C-reactive protein predicts mortality in patients referred for coronary angiography and symptoms of heart failure with preserved ejection fraction

Impact of Acute Antioxidant and Tetrahydrobiopterin (BH4) Administration on Locomotor Muscle Microvascular Function in Patients With Heart Failure

BACKGROUND

Peripheral microvascular dysfunction is a hallmark feature of both heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) pathophysiology, due partly to impairments in nitric oxide signaling secondary to tetrahydrobiopterin (BH4) deficiency and oxidative stress.

METHODS

Using a randomized, double-blind, placebo-controlled crossover design, this study examined the impact of enteral BH4 (10 mg/kg), an antioxidant cocktail (AOx), and coadministration of these 2 agents (BH4+AOx) on microvascular function in patients with HFrEF (n=14, 64±10 years) and HFpEF (n=19, 74±9 years). Passive limb movement was utilized to assess locomotor muscle microvascular function, and biomarkers of inflammation and oxidative damage were measured.

RESULTS

Compared with placebo, the peak change in leg blood flow was not statistically different after AOx administration (HFrEF, P=0.60; HFpEF, P=0.61), but improved following BH4 (P=0.033) and BH4+AOx (P=0.019) in both HFrEF (placebo: 234±31; BH4: 357±45; BH4+AOx: 355±49 mL/min) and HFpEF (placebo: 269±33; BH4: 367±47; BH4+AOx: 394±65 mL/min). The total hyperemic response to passive limb movement (leg blood flow area under the curve) was not statistically different across treatments in patients with HFrEF (P=0.29), but increased following BH4 (P=0.016) and BH4+AOx (P=0.040) in the HFpEF group. CRP (C-reactive protein) was lower following BH4 (P=0.007) and BH4+AOx (P=0.007) in HFpEF (placebo: 4268±547; BH4: 2721±391; BH4+AOx: 2779±376 ng/mL), but was not statistically different in HFrEF (P=0.39).

CONCLUSIONS

Together, these results provide new evidence for the efficacy of acute BH4 administration to improve some aspects of locomotor muscle microvascular function in patients with HFrEF and HFpEF, with no apparent benefit of AOx administration, alone or in combination with BH4, in either group. These findings lend further conceptual support for the nitric oxide pathway as a modifiable target in the treatment of heart failure.

Relationship between the HDL-C/CRP ratio and all-cause mortality in patients with chronic heart failure: a retrospective analysis from Yunnan Province, China

OBJECTIVE

To clarify whether the high-density lipoprotein cholesterol/C reactive protein (HDL-C/CRP) ratio can be used as a new prognosticator of all-cause mortality in patients with chronic heart failure (CHF) (New York Heart Association (NYHA) cardiac class III/IV).

DESIGN

Retrospective study.

BACKGROUND

Several papers have revealed that HDL-C and CRP can act as anti-inflammatory and pro-inflammatory factors, respectively, to affect disease progression in patients with heart failure, and the balance of the two has been shown to affect the prognosis of patients with heart failure with preserved ejection fraction (HFpEF), but none of the above studies involved patients with the more severe forms of heart failure with mildly reduced ejection fraction and heart failure with reduced ejection fraction; therefore, the present study is to extend the balance of HDL-C and CRP to the whole range of types of patients CHF to further confirm its importance.

SETTING

This study is from a single centre in Yunnan Province, China.

PARTICIPANTS

After excluding ineligible patients, we finally included 1192 patients with CHF from January 2017 to October 2021.

PRIMARY AND SECONDARY MEASURES

The primary outcome was all-cause mortality in patients with CHF between January 2017 and October 2021. No secondary outcome measures were performed.

RESULTS

All patients were divided into four groups according to the quartiles of the HDL-C/CRP ratio. Using the Kaplan-Meier analysis, the risk of all-cause mortality was always the highest for Q1 (HDL-C/CRP<0.395) and the lowest for group Q4 (HDL-C/CRP≥3.4163). Cox univariate and multivariate regression analyses showed that HDL-C/CRP was consistently an independent risk factor for death from CHF. Based on the receiver operating characteristic curve, the area under the curve for HDL-C/CRP was 0.7254 (p<0.001), with a sensitivity of 65.5% and a specificity of 69.6%.

CONCLUSIONS

The HDL-C/CRP ratio is an independent prognostic indicator of all-cause mortality in patients with CHF in NYHA cardiac function class III/IV, which has good specificity and sensitivity. Patients with lower levels of the HDL-C/CRP ratio are at a greater risk of death than patients with higher levels of the HDL-C/CRP ratio.

Comparison of clinical characteristics and prognostic factors in patients with heart failure with preserved ejection fraction with and without renal dysfunction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) with renal dysfunction (RD) is considered to be a specific phenotype of HFpEF. This study aimed to compare the clinical characteristics and prognostic factors for in-hospital mortality between HFpEF-diagnosed patients with and without RD.

METHODS

This multicenter retrospective study included 5867 consecutive patients with acute HFpEF. RD was defined by an estimated glomerular filtration rate (eGFR) of <60 mL/min per 1.73 m2. Kaplan-Meier survival curves and log-rank tests were used to compare the in-hospital mortality between the groups. Univariable and multivariable Cox regression analyses were performed to identify significant prognostic factors.

RESULTS

Across the study cohort, 68% of patients had RD. In-hospital mortality was significantly higher in HFpEF patients with RD than in those without RD. The comorbidities and laboratory data differed significantly between the groups. Independent prognostic factors for in-hospital mortality in the HFpEF patients with RD were age (hazard ratio [HR], 1.039), systolic blood pressure (HR, 0.991), eGFR (HR, 0.981), C-reactive protein (CRP; HR, 1.028), diuretics (HR, 0.374), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE-I/ARBs; HR, 0.680), and beta-blockers (HR, 0.662). In HFpEF patients without RD, age (HR, 1.039), systolic blood pressure (HR, 0.979), and ACE-I/ARBs (HR, 0.373) were independent prognostic factors.

CONCLUSIONS

Significant differences in the clinical characteristics and prognostic factors, such as CRP and beta-blockers, were observed between the HFpEF patients with and without RD. These results have implications for future research and may help guide individualized patient management strategies.

IL-6 and hsCRP predict cardiovascular mortality in patients with heart failure with preserved ejection fraction

AIMS

Inflammation accompanies heart failure (HF) and elevated levels of inflammatory biomarkers are linked to new onset of HF. However, whether the prognostic relevance of inflammatory biomarkers is different in HF with reduced (HFrEF) and preserved ejection fraction (HFpEF) is unclear. The aim of the current study is to explore the role of inflammation on the mortality risk in patients with HF.

METHODS

We analysed interleukin-6 and hsCRP levels by ELISA and immunonephelometry, respectively, in HFpEF and HFrEF patients referred for coronary angiography and assessed the prognostic value in the Ludwigshafen Risk and Cardiovascular Health (LURIC) study.

RESULTS

HF was present in 1086 patients (N = 506 HFpEF; N = 580 HFrEF; mean age 65 ± 10 years; 28% female). Increasing IL-6 levels were significantly associated with increased CV mortality in HFpEF [1.5 (95% CI: 1.1-2.2), P = 0.018] but not HFrEF [HR 1.3 (95% CI: 1.0-1.7), P = 0.06] patients. High-sensitive CRP followed a similar pattern but failed to reach statistical significance after full-adjustment (HFpEF: HR 1.4 95%C I: 1.0-2.0; P = 0.065; HFrEF HR: 1.0 95% CI: 0.7-1.3; P = 0.800). Interaction analysis in patients stratified by IL-6 and N terminal pro brain natriuretic peptide (NT-proBNP) above and below the median revealed a stepwise increase in CV-mortality in HFpEF (P = 0.036) but not HFrEF patients (P = 0.220). To investigate the relationship between IL-6 and NT-proBNP, we assessed the genetic IL6-Receptor variant p.Asp358Ala (rs2228145) which is linked to impaired IL-6 receptor signalling. Homozygous carriers with HFpEF but not HFrEF exhibited significantly lower NT-pro-BNP levels compared with wildtype carriers (HFpEF 779 pg/mL ± 787 vs. 1180 pg/ mL ± 1532; P = 0.008; HFrEF 2289 pg/ mL ± 3439 vs. 2326 pg/ mL ± 3386; P = 0.94), raising the hypothesis that IL-6 signalling may play a pathophysiological role in HFpEF.

CONCLUSIONS

These data suggest a predictive value of elevated IL-6 for CV-mortality in HFpEF but not in HFrEF patients.

Prognostic value of preoperative high-sensitivity C-reactive protein to albumin ratio in patients with dilated cardiomyopathy receiving pacemaker therapy: A retrospective two-center study in China

Background

Despite receiving pacemaker therapy, patients with heart failure with reduced ejection fraction (HFrEF) due to dilated cardiomyopathy (DCM) remain at an increased risk of adverse cardiovascular events. The high-sensitivity C-reactive protein (hs-CRP)-to-albumin ratio (CAR) is a novel indicator. This study aimed to assess the prognostic value of preoperative CAR in this population.

Methods

Patients with DCM who underwent cardiac resynchronization therapy (CRT) or implantable cardiac defibrillator (ICD) implantation for HFrEF between 2018 and 2023 were involved. The primary endpoint was major adverse cardiac events (MACE). Cox regression models were used to investigate predictors for MACE. Receiver operating characteristic (ROC) curve analysis was utilized to evaluate the diagnostic efficacy and identify the optimal cutoff point.

Results

We enrolled 250 patients, of whom 78 experienced MACE. Patients who experienced MACE had a significantly higher CAR than those without MACE (p < 0.001). Multivariate Cox regression analysis indicated CAR as an independent predictor for MACE (hazard ratio = 4.301, 95 % confidence interval [CI] 1.833-10.091, p < 0.001). ROC curve analysis demonstrated the discriminatory ability of CAR in predicting MACE (area under the curve [AUC] = 0.732, 95 % CI 0.666-0.792, p < 0.001), with an optimal threshold of 0.08. Furthermore, the incidence of MACE was significantly higher in the high-CAR (> 0.08) group compared to the low-CAR (≤ 0.08) group (48.8 % vs. 13.6 %, p < 0.001).

Conclusion

Among patients with DCM and HFrEF treated with CRT or ICD, CAR can serve as an independent risk predictor, with higher levels associated with poorer outcomes.

Combination of C-reactive protein and fibrinogen-to-albumin ratio as a novel predictor of all-cause mortality in heart failure patients

Heart failure (HF) is a common cardiovascular disease that is related to systemic inflammation. This study aimed to assess the role of C-reactive protein (CRP) combined with fibrinogen-to-albumin ratio (C-FAR) on the prognosis of all-cause mortality in different types of HF. A total of 1,221 hospitalized HF patients from the First Affiliated Hospital of Kunming Medical University between January 2017 and October 2021 were retrospectively analyzed. Patients were categorized into a low C-FAR group (C-FAR < 0.69) and a high C-FAR group (C-FAR ≥ 0.69) according to the median C-FAR value. We used Kaplan-Meier plots, restricted cubic spline regression, Cox survival analyses, and time-dependent receiver operating characteristic (ROC) analyses to evaluate the prognostic role of C-FAR on all-cause mortality in different types of HF. After excluding patients lost to follow-up and those with missing data, we ultimately included 1,196 patients with HF. The Kaplan-Meier plots showed that HF patients with high C-FAR levels had a significantly greater risk of all-cause mortality. In all four Cox proportional risk models, C-FAR was an independent predictor of all-cause mortality. Based on the ROC curve, the area under the curve (AUC) for C-FAR was greater than the AUC for Lg BNP. In the subgroup analyses, patients had the highest risk of all-cause mortality when FAR ≥ 0.091 and CRP ≥ 7.470. Regardless of the type of HF, C-FAR can be a good predictor of prognosis for all-cause mortality in HF patients, and patients with high C-FAR had a significantly increased risk of death compared to those with low C-FAR.

Biomarkers in Heart Failure with Preserved Ejection Fraction: A Perpetually Evolving Frontier

Heart failure with preserved ejection fraction (HFpEF) represents a complex clinical syndrome, often very difficult to diagnose using the available tools. As the global burden of this disease is constantly growing, surpassing the prevalence of heart failure with reduced ejection fraction, during the last few years, efforts have focused on optimizing the diagnostic and prognostic pathways using an immense panel of circulating biomarkers. After the paradigm of HFpEF development emerged more than 10 years ago, suggesting the impact of multiple comorbidities on myocardial structure and function, several phenotypes of HFpEF have been characterized, with an attempt to find an ideal biomarker for each distinct pathophysiological pathway. Acknowledging the limitations of natriuretic peptides, hundreds of potential biomarkers have been evaluated, some of them demonstrating encouraging results. Among these, soluble suppression of tumorigenesis-2 reflecting myocardial remodeling, growth differentiation factor 15 as a marker of inflammation and albuminuria as a result of kidney dysfunction or, more recently, several circulating microRNAs have proved their incremental value. As the number of emerging biomarkers in HFpEF is rapidly expanding, in this review, we aim to explore the most promising available biomarkers linked to key pathophysiological mechanisms in HFpEF, outlining their utility for diagnosis, risk stratification and population screening, as well as their limitations.

Increased Tryptophan Catabolism Provides Predictive Value to Chronic Heart Failure Patients with Low-Grade Inflammation

Kynurenine to tryptophan ratio (KTR), which serves as an indicator for evaluating indoleamine-2,3-dioxygenase activity and inflammation, has been reported to be linked with cardiovascular incidences. However, its correlation with cardiovascular outcomes in patients suffering from heart failure (HF) remains to be explored. The objective of this study was to investigate the prognostic value of KTR in HF. The concentration of tryptophan and kynurenine were quantified by liquid chromatography-tandem mass spectrometry, and the KTR value was calculated in a population of 3150 HF patients. The correlation between plasma KTR levels and the occurrence of adverse cardiovascular events was evaluated for its prognostic value. We also assessed the role of KTR in addition to the classic inflammatory biomarker hypersensitive C-reactive protein (hs-CRP) in different subtypes of HF. We found that increased KTR levels were associated with an elevated risk and severity of the primary endpoints in different subtypes of HF. The simultaneous evaluation of KTR and hs-CRP levels enhanced risk categorization among HF patients. Furthermore, the KTR index presented complementary prognostic value for those HF patients with low-grade inflammation (hs-CRP ≤ 6 mg/L). Our results indicated plasma KTR is an independent risk factor for cardiovascular events. Plasma KTR levels in patients with HF can provide both concurrent and complementary prognostic value to hs-CRP.

Interrelationship between Altered Left Ventricular Ejection Fraction and Nutritional Status in the Post-Acute Myocardial Infarction Patient

There is currently little research on the effects of reduced left ventricular ejection fraction and altered nutritional status in patients with acute myocardial infarction. We therefore examined the interrelationship between the parameters of left ventricular dysfunction after acute myocardial infarction and changes in the Geriatric Nutrition Risk Index (GNRI) and the Nutrition Status Control Index (CONUT). Based on the evidence, frailty is considered to be an important factor affecting the prognosis of cardiovascular disease, so it is important to detect malnutrition early to prevent adverse cardiovascular events. This study was an observational, prospective study that included a total of 73 subjects who presented at the 3-month AMI follow-up. All subjects were subjected to laboratory tests and the groups were divided as follows: group 1, in which we calculated the CONUT score, (CONUT < 3 points, n = 57) patients with normal nutritional status and patients with moderate to severe nutritional deficiency (CONUT ≥ 3, n = 16). In group 2, the GNRI score was calculated and out of the 73 patients we had: GNRI ≥ 98, n = 50, patients with normal nutritional status, and GNRI < 98, n = 23, patients with altered nutritional status. The results of this study showed that we had significant differences between LVEF values at 3 months post-infarction where, in the CONUT group, patients with altered nutritional status had lower LVEF values (46.63 ± 3.27% versus 42.94 ± 2.54%, p < 0.001) compared to CONUT < 3. Also, in the GNRI group, we had lower LVEF values in patients with impaired nutritional status (46.48 ± 3.35% versus 44.39 ± 3.35%, p = 0.01). It can be seen that LVEF values are improved at 3 months post infarction in both groups, in patients with impaired nutritional status and in patients with good nutritional status. Patients with impaired nutritional status have lower ejection fraction and worse outcomes in both the CONUT and GNRI groups at 3 months post acute myocardial infarction.

The Simplified Thrombo-Inflammatory Score as a Novel Predictor of All-Cause Mortality in Patients with Heart Failure: A Retrospective Cohort Study

Background

The simplified thrombo-inflammatory score (sTIPS) has recently emerged as a novel prognostic score. Hence, we investigated the prognostic value of sTIPS for predicting long-term mortality in patients with heart failure (HF).

Methods

A total of 3741 patients were analyzed in this study. The sTIPS was calculated based on the white blood cell count (WBC) and the mean platelet volume to platelet count (MPV/PC) ratio at admission. The mean follow-up time was 22.75 months. Multivariable Cox regression analyses were used to investigate the associations between the sTIPS and all-cause mortality (ACM).

Results

In the whole study population, multivariate Cox regression analysis showed that patients in both the sTIPS 2 and sTIPS 1 groups had significantly increased risk of ACM as compared with patients in the sTIPS 0 group (hazard ratio [HR]=1.706, 95% confidence interval [CI]: 1.405-2.072, P<0.001 and HR = 1.431, 95% CI 1.270-1.612, P<0.001). The same significant trend was observed in heart failure with preserved ejection fraction (HFpEF) patients (sTIPS1 vs sTIPS0: HR = 1.366, 95% CI 1.100-1.697, P = 0.005; sTIPS2 vs sTIPS0: HR = 1.995, 95% CI 1.460-2.725, P<0.001). However, only sTIPS 1 group had a significantly increased the risk of ACM compared to the sTIPS 0 group among patients with HFmrEF (sTIPS1 vs sTIPS0: HR = 1.648, 95% CI 1.238-2.194, P = 0.001) and HFrEF (sTIPS1 vs sTIPS0: HR = 1.322, 95% CI 1.021-1.712, P = 0.035).

Conclusion

sTIPS is useful in predicting risk for long-term mortality in patients with HF.

Analysis of type 2 diabetes heterogeneity with a tree-like representation: insights from the prospective German Diabetes Study and the LURIC cohort

BACKGROUND

Heterogeneity in type 2 diabetes can be represented by a tree-like graph structure by use of reversed graph-embedded dimensionality reduction. We aimed to examine whether this approach can be used to stratify key pathophysiological components and diabetes-related complications during longitudinal follow-up of individuals with recent-onset type 2 diabetes.

METHODS

For this cohort analysis, 927 participants aged 18-69 years from the German Diabetes Study (GDS) with recent-onset type 2 diabetes were mapped onto a previously developed two-dimensional tree based on nine simple clinical and laboratory variables, residualised for age and sex. Insulin sensitivity was assessed by a hyperinsulinaemic-euglycaemic clamp, insulin secretion was assessed by intravenous glucose tolerance test, hepatic lipid content was assessed by 1 H magnetic resonance spectroscopy, serum interleukin (IL)-6 and IL-18 were assessed by ELISA, and peripheral and autonomic neuropathy were assessed by functional and clinical measures. Participants were followed up for up to 16 years. We also investigated heart failure and all-cause mortality in 794 individuals with type 2 diabetes undergoing invasive coronary diagnostics from the Ludwigshafen Risk and Cardiovascular Health (LURIC) cohort.

FINDINGS

There were gradients of clamp-measured insulin sensitivity (both dimensions: p<0·0001) and insulin secretion (pdim1<0·0001, pdim2=0·00097) across the tree. Individuals in the region with the lowest insulin sensitivity had the highest hepatic lipid content (n=205, pdim1<0·0001, pdim2=0·037), pro-inflammatory biomarkers (IL-6: n=348, pdim1<0·0001, pdim2=0·013; IL-18: n=350, pdim1<0·0001, pdim2=0·38), and elevated cardiovascular risk (nevents=143, pdim1=0·14, pdim2<0·00081), whereas individuals positioned in the branch with the lowest insulin secretion were more prone to require insulin therapy (nevents=85, pdim1=0·032, pdim2=0·12) and had the highest risk of diabetic sensorimotor polyneuropathy (nevents=184, pdim1=0·012, pdim2=0·044) and cardiac autonomic neuropathy (nevents=118, pdim1=0·0094, pdim2=0·06). In the LURIC cohort, all-cause mortality was highest in the tree branch showing insulin resistance (nevents=488, pdim1=0·12, pdim2=0·0032). Significant gradients differentiated individuals having heart failure with preserved ejection fraction from those who had heart failure with reduced ejection fraction.

INTERPRETATION

These data define the pathophysiological underpinnings of the tree structure, which has the potential to stratify diabetes-related complications on the basis of routinely available variables and thereby expand the toolbox of precision diabetes diagnosis.

FUNDING

German Diabetes Center, German Federal Ministry of Health, Ministry of Culture and Science of the state of North Rhine-Westphalia, German Federal Ministry of Education and Research, German Diabetes Association, German Center for Diabetes Research, European Community, German Research Foundation, and Schmutzler Stiftung.

Inflammation in Heart Failure-Future Perspectives

Chronic heart failure is a terminal point of a vast majority of cardiac or extracardiac causes affecting around 1-2% of the global population and more than 10% of the people above the age of 65. Inflammation is persistently associated with chronic diseases, contributing in many cases to the progression of disease. Even in a low inflammatory state, past studies raised the question of whether inflammation is a constant condition, or if it is, rather, triggered in different amounts, according to the phenotype of heart failure. By evaluating the results of clinical studies which focused on proinflammatory cytokines, this review aims to identify the ones that are independent risk factors for heart failure decompensation or cardiovascular death. This review assessed the current evidence concerning the inflammatory activation cascade, but also future possible targets for inflammatory response modulation, which can further impact the course of heart failure.

The GLVC scoring system: a single-center model for predicting survival and hospitalization in patients with heart failure

BACKGROUND

Heart failure (HF) is the only cardiovascular disease with an ever-increasing incidence.

AIMS

The aim of this study was to assess the predictors of adverse clinical events (CE) and the creation and evaluation of the prognostic value of a novel personalized scoring system in patients with HF.

METHODS

The study included 113 HF patients (median age 64 years (IQR 58-69); 57.52% male). The new novel prognostic score named GLVC (G, global longitudinal peak strain (GLPS); L, left ventricular diastolic diameter (LVDD); V, oxygen pulse (VO2/HR); and C, high sensitivity C-reactive protein (hs-CRP)) was created. The Kaplan-Meier method and log-rank test were used to compare the CE.

RESULTS

Results from final analyses showed that low GLPS (< 13.9%, OR = 2.66, 95% CI = 1.01-4.30, p = 0.002), high LVDD (> 56 mm, OR = 2.37, 95% CI = 1.01-5.55, p = 0.045), low oxygen pulse (< 10, OR = 2.8, 95% CI = 1.17-6.70, p = 0.019), and high hs-CRP (> 2.38 µg/ml, OR = 2.93, 95% CI = 1.31-6.54, p = 0.007) were independent prognostic factors for adverse CE in HF population. All the patients were stratified into a low-risk or high-risk group according to a novel "GLVC" scoring system. The Kaplan-Meier analyses demonstrated that patients in the high-risk group were more predisposed to having higher adverse clinical events compared to patients in the low-risk group.

CONCLUSIONS

A novel and comprehensive personalized "GLVC" scoring system is an easily available and effective tool for predicting the adverse outcomes in HF.

Selvester QRS Score is a Predictor of Mortality in Heart Failure with Preserved Ejection Fraction

BACKGROUND

The Selvester QRS (S-QRS) score on a 12-lead electrocardiogram (ECG) is associated with both the amount of myocardial scar and poor prognosis in myocardial infarction patients. However, its prognostic value in heart failure (HF) with preserved ejection fraction (HFpEF) is unknown.

OBJECTIVE

This study aims to investigate the predictive value of the S-QRS score for mortality in HFpEF.

METHODS

359 patients were retrospectively enrolled in this study. Electrocardiographic, echocardiographic, and laboratory features of the patients were recorded. The simplified S-QRS score was measured and recorded. The mean follow-up time of the patients was 38.1±9.5 months. Statistical significance was set at p < 0.05.

RESULTS

Of 359 patients, 270 were in the survivor group, and 89 were in the deceased group. Age, Hs-CRP, troponin, pro-BNP, left atrial (LA) diameter, LA volume index, QRS duration, Tpe, and S-QRS score were statistically high in the deceased group. In multivariate logistic regression analysis, age, Hs-CRP, NT-proBNP, LA diameter, LA volume index, Tpe, and S-QRS score were shown to be independent risk factors for mortality. In the receiver-operating characteristic (ROC) analysis, the cut-off value of the S-QRS score was 5.5, the sensitivity was 80.8%, and the specificity was 77.2% (AUC:0.880, p:0.00). In Kaplan-Meier analysis, it was found that mortality was higher in the group with S-QRS score ≥ 5.5 than in the group with S-QRS score < 5.5. (Long-rank, p:0.00).

CONCLUSIONS

We think that the S-QRS score can be used as a prognostic indicator of long-term mortality in patients with HFpEF.

Interferon hyperactivity impairs cardiogenesis in Down syndrome via downregulation of canonical Wnt signaling

Congenital heart defects (CHDs) are frequent in children with Down syndrome (DS), caused by trisomy of chromosome 21. However, the underlying mechanisms are poorly understood. Here, using a human-induced pluripotent stem cell (iPSC)-based model and the Dp(16)1Yey/+ (Dp16) mouse model of DS, we identified downregulation of canonical Wnt signaling downstream of increased dosage of interferon (IFN) receptors (IFNRs) genes on chromosome 21 as a causative factor of cardiogenic dysregulation in DS. We differentiated human iPSCs derived from individuals with DS and CHDs, and healthy euploid controls into cardiac cells. We observed that T21 upregulates IFN signaling, downregulates the canonical WNT pathway, and impairs cardiac differentiation. Furthermore, genetic and pharmacological normalization of IFN signaling restored canonical WNT signaling and rescued defects in cardiogenesis in DS in vitro and in vivo. Our findings provide insights into mechanisms underlying abnormal cardiogenesis in DS, ultimately aiding the development of therapeutic strategies.

Inflammation as a therapeutic target in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for around half of all cases of heart failure and may become the dominant type of heart failure in the near future. Unlike HF with reduced ejection fraction there are few evidence-based treatment strategies available. There is a significant unmet need for new strategies to improve clinical outcomes in HFpEF patients. Inflammation is widely thought to play a key role in HFpEF pathophysiology and may represent a viable treatment target. In this review focusing predominantly on clinical studies, we will summarise the role of inflammation in HFpEF and discuss potential therapeutic strategies targeting inflammation.

Red cell distribution width (RDW) is correlated to time of oxygen desaturation < 90% and length of sleep apneas in patients with sleep disorder breathing (SDB) and acute heart failure with preserved ejection fraction (HFpEF)

Background

Heart failure with preserved ejection fraction (HFpEF) is very frequently associated to sleep breathing disorders (SDB). Red blood cell distribution width (RDW) has been shown to be a potential inflammatory index linked to the degree of hypoxia and oxidative stress.

Aim

To identify the existence of a possible relationship between sleep apnea, oxygen saturation (SaO2) and RDW in a population of subjects affected by acute HFpEF (AHFpEF).

Methods

AHFpEF patients with known history of SDB were enrolled and performed blood chemistry, echocardiography, and 24-h polysomnography (PSG).

Results

A total of 34 acute HFpEF patients (mean age 72.8 +/-8.63) were enrolled in the study. A control group of 24 non-HF patients were considered. Compared to controls, HFpEF patients showed a higher mean apnea hypopnea index (AHI), with prevalence of central apneas. A moderate to severe desaturation pattern was observed in AHFpEF vs. controls. RDW was significantly higher in AHFpEF patients vs. controls (mean value 14.7 +/-2.6 % vs. 9.1 +/-2.2, p < 0.05). In AHFpEF, RDW showed a positive correlation with time of SaO2 < 90% (r = 0.35, p = 0.04), and with mean length of apneic events (60 +/-28 s, r = 0.29, p = 0.03).

Conclusion

In patients with AHFpEF and SDB, a dependence relationship between RDW and duration of oxygen desaturation was observed, as if oxidative stress and inflammation related to RDW increase could also be linked to severity of sleep disorders in this population.

Laboratory and Metabolomic Fingerprint in Heart Failure with Preserved Ejection Fraction: From Clinical Classification to Biomarker Signature

Heart failure with preserved ejection fraction (HFpEF) remains a poorly characterized syndrome with many unknown aspects related to different patient profiles, various associated risk factors and a wide range of aetiologies. It comprises several pathophysiological pathways, such as endothelial dysfunction, myocardial fibrosis, extracellular matrix deposition and intense inflammatory system activation. Until now, HFpEF has only been described with regard to clinical features and its most commonly associated risk factors, disregarding all biological mechanisms responsible for cardiovascular deteriorations. Recently, innovations in laboratory and metabolomic findings have shown that HFpEF appears to be strictly related to specific cells and molecular mechanisms' dysregulation. Indeed, some biomarkers are efficient in early identification of these processes, adding new insights into diagnosis and risk stratification. Moreover, recent advances in intermediate metabolites provide relevant information on intrinsic cellular and energetic substrate alterations. Therefore, a systematic combination of clinical imaging and laboratory findings may lead to a 'precision medicine' approach providing prognostic and therapeutic advantages. The current review reports traditional and emerging biomarkers in HFpEF and it purposes a new diagnostic approach based on integrative information achieved from risk factor burden, hemodynamic dysfunction and biomarkers' signature partnership.

Advances in congestive heart failure biomarkers

Congestive heart failure (CHF) is the leading cause of morbidity and mortality in the elderly worldwide. Although many biomarkers associated with in heart failure, these are generally prognostic and identify patients with moderate and severe disease. Unfortunately, the role of biomarkers in decision making for early and advanced heart failure remains largely unexplored. Previous studies suggest the natriuretic peptides have the potential to improve the diagnosis of heart failure, but they still have significant limitations related to cut-off values. Although some promising cardiac biomarkers have emerged, comprehensive data from large cohort studies is lacking. The utility of multiple biomarkers that reflect various pathophysiologic pathways are increasingly being explored in heart failure risk stratification and to diagnose disease conditions promptly and accurately. MicroRNAs serve as mediators and/or regulators of renin-angiotensin-induced cardiac remodeling by directly targeting enzymes, receptors and signaling molecules. The role of miRNA in HF diagnosis is a promising area of research and further exploration may offer both diagnostic and prognostic applications and phenotype-specific targets. In this review, we provide insight into the classification of different biochemical and molecular markers associated with CHF, examine clinical usefulness in CHF and highlight the most clinically relevant.

Biomarkers in HFpEF for Diagnosis, Prognosis, and Biological Phenotyping

PURPOSE OF REVIEW

The heterogeneity of heart failure with preserved ejection fraction (HFpEF) is responsible for the limited success of broad management strategies. The role of biomarkers has been evolving helping to provide insight into the diversity of pathophysiology, prognosis, and potential targets for treatments. We will review the role of traditional and novel biomarkers in diagnosing, prognosticating, and evolving the management of patients with HFpEF. As circulating biomarker discovery rapidly evolves, we will explore technology for new biomarker discovery with examples of successful implementation.

RECENT FINDINGS

Besides cardiac-specific biomarkers (natriuretic peptides and troponin), other novel nonspecific biomarkers increasingly identify the diversity of pathophysiological mechanisms of HFpEF including inflammation, fibrosis, and renal dysfunction. Newer approaches have provided increasing granularity providing opportunities to integrate large amounts of information from proteomics and genomics as biomarkers of interest in HFpEF. HFpEF has been marked with failure of many medications to show benefit, whether measuring single targeted biomarkers or broader targeted discovery proteomics or genomic circulating biomarkers are providing increasing opportunities to better understand and manage HFpEF patients.

The usefulness of C-reactive protein to predict improving left ventricular function after aortic valve replacement in patients with aortic regurgitation

Background

We aimed to clarify the predictive factors for left ventricular (LV) function after aortic valve replacement (AVR) in patients with aortic regurgitation (AR).

Methods and results

Among 555 patients who underwent AVR at our institution from January 2015 to December 2020, we enrolled 44 patients for whom only AVR (or AVR + aortic replacement) was performed. We defined LV dysfunction under any of the following criteria: LV ejection fraction (LVEF) <50 %, LV diastolic dimension >65 mm, LV systolic dimension (LVDs) >50 mm, or LVDs/body surface area > 25 mm/m2. Multivariable logistic regression analysis revealed high natural logarithm (ln) C-reactive protein (CRP) and low LVEF in the pre-AVR period significantly associated with LV dysfunction after AVR (ln CRP: odds ratio [OR] 4.15, 95 % confidence interval [CI] 1.44-11.98, p < 0.01; LVEF: OR 0.79, 95%CI 0.65-0.97, p < 0.05). Receiver-operating characteristic analysis revealed an area under curve of CRP and LVEF in the pre-AVR period for LV dysfunction after AVR of 0.84 and 0.83, respectively. Upon dividing the patients into four groups according to cutoff values of CRP (0.13 mg/dL) and LVEF (50 %) in the pre-AVR period, no patients (0/19) had LV dysfunction in the low CRP (<0.13 mg/dL) and high LVEF (≥50 %) group, and all patients (5/5) in the high CRP (≥0.13 mg/dL) and low LVEF (<50 %) group had LV dysfunction after AVR.

Conclusion

High CRP level was significantly and independently associated with LV dysfunction after AVR. Combination of CRP and LVEF values might be useful for predicting improvement in LV function after AVR.

A Novel Three-Dimensional and Tissue Doppler Echocardiographic Index for Diagnosing and Prognosticating Heart Failure With Preserved Ejection Fraction

Introduction

The diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. In this study, a novel echocardiography index based on three-dimensional and tissue Doppler echocardiography for diagnosing and estimating prognosis in HFpEF.

Materials and Methods

Patients with symptoms and/or signs of heart failure and normal left ventricular ejection fraction (LVEF ≥50%) who underwent right heart catheterization were screened. Patients were divided based on pulmonary capillary wedge pressure (PCWP) of ≥15 mmHg and PCWP <15 mmHg. A diagnosis of HFpEF was confirmed by PCWP of ≥15 mmHg according to ESC guidelines. A novel index was calculated by the ratio between stroke volume standardized to body surface area (SVI) and tissue Doppler mitral annulus systolic peak velocity S' (SVI/S'). Its diagnostic and prognostic values were determined.

Results

A total of 104 patients (mean age 64 ± 12 years) were included. Of these, 63 had PCWP ≥15 mmHg and 41 patients had PCWP <15 mmHg. Compared to the PCWP <15 mmHg group, the ≥15 mmHg group had a significantly lower SVI/S' (P < 0.001). Logistic regression showed that SVI/S' was associated with high PCWP measured invasively. The SVI/S' had an area under the curve of 0.761 for diagnosing classifying between PCWP ≥15 mmHg and <15 mmHg. Kaplan–Meier analysis showed that the lower SVI/S' group showed a poorer prognosis.

Conclusions

SVI/S' is a non-invasive index calculated by three-dimensional and tissue Doppler echocardiography. It is a surrogate measure of PCWP and can be used to diagnose and determine prognosis in HFpEF.

Indicators of endothelial function and systemic immune inflammatory response in patients with chronic heart failure and coexisting primary hypothyroidism

Chronic heart failure is one of the leading causes of death globally, affecting 1.5 to 2% of the total world population and 2.9 to 3.9% of the total Western European population. Chronic heart failure often progresses rapidly in coexistence with endocrine pathology, namely hypothyroidism, that results in a more rapid development and further progression of endothelial dysfunction and the development of a systemic inflammatory response. The aim of our research was to study the levels of endothelin-1, C-reactive protein, tumor necrosis factor α and their correlation with the levels of thyroid-stimulating hormone, thyroxine in patients with chronic heart failure and coexisting hypothyroidism. There were examined 38 patients with chronic heart failure and coexisting hypothyroidism and 42 patients with chronic heart failure without hypothyroidism. The serum levels of endothelin-1, C-reactive protein, tumor necrosis factor α were determined by the enzyme-linked immunosorbent assay, while the levels of thyroid-stimulating hormone and thyroxine were determined by the electrochemiluminescence immunoassay. In patients with chronic heart failure and coexisting hypothyroidism, the levels of endothelin-1, C-reactive protein, and tumor necrosis factor α were 2.9, 1.5 and 2.27 times higher than those in patients without hypothyroidism. In Group I, there was a moderate positive correlation between the serum levels of endothelin-1 and thyroid-stimulating hormone and a weak negative correlation between the levels of thyroxine and endothelin-1. In Group II, there was a weak correlation between the levels of endothelin-1 and thyroid-stimulating hormone and no correlation between the levels of thyroxine and endothelin-1. In Group I, there was a strong positive correlation between C-reactive protein and thyroid-stimulating hormone levels as well; in Group II, no similar correlation was found. In Group I, there was found a moderate negative correlation between tumor necrosis factor α and thyroxine levels. According to our results, there was a close correlation between the markers of endothelial dysfunction, immune inflammatory response, and single markers of hypothyroidism.

Relationship Between High-Sensitivity C-Reactive Protein and Long-Term Outcomes in Elderly Patients With 3-Vessel Disease

The prognostic value of high-sensitivity C-reactive protein (hsCRP) in complex coronary artery disease has not been fully established. We aimed to determine the association between hsCRP and long-term outcomes in elderly patients with 3-vessel disease (TVD). From April 2004 to February 2011, 3069 patients aged ≥65 years with TVD were consecutively enrolled and received medical treatment alone, percutaneous coronary intervention, or coronary artery bypass grafting. The patients were divided into 2 groups according to their hsCRP levels: <3.00 mg/L (62.1%) and ≥3.00 mg/L (37.9%). The mean age was 71 ± 4 years. The high hsCRP group had more risk factors and more frequently received conservative treatment than the low hsCRP group. During a median follow-up period of 6.2 years, elevated hsCRP was significantly associated with increased all-cause death (19.5% vs 29.6%, P < .001), cardiac death (9.4% vs 15.2%, P = .001), and major adverse cardiovascular and cerebrovascular events (34.1% vs 42.5%, P = .001). Multivariable Cox regression analyses revealed that hsCRP was an independent predictor for all of these events. Combining hsCRP with Synergy between PCI with TAXUS and Cardiac Surgery score II further improved the predictive power of the score. The relationship between hsCRP and mortality was relatively consistent across subgroups. Overall, hsCRP could prove useful for risk prediction in elderly patients.

Mid- to Late-Life Inflammation and Risk of Cardiac Dysfunction, HFpEF and HFrEF in Late Life

BACKGROUND

Epidemiologic data supporting the association of accumulated inflammation from mid- to late life with late-life risk of cardiac dysfunction and heart failure (HF) is limited.

METHODS AND RESULTS

Among 4011 participants in the Atherosclerosis Risk in Communities study who were free of prevalent cardiovascular disease at study Visit 5, accumulated inflammation was defined as time-averaged high-sensitivity c-reactive protein (hsCRP) over 3 visits spanning 1990 to 2013. Associations with left ventricular (LV) function at Visit 5 and with incident adjudicated HF post Visit 5 were assessed using linear and Cox regression, adjusting for demographics and comorbidities. Higher accumulated hsCRP was associated with greater LV mass index, lower e', higher E/e', and higher adjusting for demographics (all P ≤0.01), but only with higher pulmonary artery systolic pressure after adjustment for comorbidities (P = 0.024). At 5.3 ± 1.2 year follow-up, higher accumulated hsCRP was associated with greater risk of incident HF (HR 1.31 [95% CI 1.18-1.47], P < 0.001), HFrEF (1.26 [1.05-1.52], P = 0.01), and HFpEF (1.30 [1.11-1.53], P = 0.001) in demographic-adjusted models, but not after adjustment for comorbidities (all P > 0.10). Only Visit 5 hsCRP remained associated with incident HF (1.12 [1.02-1.24], P = 0.02) after full adjustment.

CONCLUSIONS

Greater accumulated inflammation is associated with worse LV function and heightened HF risk in late-life. These relationships are attenuated after adjusting for HF risk factors.

Prevalence of Coronary Artery Disease and Coronary Microvascular Dysfunction in Patients With Heart Failure With Preserved Ejection Fraction

Importance

Coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) may contribute to the pathophysiologic characteristics of heart failure with preserved ejection fraction (HFpEF). However, the prevalence of CAD and CMD have not been systematically studied.

Objective

To examine the prevalence of CAD and CMD in hospitalized patients with HFpEF.

Design, Setting, and Participants

A total of 106 consecutive patients hospitalized with HFpEF were evaluated in this prospective, multicenter, cohort study conducted between January 2, 2017, and August 1, 2018; data analysis was performed from March 4 to September 6, 2019. Participants underwent coronary angiography with guidewire-based assessment of coronary flow reserve, index of microvascular resistance, and fractional flow reserve, followed by coronary vasoreactivity testing. Cardiac magnetic resonance imaging was performed with late gadolinium enhancement and assessment of extracellular volume. Myocardial perfusion was assessed qualitatively and semiquantitatively using the myocardial-perfusion reserve index.

Main Outcomes and Measures

The prevalence of obstructive epicardial CAD, CMD, and myocardial ischemia, infarction, and fibrosis.

Results

Of 106 participants enrolled (53 [50%] women; mean [SD] age, 72 [9] years), 75 had coronary angiography, 62 had assessment of coronary microvascular function, 41 underwent coronary vasoreactivity testing, and 52 received cardiac magnetic resonance imaging. Obstructive epicardial CAD was present in 38 of 75 participants (51%, 95% CI, 39%-62%); 19 of 38 (50%; 95% CI, 34%-66%) had no history of CAD. Endothelium-independent CMD (ie, coronary flow reserve <2.0 and/or index of microvascular resistance ≥25) was identified in 41 of 62 participants (66%; 95% CI, 53%-77%). Endothelium-dependent CMD (ie, abnormal coronary vasoreactivity) was identified in 10 of 41 participants (24%; 95% CI, 13%-40%). Overall, 45 of 53 participants (85%; 95% CI, 72%-92%) had evidence of CMD and 29 of 36 (81%; 95% CI, 64%-91%) of those without obstructive epicardial CAD had CMD. Cardiac magnetic resonance imaging findings included myocardial-perfusion reserve index less than or equal to 1.84 (ie, impaired global myocardial perfusion) in 29 of 41 patients (71%; 95% CI, 54%-83%), visual perfusion defect in 14 of 46 patients (30%; 95% CI, 19%-46%), ischemic late gadolinium enhancement (ie, myocardial infarction) in 14 of 52 patients (27%; 95% CI, 16%-41%), and extracellular volume greater than 30% (ie, diffuse myocardial fibrosis) in 20 of 48 patients (42%; 95% CI, 28%-56%). Patients with obstructive CAD had more adverse events during follow-up (28 [74%]) than those without obstructive CAD (17 [46%]).

Conclusions and Relevance

In this cohort study, 91% of patients with HFpEF had evidence of epicardial CAD, CMD, or both. Of those without obstructive CAD, 81% had CMD. Obstructive epicardial CAD and CMD appear to be common and often unrecognized in hospitalized patients with HFpEF and may be therapeutic targets.

Molecular Imaging of Inflammation and Fibrosis in Pressure Overload Heart Failure

[Figure: see text].

High density lipoprotein cholesterol / C reactive protein ratio in heart failure with preserved ejection fraction

AIMS

The impacts of high density lipoprotein cholesterol (HDL-C) as an anti-inflammatory and C reactive protein (CRP) as inflammatory properties on the pathogenesis of heart failure were reported. At present, the clinical significance of the HDL-C/CRP ratio in heart failure with preserved ejection fraction (HFpEF) patients remains unknown.

METHODS AND RESULTS

We examined the data on 796 consecutive HFpEF (left ventricular ejection fraction ≥50%) patients hospitalized due to acute decompensated heart failure from the PURSUIT-HFpEF registry, a prospective, multicentre observational study. We calculated the HDL/CRP ratios and evaluated the relationship between the values and clinical outcomes, including degree of cardiac function. The mean follow-up duration was 420 ± 346 days. All-cause death occurred in 118 patients, of which 51 were cardiac deaths. HDL/CRP ≤ 4.05 was independently and significantly associated with all-cause death (odds ratio = 1.84, 95% CI: 1.06-3.20, P = 0.023), and HDL/CRP ≤ 3.14 was associated with cardiac death by multivariate Cox proportional hazard analysis (odds ratio = 2.86, 95% CI: 1.36-6.01, P = 0.003). HDL-C/CRP ratio significantly correlated with the product of the left atrial volume and left ventricular mass index as well as the tricuspid annular plane systolic excursion by multiple regression analysis (standardized beta-coefficient = -0.085, P = 0.034 and standardized beta-coefficient = 0.081, P = 0.044, respectively).

CONCLUSIONS

HDL-C/CRP ratio was a useful marker for predicting all-cause death and cardiac death and correlated with left ventricular diastolic function and right ventricular systolic function in HFpEF patients.

Various aspects of inflammation in heart failure

Despite significant advances in the prevention and treatment of heart failure (HF), the prognosis in patients who have been hospitalised on at least one occasion due to exacerbation of HF is still poor. Therefore, a better understanding of the underlying pathophysiological mechanisms of HF is crucial in order to achieve better results in the treatment of this clinical syndrome. One of the areas that, for years, has aroused the interest of researchers is the activation of the immune system and the elevated levels of biomarkers of inflammation in patients with both ischaemic and non-ischaemic HF. Additionally, it is intriguing that the level of circulating pro-inflammatory biomarkers correlates with the severity of the disease and prognosis in this group of patients. Unfortunately, clinical trials aimed at assessing interventions to modulate the inflammatory response in HF have been disappointing, and the modulation of the inflammatory response has had either no effect or even a negative effect on the HF prognosis. The article presents a summary of current knowledge on the role of immune system activation and inflammation in the pathogenesis of HF. Understanding the immunological mechanisms pathogenetically associated with left ventricular remodelling and progression of HF may open up new therapeutic possibilities for HF.

NETosis as a Pathogenic Factor for Heart Failure

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

Sodium glucose cotransporter 2 inhibitors: mechanisms of action in heart failure

Diabetes is a key independent risk factor in the development of heart failure (HF) and a strong, adverse prognostic factor in HF patients. HF remains the primary cause of hospitalisation for diabetics and, as previous studies have shown, when HF occurs in these patients, intensive glycaemic control does not directly improve the prognosis. Recent clinical studies assessing a new class of antidiabetic drugs, sodium-glucose cotransporter 2 inhibitors (SGLT2is) showed some unexpected beneficial results. Patients treated with SGLT2is had a significant decrease in both cardiovascular (CV) and all-cause mortality and less hospitalisations due to HF compared to those given a placebo. These significant clinical benefits occurred quickly after the drugs were administered and were not solely due to improved glycaemic control. These groundbreaking clinical trials’ results have already changed clinical practice in the management of patients with diabetes at high CV risk. These trials have triggered numerous experimental studies aimed at explaining the mechanisms of action of this unique group of drugs. This article presents the current state of knowledge about the mechanisms of action of SGLT2is developed for the treatment of diabetes and which, thanks to their cardioprotective effects, may, in the future, become a treatment for patients with HF.

Coronary microvascular dysfunction in hypertrophy and heart failure

Left ventricular (LV) hypertrophy (LVH) is a growth in left myocardial mass mainly caused by increased cardiomyocyte size. LVH can be a physiological adaptation to physical exercise or a pathological condition either primary, i.e. genetic, or secondary to LV overload. Patients with both primary and secondary LVH have evidence of coronary microvascular dysfunction (CMD). The latter is mainly due to capillary rarefaction and adverse remodelling of intramural coronary arterioles due to medial wall thickening with an increased wall/lumen ratio. An important feature of this phenomenon is the diffuse nature of this remodelling, which generally affects the coronary microvessels in the whole of the left ventricle. Patients with LVH secondary to arterial hypertension can develop both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). These patients can develop HFrEF via a 'direct pathway' with an interval myocardial infarction and also in its absence. On the other hand, patients can develop HFpEF that can then progress to HFrEF with or without interval myocardial infarction. A similar evolution towards LV dysfunction and both HFpEF and HFrEF can occur in patients with hypertrophic cardiomyopathy, the most common genetic cardiomyopathy with a phenotype characterized by massive LVH. In this review article, we will discuss both the experimental and clinical studies explaining the mechanisms responsible for CMD in LVH as well as the evidence linking CMD with HFpEF and HFrEF.

Characterization of the inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction: a hypothesis to explain influence of sex on the evolution and potential treatment of the disease

Accumulating evidence points to the existence of an inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction (HFpEF), which is characterized by biomarkers of inflammation, an expanded epicardial adipose tissue mass, microvascular endothelial dysfunction, normal-to-mildly increased left ventricular volumes and systolic blood pressures, and possibly, altered activity of adipocyte-associated inflammatory mediators. A broad range of adipogenic metabolic and systemic inflammatory disorders - e.g. obesity, diabetes and metabolic syndrome as well as rheumatoid arthritis and psoriasis - can cause this phenotype, independent of the presence of large vessel coronary artery disease. Interestingly, when compared with men, women are both at greater risk of and may suffer greater cardiac consequences from these systemic inflammatory and metabolic disorders. Women show disproportionate increases in left ventricular filling pressures following increases in central blood volume and have greater arterial stiffness than men. Additionally, they are particularly predisposed to epicardial and intramyocardial fat expansion and imbalances in adipocyte-associated proinflammatory mediators. The hormonal interrelationships seen in inflammatory-metabolic phenotype may explain why mineralocorticoid receptor antagonists and neprilysin inhibitors may be more effective in women than in men with HFpEF. Recognition of the inflammatory-metabolic phenotype may improve an understanding of the pathogenesis of HFpEF and enhance the ability to design clinical trials of interventions in this heterogeneous syndrome.

High-sensitivity C-reactive protein in chronic heart failure: patient characteristics, phenotypes, and mode of death

AIMS

Plasma concentrations of high-sensitivity C-reactive protein (hsCRP) are often raised in chronic heart failure (CHF) and might indicate inflammatory processes that could be a therapeutic target. We aimed to study the associations between hsCRP, mode and cause of death in patients with CHF.

METHODS AND RESULTS

We enrolled 4423 patients referred to a heart failure clinic serving a local population. CHF was defined as relevant symptoms or signs with either a reduced left ventricular ejection fraction <40% or raised plasma concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP >125 pg/mL). The median [interquartile range (IQR)] plasma hsCRP for patients diagnosed with CHF (n = 3756) was 3.9 (1.6-8.5) mg/L and 2.7 (1.3-5.1) mg/L for those who were not (n = 667; P < 0.001). Patients with hsCRP ≥10 mg/L (N = 809; 22%) were older and more congested than those with hsCRP <2 mg/L (N = 1117, 30%). During a median follow-up of 53 (IQR 28-93) months, 1784 (48%) patients with CHF died. Higher plasma hsCRP was associated with greater mortality, independent of age, symptom severity, creatinine, and NT-proBNP. Comparing a hsCRP ≥10 mg/L to <2 mg/L, the hazard ratio for all-cause mortality was 2.49 (95% confidence interval 2.19-2.84; P < 0.001), for cardiovascular (CV) mortality was 2.26 (1.91-2.68; P < 0.001), and for non-CV mortality was 2.96 (2.40-3.65; P < 0.001).

CONCLUSION

In patients with CHF, a raised plasma hsCRP is associated with more congestion and a worse prognosis. The proportion of deaths that are non-CV also increases with higher hsCRP.

Factors Associated With Elevated N-Terminal Pro B-Type Natriuretic Peptide Concentrations at the Convalescent Stage and 1-Year Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Background: Little is known about factors associated with elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) at the convalescent stage and their effects on 1-year outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results: This study included 469 patients with HFpEF. Elevated NT-proBNP was defined as the highest quartile. The first 3 quartiles (Q1-Q3) were combined together for comparison with the fourth quartile (Q4). Median NT-proBNP concentrations in Q1-Q3 and Q4 were 669 and 3,504 pg/mL, respectively. Multivariate logistic regression analysis revealed that low albumin (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.35-4.39; P=0.003), low estimated glomerular filtration rate (OR 5.83; 95% CI 3.46-9.83; P<0.001), high C-reactive protein (OR 2.09; 95% CI 1.21-3.63; P=0.009), and atrial fibrillation at discharge (OR 2.33; 95% CI 1.40-3.89; P=0.001) were associated with elevated NT-proBNP. Cumulative rates of all-cause mortality and heart failure rehospitalization were significantly higher in Q4 than in Q1-Q3 (P=0.001 and P<0.001, respectively). Incidence and hazard ratios of these adverse events increased when the number of associated factors for elevated NT-proBNP clustered together (P<0.001 and P=0.002, respectively). Conclusions: In addition to atrial fibrillation, extracardiac factors (malnutrition, renal impairment and inflammation) were associated with elevated NT-proBNP at the convalescent stage, and led to poor prognosis in patients with HFpEF.

Emerging trends in cardiovascular research: HFpEF in the spotlight. A bibliometric analysis of the years 2009-2016

INTRODUCTION

Up to 50% of patients suffering from acute decompensated heart failure show normal or slightly reduced left ventricular ejection fraction (LVEF). This syndrome, which is known as heart failure with preserved ejection fraction (HFpEF) is associated with increasing age. Epidemiological studies could portrait an increasing importance and an even emerging prevalence in the past decades. Still, there is currently no evidenced based medical treatment option available. Our aims were to identify upcoming trends and emerging concepts and to point out important centers in the global research of HFpEF.

EVIDENCE ACQUISITION

We performed a bibliometric study on current science in the field of HFpEF to identify study characteristics, impact factors and the countries of origin of basic and clinical studies that were published within the years 2009 to 2016. We further prepared density equalizing maps for visualization of the obtained data.

EVIDENCE SYNTHESIS

A total of 5413 studies was screened, of which 794 were found eligible. The scientific output in clinical studies rose from 25 in 2009 to 165 in 2016. Most of the publications had a clinical topic, followed by studies on new imaging techniques. Basic research trials were by far beyond. The USA, Japan and Germany were identified as the most important national contributors to global scientific output.

CONCLUSIONS

This first bibliometric study in the field of HFpEF shows a substantial increase of research within the last decade, mainly in the USA, Japan, and continental Europe. As an ongoing therapeutic trend in this field, we identified RAAS-blockade and 5-phosphodiesterase-inhibition.

Diagnostic and prognostic value of serum C-reactive protein in heart failure with preserved ejection fraction: a systematic review and meta-analysis

Heart failure (HF) is a major epidemic with rising morbidity and mortality rates that encumber global healthcare systems. While some studies have demonstrated the value of CRP in predicting (i) the development of HFpEF and (ii) long-term clinical outcomes in HFpEF patients, others have shown no such correlation. As a result, we conducted the following systematic review and meta-analysis to assess both the diagnostic and prognostic role of CRP in HFpEF. PubMed and Embase were searched for studies that assess the relationship between CRP and HFpEF using the following search terms: (((C-reactive protein) AND ((preserved ejection fraction) OR (diastolic heart failure))). The search period was from the start of database to August 6, 2019, with no language restrictions. A total of 312 and 233 studies were obtained from PubMed and Embase respectively, from which 19 studies were included. Our meta-analysis demonstrated the value of a high CRP in predicting the development of not only new onset HFpEF (HR: 1.08; 95% CI: 1.00-1.16; P = 0.04; I² = 22%), but also an increased risk of cardiovascular mortality when used as a categorical (HR: 2.52; 95% CI: 1.61-3.96; P < 0.0001; I² = 19%) or a continuous variable (HR: 1.24; 95% CI: 1.04-1.47; P = 0.01; I² = 28%), as well as all-cause mortality when used as a categorical (HR: 1.78; 95% CI: 1.53-2.06; P < 0.00001; I² = 0%) or a continuous variable: (HR: 1.06; 95% CI: 1.02-1.06; P = 0.003; I² = 61%) in HFpEF patients. CRP can be used as a biomarker to predict the development of HFpEF and long-term clinical outcomes in HFpEF patients, in turn justifying its use as a simple, accessible parameter to guide clinical management in this patient population. However, more prospective studies are still required to not only explore the utility and dynamicity of CRP in HFpEF but also to determine whether risk stratification algorithms incorporating CRP actually provide a material benefit in improving patient prognosis.

IL-1 Blockade in Patients With Heart Failure With Preserved Ejection Fraction

Background Enhanced inflammation may lead to exercise intolerance in heart failure with preserved ejection fraction. The aim of the current study was to determine whether IL (interleukin)-1 blockade with anakinra improved cardiorespiratory fitness in heart failure with preserved ejection fraction. Methods and Results Thirty-one patients with heart failure with preserved ejection fraction and CRP (C-reactive protein) >2 mg/L were randomized to anakinra (100 mg subcutaneously daily, N=21) or placebo (N=10) for 12 weeks. We measured peak oxygen consumption (Vo₂), ventilatory efficiency (V_E/Vco₂ slope), and high-sensitivity CRP and NT-proBNP (N-terminal pro-B-type natriuretic peptide) at 4, 12, and 24 weeks. Twenty-eight patients completed ≥2 visits, 18 women (64%), 27 (96%) obese. There were no differences in peak Vo₂ or V_E/Vco₂ slope between groups at baseline. Peak Vo₂ was not changed after 12 weeks of anakinra (from 13.6 [11.8-18.0] to 14.2 [11.2-18.5] mL·kg^-1·min^-1, P=0.89), or placebo (14.9 [11.7-17.2] to 15.0 [13.8-16.9] mL·kg^-1·min^-1, P=0.40), without significant between-group differences in changes at 12 weeks (-0.4 [95% CI, -2.2 to +1.4], P=0.64). V_E/Vco₂ slope was also unchanged with anakinra (from 28.3 [27.2-33.0] to 30.5 [26.3-32.8], P=0.97) or placebo (from 31.6 [27.3-36.9] to 31.2 [27.8-33.4], P=0.78), without significant between-group differences in changes at 12 weeks (+1.2 [95% CI, -1.8 to +4.3], P=0.97). Within the anakinra-treated patients, high-sensitivity CRP and NT-proBNP levels were lower at 4 weeks compared with baseline ( P=0.026 and P=0.022 versus placebo [between-group analysis], respectively). Conclusions Treatment with anakinra for 12 weeks failed to improve peak Vo₂ and V_E/Vco₂ slope in a group of obese heart failure with preserved ejection fraction patients. The favorable trends in high-sensitivity CRP and NT-proBNP with anakinra deserve exploration in future studies. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02173548.

Biomarkers of Inflammation in Left Ventricular Diastolic Dysfunction

Left ventricular diastolic dysfunction (LVDD) is an important precursor to many different cardiovascular diseases. Diastolic abnormalities have been studied extensively in the past decade, and it has been confirmed that one of the mechanisms leading to heart failure is a chronic, low-grade inflammatory reaction. The triggers are classical cardiovascular risk factors, grouped under the name of metabolic syndrome (MetS), or other systemic diseases that have an inflammatory substrate such as chronic obstructive pulmonary disease. The triggers could induce myocardial apoptosis and reduce ventricular wall compliance through the release of cytokines by multiple pathways such as (1) immune reaction, (2) prolonged cell hypoxemia, or (3) excessive activation of neuroendocrine and autonomic nerve function disorder. The systemic proinflammatory state causes coronary microvascular endothelial inflammation which reduces nitric oxide bioavailability, cyclic guanosine monophosphate content, and protein kinase G (PKG) activity in adjacent cardiomyocytes favoring hypertrophy development and increases resting tension. So far, it has been found that inflammatory cytokines associated with the heart failure mechanism include TNF-α, IL-6, IL-8, IL-10, IL-1α, IL-1β, IL-2, TGF-β, and IFN-γ. Some of them could be used as diagnosis biomarkers. The present review aims at discussing the inflammatory mechanisms behind diastolic dysfunction and their triggering conditions, cytokines, and possible future inflammatory biomarkers useful for diagnosis.

C-reactive protein decrease associates with mortality reduction only in heart failure with preserved ejection fraction

AIMS

The prognostic role of high-sensitivity C-reactive protein (hsCRP) in acute heart failure is less well established than for chronic heart failure and the impact of its variation is unknown. We studied the impact of hsCRP variation in acute heart failure and whether it differed according to left ventricular function.

METHODS

We analyzed patients prospectively included in an acute heart failure registry. Admission and discharge hsCRP were evaluated as part of the registry's protocol and its relative variation (ΔhsCRP) was assessed. ΔhsCRP during hospitalization =  [(admission hsCRP - discharge hsCRP)/admission hsCRP] × 100. Endpoint: all-cause death; follow-up: 3 years. A multivariate Cox-regression model was used to assess the prognostic value of ΔhsCRP (continuous and categorical variable: cut-off 40% decrease); analysis was stratified according to ventricular function.

RESULTS

We studied 439 patients: mean age 75 years, 50.1% men and 69.2% had heart failure with reduced ejection fraction (HFrEF). Median discharge hsCRP was 12.4 mg/l and median ΔhsCRP was ∼40%. During follow-up 247 patients (56.3%) died: 73 (54.1%) heart failure with preserved ejection fraction (HFpEF) patients and 174 (57.2%) HFrEF patients. The multivariate-adjusted hazard ratio of 3-year mortality in HFpEF patients with hsCRP decrease of at least 40% during hospitalization was 0.56 (95% CI 0.32-0.99). A decrease of at least 40% in hsCRP was not mortality-associated in HFrEF patients. There was interaction between ΔhsCRP and left ventricular ejection fraction.

CONCLUSION

A decrease of at least 40% in hsCRP in acute heart failure was associated with a 44% decrease in 3-year death risk in HFpEF patients. No association between ΔhsCRP and prognosis existed in HFrEF patients. Inflammation appears to play a different role according to left ventricular function.

Geriatric nutritional risk index predicts all-cause deaths in heart failure with preserved ejection fraction

AIMS

The objective of the study was to evaluate whether the geriatric nutritional risk index (GNRI) at discharge may be helpful in predicting the long-term prognosis of patients hospitalized with heart failure (HF) with preserved ejection fraction (HFpEF, left ventricular ejection fraction ≥50%), a common HF phenotype in the elderly.

METHODS AND RESULTS

Overall, 110 elderly HFpEF patients (≥65 years) from the Ibaraki Cardiovascular Assessment Study-HF (n = 838) were enrolled. The mean age was 78.5 ± 7.2 years, and male patients accounted for 53.6% (n = 59). All-cause mortality was compared between the low GNRI (<92) with moderate or severe nutritional risk group and the high GNRI (≥92) with no or low nutritional risk group. Cox proportional hazard regression models were constructed to evaluate the influence of the GNRI on all-cause death with the following covariates using forward stepwise selection: age, sex, nutritional status based on the GNRI as a categorical variable, history of HF hospitalization, haemoglobin level, estimated glomerular filtration rate, log brain natriuretic peptide levels (logBNP), history of hypertension, log C-reactive protein levels, left ventricular ejection fraction, left ventricular mass index, and the New York Heart Association functional classification (I/II or III class). The prognostic value of the GNRI was compared with that of serum albumin using C-statistics. The GNRI was added to the logBNP, serum albumin or the body mass index was added to the logBNP, and the C-statistic was compared using DeLong's test. Cox regression analysis revealed that age and a low GNRI were independent predictors of all-cause death (P < 0.05, n = 103; hazard ratio = 1.095, 95% confidence interval = 1.031-1.163, for age, and hazard ratio = 3.075, 95% confidence interval = 1.244-7.600, for the GNRI). DeLong's test for the two correlated receiver operating characteristic curves [area under the receiver operating characteristic curve (AUROC) of serum albumin, 0.71; AUROC of the GNRI, 0.75] demonstrated significant differences between the groups (P = 0.038). Adding the GNRI to the logBNP increased the AUROC for all-cause death significantly (0.71 and 0.80, respectively; P = 0.040, n = 105). The addition of serum albumin or the body mass index to the logBNP did not significantly increase the AUROC for all-cause death (P = 0.082 and P = 0.29, respectively).

CONCLUSIONS

Nutritional screening using the GNRI at discharge is helpful to predict the long-term prognosis of elderly HFpEF patients.

ALDH2 rs671 polymorphism and the risk of heart failure with preserved ejection fraction (HFpEF) in patients with cardiovascular diseases

Aldehyde dehydrogenase 2 (ALDH2) rs671 polymorphism is an established genetic risk of hypertension, diabetes, and coronary heart diseases in Asian population. Previous experimental data showed ALDH2 regulated inflammation, a potential mechanism of heart failure with preserved ejection fraction (HFpEF). However, clinically, the association between ALDH2 polymorphism and incidence of HFpEF remains unknown. In this prospective cross-sectional study, ALDH2 genotyping was performed in 613 consecutive patients enrolled with cardiovascular diseases (CVDs), including hypertension, coronary heart diseases, and/or diabetes mellitus, with normal left ventricular ejection fraction (LVEF). HFpEF was diagnosed according to symptoms and/or signs of dyspnea, fatigue or ankle swelling, N-terminal pro-B-Type natriuretic peptide (NT pro-BNP ≥ 280 pg/mL), LVEF ≥ 50%, and at least one additional criterion: left atrial enlargement (left atrial diameter > 40 mm), diastolic dysfunction (E/E' ≥ 13 or E'/A' < 1) or concurrently with atrial fibrillation. Finally, of 613 patients with CVD, 379 patients (61.8%) were assigned to the wild-type ALDH2*1/*1 group and 234 patients (38.2%) to the mutation-type ALDH2*2 group according to genotyping results. Sixty-nine patients (11.3%) were diagnosed with HFpEF. In ALDH2*2 group, the occurrence of HFpEF was higher (15.4% vs. 8.7%, p = 0.011) than that in ALDH2*1/*1 group. Leukocyte count, the indicator of systemic inflammation, was significantly higher (6.9 ± 2.4 × 10⁹/L vs. 6.5 ± 1.9 × 10⁹/L, p = 0.010) in ALDH2*2 group compared to ALDH2*1/*1 group. In conclusion, ALDH2*2 variant is associated with the risk of HFpEF in patients with CVD. Increased systemic inflammation probably involved in this disease process.

Renal function, N-terminal Pro-B-Type natriuretic peptide, propeptide big-endothelin and patients with heart failure and preserved ejection fraction

Renal dysfunction may limit the clinical application of NT-proBNP in the diagnosis of heart failure. In general practice, where echocardiography is not readily available, a biomarker for the diagnosis of a heart failure with preserved ejection fraction (HFpEF) would be useful. Since cardiac diseases frequently coincide with renal disease, there is a high need of valid risk stratification methods in patients affected with both. We therefore examined NT-proBNP and another biomarker, Big-Endothelin-1, as a marker of HFpEF in patients with CKD. NT-proBNP and Big-ET-1 were determined in 439 patients with HFpEF in the Ludwigshafen Risk and Cardiovascular Health (LURIC) study. NT-proBNP plasma level has shown an exponential increase with declining GFR, while Big-ET-1 plasma level increased only in a moderate and linear fashion. In patients without CKD, a NT-proBNP cut-off point at 250 pg/mL was suitable for the discrimination between HFpEF and patients without HF. When the GFR was less than 60 mL/min/1.73m², the NT-proBNP cut-off point should be raised to 750 pg/mL. At a cutoff point at 0.85 fmol/L, Big-ET-1 allowed to distinguish patients with HFpEF from persons without HF, independently of GFR. In general, NT-proBNP is a good indicator of suspected heart failure. While for NT-proBNP different cut-off points have to be considered in the diagnosis of HFpEF, a single cut-off point of Big-ET-1 was appropriate in the diagnosis of HFpEF, regardless of the presence or absence of CKD. An additional measurement of Big-ET-1 improves the diagnosis of HFpEF in patients with chronic kidney disease.

High-sensitivity C-reactive protein in heart failure with preserved ejection fraction

Background

Microvascular inflammation may contribute to the pathogenesis of both heart failure with preserved ejection fraction (HFpEF) and pulmonary hypertension (PH). We investigated whether the inflammation biomarker C-reactive protein (CRP) was associated with clinical characteristics, disease severity or PH in HFpEF.

Methods

Patients in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart failure (RELAX) trial had baseline high-sensitivity CRP levels measured (n = 214). Clinical characteristics, exercise performance, echocardiographic variables and biomarkers of neurohumoral activation, fibrosis and myocardial necrosis were assessed. Patients with normal (≤3mg/L) versus high (>3mg/L) CRP levels were compared.

Results

The median CRP level was 3.69mg/L. CRP was elevated in 57% of patients. High CRP levels were associated with younger age, higher body mass index (BMI), chronic obstructive pulmonary disease (COPD), lower peak oxygen consumption and higher endothelin-1 and aldosterone levels. CRP increased progressively with the number of comorbidities (0.7mg/L per increment in comorbidity number, P = 0.02). Adjusting for age, BMI and statin use, high CRP levels were additionally associated with atrial fibrillation, right ventricular dysfunction, and higher N-terminal pro-B-type natriuretic peptide levels (P<0.05 for all). CRP was not associated with PH or left ventricular function. CRP did not identify responders to sildenafil(P-value for interaction 0.13).

Conclusions

In HFpEF, high CRP is associated with greater comorbidity burden and some markers of disease severity but CRP was normal in 40% of patients. These findings support the presence of comorbidity-driven systemic inflammation in HFpEF but also the need to study other biomarkers which may better reflect the presence of systemic inflammation.

Pro-Inflammatory Biomarkers in Stable Versus Acutely Decompensated Heart Failure With Preserved Ejection Fraction

Background

Underlying inflammation has been increasingly recognized in heart failure with a preserved ejection fraction (HFpEF). In this study we tested the hypothesis that pro‐inflammatory biomarkers are elevated in patients with acutely decompensated HFpEF (AD‐HFpEF) compared with patients with stable HFpEF (S‐HFpEF).

Methods and Results

Using a post hoc analysis the serum biomarkers tumor necrosis factor‐alpha, high‐sensitivity C‐reactive protein interleukin 6 and pentraxin 3 (PTX3) and clinical, demographic, echocardiographic‐Doppler and clinical outcomes data were analyzed in HFpEF patients enrolled in NHLBI Heart Failure Research Network clinical trials which enrolled patients with either AD‐HFpEF or S‐HFpEF. Compared to S‐HFpEF, AD‐HFpEF patients had higher levels of PTX3 (3.08 ng/mL versus 1.27 ng/mL, P<0.0001), interleukin‐6 (4.14 pg/mL versus 1.71 pg/mL, P<0.0001), tumor necrosis factor‐alpha (11.54 pg/mL versus 8.62 pg/mL, P=0.0015), and high‐sensitivity C‐reactive protein (11.90 mg/dL versus 3.42 mg/dL, P<0.0001). Moreover, high‐sensitivity C‐reactive protein, interleukin‐6 and PTX3 levels were significantly higher in AD‐HFpEF compared with S‐HFpEF patients admitted for decompensated HF within the previous year. PTX3 was positively correlated with left atrial volume index (r=0.41, P=0.0017) and left ventricular mass (r=0.26, P=0.0415), while tumor necrosis factor‐alpha was inversely correlated with E/A ratio (r=−0.31, P=0.0395).

Conclusions

Levels of pro‐inflammatory biomarkers are strikingly higher in AD‐HFpEF compared with S‐HFpEF patients. PTX3 and tumor necrosis factor‐alpha are correlated with echocardiographic‐Doppler evidence of diastolic dysfunction. Taken together these data support the concept that a heightened pro‐inflammatory state has a pathophysiologic role in the development of AD‐HFpEF.

Predicting new-onset HF in patients undergoing coronary or peripheral angiography: results from the Catheter Sampled Blood Archive in Cardiovascular Diseases (CASABLANCA) study

Aims

Methods to identify patients at risk for incident HF would be welcome as such patients might benefit from earlier interventions.

Methods and results

From a registry of 1251 patients referred for coronary and/or peripheral angiography, we sought to identify independent predictors of incident HF during follow‐up and develop a clinical and biomarker strategy to predict this outcome. There were 991 patients free of prevalent HF at baseline. Cox proportional hazard models were developed to predict adjudicated diagnosis of incident HF. Model discrimination and reclassification were evaluated. At follow‐up, 177 (18%) developed new‐onset HF. Independent predictors of new‐onset HF included five clinical variables (age, male sex, heart rate, history of atrial fibrillation/flutter, and history of hypertension) and two biomarkers (amino‐terminal pro‐B type natriuretic peptide and ST2). The c‐statistic for the model without biomarkers was 0.69; including biomarkers increased the c‐statistic to 0.76 (P < 0.001). A score was developed from the model. Patients in the highest score quintile had shortest time to incident HF compared with lower quintiles (log‐rank P < 0.001). Following 100 bootstrap iterations, internal validation was confirmed with Harrell's c‐statistic of 0.77. Use of angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers, and beta‐blockers at enrollment was associated with substantial attenuation of predictive value of the risk score.

Conclusions

Patients undergoing coronary/peripheral angiographic procedures are a population at high risk for incident HF. We describe an accurate clinical and biomarker strategy for predicting incident HF and possibly intervening in such patients (NCT00842868).

Novel Biomarkers for the Risk Stratification of Heart Failure with Preserved Ejection Fraction

PURPOSE OF REVIEW

The use of biomarkers in heart failure (HF) is a rapidly changing field. The purpose of this review is to assess the current evidence of the use of biomarkers for risk stratification in patients with HF with preserved ejection fraction (HFpEF).

RECENT FINDINGS

Despite differences in pathophysiology between HF with reduced ejection fraction and HFpEF, traditional HF biomarkers such as brain natriuretic peptide and troponin retain prognostic value in most HFpEF-specific populations. Biomarkers of key pathophysiologic components of HFpEF, such as myocardial fibrosis, remodeling, and systemic inflammation are also valuable prognostic markers. Further investigation into HF biomarkers may identify significant therapeutic targets for the treatment of HFpEF.