Expert proposal to characterize cardiac diseases with normal or preserved left ventricular ejection fraction and symptoms of heart failure by comprehensive echocardiography

Effectiveness of pedometer-based walking programmes in improving some modifiable risk factors of stroke among community-dwelling older adults: a systematic review, theoretical synthesis and meta-analysis

BACKGROUND

Pedometer-based walking programs hold promise as a health promotion strategy for stroke prevention in community-dwelling older adults, particularly when targeted at physical activity-related modifiable risk factors. The question arises: What is the effectiveness of pedometer-based walking program interventions in improving modifiable stroke risk factors among community-dwelling older adults?

METHOD

Eight databases were searched up to December 2nd, 2023, following the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Inclusion criteria focused on randomized controlled trials (RCTS) involving community-dwelling older adults and reported in English. Two independent reviewers utilized Physiotherapy Evidence Database (PEDro) tool to extract data, assess eligibility, evaluate study quality, and identify potential bias. Standardized mean difference (SMD) was employed as summary statistics for primary -physical activity level -and secondary outcomes related to cardiovascular function (blood pressure) and metabolic syndrome, including obesity (measured by body mass index and waist circumference), fasting blood sugar, glycated hemoglobin, high-density lipoprotein cholesterol (HDL-C), and triglycerides. A random-effects model was used to generate summary estimates of effects.

RESULTS

The review analyzed eight studies involving 1546 participants aged 60-85 years, with 1348 successfully completing the studies. Across these studies, pedometer-based walking programs were implemented 2-3 times per week, with sessions lasting 40-60 minutes, over a duration of 4-26 weeks. The risk of bias varied from high to moderate. Our narrative synthesis revealed positive trends in HDL-C levels, fasting blood sugar, and glycated hemoglobin, suggesting improved glycemic control and long-term blood sugar management. However, the impact on triglycerides was only marginal. Primary meta-analysis demonstrated significantly improved physical activity behavior (SMD=0.44,95%CI:0.26, 0.61,p=<0.00001;I2=0%;4 studies; 532 participants) and systolic blood pressure (SMD=-0.34,95%CI:-0.59,-0.09;p=<0.008;I2=65%,2 studies;249 participants), unlike diastolic blood pressure (SMD=0.13,95%CI:-0.13,-0.38,p=0.33; I2=91%; 2 studies; 237 participants). Interventions based on social cognitive, self-efficacy, and self-efficiency theory(ies), and social cognitive theory applied in an ecological framework, were linked to successful physical activity behavior outcomes.

CONCLUSION

Pedometer-based walking programs, utilizing interpersonal health behavior theory/ecological framework, enhance physical activity behavior and have antihypertensive effects in community-dwelling older adults. While they do not significantly affect diastolic blood pressure, these programs potentially serve as a primary stroke prevention strategy aligning with global health goals.

TRIAL REGISTRATION

Registration Number: INPLASY202230118.

The prognostic value of the visually assessed time difference between mitral valve and tricuspid valve opening score for patients with heart failure with mildly reduced ejection fraction

BACKGROUND

The visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score was correlated with the increase of left ventricular filling pressure (LVFP).

HYPOTHESIS

We suspected that the VMT score might be a valuable prognostic biomarker for heart failure with mildly reduced ejection fraction (HFmrEF) patients. This study was to evaluate the predictive value of VMT score for 1-year all-cause and cardiovascular disease (CVD)-cause mortality in HFmrEF patients.

METHODS

This cohort study enrolled 379 patients aged ≥18 years old with HFmrEF. Univariable and multivariable Cox regression analysis was employed to assess the association between VMT score and all-cause or CVD-cause mortality in HFmrEF patients. Hazards ratio (HR), and 95% confidence interval (CI) were effect sizes. Kaplan-Meier curves showed the survival probability of patients. The area under the curve (AUC) evaluated the prognostic value of the VMT score.

RESULTS

The risk of all-cause mortality was increased in HFmrEF patients in the VMT score of 2 (HR = 2.80, 95%CI: 1.04-7.52) and 3 (HR = 4.29, 95%CI: 1.58-11.66). The VMT score of 3 was associated with an increased risk of 1-year CVD-cause mortality in patients with HFmrEF (HR = 7.63, 95%CI: 1.70-34.33). The AUC of VMT score for predicting 1-year all-cause mortality of HFmrEF patients was 0.724, and for predicting 1-year CVD-cause mortality of HFmrEF patients was 0.748. The survival probability of patients with the VMT score < 2 was higher than those with the VMT score of 2 and 3.

CONCLUSION

The VMT score might be a reliable prognostic index for 1-year all-cause or CVD-cause mortality of HFmrEF patients.

Diagnosis of heart failure with preserved ejection fraction: a systematic narrative review of the evidence

Heart failure (HF) with preserved ejection fraction (HFpEF) is a common condition in clinical practice, affecting more than half of patients with HF. HFpEF is associated with morbidity and mortality and with considerable healthcare resource utilization and costs. Therefore, early diagnosis is crucial to facilitate prompt management, particularly initiation of sodium-glucose co-transporter 2 inhibitors. Although European guidelines define HFpEF as the presence of symptoms with or without signs of HF, left ventricular EF ≥ 50%, and objective evidence of cardiac structural and/or functional abnormalities, together with elevated natriuretic peptide levels, the diagnosis of HFpEF remains challenging. First, there is no clear consensus on how HFpEF should be defined. Furthermore, diagnostic tools, such as natriuretic peptide levels and resting echocardiogram findings, are significantly limited in the diagnosis of HFpEF. As a result, some patients are overdiagnosed (i.e., elderly people with comorbidities that mimic HF), although in other cases, HFpEF is overlooked. In this manuscript, we perform a systematic narrative review of the diagnostic approach to patients with HFpEF. We also propose a comprehensible algorithm that can be easily applied in daily clinical practice and could prove useful for confirming or ruling out a diagnosis of HFpEF.

GSTM2 alleviates heart failure by inhibiting DNA damage in cardiomyocytes

BACKGROUND

Heart failure (HF) seriously threatens human health worldwide. However, the pathological mechanisms underlying HF are still not fully clear.

RESULTS

In this study, we performed proteomics and transcriptomics analyses on samples from human HF patients and healthy donors to obtain an overview of the detailed changes in protein and mRNA expression that occur during HF. We found substantial differences in protein expression changes between the atria and ventricles of myocardial tissues from patients with HF. Interestingly, the metabolic state of ventricular tissues was altered in HF samples, and inflammatory pathways were activated in atrial tissues. Through analysis of differentially expressed genes in HF samples, we found that several glutathione S-transferase (GST) family members, especially glutathione S-transferase M2-2 (GSTM2), were decreased in all the ventricular samples. Furthermore, GSTM2 overexpression effectively relieved the progression of cardiac hypertrophy in a transverse aortic constriction (TAC) surgery-induced HF mouse model. Moreover, we found that GSTM2 attenuated DNA damage and extrachromosomal circular DNA (eccDNA) production in cardiomyocytes, thereby ameliorating interferon-I-stimulated macrophage inflammation in heart tissues.

CONCLUSIONS

Our study establishes a proteomic and transcriptomic map of human HF tissues, highlights the functional importance of GSTM2 in HF progression, and provides a novel therapeutic target for HF.

Antagonism of contractile forces in left ventricular hypertrophy: a diagnostic challenge for better pathophysiological and clinical understanding

Cardiac function is characterised by haemodynamic parameters in the clinical scenario. Due to recent development in imaging techniques, the clinicians focus on the quantitative assessment of left ventricular size, shape and motion patterns mostly analysed by echocardiography and cardiac magnetic resonance. Because of the physiologically known antagonistic structure and function of the heart muscle, the effective performance of the heart remains hidden behind haemodynamic parameters. In fact, a smaller component of oblique transmural netting of cardiac muscle fibres simultaneously engenders contracting and dilating force vectors, while the predominant mass of the tangentially aligned fibres only acts in one direction. In case of hypertrophy, an increased influence of the dilating transmural fibre component might counteract systolic wall thickening, thereby counteract cardiac output. A further important aspect is the response to inotropic stimulation that is different for the tangentially aligned fibre component in comparison to the transmural component. Both aspects highlight the importance to integrate the analysis of intramural fibre architecture into the clinical cardiac diagnostics.

The prognostic impact of specialist cardiology input in patients admitted for heart failure and normal ejection fraction

AIMS

Specialist cardiology care is associated with a prognostic benefit in patients with heart failure (HF) with reduced ejection fraction (HFrEF) admitted with decompensated HF. However, up to one third of patients admitted with HF and normal ejection fraction (HFnEF) do not receive specialist cardiology input. Whether this has prognostic implications is unknown.

METHODS AND RESULTS

Data on patients hospitalized with HFnEF from two tertiary centres were analysed. The primary outcome measure was all-cause mortality during follow-up. The secondary outcome was in-hospital mortality. A total of 1413 patients were included in the study. Of these, 23% (n = 322) did not receive in-hospital specialist cardiology input. Patients seen by a cardiologist were less likely to have hypertension (73% vs. 79%, P = 0.03) and respiratory co-morbidities (25% vs. 31%, P = 0.02) compared with those who did not receive specialist input. Similarly, clinical presentation was more severe for those who received specialist input (New York Heart Association III/IV 83% vs. 75% respectively, P = 0.003; moderate-to-severe peripheral oedema 65% vs. 54%, P < 0.001). Medical management was similar, except for a higher use of diuretics (90% vs. 86%, P = 0.04) and a longer length of stay for patients who received specialist input (9 vs. 4 days, P < 0.001). Long-term outcomes were comparable between patients who received specialist input and those who did not. However, specialist input was independently associated with lower in-hospital mortality (hazard ratio 0.19, confidence interval 0.09-0.43, P < 0.001).

CONCLUSIONS

In-hospital cardiology specialist input has no long-term prognostic advantage in patients with HFnEF but is independently associated with reduced in-hospital mortality.

Echocardiography Imaging of the Right Ventricle: Focus on Three-Dimensional Echocardiography

Right ventricular function strongly predicts cardiac death and adverse cardiac events in patients with cardiac diseases. However, the accurate right ventricular assessment by two-dimensional echocardiography is limited due to its complex anatomy, shape, and load dependence. Advances in cardiac imaging and three-dimensional echocardiography provided more reliable information on right ventricular volumes and function without geometrical assumptions. Furthermore, the pathophysiology of right ventricular dysfunction and tricuspid regurgitation is frequently connected. Three-dimensional echocardiography allows a more in-depth structural and functional evaluation of the tricuspid valve. Understanding the anatomy and pathophysiology of the right side of the heart may help in diagnosing and managing the disease by using reliable imaging tools. The present review describes the challenging echocardiographic assessment of the right ventricle and tricuspid valve apparatus in clinical practice with a focus on three-dimensional echocardiography.

ECHOCARDIOGRAPHIC METHODS FOR ASSESSING LEFT VENTRICULAR SYSTOLIC FUNCTION

Transthoracic echocardiography (TTE) is the recommended primary method of assessing cardiac function. The measurement of LVEF determines the strategy for treatment of patients, as well as influences their prognosis. 3D echocardiography has higher accuracy and reproducibility than 2D echocardiography; hence it is currently recommended for volume and LVEF measurements. New echocardiographic techniques: global longitudinal strain measured by speckle tracking and myocardial work allow earlier detection of myocardial abnormalities. In addition, they have greater sensitivity in detecting ischemia, fibrosis and left ven¬tricular systolic dyssynchrony. In some myocardial pathologies, such as amyloidosis, hypertrophic cardiomyopathy or Chagas disease, we observe characteristic patterns of myocardial deformation (strain), which are their hallmarks. Myocardial work, on the other hand, allows assessment of contractility independent of the effect of afterload. The new echocardiographic techniques provide additional diagnostic tools for assessing left ventricular systolic function and informa¬tion on prognosis, and hence their use can be expected to become more widespread in daily clinical practice.