1
|
Magrì D, Gallo G, Piepoli M, Salvioni E, Mapelli M, Vignati C, Fiori E, Muthukkattil ML, Corrà U, Metra M, Paolillo S, Maruotti A, Di Loro PA, Senni M, Lagioia R, Scrutinio D, Emdin M, Passino C, Parati G, Sinagra G, Correale M, Badagliacca R, Sciomer S, Di Lenarda A, Agostoni P, Filardi PP. What about chronotropic incompetence in heart failure with mildly reduced ejection fraction? Clinical and prognostic implications from the Metabolic Exercise combined with Cardiac and Kidney Indexes score dataset. Eur J Prev Cardiol 2024; 31:263-271. [PMID: 37890033 DOI: 10.1093/eurjpc/zwad338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
AIMS Chronotropic incompetence (CI) is a strong predictor of outcome in heart failure with reduced ejection fraction, however no data on its clinical and prognostic impacts in heart failure with mildly reduced ejection fraction (HFmrEF) are available. Therefore, the study aims to investigate, in a large multicentre HFmrEF cohort, the prevalence of CI as well as its relationship with exercise capacity and its prognostic role over the cardiopulmonary exercise testing (CPET) parameters. METHODS AND RESULTS Within the Metabolic Exercise combined with Cardiac and Kidney Indexes (MECKI) database, we analysed data of 864 HFmrEF out of 1164 stable outpatients who performed a maximal CPET at the cycle ergometer and who had no significant rhythm disorders or comorbidities. The primary study endpoint was cardiovascular (CV) death. All-cause death was also explored. Chronotropic incompetence prevalence differed depending on the method (peak heart rate, pHR% vs. pHR reserve, pHRR%) and the cut-off adopted (pHR% from ≤75% to ≤60% and pHRR% ≤ 65% to ≤50%), ranging from 11% to 62%. A total of 84 (9.7%) CV deaths were collected, with 39 (4.5%) occurring within 5 years. At multivariate analysis, both pHR% [hazard ratio 0.97 (0.95-0.99), P < 0.05] and pHRR% [hazard ratio 0.977 (0.961-0.993), P < 0.01] were associated with the primary endpoint. A pHR% ≤ 75% and a pHRR% ≤ 50% represented the most accurate cut-off values in predicting the outcome. CONCLUSION The study suggests an association between blunted exercise-HR response, functional capacity, and CV death risk among patients with HFmrEF. Whether the CI presence might be adopted in daily HFmrEF management needs to be addressed in larger prospective studies.
Collapse
Affiliation(s)
- Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Giovanna Gallo
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Massimo Piepoli
- Department of Biomedical Science for Health, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy, and Clinical Cardiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | | | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milano, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milano, Italy
| | - Emiliano Fiori
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Melwyn Luis Muthukkattil
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno Institute, Via Revislate 13, 28010 Veruno, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza del Mercato 15, 25121 Brescia, Italy
| | - Stefania Paolillo
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonello Maruotti
- Dipartimento di Giurisprudenza, Economia, Politica e Lingue Moderne, Libera Università Maria Ss Assunta, Via della Traspontina 21, 00193 Roma, Italy
| | - Pierfrancesco Alaimo Di Loro
- Dipartimento di Giurisprudenza, Economia, Politica e Lingue Moderne, Libera Università Maria Ss Assunta, Via della Traspontina 21, 00193 Roma, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Rocco Lagioia
- Division of Cardiology, 'S. Maugeri' Foundation, IRCCS, Institute of Cassano Murge, Via Generale Bellomo 73-75, 70124 Bari, Italy
| | - Domenico Scrutinio
- Division of Cardiology, 'S. Maugeri' Foundation, IRCCS, Institute of Cassano Murge, Via Generale Bellomo 73-75, 70124 Bari, Italy
| | - Michele Emdin
- Life Science Institute, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Claudio Passino
- Life Science Institute, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milano, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Via della Pietà 19, 34129 Trieste, Italy
| | - Michele Correale
- Department of Cardiology, University of Foggia, Via Antonio Gramsci 89, 71122 Foggia, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, 'Sapienza', Rome University, Via del Policlinico 155, 00161 Rome, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, 'Sapienza', Rome University, Via del Policlinico 155, 00161 Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority n°1 and University of Trieste, Via Slataper 9, 34134 Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Festa del Perdono 7, 20122 Milano, Italy
| | - Pasquale Perrone Filardi
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Via Leonardo Bianchi, 80131 Napoli, Italy
| |
Collapse
|
2
|
Anker SD, Usman MS, Anker MS, Butler J, Böhm M, Abraham WT, Adamo M, Chopra VK, Cicoira M, Cosentino F, Filippatos G, Jankowska EA, Lund LH, Moura B, Mullens W, Pieske B, Ponikowski P, Gonzalez-Juanatey JR, Rakisheva A, Savarese G, Seferovic P, Teerlink JR, Tschöpe C, Volterrani M, von Haehling S, Zhang J, Zhang Y, Bauersachs J, Landmesser U, Zieroth S, Tsioufis K, Bayes-Genis A, Chioncel O, Andreotti F, Agabiti-Rosei E, Merino JL, Metra M, Coats AJS, Rosano GMC. Patient phenotype profiling in heart failure with preserved ejection fraction to guide therapeutic decision making. A scientific statement of the Heart Failure Association, the European Heart Rhythm Association of the European Society of Cardiology, and the European Society of Hypertension. Eur J Heart Fail 2023; 25:936-955. [PMID: 37461163 DOI: 10.1002/ejhf.2894] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 07/26/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents a highly heterogeneous clinical syndrome affected in its development and progression by many comorbidities. The left ventricular diastolic dysfunction may be a manifestation of various combinations of cardiovascular, metabolic, pulmonary, renal, and geriatric conditions. Thus, in addition to treatment with sodium-glucose cotransporter 2 inhibitors in all patients, the most effective method of improving clinical outcomes may be therapy tailored to each patient's clinical profile. To better outline a phenotype-based approach for the treatment of HFpEF, in this joint position paper, the Heart Failure Association of the European Society of Cardiology, the European Heart Rhythm Association and the European Hypertension Society, have developed an algorithm to identify the most common HFpEF phenotypes and identify the evidence-based treatment strategy for each, while taking into account the complexities of multiple comorbidities and polypharmacy.
Collapse
Affiliation(s)
- Stefan D Anker
- Department of Cardiology, Deutsches Herzzentrum der Charité (Campus CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik fär Kardiologie, Angiologie und Intensivmedizin (Campus CBF), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Francesco Cosentino
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Moura
- Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal; Serviço de Cardiologia, Hospital das Forças Armadas-Pólo do Porto, Porto, Portugal
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk and Faculty of Medicine and Life Sciences, University Hasselt, Belgium
| | - Burkert Pieske
- Berlin-Brandenburgische Gesellschaft für Herz-Kreislauferkrankungen (BBGK), Berlin, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Cardiology Department, Wroclaw Medical University, Wroclaw, Poland
| | - Jose R Gonzalez-Juanatey
- Cardiology Department, Hospital Clínico Universitario, Santiago de Compostela, IDIS, CIBERCV, Santiago de Compostela, Spain
| | - Amina Rakisheva
- Department of Cardiology, Scientific Institution of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Petar Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade & Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - Carsten Tschöpe
- Department of Cardiology, Deutsches Herzzentrum der Charité (Campus CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine (CVK), Charité Universitätsmedizin, Berlin, Germany
| | - Maurizio Volterrani
- Cardio-Pulmonary Department, San Raffaele Open University of Rome; Exercise Science and Medicine, IRCCS San Raffaele - Rome, Italy
| | | | - Jian Zhang
- Fuwai Hospital Chinese Academic of Medical Science, Beijing, China
| | - Yuhui Zhang
- Fuwai Hospital Chinese Academic of Medical Science, Beijing, China
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ulf Landmesser
- Deutsches Herzzentrum der Charité, Klinik fär Kardiologie, Angiologie und Intensivmedizin (Campus CBF), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba Winnipeg, Winnipeg, Manitoba, Canada
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, CIBERCV, Barcelona, Spain
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Felicita Andreotti
- Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
- Catholic University Medical School, Rome, Italy
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Jose L Merino
- Department of Cardiology, La Paz University Hospital, IdiPaz, Universidad Autonoma, Madrid, Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe M C Rosano
- Cardio-Pulmonary Department, San Raffaele Open University of Rome; Exercise Science and Medicine, IRCCS San Raffaele - Rome, Italy
| |
Collapse
|
3
|
Wernhart S, Papathanasiou M, Rassaf T, Luedike P. The controversial role of beta-blockers in heart failure with preserved ejection fraction. Pharmacol Ther 2023; 243:108356. [PMID: 36750166 DOI: 10.1016/j.pharmthera.2023.108356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/07/2023]
Abstract
Beta-blocker (BB) therapy is a main pillar in treating patients with heart failure and reduced ejection fraction and has shown a prognostic benefit. However, evidence for application of BB in heart failure with preserved ejection fraction (HFpEF), especially in the absence of coronary artery disease, atrial fibrillation or arterial hypertension, is scarce. HFpEF is characterized by elevations in left atrial pressure and reduced compliance of the left ventricle leading to a hampered increase of cardiac output (CO) during exercise, which results in exertional dyspnea. This may be due to either a limited increase in stroke volume or reduced chronotropy during physical activity. We critically discuss the pathophysiological background of HFpEF, current data on BB in heart failure therapy, as well as the potential benefits and harms of BB therapy in HFpEF. Furthermore, we argue that non-cardio selective BB with peripheral activity to reduce afterload may be more suitable in this population than cardio-selective BB. Although preliminary data on BB in HFpEF are available, multicenter prospective trials to assess a reduction of cardiovascular morbidity are warranted. Future trials need to focus on phenotyping HFpEF patients and assess who may benefit most from tailored BB therapy.
Collapse
Affiliation(s)
- Simon Wernhart
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Maria Papathanasiou
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Tienush Rassaf
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Peter Luedike
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany.
| |
Collapse
|
4
|
Marston S, Pinto JR. Suppression of lusitropy as a disease mechanism in cardiomyopathies. Front Cardiovasc Med 2023; 9:1080965. [PMID: 36698941 PMCID: PMC9870330 DOI: 10.3389/fcvm.2022.1080965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
In cardiac muscle the action of adrenaline on β1 receptors of heart muscle cells is essential to adjust cardiac output to the body's needs. Adrenergic activation leads to enhanced contractility (inotropy), faster heart rate (chronotropy) and faster relaxation (lusitropy), mainly through activation of protein kinase A (PKA). Efficient enhancement of heart output under stress requires all of these responses to work together. Lusitropy is essential for shortening the heartbeat when heart rate increases. It therefore follows that, if the lusitropic response is not present, heart function under stress will be compromised. Current literature suggests that lusitropy is primarily achieved due to PKA phosphorylation of troponin I (TnI) and phospholamban (PLB). It has been well documented that PKA-induced phosphorylation of TnI releases Ca2+ from troponin C faster and increases the rate of cardiac muscle relaxation, while phosphorylation of PLB increases SERCA activity, speeding up Ca2+ removal from the cytoplasm. In this review we consider the current scientific evidences for the connection between suppression of lusitropy and cardiac dysfunction in the context of mutations in phospholamban and thin filament proteins that are associated with cardiomyopathies. We will discuss what advances have been made into understanding the physiological mechanism of lusitropy due to TnI and PLB phosphorylation and its suppression by mutations and we will evaluate the evidence whether lack of lusitropy is sufficient to cause cardiomyopathy, and under what circumstances, and consider the range of pathologies associated with loss of lusitropy. Finally, we will discuss whether suppressed lusitropy due to mutations in thin filament proteins can be therapeutically restored.
Collapse
Affiliation(s)
- Steven Marston
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jose Renato Pinto
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL, United States
| |
Collapse
|
5
|
Palau P, Domínguez E, Seller J, Sastre C, Sanchis J, López L, Bodí V, Llàcer P, Miñana G, Espriella RDELA, Bayés-Genís A, Núñez J. Chronotropic index and long-term outcomes in heart failure with preserved ejection fraction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022:S1885-5857(22)00211-0. [PMID: 36038124 DOI: 10.1016/j.rec.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Little is known about the usefulness of heart rate (HR) response to exercise for risk stratification in heart failure with preserved ejection fraction (HFpEF). Therefore, this study aimed to assess the association between HR response to exercise and the risk of total episodes of worsening heart failure (WHF) in symptomatic stable patients with HFpEF. METHODS This single-center study included 133 patients with HFpEF (NYHA II-III) who performed maximal cardiopulmonary exercise testing. HR response to exercise was evaluated using the chronotropic index (CIx) formula. A negative binomial regression method was used. RESULTS The mean age of the sample was 73.2± 10.5 years; 56.4% were female, and 51.1% were in atrial fibrillation. The median for CIx was 0.4 [0.3-0.55]. At a median follow-up of 2.4 [1.6-5.3] years, a total of 146 WHF events in 58 patients and 41 (30.8%) deaths were registered. In the whole sample, CIx was not associated with adverse outcomes (death, P=.319, and WHF events, P=.573). However, we found a differential effect across electrocardiographic rhythms for WHF events (P for interaction=.002). CIx was inversely and linearly associated with the risk of WHF events in patients with sinus rhythm and was positively and linearly associated with those with atrial fibrillation. CONCLUSIONS In patients with HFpEF, CIx was differentially associated with the risk of total WHF events across rhythm status. Lower CIx emerged as a risk factor for predicting higher risk in patients with sinus rhythm. In contrast, higher CIx identified a higher risk in those with atrial fibrillation.
Collapse
Affiliation(s)
- Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
| | - Eloy Domínguez
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Universitat Jaume I, Castellón, Spain.
| | - Julia Seller
- Servicio de Cardiología, Hospital de Denia, Denia, Alicante, Spain
| | - Clara Sastre
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Laura López
- Facultad de Fisioterapia. Universitat de València, Valencia, Spain
| | - Vicent Bodí
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Pau Llàcer
- Servicio de Medicina Interna, Hospital Ramón y Cajal, Madrid, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Rafael dE lA Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| |
Collapse
|
6
|
Formiga F, Chivite D, Nuñez J, Moreno García MC, Manzano L, Arévalo-Lorido JC, Cerqueiro JM, García Campos Á, Trullàs JC, Montero-Pérez-Barquero M. Beta-blocker use in patients with heart failure with preserved ejection fraction and sinus rhythm. Rev Port Cardiol 2022; 41:853-861. [DOI: 10.1016/j.repc.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022] Open
|
7
|
Kagami K, Obokata M, Harada T, Kato T, Wada N, Adachi T, Ishii H. Diastolic Filling Time, Chronotropic Response, and Exercise Capacity in Heart Failure and Preserved Ejection Fraction With Sinus Rhythm. J Am Heart Assoc 2022; 11:e026009. [PMID: 35766289 PMCID: PMC9333393 DOI: 10.1161/jaha.121.026009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Exercise‐induced high heart rate may impair exercise tolerance by reducing diastolic filling time and ventricular filling in heart failure with preserved ejection fraction (HFpEF). Given the importance of chronotropic response, we hypothesized that reduction in diastolic filling time because of exercise‐induced increased heart rate would not impair cardiac output reserve and exercise capacity. We sought to determine the association between heart rate, diastolic filling time, hemodynamics, and exercise capacity in HFpEF. Methods and Results Patients with HFpEF (n=66) and controls without HF (n=107) underwent bicycle exercise echocardiography with simultaneous expired gas analysis to measure oxygen consumption. Diastolic filling time was assessed by the overlap time between mitral E‐ and A‐waves (longer overlap time indicates shorter diastolic filling duration). Overlap time increased (ie, diastolic filling time shortened) in HFpEF and controls as heart rate increased with exercise, and the relationship was similar between the groups. Greater heart rate response correlated with higher cardiac output (r=0.51, P<0.0001) and oxygen consumption (r=0.50, P<0.0001) during peak exercise. Shorter diastolic filling time, as assessed by longer overlap time, was correlated with higher cardiac output (r=0.47, P<0.0001) and peak oxygen consumption (r=0.38, P=0.007), not with E/e′ or right ventricular‐pulmonary artery uncoupling. Longer overlap time was associated with mitral A velocity (r=0.53, P<0.0001) and left atrial booster pump strain (r=0.42, P<0.0001). Conclusions Shortening of diastolic filling interval in tandem with increased heart rate during exercise does not limit cardiac output reserve or exercise capacity in HFpEF.
Collapse
Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan.,Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| |
Collapse
|
8
|
Signaling cascades in the failing heart and emerging therapeutic strategies. Signal Transduct Target Ther 2022; 7:134. [PMID: 35461308 PMCID: PMC9035186 DOI: 10.1038/s41392-022-00972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic heart failure is the end stage of cardiac diseases. With a high prevalence and a high mortality rate worldwide, chronic heart failure is one of the heaviest health-related burdens. In addition to the standard neurohormonal blockade therapy, several medications have been developed for chronic heart failure treatment, but the population-wide improvement in chronic heart failure prognosis over time has been modest, and novel therapies are still needed. Mechanistic discovery and technical innovation are powerful driving forces for therapeutic development. On the one hand, the past decades have witnessed great progress in understanding the mechanism of chronic heart failure. It is now known that chronic heart failure is not only a matter involving cardiomyocytes. Instead, chronic heart failure involves numerous signaling pathways in noncardiomyocytes, including fibroblasts, immune cells, vascular cells, and lymphatic endothelial cells, and crosstalk among these cells. The complex regulatory network includes protein-protein, protein-RNA, and RNA-RNA interactions. These achievements in mechanistic studies provide novel insights for future therapeutic targets. On the other hand, with the development of modern biological techniques, targeting a protein pharmacologically is no longer the sole option for treating chronic heart failure. Gene therapy can directly manipulate the expression level of genes; gene editing techniques provide hope for curing hereditary cardiomyopathy; cell therapy aims to replace dysfunctional cardiomyocytes; and xenotransplantation may solve the problem of donor heart shortages. In this paper, we reviewed these two aspects in the field of failing heart signaling cascades and emerging therapeutic strategies based on modern biological techniques.
Collapse
|
9
|
Palau P, Seller J, Domínguez E, Sastre C, Ramón JM, de La Espriella R, Santas E, Miñana G, Bodí V, Sanchis J, Valle A, Chorro FJ, Llácer P, Bayés-Genís A, Núñez J. Effect of β-Blocker Withdrawal on Functional Capacity in Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2021; 78:2042-2056. [PMID: 34794685 DOI: 10.1016/j.jacc.2021.08.073] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronotropic incompetence has shown to be associated with a decrease in exercise capacity in heart failure with preserved ejection fraction (HFpEF), yet β-blockers are commonly used in HFpEF despite the lack of robust evidence. OBJECTIVES This study aimed to evaluate the effect of β-blocker withdrawal on peak oxygen consumption (peak Vo2) in patients with HFpEF and chronotropic incompetence. METHODS This is a multicenter, randomized, investigator-blinded, crossover clinical trial consisting of 2 treatment periods of 2 weeks separated by a washout period of 2 weeks. Patients with stable HFpEF, New York Heart Association functional classes II and III, previous treatment with β-blockers, and chronotropic incompetence were first randomized to withdrawing from (arm A: n = 26) versus continuing (arm B: n = 26) β-blocker treatment and were then crossed over to receive the opposite intervention. Changes in peak Vo2 and percentage of predicted peak Vo2 (peak Vo2%) measured at the end of the trial were the primary outcome measures. To account for the paired-data nature of this crossover trial, linear mixed regression analysis was used. RESULTS The mean age was 72.6 ± 13.1 years, and most of the patients were women (59.6%) in New York Heart Association functional class II (66.7%). The mean peakVo2 and peak Vo2% were 12.4 ± 2.9 mL/kg/min, and 72.4 ± 17.8%, respectively. No significant baseline differences were found across treatment arms. Peak Vo2 and peak Vo2% increased significantly after β-blocker withdrawal (14.3 vs 12.2 mL/kg/min [Δ +2.1 mL/kg/min]; P < 0.001 and 81.1 vs 69.4% [Δ +11.7%]; P < 0.001, respectively). CONCLUSIONS β-blocker withdrawal improved maximal functional capacity in patients with HFpEF and chronotropic incompetence. β-blocker use in HFpEF deserves profound re-evaluation. (β-blockers Withdrawal in Patients With HFpEF and Chronotropic Incompetence: Effect on Functional Capacity [PRESERVE-HR]; NCT03871803; 2017-005077-39).
Collapse
Affiliation(s)
- Patricia Palau
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Julia Seller
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | | | - Clara Sastre
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Jose María Ramón
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Rafael de La Espriella
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | - F Javier Chorro
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Pau Llácer
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Internal Medicine Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain.
| |
Collapse
|
10
|
Lin Y, Fu S, Yao Y, Li Y, Zhao Y, Luo L. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med 2021; 19:291. [PMID: 34229717 PMCID: PMC8259336 DOI: 10.1186/s12967-021-02935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a leading cause of hospitalizations and mortality when diagnosed at the age of ≥ 65 years. HFpEF represents multifactorial and multisystemic syndrome and has different pathophysiology and phenotypes. Its diagnosis is difficult to be established based on left ventricular ejection fraction and may benefit from individually tailored approaches, underlying age-related changes and frequent comorbidities. Compared with the rapid development in the treatment of heart failure with reduced ejection fraction, HFpEF presents a great challenge and needs to be addressed considering the failure of HF drugs to improve its outcomes. Further extensive studies on the relationships between HFpEF, aging, and comorbidities in carefully phenotyped HFpEF subgroups may help understand the biology, diagnosis, and treatment of HFpEF. The current review summarized the diagnostic and therapeutic development of HFpEF based on the complex relationships between aging, comorbidities, and HFpEF.
Collapse
Affiliation(s)
- Ying Lin
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Yao Yao
- Centre for the Study of Ageing and Human Development and Geriatrics Division, Medical School of Duke University, Durham, NC, 27708, USA
- Centre for Healthy Ageing and Development Studies, National School of Development, Peking University, Beijing, 100871, China
| | - Yulong Li
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
| | - Leiming Luo
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| |
Collapse
|
11
|
Mishra S, Kass DA. Cellular and molecular pathobiology of heart failure with preserved ejection fraction. Nat Rev Cardiol 2021; 18:400-423. [PMID: 33432192 PMCID: PMC8574228 DOI: 10.1038/s41569-020-00480-6] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/30/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure worldwide, is increasing in prevalence, confers substantial morbidity and mortality, and has very few effective treatments. HFpEF is arguably the greatest unmet medical need in cardiovascular disease. Although HFpEF was initially considered to be a haemodynamic disorder characterized by hypertension, cardiac hypertrophy and diastolic dysfunction, the pandemics of obesity and diabetes mellitus have modified the HFpEF syndrome, which is now recognized to be a multisystem disorder involving the heart, lungs, kidneys, skeletal muscle, adipose tissue, vascular system, and immune and inflammatory signalling. This multiorgan involvement makes HFpEF difficult to model in experimental animals because the condition is not simply cardiac hypertrophy and hypertension with abnormal myocardial relaxation. However, new animal models involving both haemodynamic and metabolic disease, and increasing efforts to examine human pathophysiology, are revealing new signalling pathways and potential therapeutic targets. In this Review, we discuss the cellular and molecular pathobiology of HFpEF, with the major focus being on mechanisms relevant to the heart, because most research has focused on this organ. We also highlight the involvement of other important organ systems, including the lungs, kidneys and skeletal muscle, efforts to characterize patients with the use of systemic biomarkers, and ongoing therapeutic efforts. Our objective is to provide a roadmap of the signalling pathways and mechanisms of HFpEF that are being characterized and which might lead to more patient-specific therapies and improved clinical outcomes.
Collapse
Affiliation(s)
- Sumita Mishra
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A. Kass
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,
| |
Collapse
|
12
|
Saw EL, Ramachandran S, Valero-Muñoz M, Sam F. Skeletal muscle (dys)function in heart failure with preserved ejection fraction. Curr Opin Cardiol 2021; 36:219-226. [PMID: 33394707 PMCID: PMC7895420 DOI: 10.1097/hco.0000000000000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Skeletal muscle dysfunction contributes to exercise intolerance, which manifests as dyspnea and fatiguability in patients with heart failure with preserved ejection fraction (HFpEF). This review aims to summarize the current understanding of skeletal muscle dysfunction in HFpEF. RECENT FINDINGS Animal and human studies in HFpEF provide insights into the pathophysiological alterations in skeletal muscle structure and function with the identification of several molecular mechanisms. Exercise training and novel pharmacological therapies that target skeletal muscle are proposed as therapeutic interventions to treat HFpEF. SUMMARY There is evidence that skeletal muscle dysfunction plays a pathophysiological role in HFpEF. However, precise mechanistic insights are needed to understand the contribution of skeletal muscle dysfunction in HFpEF.
Collapse
Affiliation(s)
- Eng Leng Saw
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Swetha Ramachandran
- Evans Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Maria Valero-Muñoz
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Flora Sam
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| |
Collapse
|
13
|
Smarz K, Tysarowski M, Zaborska B, Pilichowska-Paszkiet E, Sikora-Frac M, Budaj A, Jaxa-Chamiec T. Chronotropic Incompetence Limits Aerobic Exercise Capacity in Patients Taking Beta-Blockers: Real-Life Observation of Consecutive Patients. Healthcare (Basel) 2021; 9:healthcare9020212. [PMID: 33669448 PMCID: PMC7920432 DOI: 10.3390/healthcare9020212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/31/2021] [Accepted: 02/10/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Chronotropic incompetence in patients taking beta-blockers is associated with poor prognosis; however, its impact on exercise capacity (EC) remains unclear. Methods: We analyzed data from consecutive patients taking beta-blockers referred for cardiopulmonary exercise testing to assess EC. Chronotropic incompetence was defined as chronotropic index (CI) ≤ 62%. Results: Among 140 patients all taking beta-blockers (age 61 ± 9.7 years; 73% males), 64% with heart failure, chronotropic incompetence was present in 80.7%. EC assessed as peak oxygen uptake was lower in the group with chronotropic incompetence, 18.3 ± 5.7 vs. 24.0 ± 5.3 mL/kg/min, p < 0.001. EC correlated positively with CI (β = 0.14, p < 0.001) and male gender (β = 5.12, p < 0.001), and negatively with age (β = −0.17, p < 0.001) and presence of heart failure (β = −3.35, p < 0.001). Beta-blocker dose was not associated with EC. Partial correlation attributable to CI accounted for more than one-third of the variance in EC explained by the model (adjusted R2 = 59.8%). Conclusions: In patients taking beta-blockers, presence of chronotropic incompetence was associated with lower EC, regardless of the beta-blocker dose. CI accounted for more than one-third of EC variance explained by our model.
Collapse
Affiliation(s)
- Krzysztof Smarz
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
- Correspondence:
| | - Maciej Tysarowski
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, NJ 07103, USA
| | - Beata Zaborska
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
| | - Ewa Pilichowska-Paszkiet
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
| | - Małgorzata Sikora-Frac
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
| | - Andrzej Budaj
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
| | - Tomasz Jaxa-Chamiec
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland; (M.T.); (B.Z.); (E.P.-P.); (M.S.-F.); (A.B.); (T.J.-C.)
| |
Collapse
|
14
|
Abstract
Heart rate is a parameter that is very easy to measure and is widely used both in clinic and during daily life activities. Its value gained more relevance with the evidence, in prospective studies and meta-analysis, of association between elevated heart rate values and diseases and outcomes.The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows to identify the cut-off value of normalcy providing info for non-pharmacological and pharmacological treatments to reduce the cardiovascular risk both in general population and in pathophysiological conditions. This paper overviews the knowledges of the role of resting heart rate as predictor of cardiovascular risk.
Collapse
Affiliation(s)
- Gino Seravalle
- Department of Cardiology, Italian Auxological Institute S. Luca Hospital, Milan, Italy -
| | | | - Guido Grassi
- Department of Health Science, Milano-Bicocca University, Milan, Italy
| |
Collapse
|
15
|
Formiga F, Palau P, Nuñez J. [Beta-blockers in heart failure with preserved ejection fraction: Prescribe or deprescribe?]. Rev Esp Geriatr Gerontol 2020; 55:129-130. [PMID: 32164956 DOI: 10.1016/j.regg.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Francesc Formiga
- Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España.
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, España
| | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, España; Centro en Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| |
Collapse
|
16
|
Abstract
Heart rate is a parameter that is widely used by the general population as a marker of health. The availability of wearable electronic heart rate monitoring devices and use of specific apps are widely used both at rest and during daily life activities. Resting heart rate values gained more relevance with the evidence of association between elevated heart rate values at rest and diseases and adverse events. Also longitudinal studies demonstrated a clear association between increase in heart rate over time and cardiovascular and all-cause mortality. The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows identification of the cutoff value of normalcy. This information can be used to select non-pharmacological and pharmacological interventions to reduce the cardiovascular risk both in the general population and in patients with pathophysiological conditions. This review provides an overview of the current knowledge of resting heart rate as cardiovascular risk factor.
Collapse
Affiliation(s)
- Gino Seravalle
- Cardiology Department, S. Luca Hospital, Istituto Auxologico Italiano IRCCS , Milan, Italy
| | - Guido Grassi
- Clinica Medica, S. Gerardo Hospital, University Milano-Bicocca , Monza, Italy
| |
Collapse
|
17
|
Palau P, Seller J, Domínguez E, Gómez I, Ramón JM, Sastre C, de la Espriella R, Santas E, Miñana G, Chorro FJ, González-Juanatey JR, Núñez J. Beta-blockers withdrawal in patients with heart failure with preserved ejection fraction and chronotropic incompetence: Effect on functional capacity rationale and study design of a prospective, randomized, controlled trial (The Preserve-HR trial). Clin Cardiol 2020; 43:423-429. [PMID: 32073676 PMCID: PMC7244302 DOI: 10.1002/clc.23345] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is complex and multifactorial. Chronotropic incompetence (ChI) has emerged as a crucial pathophysiological mechanism. Beta‐blockers, drugs with negative chronotropic effects, are commonly used in HFpEF, although current evidence does not support its routine use in these patients. Hypothesis We postulate beta‐blockers may have deleterious effects in HFpEF and ChI. This work aims to evaluate the short‐term effect of beta‐blockers withdrawal on functional capacity assessed by the maximal oxygen uptake (peakVO2) in patients with HFpEF and ChI. Methods This is a prospective, crossover, randomized (1:1) and multicenter study. After randomization, the clinical and cardiac rhythm will be continuously registered for 30 days. PeakVO2 is assessed by cardiopulmonary exercise testing (CPET) at 15 and 30 days in both groups. Secondary endpoints include quality of life, cognitive, and safety assessment. Patients with stable HFpEF, functional class New York Heart Association (NYHA) II‐III, chronic treatment with beta‐blockers, and ChI will be enrolled. A sample size estimation [alfa: 0.05, power: 90%, a 20% loss rate, and delta change of mean peakVO2: +1.2 mL/kg/min (SD ± 2.0)] of 52 patients is necessary to test our hypothesis. Results Patients started enrolling in October 2018. As January 14th, 2020, 28 patients have been enrolled. It is projected to enroll the last patient at the end of July 2020. Conclusions Optimizing therapy that improves functional capacity remains an unmeet priority in HFpEF. Deprescribing beta‐blockers in patients with HFpEF and ChI seems a plausible intervention to improve functional capacity. This trial is an attempt towards precision medicine in this complex syndrome. Trial registration http://clinicaltrials.gov: NCT03871803.
Collapse
Affiliation(s)
| | - Julia Seller
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | | | - Inés Gómez
- Cardiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.,CIBERCV, Madrid, Spain
| | - José María Ramón
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - Clara Sastre
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | | | - Enrique Santas
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - Gema Miñana
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - Francisco J Chorro
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - José Ramón González-Juanatey
- Cardiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.,CIBERCV, Madrid, Spain
| | - Julio Núñez
- CIBERCV, Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| |
Collapse
|
18
|
Packer M. Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment. Eur J Heart Fail 2019; 22:214-227. [PMID: 31849132 DOI: 10.1002/ejhf.1646] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023] Open
Abstract
Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College London, London, UK
| |
Collapse
|
19
|
Tomasoni D, Adamo M, Lombardi CM, Metra M. Highlights in heart failure. ESC Heart Fail 2019; 6:1105-1127. [PMID: 31997538 PMCID: PMC6989277 DOI: 10.1002/ehf2.12555] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.
Collapse
Affiliation(s)
- Daniela Tomasoni
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Carlo Mario Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| |
Collapse
|
20
|
Packer M. Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re-evaluation. J Cardiovasc Electrophysiol 2019; 30:3020-3024. [PMID: 31626365 DOI: 10.1111/jce.14236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/19/2019] [Accepted: 10/09/2019] [Indexed: 01/03/2023]
Abstract
Atrial fibrillation (AF) is common in patients with obesity and diabetes; the arrhythmia (if long-standing) is typically managed by rate control and anticoagulation. However, the coexistence of these two metabolic disorders complicates therapeutic options for rate control. The likely pathogenesis of AF in these patients is an expansion of epicardial adipose tissue whose inflammation is transmitted to the left atrium causing electromechanical remodeling. However, this same process is also transmitted to the left ventricle (LV), impairing its distensibility and its ability to tolerate volume, leading to heart failure with preserved ejection fraction. Unfortunately, the latter diagnosis (although commonly present in patients with AF and a coexistent metabolic disorder) is often ignored. To achieve rate control, physicians prescribe intensive treatment with atrioventricular (AV) nodal-blocking drugs, often at doses that are titrated to blunt exercise as well as resting heart rate responses. However, strict rate control (target rate, <80/min) is associated with somewhat worse outcomes than lenient rate control (target rate, <110/min). Furthermore, any rate slowing that facilitates diastolic filling may aggravate filling pressures that are already disproportionately increased because the LV is stiff and overfilled as a result of cardiac inflammation. Rate slowing in AF with beta blockers may not achieve the benefit expected from the blockade of adrenergically mediated cardiotoxicity, and some AV nodal-blocking drugs (digoxin and dronedarone) can increase the risk of death in patients with AF. Finally, cardiac fibrosis in obesity and diabetes may affect the conduction system, which can predispose to serious bradyarrhythmias if patients are prescribed AV nodal-blocking drugs.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.,Imperial College London, London, United Kingdom
| |
Collapse
|
21
|
Nemoto S, Kasahara Y, Izawa KP, Watanabe S, Yoshizawa K, Takeichi N, Kamiya K, Suzuki N, Omiya K, Matsunaga A, Akashi YJ. Effects of αβ-Blocker Versus β1-Blocker Treatment on Heart Rate Response During Incremental Cardiopulmonary Exercise in Japanese Male Patients with Subacute Myocardial Infarction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2838. [PMID: 31398919 PMCID: PMC6720421 DOI: 10.3390/ijerph16162838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 11/17/2022]
Abstract
A simplified substitute for heart rate (HR) at the anaerobic threshold (AT), i.e., resting HR plus 30 beats per minute or a percentage of predicted maximum HR, is used as a way to determine exercise intensity without cardiopulmonary exercise testing (CPX) data. However, difficulties arise when using this method in subacute myocardial infarction (MI) patients undergoing beta-blocker therapy. This study compared the effects of αβ-blocker and β1-blocker treatment to clarify how different beta blockers affect HR response during incremental exercise. MI patients were divided into αβ-blocker (n = 67), β1-blocker (n = 17), and no-β-blocker (n = 47) groups. All patients underwent CPX one month after MI onset. The metabolic chronotropic relationship (MCR) was calculated as an indicator of HR response from the ratio of estimated HR to measured HR at AT (MCR-AT) and peak exercise (MCR-peak). MCR-AT and MCR-peak were significantly higher in the αβ-blocker group than in the β1-blocker group (p < 0.001, respectively). Multiple regression analysis revealed that β1-blocker but not αβ-blocker treatment significantly predicted lower MCR-AT and MCR-peak (β = -0.432, p < 0.001; β = -0.473, p < 0.001, respectively). Based on these results, when using the simplified method, exercise intensity should be prescribed according to the type of beta blocker used.
Collapse
Affiliation(s)
- Shinji Nemoto
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama 241-0811 Japan.
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara 252-0373, Japan.
| | - Yusuke Kasahara
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama 241-0811 Japan
| | - Kazuhiro P Izawa
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan
| | - Satoshi Watanabe
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki 216-8511, Japan
| | - Kazuya Yoshizawa
- Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
| | - Naoya Takeichi
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki 216-8511, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara 252-0373, Japan
| | - Norio Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Kazuto Omiya
- Department of Internal Medicine, Shimazu Medical Clinic, Yokohama 226-0026, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara 252-0373, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine Hospital, Kawasaki 216-8511, Japan
| |
Collapse
|
22
|
Domínguez E, Palau P, Núñez E, Ramón JM, López L, Melero J, Bellver A, Santas E, Chorro FJ, Núñez J. Heart rate response and functional capacity in patients with chronic heart failure with preserved ejection fraction. ESC Heart Fail 2018; 5:579-585. [PMID: 29573575 PMCID: PMC6073018 DOI: 10.1002/ehf2.12281] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/05/2018] [Indexed: 12/23/2022] Open
Abstract
Aims The mechanisms of exercise intolerance in heart failure with preserved ejection fraction (HFpEF) are not yet elucidated. Chronotropic incompetence has emerged as a potential mechanism. We aimed to evaluate whether heart rate (HR) response to exercise is associated to functional capacity in patients with symptomatic HFpEF. Methods and results We prospectively studied 74 HFpEF patients [35.1% New York Heart Association Class III, 53% female, age (mean ± standard deviation) 72.5 ± 9.1 years, and 59.5% atrial fibrillation]. Functional performance was assessed by peak oxygen consumption (peak VO2). The mean (standard deviation) peak VO2 was 10 ± 2.8 mL/min/kg. The following chronotropic parameters were calculated: Delta‐HR (HR at peak exercise − HR at rest), chronotropic index (CI) = (HR at peak exercise − resting HR)/[(220 − age) − resting HR], and CI according to the equation developed by Keteyian et al. (CIK) (HR at peak exercise − HR at rest)/[119 + (HR at rest/2) − (age/2) − 5 − HR at rest]. In a bivariate setting, peak VO2 was positively and significantly correlated with Delta‐HR (r = 0.35, P = 0.003), CI (r = 0.27, P = 0.022), CIK (r = 0.28, P = 0.018), and borderline with HR at peak exercise (r = 0.22, P = 0.055). In a multivariable linear regression analysis that included clinical, analytical, echocardiographic, and functional capacity covariates, the chronotropic parameters were positively associated with peak VO2. We found a linear relationship between Delta‐HR and peak VO2 (β coefficient of 0.03; 95% confidence interval: 0.004–0.05; P = 0.030); conversely, the association among CIs and peak VO2 was exponentially shaped. Conclusions In patients with chronic HFpEF, the HR response to exercise was positively associated to patient's functional capacity.
Collapse
Affiliation(s)
- Eloy Domínguez
- Cardiology Department, Hospital General Universitari de Castelló, Universitat Jaume I, Castellón, Spain
| | - Patricia Palau
- Cardiology Department, Hospital General Universitari de Castelló, Universitat Jaume I, Castellón, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Spain
| | - José María Ramón
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Spain
| | - Laura López
- Facultat de Fisioteràpia, Universitat de València, Valencia, Spain
| | - Joana Melero
- Cardiology Department, Hospital General Universitari de Castelló, Universitat Jaume I, Castellón, Spain
| | - Alejandro Bellver
- Cardiology Department, Hospital General Universitari de Castelló, Universitat Jaume I, Castellón, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Spain
| | - Francisco J Chorro
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Spain
| |
Collapse
|