVD progresses in women and elicits clinical outcomes is lacking, leading CVD to be under-diagnosed and under-treated in women. A clear example of this differential presentation of CVD pathophysiologies in females is the strikingly higher prevalence of heart failure with preserved ejection fraction (HFpEF). Women with a history of pre-eclampsia or those who present with co-morbidities such as obesity, hypertension, and diabetes mellitus are at increased risk of developing HFpEF. Long understood to be a critical CVD risk factor, our understanding of how gender differentially affects the development of CVD has been greatly expanded by extensive genomic and transcriptomic studies. These studies uncovered a pivotal role for differential microRNA (miRNA) expression in response to systemic inflammation, where their co-ordinated expression forms a post-transcriptional regulatory network that instigates microcirculation defects. Importantly, the potential sex-biased expression of the given miRNAs may explain sex-specific cardiovascular pathophysiologies in women, such as HFpEF. Sex-biased miRNAs are regulated by oestrogen (E2) in their transcription and processing or are expressed from loci on the X-chromosome due to incomplete X-chromosome inactivation. Interestingly, while E2-induced miRNAs predominantly appear to serve protective functions, it could be argued that many X-linked miRNAs have been found to challenge microvascular and myocardial integrity. Therefore, menopausal E2 deficiency, resulting in protective miRNA loss, and the augmentation of X-linked miRNA expression, may well contribute to the molecular mechanisms that underlie the female-specific cardiovascular aetiology in HFpEF.
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Affiliation(s)
- Barend W Florijn
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Roel Bijkerk
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Eric P van der Veer
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Anton Jan van Zonneveld
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
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Hage C, Michaëlsson E, Linde C, Donal E, Daubert JC, Gan LM, Lund LH. Inflammatory Biomarkers Predict Heart Failure Severity and Prognosis in Patients With Heart Failure With Preserved Ejection Fraction: A Holistic Proteomic Approach. ACTA ACUST UNITED AC 2017; 10:CIRCGENETICS.116.001633. [PMID: 28100627 DOI: 10.1161/circgenetics.116.001633] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 11/29/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Underlying mechanisms in heart failure (HF) with preserved ejection fraction remain unknown. We investigated cardiovascular plasma biomarkers in HF with preserved ejection fraction and their correlation to diastolic dysfunction, functional class, pathophysiological processes, and prognosis. METHODS AND RESULTS In 86 stable patients with HF and EF ≥45% in the Karolinska Rennes (KaRen) biomarker substudy, biomarkers were quantified by a multiplex immunoassay. Orthogonal projection to latent structures by partial least square analysis was performed on 87 biomarkers and 240 clinical variables, ranking biomarkers associated with New York Heart Association (NYHA) Functional class and the composite outcome (all-cause mortality and HF hospitalization). Biomarkers significantly correlated with outcome were analyzed by multivariable Cox regression and correlations with echocardiographic measurements performed. The orthogonal partial least square outcome-predicting biomarker pattern was run against the Ingenuity Pathway Analysis (IPA) database, containing annotated data from the public domain. The orthogonal partial least square analyses identified 32 biomarkers correlated with NYHA class and 28 predicting outcomes. Among outcome-predicting biomarkers, growth/differentiation factor-15 was the strongest and an additional 7 were also significant in Cox regression analyses when adjusted for age, sex, and N-terminal probrain natriuretic peptide: adrenomedullin (hazard ratio per log increase 2.53), agouti-related protein; (1.48), chitinase-3-like protein 1 (1.35), C-C motif chemokine 20 (1.35), fatty acid-binding protein (1.33), tumor necrosis factor receptor 1 (2.29), and TNF-related apoptosis-inducing ligand (0.34). Twenty-three of them correlated with diastolic dysfunction (E/e') and 5 with left atrial volume index. The IPA suggested that increased inflammation, immune activation with decreased necrosis and apoptosis preceded poor outcome. CONCLUSIONS In HF with preserved ejection fraction, novel biomarkers of inflammation predict HF severity and prognosis that may complement or even outperform traditional markers, such as N-terminal probrain natriuretic peptide. These findings lend support to a hypothesis implicating global systemic inflammation in HF with preserved ejection fraction. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov; Unique identifier: NCT00774709.
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Affiliation(s)
- Camilla Hage
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.).
| | - Erik Michaëlsson
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
| | - Cecilia Linde
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
| | - Erwan Donal
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
| | - Jean-Claude Daubert
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
| | - Li-Ming Gan
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
| | - Lars H Lund
- From the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.H., C.L., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (C.H., C.L., L.H.L.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden (E.M., L.-M.G.); Département de Cardiologie and CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, France (E.D., J.-C.D.); and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sweden (L.-M.G.)
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323
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Abstract
Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- School of Medicine, University of California, San Francisco, CA, USA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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324
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Bowen TS, Brauer D, Rolim NPL, Bækkerud FH, Kricke A, Ormbostad Berre AM, Fischer T, Linke A, da Silva GJ, Wisloff U, Adams V. Exercise Training Reveals Inflexibility of the Diaphragm in an Animal Model of Patients With Obesity-Driven Heart Failure With a Preserved Ejection Fraction. J Am Heart Assoc 2017; 6:e006416. [PMID: 29066440 PMCID: PMC5721851 DOI: 10.1161/jaha.117.006416] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Respiratory muscle weakness contributes to exercise intolerance in patients with heart failure with a preserved ejection fraction (HFpEF)-a condition characterized by multiple comorbidities with few proven treatments. We aimed, therefore, to provide novel insight into the underlying diaphragmatic alterations that occur in HFpEF by using an obese cardiometabolic rat model and further assessed whether exercise training performed only after the development of overt HFpEF could reverse impairments. METHODS AND RESULTS Obese ZSF1 rats (n=12) were compared with their lean controls (n=8) at 20 weeks, with 3 additional groups of obese ZSF1 rats compared at 28 weeks following 8 weeks of either sedentary behavior (n=13), high-intensity interval training (n=11), or moderate-continuous training (n=11). Obese rats developed an obvious HFpEF phenotype at 20 and 28 weeks. In the diaphragm at 20 weeks, HFpEF induced a shift towards an oxidative phenotype and a fiber hypertrophy paralleled by a lower protein expression in MuRF1 and MuRF2, yet mitochondrial and contractile functional impairments were observed. At 28 weeks, neither the exercise training regimen of high-intensity interval training or moderate-continuous training reversed any of the diaphragm alterations induced by HFpEF. CONCLUSIONS This study, using a well-characterized rat model of HFpEF underpinned by multiple comorbidities and exercise intolerance (ie, one that closely resembles the patient phenotype), provides evidence that diaphragm alterations and dysfunction induced in overt HFpEF are not reversed following 8 weeks of aerobic exercise training. As such, whether alternative therapeutic interventions are required to treat respiratory muscle weakness in HFpEF warrants further investigation.
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Affiliation(s)
- T Scott Bowen
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
| | - Dominic Brauer
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
| | - Natale P L Rolim
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Fredrik H Bækkerud
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Angela Kricke
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
| | - Anne-Marie Ormbostad Berre
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tina Fischer
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
| | - Gustavo Justo da Silva
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ulrik Wisloff
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- School of Human Movement & Nutrition Sciences, University of Queensland, Australia
| | - Volker Adams
- Department of Internal Medicine and Cardiology, Leipzig University-Heart Center, Leipzig, Germany
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325
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Van Linthout S, Hamdani N, Miteva K, Koschel A, Müller I, Pinzur L, Aberman Z, Pappritz K, Linke WA, Tschöpe C. Placenta-Derived Adherent Stromal Cells Improve Diabetes Mellitus-Associated Left Ventricular Diastolic Performance. Stem Cells Transl Med 2017; 6:2135-2145. [PMID: 29024485 PMCID: PMC5702519 DOI: 10.1002/sctm.17-0130] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/25/2017] [Indexed: 12/23/2022] Open
Abstract
Left ventricular (LV) diastolic dysfunction is among others attributed to cardiomyocyte stiffness. Mesenchymal stromal cells (MSC) have cardiac-protective properties. We explored whether intravenous (i.v.) application of PLacenta-eXpanded (PLX) MSC-like cells (PLX) improves LV diastolic relaxation in streptozotocin (STZ)-induced diabetic mice and investigated underlying mechanisms. Diabetes mellitus was induced by STZ application (50 mg/kg body weight) during five subsequent days. One week after the first STZ injection, PLX or saline were i.v. applied. Two weeks later, mice were hemodynamically characterized and sacrificed. At this early stage of diabetic cardiomyopathy with low-grade inflammation and no cardiac fibrosis, PLX reduced LV vascular cell adhesion molecule-1, transforming growth factor-β1, and interferon-γ mRNA expression, induced the percentage of circulating regulatory T cells, and decreased the splenic pro-fibrotic potential in STZ mice. STZ + PLX mice exhibited higher LV vascular endothelial growth factor mRNA expression and arteriole density versus STZ mice. In vitro, hyperglycemic PLX conditioned medium restored the hyperglycemia-impaired tube formation and adhesion capacity of human umbelical vein endothelial cells (HUVEC) via increasing nitric oxide (NO) bioavailability. PLX further induced the diabetes-downregulated activity of the NO downstream protein kinase G, as well as of protein kinase A, in STZ mice, which was associated with a raise in phosphorylation of the titin isoforms N2BA and N2B. Concomitantly, the passive force was lower in single isolated cardiomyocytes from STZ + PLX versus from STZ mice, which led to an improvement of LV diastolic relaxation. We conclude that i.v. PLX injection improves diabetes mellitus-associated diastolic performance via decreasing cardiomyocyte stiffness. Stem Cells Translational Medicine 2017;6:2135-2145.
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Affiliation(s)
- Sophie Van Linthout
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany.,Department of Cardiology, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research) partner site Berlin, Germany
| | - Nazha Hamdani
- Department of Cardiovascular Physiology, Ruhr University Bochum, Bochum, Germany
| | - Kapka Miteva
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany.,Department of Cardiology, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Annika Koschel
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany
| | - Irene Müller
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany.,DZHK (German Center for Cardiovascular Research) partner site Berlin, Germany
| | | | | | - Kathleen Pappritz
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany.,DZHK (German Center for Cardiovascular Research) partner site Berlin, Germany
| | | | - Carsten Tschöpe
- Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Charité - Universitätsmedizin Berlin, Germany.,Department of Cardiology, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany.,DZHK (German Center for Cardiovascular Research) partner site Berlin, Germany
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326
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Shillcutt SK, Chacon MM, Brakke TR, Roberts EK, Schulte TE, Markin N. Heart Failure With Preserved Ejection Fraction: A Perioperative Review. J Cardiothorac Vasc Anesth 2017; 31:1820-1830. [PMID: 28869075 DOI: 10.1053/j.jvca.2017.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Sasha K Shillcutt
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE.
| | - M Megan Chacon
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Tara R Brakke
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Ellen K Roberts
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Thomas E Schulte
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
| | - Nicholas Markin
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE
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327
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Tam MC, Lee R, Cascino TM, Konerman MC, Hummel SL. Current Perspectives on Systemic Hypertension in Heart Failure with Preserved Ejection Fraction. Curr Hypertens Rep 2017; 19:12. [PMID: 28233237 DOI: 10.1007/s11906-017-0709-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a prevalent but incompletely understood syndrome. Traditional models of HFpEF pathophysiology revolve around systemic HTN and other causes of increased left ventricular afterload leading to left ventricular hypertrophy (LVH) and diastolic dysfunction. However, emerging models attribute the development of HFpEF to systemic proinflammatory changes secondary to common comorbidities which include HTN. Alterations in passive ventricular stiffness, ventricular-arterial coupling, peripheral microvascular function, systolic reserve, and chronotropic response occur. As a result, HFpEF is heterogeneous in nature, making it difficult to prescribe uniform therapies to all patients. Nonetheless, treating systemic HTN remains a cornerstone of HFpEF management. Antihypertensive therapies have been linked to LVH regression and improvement in diastolic dysfunction. However, to date, no therapies have definitive mortality benefit in HFpEF. Non-pharmacologic management for HTN, including dietary modification, exercise, and treating sleep disordered breathing, may provide some morbidity benefit in the HFpEF population. Future research is need to identify effective treatments, perhaps in more specific subgroups, and focus may need to shift from reducing mortality to improving exercise capacity and symptoms. Tailoring antihypertensive therapies to specific phenotypes of HFpEF may be an important component of this strategy.
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Affiliation(s)
- Marty C Tam
- Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ran Lee
- Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Thomas M Cascino
- Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Matthew C Konerman
- Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott L Hummel
- Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA. .,Ann Arbor Veterans Affairs Health System, 1500 E. Medical Center Drive, 2383 CVC/SPC 5853, Ann Arbor, MI, 48109, USA.
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328
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Prat V, Rozec B, Gauthier C, Lauzier B. Human heart failure with preserved ejection versus feline cardiomyopathy: what can we learn from both veterinary and human medicine? Heart Fail Rev 2017; 22:783-794. [DOI: 10.1007/s10741-017-9645-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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329
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Gevaert AB, Shakeri H, Leloup AJ, Van Hove CE, De Meyer GRY, Vrints CJ, Lemmens K, Van Craenenbroeck EM. Endothelial Senescence Contributes to Heart Failure With Preserved Ejection Fraction in an Aging Mouse Model. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003806. [PMID: 28611124 DOI: 10.1161/circheartfailure.116.003806] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/01/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Because of global aging, the prevalence of heart failure with preserved ejection fraction (HFpEF) continues to rise. Although HFpEF pathophysiology remains incompletely understood, endothelial inflammation is stated to play a central role. Cellular senescence is a process of cellular growth arrest linked with aging and inflammation. We used mice with accelerated aging to investigate the role of cellular senescence in HFpEF development. METHODS AND RESULTS Senescence-accelerated mice (SAM, n=18) and control mice with normal senescence (n=15) were fed normal chow or a high-fat, high-salt diet (WD). Vascular and cardiac function was assessed at 8, 16, and 24 weeks of age. At 24 weeks, both SAM on WD (SAM-WD) and SAM on regular diet displayed endothelial dysfunction, as evidenced by impaired acetylcholine-induced relaxation of aortic segments and reduced basal nitric oxide. At week 24, SAM-WD had developed HFpEF, characterized by diastolic dysfunction, left ventricular hypertrophy, left atrial dilatation, and interstitial fibrosis. Also, exercise capacity was reduced and lung weight increased. Cardiovascular inflammation and senescence were assessed by immunohistochemical and immunofluorescence staining of hearts and aortas. SAM-WD showed increased endothelial inflammation (intercellular adhesion molecule 1 expression) and increased endothelial senescence (acetyl-p53/CD31 costaining). The latter correlated with diastolic function and intercellular adhesion molecule 1 expression. CONCLUSIONS SAM develop endothelial dysfunction. Adding a high-salt, high-fat diet accelerates endothelial senescence and instigates endothelial inflammation. This coincides with hemodynamic and structural changes typical of HFpEF. Targeting endothelial senescence could be a new therapeutic avenue in HFpEF.
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Affiliation(s)
- Andreas B Gevaert
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.).
| | - Hadis Shakeri
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Arthur J Leloup
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Cor E Van Hove
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Guido R Y De Meyer
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Christiaan J Vrints
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Katrien Lemmens
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
| | - Emeline M Van Craenenbroeck
- From the Research Group Physiopharmacology (A.B.G., H.S., A.J.L., C.E.V.H., G.R.Y.D.M., K.L.), and Research Group Cardiovascular Diseases, Translational Pathophysiological Research (A.B.G., C.E.V.H., C.J.V., K.L., E.M.V.C.), University of Antwerp, Belgium; and Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium (A.B.G., C.J.V., E.M.V.C.)
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330
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Reddy YNV, Lewis GD, Shah SJ, LeWinter M, Semigran M, Davila-Roman VG, Anstrom K, Hernandez A, Braunwald E, Redfield MM, Borlaug BA. INDIE-HFpEF (Inorganic Nitrite Delivery to Improve Exercise Capacity in Heart Failure With Preserved Ejection Fraction): Rationale and Design. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003862. [PMID: 28476756 DOI: 10.1161/circheartfailure.117.003862] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/29/2017] [Indexed: 02/06/2023]
Abstract
Approximately half of patients with heart failure have preserved ejection fraction. There is no proven treatment that improves outcome. The pathophysiology of heart failure with preserved ejection fraction is complex and includes left ventricular systolic and diastolic dysfunction, pulmonary vascular disease, endothelial dysfunction, and peripheral abnormalities. Multiple lines of evidence point to impaired nitric oxide (NO)-cGMP bioavailability as playing a central role in each of these abnormalities. In contrast to traditional organic nitrate therapies, an alternative strategy to restore NO-cGMP signaling is via inorganic nitrite. Inorganic nitrite, previously considered to be an inert byproduct of NO metabolism, functions as an important in vivo reservoir for NO generation, particularly under hypoxic and acidosis conditions. As such, inorganic nitrite becomes most active at times of greater need for NO signaling, as during exercise when left ventricular filling pressures and pulmonary artery pressures increase. Herein, we present the rationale and design for the INDIE-HFpEF trial (Inorganic Nitrite Delivery to Improve Exercise Capacity in Heart Failure with Preserved Ejection Fraction), which is a multicenter, randomized, double-blind, placebo-controlled cross-over study assessing the effect of inhaled inorganic nitrite on peak exercise capacity, conducted in the National Heart, Lung, and Blood Institute-sponsored Heart Failure Clinical Research Network. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02742129.
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Affiliation(s)
- Yogesh N V Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Gregory D Lewis
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Sanjiv J Shah
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Martin LeWinter
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Marc Semigran
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Victor G Davila-Roman
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Kevin Anstrom
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Adrian Hernandez
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Eugene Braunwald
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Margaret M Redfield
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Barry A Borlaug
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Y.N.V.R., M.M.R., B.A.B.); Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston (G.D.L., M.S.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Cardiology Unit, University of Vermont College of Medicine, Burlington (M.L.W.); Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.); Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (K.A., A.H.); and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.B.).
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331
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Management of Heart Failure with Preserved Ejection Fraction: Current Challenges and Future Directions. Am J Cardiovasc Drugs 2017; 17:283-298. [PMID: 28316006 DOI: 10.1007/s40256-017-0219-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF in patients older than 65 years. Among elderly women living in the community, HFpEF comprises nearly 90% of incident HF cases. The health and economic impact of HFpEF is at least as great as that of HF with reduced ejection fraction (HFrEF), with similar severity of acute hospitalization rates and substantial mortality. Despite the importance of HFpEF, our understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. Unlike the management of HFrEF, there is a paucity of large evidence-based trials demonstrating morbidity and mortality benefit for the treatment of HFpEF. The agents tested in trials to date, which were based upon an incomplete understanding of the pathophysiology of HFpEF, have not been positive. There is an urgent need to understand HFpEF pathophysiology and to focus on developing novel therapeutic targets.
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332
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Abstract
PURPOSE OF REVIEW With the intention to summarize the currently available evidence on the pathophysiological relevance of inflammation in heart failure, this review addresses the question whether inflammation is a cause or consequence of heart failure, or both. RECENT FINDINGS This review discusses the diversity (sterile, para-inflammation, chronic inflammation) and sources of inflammation and gives an overview of how inflammation (local versus systemic) can trigger heart failure. On the other hand, the review is outlined how heart failure-associated wall stress and signals released by stressed, malfunctioning, or dead cells (DAMPs: e.g., mitochondrial DNA, ATP, S100A8, matricellular proteins) induce cardiac sterile inflammation and how heart failure provokes inflammation in various peripheral tissues in a direct (inflammatory) and indirect (hemodynamic) manner. The crosstalk between the heart and peripheral organs (bone marrow, spleen, gut, adipose tissue) is outlined and the importance of neurohormonal mechanisms including the renin angiotensin aldosteron system and the ß-adrenergic nervous system in inflammation and heart failure is discussed. Inflammation and heart failure are strongly interconnected and mutually reinforce each other. This indicates the difficulty to counteract inflammation and heart failure once this chronic vicious circle has started and points out the need to control the inflammatory process at an early stage avoiding chronic inflammation and heart failure. The diversity of inflammation further addresses the need for a tailored characterization of inflammation enabling differentiation of inflammation and subsequent target-specific strategies. It is expected that the characterization of the systemic and/or cardiac immune profile will be part of precision medicine in the future of cardiology.
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Affiliation(s)
- Sophie Van Linthout
- Berlin-Brandenburg Center for Regenerative Therapies, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Carsten Tschöpe
- Berlin-Brandenburg Center for Regenerative Therapies, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Cardiology, Campus Virchow Klinikum, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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333
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Tsukamoto O, Kitakaze M. Radiation-induced HFpEF model as a potential tool for the exploration of novel therapeutic targets. Am J Physiol Heart Circ Physiol 2017. [DOI: 10.1152/ajpheart.00307.2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Osamu Tsukamoto
- Department of Medial Biochemistry, Osaka University Graduate School of Medicine, Suita 565-0871, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Suita 565-8565, Japan
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334
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Fraser AG, Gillebert TC, Leite-Moreira AF. Ventricular-arterial coupling in heart failure with preserved ejection fraction: the devil is in the details. Cardiovasc Res 2017; 113:844-846. [DOI: 10.1093/cvr/cvx107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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335
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Targeting Endothelial Function to Treat Heart Failure with Preserved Ejection Fraction: The Promise of Exercise Training. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:4865756. [PMID: 28706575 PMCID: PMC5494585 DOI: 10.1155/2017/4865756] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 12/22/2022]
Abstract
Although the burden of heart failure with preserved ejection fraction (HFpEF) is increasing, there is no therapy available that improves prognosis. Clinical trials using beta blockers and angiotensin converting enzyme inhibitors, cardiac-targeting drugs that reduce mortality in heart failure with reduced ejection fraction (HFrEF), have had disappointing results in HFpEF patients. A new “whole-systems” approach has been proposed for designing future HFpEF therapies, moving focus from the cardiomyocyte to the endothelium. Indeed, dysfunction of endothelial cells throughout the entire cardiovascular system is suggested as a central mechanism in HFpEF pathophysiology. The objective of this review is to provide an overview of current knowledge regarding endothelial dysfunction in HFpEF. We discuss the molecular and cellular mechanisms leading to endothelial dysfunction and the extent, presence, and prognostic importance of clinical endothelial dysfunction in different vascular beds. We also consider implications towards exercise training, a promising therapy targeting system-wide endothelial dysfunction in HFpEF.
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336
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Association between suPAR and cardiac diastolic dysfunction among patients with preserved ejection fraction. Heart Vessels 2017; 32:1327-1336. [DOI: 10.1007/s00380-017-1002-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/26/2017] [Indexed: 12/22/2022]
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337
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Bellumkonda L, Tyrrell D, Hummel SL, Goldstein DR. Pathophysiology of heart failure and frailty: a common inflammatory origin? Aging Cell 2017; 16:444-450. [PMID: 28266167 PMCID: PMC5418206 DOI: 10.1111/acel.12581] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 12/23/2022] Open
Abstract
Frailty, a clinical syndrome that typically occurs in older adults, implies a reduced ability to tolerate biological stressors. Frailty accompanies many age‐related diseases but can also occur without overt evidence of end‐organ disease. The condition is associated with circulating inflammatory cytokines and sarcopenia, features that are shared with heart failure (HF). However, the biological underpinnings of frailty remain unclear and the interaction with HF is complex. Here, we describe the inflammatory pathophysiology that is associated with frailty and speculate that the inflammation that occurs with frailty shares common origins with HF. We discuss the limitations in investigating the pathophysiology of frailty due to few relevant experimental models. Leveraging current therapies for advanced HF and current known therapies to address frailty in humans may enable translational studies to better understand the inflammatory interactions between frailty and HF.
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Affiliation(s)
- Lavanya Bellumkonda
- Section of Cardiovascular Medicine; Department of Medicine; Yale School of Medicine; New Haven CT USA
| | - Daniel Tyrrell
- Section of Cardiovascular Medicine; Department of Medicine; University of Michigan; Ann Arbor MI USA
| | - Scott L. Hummel
- Section of Cardiovascular Medicine; Department of Medicine; University of Michigan; Ann Arbor MI USA
- Ann Arbor Veterans Affairs Healthcare System; Ann Arbor MI USA
| | - Daniel R. Goldstein
- Section of Cardiovascular Medicine; Department of Medicine; University of Michigan; Ann Arbor MI USA
- Institute of Gerontology; University of Michigan; Ann Arbor MI USA
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338
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Shah SJ. Precision Medicine for Heart Failure with Preserved Ejection Fraction: An Overview. J Cardiovasc Transl Res 2017; 10:233-244. [PMID: 28585183 PMCID: PMC5540576 DOI: 10.1007/s12265-017-9756-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 12/11/2022]
Abstract
There are few proven therapies for heart failure with preserved ejection fraction (HFpEF). The lack of therapies, along with increased recognition of the disorder and its underlying pathophysiology, has led to the acknowledgement that HFpEF is heterogeneous and is not likely to respond to a one-size-fits-all approach. Thus, HFpEF is a prime candidate to benefit from a precision medicine approach. For this reason, we have assembled a compendium of papers on the topic of precision medicine in HFpEF in the Journal of Cardiovascular Translational Research. These papers cover a variety of topics relevant to precision medicine in HFpEF, including automated identification of HFpEF patients; machine learning, novel molecular approaches, genomics, and deep phenotyping of HFpEF; and clinical trial designs that can be used to advance precision medicine in HFpEF. In this introductory article, we provide an overview of precision medicine in HFpEF with the hope that the work described here and in the other papers in this special theme issue will stimulate investigators and clinicians to advance a more targeted approach to HFpEF classification and treatment.
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Affiliation(s)
- Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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339
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Saiki H, Moulay G, Guenzel AJ, Liu W, Decklever TD, Classic KL, Pham L, Chen HH, Burnett JC, Russell SJ, Redfield MM. Experimental cardiac radiation exposure induces ventricular diastolic dysfunction with preserved ejection fraction. Am J Physiol Heart Circ Physiol 2017; 313:H392-H407. [PMID: 28550173 PMCID: PMC5582918 DOI: 10.1152/ajpheart.00124.2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/28/2017] [Accepted: 05/12/2017] [Indexed: 01/09/2023]
Abstract
Breast cancer radiotherapy increases the risk of heart failure with preserved ejection fraction (HFpEF). Cardiomyocytes are highly radioresistant, but radiation specifically affects coronary microvascular endothelial cells, with subsequent microvascular inflammation and rarefaction. The effects of radiation on left ventricular (LV) diastolic function are poorly characterized. We hypothesized that cardiac radiation exposure may result in diastolic dysfunction without reduced EF. Global cardiac expression of the sodium-iodide symporter (NIS) was induced by cardiotropic gene (adeno-associated virus serotype 9) delivery to 5-wk-old rats. SPECT/CT (125I) measurement of cardiac iodine uptake allowed calculation of the 131I doses needed to deliver 10- or 20-Gy cardiac radiation at 10 wk of age. Radiated (Rad; 10 or 20 Gy) and control rats were studied at 30 wk of age. Body weight, blood pressure, and heart rate were similar in control and Rad rats. Compared with control rats, Rad rats had impaired exercise capacity, increased LV diastolic stiffness, impaired LV relaxation, and elevated filling pressures but similar LV volume, EF, end-systolic elastance, preload recruitable stroke work, and peak +dP/dt Pathology revealed reduced microvascular density, mild concentric cardiomyocyte hypertrophy, and increased LV fibrosis in Rad rats compared with control rats. In the Rad myocardium, oxidative stress was increased and in vivo PKG activity was decreased. Experimental cardiac radiation exposure resulted in diastolic dysfunction without reduced EF. These data provide insight into the association between cardiac radiation exposure and HFpEF risk and lend further support for the importance of inflammation-related coronary microvascular compromise in HFpEF.NEW & NOTEWORTHY Cardiac radiation exposure during radiotherapy increases the risk of heart failure with preserved ejection fraction. In a novel rodent model, cardiac radiation exposure resulted in coronary microvascular rarefaction, oxidative stress, impaired PKG signaling, myocardial fibrosis, mild cardiomyocyte hypertrophy, left ventricular diastolic dysfunction, and elevated left ventricular filling pressures despite preserved ejection fraction.
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Affiliation(s)
- Hirofumi Saiki
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gilles Moulay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Adam J Guenzel
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Weibin Liu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Kelly L Classic
- Division of Medical Physics, Mayo Clinic, Rochester, Minnesota
| | - Linh Pham
- Department of Molecular Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Horng H Chen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - John C Burnett
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Stephen J Russell
- Department of Molecular Medicine, Mayo Clinic, Rochester, Minnesota; and.,Division of Hematology, Mayo Clinic, Rochester, Minnesota
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340
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Hotta K, Chen B, Behnke BJ, Ghosh P, Stabley JN, Bramy JA, Sepulveda JL, Delp MD, Muller-Delp JM. Exercise training reverses age-induced diastolic dysfunction and restores coronary microvascular function. J Physiol 2017; 595:3703-3719. [PMID: 28295341 PMCID: PMC5471361 DOI: 10.1113/jp274172] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/20/2017] [Indexed: 12/14/2022] Open
Abstract
KEY POINTS In a rat model of ageing that is free of atherosclerosis or hypertension, E/A, a diagnostic measure of diastolic filling, decreases, and isovolumic relaxation time increases, indicating that both active and passive ventricular relaxation are impaired with advancing age. Resting coronary blood flow and coronary functional hyperaemia are reduced with age, and endothelium-dependent vasodilatation declines with age in coronary resistance arterioles. Exercise training reverses age-induced declines in diastolic and coronary microvascular function. Thus, microvascular dysfunction and inadequate coronary perfusion are likely mechanisms of diastolic dysfunction in aged rats. Exercise training, initiated at an advanced age, reverses age-related diastolic and microvascular dysfunction; these data suggest that late-life exercise training can be implemented to improve coronary perfusion and diastolic function in the elderly. ABSTRACT The risk for diastolic dysfunction increases with advancing age. Regular exercise training ameliorates age-related diastolic dysfunction; however, the underlying mechanisms have not been identified. We investigated whether (1) microvascular dysfunction contributes to the development of age-related diastolic dysfunction, and (2) initiation of late-life exercise training reverses age-related diastolic and microvascular dysfunction. Young and old rats underwent 10 weeks of exercise training or remained as sedentary, cage-controls. Isovolumic relaxation time (IVRT), early diastolic filling (E/A), myocardial performance index (MPI) and aortic stiffness (pulse wave velocity; PWV) were evaluated before and after exercise training or cage confinement. Coronary blood flow and vasodilatory responses of coronary arterioles were evaluated in all groups at the end of training. In aged sedentary rats, compared to young sedentary rats, a 42% increase in IVRT, a 64% decrease in E/A, and increased aortic stiffness (PWV: 6.36 ± 0.47 vs.4.89 ± 0.41, OSED vs. YSED, P < 0.05) was accompanied by impaired coronary blood flow at rest and during exercise. Endothelium-dependent vasodilatation was impaired in coronary arterioles from aged rats (maximal relaxation to bradykinin: 56.4 ± 5.1% vs. 75.3 ± 5.2%, OSED vs. YSED, P < 0.05). After exercise training, IVRT, a measure of active ventricular relaxation, did not differ between old and young rats. In old rats, exercise training reversed the reduction in E/A, reduced aortic stiffness, and eliminated impairment of coronary blood flow responses and endothelium-dependent vasodilatation. Thus, age-related diastolic and microvascular dysfunction are reversed by late-life exercise training. The restorative effect of exercise training on coronary microvascular function may result from improved endothelial function.
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Affiliation(s)
- Kazuki Hotta
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Bei Chen
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, USA
| | - Bradley J Behnke
- Department of Kinesiology & Johnson Cancer Research Center, Kansas State University, Manhattan, KS, USA
| | - Payal Ghosh
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - John N Stabley
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy A Bramy
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Jaime L Sepulveda
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Michael D Delp
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL, USA
| | - Judy M Muller-Delp
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
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341
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Abstract
Most elderly patients, particularly women, who have heart failure, have a preserved ejection fraction. Patients with this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. Despite the importance of heart failure with preserved ejection fraction (HFpEF), the understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. Unlike the management of HFrEF, there is a paucity of large evidence-based trials demonstrating morbidity and mortality benefit for the treatment of HFpEF. An update is presented on information regarding pathophysiology, diagnosis, management, and future directions in this important and growing disorder.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Dalane W Kitzman
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA.
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342
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Dou H, Feher A, Davila AC, Romero MJ, Patel VS, Kamath VM, Gooz MB, Rudic RD, Lucas R, Fulton DJ, Weintraub NL, Bagi Z. Role of Adipose Tissue Endothelial ADAM17 in Age-Related Coronary Microvascular Dysfunction. Arterioscler Thromb Vasc Biol 2017; 37:1180-1193. [PMID: 28473444 DOI: 10.1161/atvbaha.117.309430] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 04/12/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE A disintegrin and metalloproteinase ADAM17 (tumor necrosis factor-α [TNF]-converting enzyme) regulates soluble TNF levels. We tested the hypothesis that aging-induced activation in adipose tissue (AT)-expressed ADAM17 contributes to the development of remote coronary microvascular dysfunction in obesity. APPROACH AND RESULTS Coronary arterioles (CAs, ≈90 µm) from right atrial appendages and mediastinal AT were examined in patients (aged: 69±11 years, BMI: 30.2±5.6 kg/m2) who underwent open heart surgery. CA and AT were also studied in 6-month and 24-month lean and obese mice fed a normal or high-fat diet. We found that obesity elicited impaired endothelium-dependent CA dilations only in older patients and in aged high-fat diet mice. Transplantation of AT from aged obese, but not from young or aged, mice increased serum cytokine levels, including TNF, and impaired CA dilation in the young recipient mice. In patients and mice, obesity was accompanied by age-related activation of ADAM17, which was attributed to vascular endothelium-expressed ADAM17. Excess, ADAM17-shed TNF from AT arteries in older obese patients was sufficient to impair CA dilation in a bioassay in which the AT artery was serially connected to a CA. Moreover, we found that the increased activity of endothelial ADAM17 is mediated by a diminished inhibitory interaction with caveolin-1, owing to age-related decline in caveolin-1 expression in obese patients and mice or to genetic deletion of caveolin-1. CONCLUSIONS The present study indicates that aging and obesity cooperatively reduce caveolin-1 expression and increase vascular endothelial ADAM17 activity and soluble TNF release in AT, which may contribute to the development of remote coronary microvascular dysfunction in older obese patients.
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Affiliation(s)
- Huijuan Dou
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Attila Feher
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Alec C Davila
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Maritza J Romero
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Vijay S Patel
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Vinayak M Kamath
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Monika Beck Gooz
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - R Daniel Rudic
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Rudolf Lucas
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - David J Fulton
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Neal L Weintraub
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.)
| | - Zsolt Bagi
- From the Vascular Biology Center (H.D., A.F., A.C.D., M.J.R., R.L., D.J.F., N.L.W., Z.B.), Department of Surgery (V.S.P., V.M.K.), Department of Medicine (N.L.W., Z.B.), and Department of Pharmacology and Toxicology (M.J.R., R.D.R., R.L., D.J.F.), Medical College of Georgia, Augusta University; and Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston (M.B.G.).
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Boudoulas KD, Triposkiadis F, Parissis J, Butler J, Boudoulas H. The Cardio-Renal Interrelationship. Prog Cardiovasc Dis 2017; 59:636-648. [DOI: 10.1016/j.pcad.2016.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 12/11/2016] [Indexed: 12/14/2022]
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Deep Phenotyping of Systemic Arterial Hemodynamics in HFpEF (Part 2): Clinical and Therapeutic Considerations. J Cardiovasc Transl Res 2017; 10:261-274. [PMID: 28401511 DOI: 10.1007/s12265-017-9736-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/30/2017] [Indexed: 01/09/2023]
Abstract
Multiple phase III trials over the last few decades have failed to demonstrate a clear benefit of various pharmacologic interventions in heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF). Therefore, a better understanding of its pathophysiology is important. An accompanying review describes key technical and physiologic aspects regarding the deep phenotyping of arterial hemodynamics in HFpEF. This review deals with the potential of this approach to enhance our clinical, translational, and therapeutic approach to HFpEF. Specifically, the role of arterial hemodynamics is discussed in relation to (1) the pathophysiology of left ventricular diastolic dysfunction, remodeling, and fibrosis, (2) impaired oxygen delivery to peripheral skeletal muscle, which affects peripheral oxygen extraction, (3) the frequent presence of comorbidities, such as renal failure and dementia in this population, and (4) the potential to enhance precision medicine approaches. A therapeutic approach to target arterial hemodynamic abnormalities that are prevalent in this population (particularly, with inorganic nitrate/nitrite) is also discussed.
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Zamani P, Tan V, Soto-Calderon H, Beraun M, Brandimarto JA, Trieu L, Varakantam S, Doulias PT, Townsend RR, Chittams J, Margulies KB, Cappola TP, Poole DC, Ischiropoulos H, Chirinos JA. Pharmacokinetics and Pharmacodynamics of Inorganic Nitrate in Heart Failure With Preserved Ejection Fraction. Circ Res 2017; 120:1151-1161. [PMID: 27927683 PMCID: PMC5376233 DOI: 10.1161/circresaha.116.309832] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/11/2016] [Accepted: 12/07/2016] [Indexed: 01/31/2023]
Abstract
RATIONALE Nitrate-rich beetroot juice has been shown to improve exercise capacity in heart failure with preserved ejection fraction, but studies using pharmacological preparations of inorganic nitrate are lacking. OBJECTIVES To determine (1) the dose-response effect of potassium nitrate (KNO3) on exercise capacity; (2) the population-specific pharmacokinetic and safety profile of KNO3 in heart failure with preserved ejection fraction. METHODS AND RESULTS We randomized 12 subjects with heart failure with preserved ejection fraction to oral KNO3 (n=9) or potassium chloride (n=3). Subjects received 6 mmol twice daily during week 1, followed by 6 mmol thrice daily during week 2. Supine cycle ergometry was performed at baseline (visit 1) and after each week (visits 2 and 3). Quality of life was assessed with the Kansas City Cardiomyopathy Questionnaire. The primary efficacy outcome, peak O2-uptake, did not significantly improve (P=0.13). Exploratory outcomes included exercise duration and quality of life. Exercise duration increased significantly with KNO3 (visit 1: 9.87, 95% confidence interval [CI] 9.31-10.43 minutes; visit 2: 10.73, 95% CI 10.13-11.33 minute; visit 3: 11.61, 95% CI 11.05-12.17 minutes; P=0.002). Improvements in the Kansas City Cardiomyopathy Questionnaire total symptom (visit 1: 58.0, 95% CI 52.5-63.5; visit 2: 66.8, 95% CI 61.3-72.3; visit 3: 70.8, 95% CI 65.3-76.3; P=0.016) and functional status scores (visit 1: 62.2, 95% CI 58.5-66.0; visit 2: 68.6, 95% CI 64.9-72.3; visit 3: 71.1, 95% CI 67.3-74.8; P=0.01) were seen after KNO3. Pronounced elevations in trough levels of nitric oxide metabolites occurred with KNO3 (visit 2: 199.5, 95% CI 98.7-300.2 μmol/L; visit 3: 471.8, 95% CI 377.8-565.8 μmol/L) versus baseline (visit 1: 38.0, 95% CI 0.00-132.0 μmol/L; P<0.001). KNO3 did not lead to clinically significant hypotension or methemoglobinemia. After 6 mmol of KNO3, systolic blood pressure was reduced by a maximum of 17.9 (95% CI -28.3 to -7.6) mm Hg 3.75 hours later. Peak nitric oxide metabolites concentrations were 259.3 (95% CI 176.2-342.4) μmol/L 3.5 hours after ingestion, and the median half-life was 73.0 (interquartile range 33.4-232.0) minutes. CONCLUSIONS KNO3 is potentially well tolerated and improves exercise duration and quality of life in heart failure with preserved ejection fraction. This study reinforces the efficacy of KNO3 and suggests that larger randomized trials are warranted. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02256345.
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Affiliation(s)
- Payman Zamani
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.).
| | - Victor Tan
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Haideliza Soto-Calderon
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Melissa Beraun
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Jeffrey A Brandimarto
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Lien Trieu
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Swapna Varakantam
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Paschalis-Thomas Doulias
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Raymond R Townsend
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Jesse Chittams
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Kenneth B Margulies
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Thomas P Cappola
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - David C Poole
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Harry Ischiropoulos
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
| | - Julio A Chirinos
- From the Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia (P.Z., V.T., H.S.-C., M.B., J.A.B., S.V., K.B.M., T.P.C., J.A.C.); Rowan University School of Osteopathic Medicine, Stratford, NJ (L.T.); Children's Hospital of Philadelphia Research Institute, PA (P.-T.D., H.I.); Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.); Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia (J.C.); Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan (D.C.P.)
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Nazário Leão R, Marques da Silva P. Diastolic dysfunction in hypertension. HIPERTENSION Y RIESGO VASCULAR 2017; 34:128-139. [PMID: 28268171 DOI: 10.1016/j.hipert.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/26/2017] [Indexed: 12/21/2022]
Abstract
Hypertension and coronary heart disease, often coexisting, are the most common risk factors for heart failure. The progression of hypertensive heart disease involves myocardial fibrosis and alterations in the left ventricular geometry that precede the functional change, initially asymptomatic. The left ventricular diastolic dysfunction is part of this continuum being defined by the presence of left ventricular diastolic dysfunction without signs or symptoms of heart failure or poor left ventricular systolic function. It is highly prevalent in hypertensive patients and is associated with increased cardiovascular morbidity and mortality. Despite its growing importance in clinical practice it remains poorly understood. This review aims to present the epidemiological fundamentals and the latest developments in the pathophysiology, diagnosis and treatment of left ventricular diastolic dysfunction.
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Affiliation(s)
- R Nazário Leão
- Unidade Funcional Medicina 2, Hospital São José, Centro Hospitalar Lisboa Central - EPE, Lisboa, Portugal; Nova Medical School, Lisboa, Portugal.
| | - P Marques da Silva
- Nova Medical School, Lisboa, Portugal; Núcleo de Investigação Arterial, Unidade Funcional Medicina 4, Hospital Santa Marta, Centro Hospitalar Lisboa Central - EPE, Lisboa, Portugal
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347
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Zamani P, Akers S, Soto-Calderon H, Beraun M, Koppula MR, Varakantam S, Rawat D, Shiva-Kumar P, Haines PG, Chittams J, Townsend RR, Witschey WR, Segers P, Chirinos JA. Isosorbide Dinitrate, With or Without Hydralazine, Does Not Reduce Wave Reflections, Left Ventricular Hypertrophy, or Myocardial Fibrosis in Patients With Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2017; 6:JAHA.116.004262. [PMID: 28219917 PMCID: PMC5523746 DOI: 10.1161/jaha.116.004262] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Wave reflections, which are increased in patients with heart failure with preserved ejection fraction, impair diastolic function and promote pathologic myocardial remodeling. Organic nitrates reduce wave reflections acutely, but whether this is sustained chronically or affected by hydralazine coadministration is unknown. Methods and Results We randomized 44 patients with heart failure with preserved ejection fraction in a double‐blinded fashion to isosorbide dinitrate (ISDN; n=13), ISDN+hydralazine (ISDN+hydral; n=15), or placebo (n=16) for 6 months. The primary end point was the change in reflection magnitude (RM; assessed with arterial tonometry and Doppler echocardiography). Secondary end points included change in left ventricular mass and fibrosis, measured with cardiac magnetic resonance imaging, and the 6‐minute walk distance. ISDN reduced aortic characteristic impedance (mean baseline=0.15 [95% CI, 0.14–0.17], 3 months=0.11 [95% CI, 0.10–0.13], 6 months=0.10 [95% CI, 0.08–0.12] mm Hg/mL per second; P=0.003) and forward wave amplitude (Pf, mean baseline=54.8 [95% CI, 47.6–62.0], 3 months=42.2 [95% CI, 33.2–51.3]; 6 months=37.0 [95% CI, 27.2–46.8] mm Hg, P=0.04), but had no effect on RM (P=0.64), left ventricular mass (P=0.33), or fibrosis (P=0.63). ISDN+hydral increased RM (mean baseline=0.39 [95% CI, 0.35–0.43]; 3 months=0.31 [95% CI, 0.25–0.36]; 6 months=0.44 [95% CI, 0.37–0.51], P=0.03), reduced 6‐minute walk distance (mean baseline=343.3 [95% CI, 319.2–367.4]; 6 months=277.0 [95% CI, 242.7–311.4] meters, P=0.022), and increased native myocardial T1 (mean baseline=1016.2 [95% CI, 1002.7–1029.7]; 6 months=1054.5 [95% CI, 1036.5–1072.3], P=0.021). A high proportion of patients experienced adverse events with active therapy (ISDN=61.5%, ISDN+hydral=60.0%; placebo=12.5%; P=0.007). Conclusions ISDN, with or without hydralazine, does not exert beneficial effects on RM, left ventricular remodeling, or submaximal exercise and is poorly tolerated. ISDN+hydral appears to have deleterious effects on RM, myocardial remodeling, and submaximal exercise. Our findings do not support the routine use of these vasodilators in patients with heart failure with preserved ejection fraction. Clinical Trial Registration URL: www.clinicaltrials.gov. Unique identifier: NCT01516346.
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Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Scott Akers
- Department of Radiology, Philadelphia Veterans' Affairs Medical Center, Philadelphia, PA
| | - Haideliza Soto-Calderon
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Melissa Beraun
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Maheswara R Koppula
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Swapna Varakantam
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Deepa Rawat
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Prithvi Shiva-Kumar
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Philip G Haines
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.,Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jesse Chittams
- Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Raymond R Townsend
- Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Walter R Witschey
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick Segers
- Biofluid, Tissue, and Solid Mechanics for Medical Applications, IBiTech, iMinds Medical IT, Ghent University, Ghent, Belgium
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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348
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Polsinelli VB, Shah SJ. Advances in the pharmacotherapy of chronic heart failure with preserved ejection fraction: an ideal opportunity for precision medicine. Expert Opin Pharmacother 2017; 18:399-409. [PMID: 28129699 DOI: 10.1080/14656566.2017.1288717] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF), which comprises approximately 50% of all heart failure patients, is a challenging and complex clinical syndrome that is often thought to lack effective treatments. Areas covered: Despite the common mantra that HFpEF has no effective treatments, closer inspection of HFpEF clinical trials reveals that several of the drugs tested are associated with benefits in exercise capacity and quality of life, and reduction in heart failure hospitalization. Here we review major randomized controlled trials in HFpEF, focusing on renin-angiotensin-aldosterone system antagonists, organic nitrates, digoxin, beta-blockers, and phosphodiesterase-5 inhibitors. In addition, we review several classes of drugs currently in development for HFpEF such as neprilysin inhibitors, inorganic nitrates (nitrites), and soluble guanylate cyclase stimulators. Expert opinion: HFpEF should not be viewed as lacking effective treatments. While there have been no breakthrough clinical trials showing a reduction in mortality, several existing medications are likely to benefit specific subgroups of HFpEF patients. HFpEF is now well known to be a heterogeneous syndrome; thus, the clinical management of HFpEF patients and future HFpEF clinical trials will both likely require a nuanced, phenotype-specific approach instead of a one-size-fits-all tactic. Drug development for HFpEF therefore represents an exciting opportunity for personalized medicine.
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Affiliation(s)
- Vincenzo B Polsinelli
- a Division of Cardiology, Department of Medicine , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Sanjiv J Shah
- a Division of Cardiology, Department of Medicine , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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Abstract
PURPOSE OF REVIEW Heart failure (HF) is a disease state with great heterogeneity, which complicates the therapeutic process. Identifying more precise HF phenotypes will allow for the development of more targeted therapies and improvement in patient outcomes. This review explores the future for precision medicine in HF treatment. RECENT FINDINGS Rather than a continuous disease spectrum with a uniform pathogenesis, HF has phenotypes with different underlying pathophysiologic features. The challenge is to establish clinical phenotypic characterizations to direct therapy. Phenomapping, a process of using machine learning algorithms applied to clinical data sets, has been used to identify phenotypically distinct and clinically meaningful HF groups. As powerful technologies extend our knowledge, future analyses may be able to compile more comprehensive phenotypic profiles using genetic, epigenetic, proteomic, and metabolomic measurements. Identifying clinical characterizations of particular HF patients that would be uniquely or disproportionately responsive to a specific treatment would allow for more direct selection of optimal therapy, reduce trial-and-error prescribing, and help avoid adverse drug reactions.
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Saiki H, Petersen IA, Scott CG, Bailey KR, Dunlay SM, Finley RR, Ruddy KJ, Yan E, Redfield MM. Risk of Heart Failure With Preserved Ejection Fraction in Older Women After Contemporary Radiotherapy for Breast Cancer. Circulation 2017; 135:1388-1396. [PMID: 28132957 DOI: 10.1161/circulationaha.116.025434] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cardiomyocytes are resistant to radiation. However, cardiac radiation exposure causes coronary microvascular endothelial inflammation, a perturbation implicated in the pathogenesis of heart failure (HF) and particularly HF with preserved ejection fraction (HFpEF). Radiotherapy for breast cancer results in variable cardiac radiation exposure and may increase the risk of HF. METHODS We conducted a population-based case-control study of incident HF in 170 female residents of Olmsted County, Minnesota (59 cases and 111 controls), who underwent contemporary (1998-2013) radiotherapy for breast cancer with computed tomography-assisted radiotherapy planning. Controls were matched to cases for age, tumor side, chemotherapy use, diabetes mellitus, and hypertension. Mean cardiac radiation dose (MCRD) in each patient was calculated from the patient's computed tomography images and radiotherapy plan. RESULTS Mean age at radiotherapy was 69±9 years. Of HF cases, 38 (64%) had EF≥50% (HFpEF), 18 (31%) had EF<50% (HF with reduced EF), and 3 (5%) did not have EF measured. The EF was ≥40% in 50 of the 56 HF cases (89%) with an EF measurement. The mean interval from radiotherapy to HF was 5.8±3.4 years. The odds of HF was higher in patients with a history of ischemic heart disease or atrial fibrillation. The MCRD was 2.5 Gy (range, 0.2-13.1 Gy) and higher in cases (3.3±2.7 Gy) than controls (2.1±2.0 Gy; P=0.004). The odds ratio (95% confidence interval) for HF per log MCRD was 9.1 (3.4-24.4) for any HF, 16.9 (3.9-73.7) for HFpEF, and 3.17 (0.8-13.0) for HF with reduced EF. The increased odds of any HF or HFpEF with increasing MCRD remained significant after adjustment for HF risk factors and in sensitivity analyses matching by cancer stage rather than tumor side. Only 18.6% of patients experienced new or recurrent ischemic events between radiotherapy and the onset of HF. CONCLUSIONS The relative risk of HFpEF increases with increasing cardiac radiation exposure during contemporary conformal breast cancer radiotherapy. These data emphasize the importance of radiotherapy techniques that limit MCRD during breast cancer treatment. Moreover, these data provide further support for the importance of coronary microvascular compromise in the pathophysiology of HFpEF.
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Affiliation(s)
- Hirofumi Saiki
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Ivy A Petersen
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Christopher G Scott
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kent R Bailey
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Shannon M Dunlay
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Randi R Finley
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kathryn J Ruddy
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Elizabeth Yan
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Margaret M Redfield
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN.
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