Activation of neurohumoral systems in postinfarction left ventricular dysfunction

A review of therapeutic approaches for post-infarction left ventricular remodeling

Left ventricular remodeling is an adaptive process initially developed in response to acute myocardial infarction (AMI), but it ends up with negative adverse outcomes such as infarcted wall thinning, ventricular dilation, and cardiac dysfunction. A prolonged excessive inflammatory reaction to cardiomyocytes death and necrosis plays the crucial role in the pathophysiological mechanisms. The pharmacological treatment includes nitroglycerine, β-blockers, ACEi/ARBs, SGLT2i, mineralocorticoid receptor antagonists, and some miscellaneous aspects. Stem cells therapy, CD34+ cells transplantation and gene therapy constitute the promissing therapeutic approaches for post AMI cardiac remodeling, thereby enhancing angiogenesis, cardiomyocytes differenciation and left ventricular function on top of inhibiting apoptosis, inflammation, and collagen deposition. All these lead to reduce infarct size, scar formation and myocardial fibrosis.

Myeloid cell-specific ablation of Runx2 gene exacerbates post-infarct cardiac remodeling

Runt-related transcription factor 2 (Runx2), a regulator of osteoblast differentiation, is pathologically involved in vascular calcification; however, the significance of Runx2 in cardiac homeostasis remains unclear. Here, we investigated the roles of Runx2 in cardiac remodeling after myocardial infarction (MI). The expression of Runx2 mRNA and protein was upregulated in murine hearts after MI. Runx2 was expressed in heart-infiltrating myeloid cells, especially in macrophages, at the border zone of post-infarct myocardium. To analyze the biological functions of Runx2 in cardiac remodeling, myeloid cell-specific Runx2 deficient (CKO) mice were exposed to MI. After MI, ventricular weight/tibia length ratio was increased in CKO mice, concomitant with severe cardiac dysfunction. Cardiac fibrosis was exacerbated in CKO mice, consistent with the upregulation of collagen 1a1 expression. Mechanistically, immunohistochemical analysis using anti-CD31 antibody showed that capillary density was decreased in CKO mice. Additionally, conditioned culture media of myeloid cells from Runx2 deficient mice exposed to MI induced the tube formation of vascular endothelial cells to a lesser extent than those from control mice. RNA-sequence showed that the expression of pro-angiogenic or anti-angiogenic factors was altered in macrophages from Runx2-deficient mice. Collectively, Runx2⁺ myeloid cells infiltrate into post-infarct myocardium and prevent adverse cardiac remodeling, at least partially, by regulating endothelial cell function.

Assessment of Ultra-Early Administration of Sacubitril Valsartan to Improve Cardiac Remodeling in Patients With Acute Myocardial Infarction Following Primary PCI: Rational and Design of a Prospective, Multicenter, Randomized Controlled Trial

Background

Despite coronary re-vascularization, the common complications of acute myocardial infarction (AMI), cardiac remodeling, and heart failure (HF), is increasing globally. Sacubitril valsartan (SV), an angiotensin receptor-neprilysin inhibitor (ARNI), has been previously demonstrated to improve HF. We further hypothesize that ultra-early SV treatment is also effective in preventing cardiac remodeling for patients with AMI following primary percutaneous coronary intervention (PCI).

Methods

The Assessment of ultra-early administration of Sacubitril Valsartan to improve cardiac remodeling in patients with Acute Myocardial Infarction following primary PCI (ASV-AMI) trial is a prospective, multicenter, randomized controlled trial in China planning to enroll at least 1,942 eligible patients from 10 centers. After successful primary PCI of culprit artery within 24 h, AMI patients are randomized to 2 h group or 3–7 days group with SV treatment. The major endpoints are echocardiographic measurement, cardiothoracic ratio, and N-Terminal pro-B-Type Natriuretic Peptide (NT pro-BNP) at baseline, 1, 3, 6, and 12 months. The secondary endpoints included MACE (cardiac arrest, cardiogenic death, myocardial infarction, and target vessel re-vascularization), in-/out-patient HF, EuroQol Five Dimensions Questionnaire (EQ-5D), and Kansas City Cardiomyopathy Questionnaire (KCCQ).

Discussion

The ASV-AMI trial is the first clinical trial of ultra-early administration of SV in the treatment of post-PCI AMI, adding more clinical evidence. Early application of SV to prevent cardiac remodeling in AMI patient is a major focus of this trial.

Clinical Trial Registration

Trial registration Chinese Clinical Trial Registry (http://www.chictr.org.cn; ChiCTR2100051979). Registered on 11 October 2021.

Comparison of the Efficacy and Safety of Sacubitril/Valsartan versus Ramipril in Patients With ST-Segment Elevation Myocardial Infarction

The role of sacubitril and/or valsartan in patient with heart failure (HF) is established. Whether sacubitril and/or valsartan plays a role in improving outcomes in patients after ST-segment elevation myocardial infarction (STEMI) is unknown. The current study aims to comparing the efficacy and safety of sacubitril and/or valsartan versus ramipril in post-STEMI patients. Patients presenting with STEMI were randomized to receive either sacubitril and/or valsartan or ramipril after primary percutaneous coronary intervention. The main efficacy endpoint was major adverse cardiac events (MACE) at 30 days and 6 months, defined as a composite of cardiac death, myocardial infarction, and HF hospitalizations. Multiple secondary clinical safety and efficacy endpoints were examined. A total of 200 patients were randomized from January 2018 to March 2019, mean age 54.5±10.4, 87% men, 75% presented with anterior wall STEMI. Baseline clinical and echocardiographic characteristics were comparable between groups. The primary endpoint of MACE was similar with sacubitril/valsartan versus ramipril at 30 days (p = 0.18); however, at 6 months, sacubitril/valsartan was associated with significant reduction of MACE (p = 0.005), mainly driven by reduction in HF hospitalizations (18% vs 36%, OR 0.40, 95% 0.22 to 0.75; p = 0.004). At 6 months, LV ejection fraction was higher with sacubitril/valsartan (46.8±12.5% vs 42.09±13.8%; p = 0.012), with improved LV remodelling (LV end diastolic dimension 50.6±3.9 mm vs 53.2±2.7 mm, p = 0.047; and LV end systolic dimension 36.1±3.4 mm versus 39.9±6.3 mm, p = 0.001) compared with ramipril. No difference in other efficacy or safety clinical endpoints was observed. In conclusion, early initiation of sacubitril/valsartan may offer clinical benefit and improvement in myocardial remodelling in post-STEMI patients.

Hyponatraemia aggravates cardiac susceptibility to ischaemia/reperfusion injury

Hyponatraemia is defined as a serum sodium concentration of <135 mEql/L and is the most common electrolyte disturbance in patients with chronic heart failure. We hypothesize that hyponatraemia may induce Ca²⁺ overload and enhance reactive oxygen species (ROS) production, which will exacerbate myocardial injury more than normonatraemia. We investigated the effect of hyponatraemia on the ability of the heart to recover from ischaemia/reperfusion episodes. Cardiomyocytes were obtained from 1- to 3-day-old Sprague Dawley rats. After isolation, cardiomyocytes were placed in Dulbecco's modified Eagle's medium (DMEM) containing low sodium concentration (110, 120, or 130 mEq/L) or normal sodium concentration (140 mEq/L) for 72 hours. Exposure of cardiomyocytes to each of the low-sodium medium significantly increased both ROS and intracellular Ca²⁺ levels compared with the exposure to the normal-sodium medium. In vivo, 8-week-old male Sprague Dawley rats were divided into four groups: control group (Con), furosemide group (Fur), low-sodium diet group (Lsd) and both furosemide and low-sodium diet group (Fur + Lsd). The hearts subjected to global ischaemia exhibited considerable decrease in left ventricular developed pressure during reperfusion, and the size of infarcts induced by ischaemia/reperfusion significantly increased in the Fur, Lsd and Fur + Lsd compared with that in the Con. Hyponatraemia aggravates cardiac susceptibility to ischaemia/reperfusion injury by Ca²⁺ overload and increasing in ROS levels.

Identification of a Common Different Gene Expression Signature in Ischemic Cardiomyopathy

The molecular mechanisms underlying the development of ischemic cardiomyopathy (ICM) remain poorly understood. Gene expression profiling is helpful to discover the molecular changes taking place in ICM. The aim of this study was to identify the genes that are significantly changed during the development of heart failure caused by ICM. The differentially expressed genes (DEGs) were identified from 162 control samples and 227 ICM patients. PANTHER was used to perform gene ontology (GO), and Reactome for pathway enrichment analysis. A protein–protein interaction network was established using STRING and Cytoscape. A further validation was performed by real-time polymerase chain reaction (RT-PCR). A total of 255 common DEGs was found. Gene ontology, pathway enrichment, and protein–protein interaction analysis showed that nucleic acid-binding proteins, enzymes, and transcription factors accounted for a great part of the DEGs, while immune system signaling and cytokine signaling displayed the most significant changes. Furthermore, seven hub genes and nine transcription factors were identified. Interestingly, the top five upregulated DEGs were located on chromosome Y, and four of the top five downregulated DEGs were involved in immune and inflammation signaling. Further, the top DEGs were validated by RT-PCR in human samples. Our study explored the possible molecular mechanisms of heart failure caused by ischemic heart disease.

Percutaneous Ventricular Restoration with a Partitioning Device for Ischemic Heart Failure Treatment

PURPOSE OF THE REVIEW

Percutaneous ventricular restoration with a ventricular partitioning device (VPD) is a novel minimally invasive procedure designed to restore the left ventricular (LV) shape by isolating the infarcted and aneurysmal LV apex from remainder of the cavity in heart failure patients with severely reduced LV ejection fraction. In this review, we perform an in-depth analysis of the design and purpose of the VPD and review the available clinical data, with special attention to hemodynamics, outcomes, and complications.

RECENT FINDINGS

PARACHUTE trials have shown >90% procedural success rate of VPD implant. Heart failure patients had improvement in hemodynamics (reduction in LV volumes and increase in LV ejection fraction) and functional status (6-min walking distance and quality of life scores) after the VPD implant. Optimal implant position is necessary to obtain a good clinical outcome. Percutaneous VPD implantation has thus far been a safe intervention capable of improving surrogate markers of heart failure but there is still a need to develop more durable devices with a long-lasting hemodynamics effect.

Angiotensin II receptor blockers suppress the release of stromal cell-derived factor-1α from infarcted myocardium in patients with acute myocardial infarction

BACKGROUND

Although angiotensin II receptor blockers (ARBs) have been shown to have anti-inflammatory effects on infarcted myocardium in experimental models, little is known in humans. Stromal cell-derived factor-1α (SDF-1α), a pro-inflammatory chemokine, is released from infarcted tissue in patients with acute myocardial infarction (AMI). This study examined whether ARBs suppress SDF-1α production in the infarcted lesion in patients with AMI.

METHODS

SDF-1α levels were measured by enzyme-linked immunosorbent assays in plasma obtained from the aortic root (AO) and the anterior interventricular vein (AIV) in 50 patients with an anterior AMI. Measurement of SDF-1α levels and left ventriculography were repeated at discharge and 6 months after AMI. Patients were divided into 2 groups according to treatment with ARBs, which were administered at the discretion of the attending physician after admission.

RESULTS

The AIV-AO gradient of SDF-1α, reflecting SDF-1α release from the infarcted myocardial region, decreased between the time of discharge and 6 months after AMI in patients taking an ARB. In contrast, the SDF-1α transcardiac gradient did not change in patients not taking an ARB. Among the clinical parameters tested, only the use of ARBs was significantly associated with percent changes in the SDF-1α transcardiac gradient from the time of discharge to 6 months after AMI in a linear regression analysis (r=-0.31, p=0.03). The SDF-1α transcardiac gradient 6 months after AMI was inversely correlated with the percent change in left ventricular (LV) ejection fraction (r=-0.52, p<0.01) and positively correlated with the percent change in LV end-diastolic volume index (r=0.57, p<0.01) and LV end-systolic volume index (r=0.54, p<0.01) during 6 months after AMI.

CONCLUSIONS

ARB treatment suppressed SDF-1α release from the infarcted myocardial region, which was associated with improvement in LV dysfunction and adverse remodeling in AMI survivors.

Amelioration of cardiac dysfunction and ventricular remodeling after myocardial infarction by danhong injection are critically contributed by anti-TGF-β-mediated fibrosis and angiogenesis mechanisms

ETHNOPHARMACOLOGICAL RELEVANCE

Danhong injection (DHI) is a standardized product extracted from Radix et Rhizoma Salviae Miltiorrhizae and Flos Carthami , which has been long applied mainly used to treat ischemic encephalopathy and cardiac diseases including myocardial infarction and angina in clinical practice.

AIM OF THE STUDY

Aim of this study was to investigate the salutary effects of DHI by slowing ventricular remodeling and improving cardiac function after myocardial infarction (MI) in rats.

MATERIALS AND METHODS

In this study, Male Sprague-Dawley rats were subjected to ligation on left anterior descending coronary artery to establish MI models and valsartan was selected as positive control. Cardiac function examination was conducted at the 1st, 3rd, 7th, 14th and the 28th days after LAD. Haematoxylin and Eosin (HE) staining and Masson staining were conducted to observe cardiac pathology and morphological changes levels of VEGF, TGF-β, MMP-2, and MMP-9 in the myocardial tissue were determined in gene and protein expressions.

RESULTS

After 3 days post-treatment and thereafter, EF and FS in DHI group were greater than that of model group (p<0.05). Compared with the MI group, ratio of infarct was markedly decreased in treated-DHI group(p<0.05). TGF-β1 protein and fibrosis-related proteins MMP-2 and MMP-9 were up-regulated after MI, and they were significantly suppressed by the administration of DHI(p<0.05 and p<0.01, respectively). Moreover, DHI improved the mRNA expression of VEGF and increased the blood vessel density of myocardial infarct border zone. DHI decreased the expression of cell apoptosis protein of caspase-3 and increased the anti-apoptotic protein, bcl-2.

CONCLUSIONS

We provided direct evidences that DHI improves cardiac remodeling and preserves ventricular function post-MI in rats. DHI conferred cardio-protection in rats with MI via anti-myocardial apoptosis, angiogenesis, reduction of myocardial fibrosis and many other aspects of joint actions.

Myocardial Production of Plasminogen Activator Inhibitor-1 is Associated with Coronary Endothelial and Ventricular Dysfunction after Acute Myocardial Infarction

AIM

Although plasminogen activator inhibitor-1 (PAI-1) is abundantly expressed in infarcted myocardium, the pathogenic role of myocardial PAI-1 remains unknown. This study examined whether PAI-1 in the infarcted lesion contributes to coronary endothelial dysfunction and left ventricular (LV) dysfunction in patients with acute myocardial infarction (AMI).

METHODS

Plasma levels of PAI-1 activity and tissue-plasminogen activator (tPA) antigen were measured 2 weeks and 6 months after MI by ELISA in plasma obtained from the aortic root (AO) and anterior interventricular vein (AIV) in 28 patients with a first AMI due to occlusion of the left anterior descending coronary artery (LAD). Coronary blood flow responses in LAD to intracoronary infusion of acetylcholine (ACh) and left ventriculography were measured at the same time points: 2 weeks and 6 months after MI.

RESULTS

The trans-myocardial gradient of PAI-1 from AO to AIV, reflecting production/release of PAI-1 in the infarcted lesion, was inversely correlated with the coronary blood flow response to ACh 6 months after MI (r=-0.43, p=0.02) and with the percentage change in LV regional motion in the LAD territory from 2 weeks to 6 months after MI (r=-0.38, p=0.04). The trans-myocardial gradient of tPA level showed no significant correlations.

CONCLUSIONS

PAI-1 produced in the infarcted myocardium and released into the coronary circulation is associated with endothelial dysfunction in resistance vessels of the infarct-related coronary arteries and with progressive dysfunction of the infarcted region of the left ventricle in AMI survivors.

Sustained myocardial production of stromal cell-derived factor-1α was associated with left ventricular adverse remodeling in patients with myocardial infarction

The role of stromal cell-derived factor-1α (SDF-1α) expressed in infarcted myocardium is unknown in humans. We examined whether SDF-1α produced in an infarcted myocardial lesion may play a role in left ventricle (LV) remodeling and dysfunction in patients with acute myocardial infarction (AMI). We measured SDF-1α levels in plasma obtained from aortic root (AO) and anterior interventricular vein (AIV) in the early phase (2 wk after MI) and the chronic phase (6 mo after MI) in 80 patients with anterior MI. An increment in SDF-1α level from AO to AIV, reflecting SDF-1α release from infarcted myocardium, was more frequent in patients with MI in the early phase of MI [n = 52 (65%), P = 0.03] but not in the chronic phase of MI [n = 46 (58%), P = 0.11] compared with that in control patients [n = 6/17 (35%)]. On linear regression analysis, the transmyocardial gradient in SDF-1α level in the chronic phase of MI was correlated with percentage changes in LV end-diastolic volume index (r = 0.39, P < 0.001), LV end-systolic volume index (r = 0.38, P < 0.001), and LV ejection fraction (r = -0.26, P = 0.01) 6 mo after AMI. By contrast, the transmyocardial gradient of SDF-1α in the early phase of MI had no significant correlations. In conclusion, the production of SDF-1α in infarcted myocardium in the chronic phase of MI was associated with LV adverse remodeling and progressive dysfunction in AMI survivors.

Augmentation of autophagy by atorvastatin via Akt/mTOR pathway in spontaneously hypertensive rats

Autophagy is activated in hypertension-induced cardiac hypertrophy. However, the mechanisms and significance of an activated autophagy are not clear. This study was designed to determine the role of atorvastatin (ATO) in cardiac autophagy and associated benefits on cardiac remodeling and left ventricular function in spontaneously hypertensive rats (SHRs). Twenty-eight male SHRs at 8 weeks of age were randomized to treatment with vehicle (saline solution; SHR+V) or ATO (SHR+ATO; 50 mg kg(-1) per day) for 6 or 12 months. Age-matched male Wistar-Kyoto (WKY) rats were used as normotensive controls. Cardiac magnetic resonance was used to evaluate cardiac function and structure. Compared with WKY rats, SHRs showed significant left ventricle (LV) dysfunction, remodeling and increases in cardiomyocyte size, which were all attenuated by 6 and 12 months of ATO treatment. Compared with WKY rats, autophagy was activated in the hearts of SHRs and this effect was amplified by chronic ATO treatment, particularly following 12 months of treatment. Protein expression levels of microtubule-associated protein-1 light chain 3-II and beclin-1, the biomarkers of an activated cardiac autophagy, were significantly elevated in ATO-treated versus vehicle-treated SHRs and control WKY rats. Cardiac Akt and phosphorylated mammalian target of rapamycin (mTOR) expression were also increased in the hearts of SHR versus WKY rats, and this effect was attenuated by ATO treatment. These findings suggest that ATO-mediated improvements in LV function and structure in SHRs may be, in part, through its regulation of cardiac autophagy via the Akt/mTOR pathway.

Functional networks of nucleocytoplasmic transport-related genes differentiate ischemic and dilated cardiomyopathies. A new therapeutic opportunity

Heart failure provokes alterations in the expression of nucleocytoplasmic transport-related genes. To elucidate the nucleocytoplasmic transport-linked functional network underlying the two major causes of heart failure, ischemic cardiomyopathy (ICM) and dilated cardiomyopathy (DCM), we examined global transcriptome profiles of left ventricular myocardium tissue samples from 31 patients (ICM, n = 10; DCM, n = 13) undergoing heart transplantation and control donors (CNT, n = 8) using RNA-Sequencing and GeneMANIA. Comparative profiling of ICM versus control and DCM versus control showed 1081 and 2440 differentially expressed genes, respectively (>1.29-fold; P<0.05). GeneMANIA revealed differentially regulated functional networks specific to ICM and DCM. In comparison with CNT, differential expression was seen in 9 and 12 nucleocytoplasmic transport-related genes in ICM and DCM groups, respectively. DDX3X, KPNA2, and PTK2B were related to ICM, while SMURF2, NUP153, IPO5, RANBP3, NOXA1, and RHOJ were involved in DCM pathogenesis. Furthermore, the two pathologies shared 6 altered genes: XPO1, ARL4, NFKB2, FHL3, RANBP2, and RHOU showing an identical trend in expression in both ICM and DCM. Notably, the core of the derived functional networks composed of nucleocytoplasmic transport-related genes (XPO1, RANBP2, NUP153, IPO5, KPNA2, and RANBP3) branched into several pathways with downregulated genes. Moreover, we identified genes whose expression levels correlated with left ventricular mass index and left ventricular function parameters in HF patients. Collectively, our study provides a clear distinction between the two pathologies at the transcriptome level and opens up new possibilities to search for appropriate therapeutic targets for ICM and DCM.

AT1 receptor blockade for the prevention of cardiovascular events after myocardial infarction

Myocardial infarction is associated with high morbidity and mortality. Multiple therapeutic modalities have been shown to be effective in reducing adverse postmyocardial infarction outcomes. The most prominent drugs that have been used in this group of patients are those that oppose the effects of the renin-angiotensin-aldosterone system. These drugs include beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and aldosterone blockers. Following initial success with angiotensin-converting enzyme inhibitors in reducing mortality and cardiac remodeling in postmyocardial infarction patients, recent focus has been on adjunctive or alternative use of angiotensin II-receptor antagonists. Multiple large-scale, randomized trials have been conducted in order to compare angiotensin II-receptor antagonists with a combination of angiotensin II-receptor antagonists and angiotensin-converting enzyme inhibitors, and with angiotensin-converting enzyme inhibitors alone in postmyocardial infarction patients and also in heart failure. Although some results are conflicting, the weight of evidence is towards equivalency of these two groups of medicines, provided that the maximum effective dose of the angiotensin II-receptor antagonists is used. The combination of an angiotensin-converting enzyme inhibitor and an angiotensin II-receptor antagonist may have additional benefits for some, but not all, patients; for example, reducing morbidity and mortality in patients with chronic heart failure but not in postmyocardial infarction patients. Indeed, in the postmyocardial infarction setting, the combination appears simply to increase the side effects, without conferring additional benefits. Use of aldosterone antagonists as adjunctive therapy in postmyocardial infarction patients is associated with added benefits in terms of mortality reduction and will become the standard of care in this group of patients.

Progressive dilation of the left atrium and ventricle after acute myocardial infarction is associated with high mortality

Background and Objectives

The purpose of this study is to identify the prevalence of progressive dilation in patients with acute myocardial infarction (AMI) combined with heart failure (HF) and determine the prognostic significance and associated factors with a geometric change of an infarcted heart.

Subjects and Methods

A total of 1310 AMI patients with HF (63.9±12.5 years, 70% male) between November 2005 and April 2011 underwent echocardiography at admission and one year later. Left ventricular (LV) remodeling is defined as 20% progression, and left atria (LA) remodeling is 10% compared with the initial volume index.

Results

The prevalence of both LA and LV remodeling was 13.9%; LV only was 9.3%, LA only 22.8% and non-remodeling was 55.1%, respectively. In the non-remodeling group, Killip class II was more frequent (83.9%, p<0.001) whereas in other remodeling groups, Killip class III was more frequent. Initial wall motion score index, ejection fraction, maximal cardiac enzyme, high sensitive C-reactive protein, B type natriuretic peptide, and triglyceride serum levels were significantly associated with heart remodeling. All causes of death occurred in 168 cases (12.8%) during the follow-up period. Mortality was the highest in the LV and LA remodeling group (20.9%) and the lowest in the non-remodeling group (11.4%). During the period of follow-up, the cumulative survival rate was significantly lower in the groups of LA and LV remodeling than in others (log rank p=0.006).

Conclusion

Total mortality was significantly increased in patients AMI with geometrically progressive LA and LV dilatation.

Galectin-3 and cardiac function in survivors of acute myocardial infarction

BACKGROUND

Galectin-3 is a biomarker associated with inflammation and fibrosis that predicts adverse outcome and relates to biomarkers of extracellular matrix turnover in patients with heart failure, particularly when left ventricular (LV) systolic function is preserved. Whether galectin-3 is related to LV remodeling after acute myocardial infarction is unknown.

METHODS AND RESULTS

Circulating galectin-3 and various extracellular matrix biomarkers were measured in 100 patients (age, 58.9±12.0 years; 77% men) admitted with acute myocardial infarction and LV dysfunction, at baseline (mean 46 hours) and at 24 weeks, with cardiac MRI at each time-point. LV remodeling was defined as change in LV end-systolic volume index. Relationships among galectin-3, biomarkers, and LV remodeling were analyzed across the entire cohort, then according to median baseline LV ejection fraction. Galectin-3 levels were elevated in 22 patients (22%) at baseline and increased significantly over time from 14.7±5.5 to 16.3±6.6 ng/mL (P=0.007). Baseline galectin-3 did not correlate with any LV parameters at baseline or change in any parameter over time. Galectin-3 was positively associated with remodeling in patients with supramedian baseline LV ejection fraction (ie, >49.2%; r=0.40; P=0.01) but not when LV ejection fraction was ≤49.2%. Galectin-3 correlated significantly with matrix metalloproteinase-3 and monocyte chemoattractant protein-1 at baseline, biomarkers that have been shown to relate to LV remodeling in this cohort.

CONCLUSIONS

Galectin-3 correlated significantly with certain biomarkers involved in extracellular matrix turnover, although no definite relationship was identified with LV remodeling. Whether galectin-3 plays a pathological role in remodeling remains unclear but merits further study.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00132093.

Heart rate variability in patients hospitalized for decompensated diastolic heart failure at admission and after clinical stabilization

Aims: We investigated heart rate variability (HRV) in patients hospitalized for decompensated diastolic heart failure and the effect of compensation course on HRV parameters. We also examined the association between the degree of diastolic dysfunction and HRV indices. Patients & methods: A total of 42 patients hospitalized for decompensated heart failure, who had a measured ejection fraction ≥50%, and ten age- and sex-matched healthy volunteers were enrolled. Results: All HRV indices were lower compared with the control group both at admission (p < 0.001) and after compensation, although a significant increase was observed in each index measured after clinical stabilization (p < 0.001). Improvement in HRV indices was lowest in patients with a restrictive pattern among groups of different degrees of diastolic dysfunction. Conclusion: Impairment in HRV in decompensated diastolic heart failure is more pronounced with increasing grade of diastolic dysfunction. It remains to be investigated whether decompensation may be predicted by marked depression in these indexes or if severely impaired HRV is a consequence of decompensation.

Copeptin: a biomarker of cardiovascular and renal function

Arginine vasopressin (AVP or antidiuretic hormone) is one of the key hormones in the human body responsible for a variety of cardiovascular and renal functions. It has so far escaped introduction into the routine clinical laboratory due to technical difficulties and preanalytical errors. Copeptin, the C-terminal part of the AVP precursor peptide, was found to be a stable and sensitive surrogate marker for AVP release. Copeptin behaves in a similar manner to mature AVP in the circulation, with respect to osmotic stimuli and hypotension. During the past years, copeptin measurement has been shown to be of interest in a variety of clinical indications, including cardiovascular diseases such as heart failure, myocardial infarction, and stroke. This review summarizes the recent progress on the diagnostic use of copeptin in cardiovascular and renal diseases and discusses the potential use of copeptin measurement in the context of therapeutic interventions with vasopressin receptor antagonists.

Early development of hyponatremia implicates short- and long-term outcomes in ST-elevation acute myocardial infarction

BACKGROUND

Clinical importance of hyponatremia in ST-elevation acute myocardial infarction (STEMI) in the era of primary intervention has not been fully understood. The aim of this study was to investigate the impact of hyponatremia on outcomes in patients with STEMI and secondarily to investigate the contribution of arginine vasopressin (AVP) to hyponatremia in STEMI.

METHODS AND RESULTS

Hyponatremia was defined as a sodium concentration <136 mmol/L at 72h after hospitalization. First, the short-term (in-hospital mortality or congestive heart failure (CHF)) and long-term prognosis (cardiac death, re-admission for CHF) in STEMI patients was conducted. Second, the relationship between serum sodium level and plasma AVP was investigated. In hyponatremic patients the incidence of in-hospital heart failure was significantly greater (P=0.0018), long-term cardiac death was a higher trend (17.2% vs. 6.3%, P=0.19) and re-admission due to CHF was significantly more frequent (20.7% vs. 4.5%, P=0.0024). Plasma AVP level was higher in the hyponatremia group (4.5 vs. 2.7 pg/ml, P=0.003), and it had a negative correlation with serum sodium level (r=-0.28, P=0.02).

CONCLUSIONS

Hyponatremia was frequently found in the early phase of STEMI, and associated with heart failure in both short- and long-term outcomes. Non-osmotic secretion of AVP could be involved in hyponatremia in STEMI patients.

Dyslipidemia, low left ventricular ejection fraction and high wall motion score index are predictors of progressive left ventricular dilatation after acute myocardial infarction

BACKGROUND AND OBJECTIVES

Left ventricular (LV) remodeling is a heterogeneous process, involving both infarcted and non-infarcted zones, which affects wall thickness and chamber size, shape and function.

SUBJECTS AND METHODS

A total of 758 consecutive patients (62.8±12.0 years, 539 males) with acute myocardial infarction (AMI), who were examined by echocardiography at admission and after 6 months. An increase in LV end-diastolic volume index >10% was defined as a progressive LV dilation. They were divided into two groups according to the extent of progressive LV dilatation during 6 months. Group I with progressive LV dilatation (n=154, 61.4±11.0 years, 110 males) vs. group II without LV dilatation (n=604, 64.1±12.0 years, 429 males).

RESULTS

The age and gender were no significant differences between two groups. The levels of glucose, creatinine, maximal creatine kinase (CK), CK-MB, troponin T and I were significantly increased in group I than in group II (p<0.05). Low ejection fraction (EF) and high wall motion score index (WMSI) were more common in group I than in group II (p<0.05). The presence of dyslipidemia {odds ratio (OR); 1.559, confidence interval (CI); 1.035-2.347, p=0.03}, low EF less than 45% (OR; 3.328, CI 2.099-5.276, p<0.01) and high WMSI above 1.5 (OR; 3.328, CI 2.099-5.276, p<0.01) were sig-nificant independent predictors of progressive LV dilatation by multivariate analysis.

CONCLUSION

Dyslipidemia, decreased systolic function and high WMSI were independent predictors of LV remodeling process in patients with AMI.

Changes in autonomic balance in patients with decompensated chronic heart failure

OBJECTIVE

In chronic heart failure (CHF) episodes of decompensation may be linked to derangements within cardiovascular reflex control. We investigated changes in autonomic tone in patients with decompensated CHF.

METHODS

We examined 17 patients with decompensated CHF (14 men, age 62 ± 2 years, LVEF 32 ± 3%) on admission and after clinical stabilization. Control group consisted of 9 patients (8 men, age 64 ± 7 years, LVEF 30 ± 7%) with stable CHF. Assessment of autonomic tone was based on 5-min ECG and blood pressure recordings using time and frequency domains of heart rate variability (HRV) and a sequence method to derive baroreflex sensitivity (BRS).

RESULTS

On admission, decompensated CHF patients had reduced HRV indices (p < 0.05) and depressed BRS (p < 0.01) as compared to those with stable CHF. After clinical stabilization (4 ± 2 days of treatment) time domain HRV indices and BRS increased (SDNN, 34.4 ± 5.4 vs. 55.8 ± 9.8 ms; RMSSD, 38.4 ± 12.0 vs. 51.1 ± 10.4 ms; BRS, 4.3 ± 0.7 vs. 7.6 ± 1.3 ms/mmHg; all p < 0.01) and became similar to those seen in stable CHF patients. Breathing with oxygen affected autonomic indices neither in decompensated nor in stable CHF patients. Eight patients developed an episode of additional CHF worsening during hospitalization, in whom the third assessment was performed on discharge. Worsening in clinical status was followed by a decrease in HRV and BRS that became similar to those noted on admission.

INTERPRETATION

HRV measures and BRS are severely deranged in the acute phase of CHF decompensation. Clinical stabilization results in an improvement of autonomic indices. However, subsequent clinical worsening adversely affects HRV and BRS.

Reinforcement of the adrenergic overdrive in the metabolic syndrome complicated by obstructive sleep apnea

BACKGROUND

Metabolic syndrome is characterized by a marked sympathetic overactivity. It is unknown, however, whether the neuroadrenergic activation can be ascribed to obstructive sleep apnoea (OSA), OSA exerts potentiating effects on the metabolic syndrome-related sympathetic activation and reflex/metabolic variables (insulin resistance) participate at the phenomenon.

METHODS AND RESULTS

We conducted a cross-sectional study of healthy individuals and metabolic syndrome patients recruited in our outpatient clinic. Fifty-five middle-age men classified according to Adult Treatment Panel III criteria and apnea-hypopnea index (overnight polysomnographic evaluation) as healthy controls without OSA and metabolic syndrome patients without and with OSA were studied. Blood pressure (Finapres), heart rate (ECG) and muscle sympathetic nerve activity (MSNA; microneurography) were measured at rest and during baroreflex manipulation. Compared with controls, patients with metabolic syndrome with and without OSA displayed higher waist-hip ratio, blood pressure, triglycerides and homeostasis model assessment index values but lower high-density lipoprotein cholesterol. MSNA was significantly higher in patients with metabolic syndrome without OSA than in controls (61.9 +/- 3.9 vs. 37.7 +/- 4.1 bursts/100 heartbeats, respectively, P < 0.01), a further marked increase being detected in patients with metabolic syndrome with OSA (77.1 +/- 4.3 bursts/100 heart beats, P < 0.01). Compared with controls, baroreflex control of heart rate and MSNA was markedly impaired in patients with metabolic syndrome with OSA, a further impairment in baroreflex-heart rate modulation being detected in metabolic syndrome with OSA. In the metabolic syndrome group as a whole, at the multivariate analysis, MSNA was significantly related to the apnoea-hypopnoea index but not to other variables.

CONCLUSION

Thus the sympathetic activation of metabolic syndrome occurs independently on OSA. OSA, however, markedly potentiates this neuroadrenergic abnormality via a hypoxic-dependent chemoreflex activation.

Beneficial effects of Mammalian target of rapamycin inhibition on left ventricular remodeling after myocardial infarction

OBJECTIVES

The extent of adverse myocardial remodeling contributes essentially to the prognosis after myocardial infarction (MI). In this study we investigated whether inhibition of "mammalian target of rapamycin" (mTOR) attenuates left ventricular (LV) remodeling after MI.

BACKGROUND

Therapeutic strategies to inhibit remodeling are currently limited to inhibition of neurohumoral activation. The mTOR-dependent signaling mechanisms are centrally involved in remodeling processes and provide new therapeutic opportunities.

METHODS

Everolimus (RAD) treatment was initiated on the day after or 3 days after induction of myocardial infarction (MI) in rats.

RESULTS

After 28 days, RAD-treated animals had reduced post-MI remodeling, with improved LV function and smaller LV end-diastolic diameters (8.9 + or - 0.3 mm vs. 11.4 + or - 0.2 mm, p < 0.05), end-diastolic volumes (304 + or - 30 microl vs. 414 + or - 16 microl, p < 0.05), and cardiac myocyte size (-40% vs. vehicle, p < 0.05). Infarct size was significantly reduced compared with vehicle-treated animals. The mTOR inhibition increased autophagy and concomitantly decreased proteasome activity in the border zone of the infarcted myocardium. Measurement of autophagic flux demonstrated that RAD did not decrease autophagosome clearance. When RAD treatment was initiated 3 days after MI, adverse remodeling was still attenuated and increased autophagy was still present. Sustained improvement of LV function was observed 3 months after MI, even when RAD treatment was discontinued after 1 month.

CONCLUSIONS

Inhibition of mTOR is a potential therapeutic strategy to limit infarct size and to attenuate adverse LV remodeling after MI.

Increased serum levels of tissue inhibitor of metalloproteinase-1 in patients with acute myocardial infarction

It has been suggested that matrix-metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of metalloproteinases (TIMPs) play a major role in the regulation of myocardial remodeling. Myocardial extracellular matrix (ECM) is highly susceptible to ischemic injury in acute myocardial infarction (AMI).We measured serum levels of TIMP-1 in the early hours of AMI to study the kinetics of these enzymes in an early ischemic phase.TIMP-1 was measured in 25 patients with AMI and 116 healthy controls. Blood samples were obtained during the first 12 hours after hospital admission. Left ventricular function (LVF) and hemodynamic data were collected during coronary intervention.TIMP-1 was significantly elevated in patients with AMI within the first hours compared to controls (P<0.05). No significant difference was observed between patients with preserved LVF and with impaired LVF. Elevated TIMP-1 levels did not correlate with increased levels of CK or CK-MB band during the first hours after AMI.Increased TIMP-1 can be detected within 12 hours in patients with AMI, suggesting early onset of remodeling. Elevation of TIMP-1 may be a surrogate marker for increased ECM-turnover. The prognostic relevance needs to be proved in long-term studies.

Sympathetic activation in congestive heart failure: reproducibility of neuroadrenergic markers

OBJECTIVE

To assess the reproducibility of the two markers of adrenergic drive, venous plasma norepinephrine (NE) and efferent postganglionic muscle sympathetic nerve activity (MSNA), in reflecting the sympathetic activation characterizing congestive heart failure (CHF).

METHODS AND MEASUREMENTS

In 19 CHF male normotensive patients (mean age: 53.0+/-2.1 years, NYHA classes II and III, left ventricular ejection fraction 35.9+/-2.9%), blood pressure (BP, Finapres), heart rate (EKG), plasma NE (HPLC assay) and MSNA (microneurography, peroneal nerve) were measured in two experimental sessions separated by a week interval. At each session, three NE samples were obtained and NE reproducibility between sessions was assessed by considering single NE samples or averaging 2-3 samples.

RESULTS

While MSNA values showed a highly significant correlation between sessions (r=0.85, P<0.001), NE values based on a single blood sample evaluation did not correlate with each other (r=0.41, P=NS). NE correlation coefficients improved and achieved statistical significance when average data from 2 and 3 blood samples were examined (r=0.54 and r=0.57, P<0.02 for both).

CONCLUSIONS

In CHF, MSNA displays a better reproducibility pattern than plasma NE. The reproducibility of the NE approach, however, can be improved by performing the assay on multiple blood samples.

Evaluation of the left ventricular remodeling in patients with myocardial infarction after revascularization with intravenous real-time myocardial contrast echocardiography

In order to evaluate the left ventricular remodeling in patients with myocardial infarction after revascularization with intravenous real-time myocardial contrast echocardiography (RT-MCE), intravenous RT-MCE was performed on 20 patients with myocardial infarction before coronary revascularization. Follow-up echocardiography was performed 3 months after coronary revascularization. Segmental wall motion was assessed using 18-segment LV model and classified as normal, hypokinesis, akinesis and dyskinesis. Myocardial perfusion was assessed by visual interpretation and divided into 3 conditions: homogeneous opacification=1; partial or reduced opacification or subendocardial contrast defect=2; contrast defect=3. Myocardial perfusion score index (MPSI) was calculated by dividing the total sum of contrast score by the total number of segments with abnormal wall motion. Twenty patients were classified into 2 groups according to the MPSI: MPSI<or=1.5 as good myocardial perfusion, MPSI>1.5 as poor myocardial perfusion. To assess the left ventricular remodeling, the following comparisons were carried out: (1) Comparisons of left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) before and 3 months after revascularization in two groups; (2) Comparisons of LVEF, LVESV and LVEDV pre-revascularization between two groups and comparisons of these 3 months post-revascularization between two groups; (3) Comparisons of the differences in LVEF, LVESV and LVEDV between 3 months post-and pre-revascularization (DeltaLVEF, DeltaLVESV and DeltaLVEDV) between two groups; (4) The linear regression analysis between DeltaLVEF, DeltaLVESV, DeltaLVEDV and MPSI. The results showed that the LVEF obtained 3 months after revascularization in patients with MPSI>1.5 was obviously lower than that in those with MPSI<or=1.5. The LVEDV obtained 3 months post-revascularization in patients with MPSI>1.5 was obviously larger than that in those with MPSI<or=1.5 (P=0.002 and 0.04). The differences in DeltaLVEF and DeltaLVEDV between patients with MPSI>1.5 and those with MPSI<or=1.5 were significant (P=0.002 and 0.001, respectively). Linear regression analysis revealed that MPSI had a negative correlation with DeltaLVEF and a positive correlation with DeltaLVESV, DeltaLVEDV (P=0.004, 0.008, and 0.016, respectively). It was concluded that RT-MCE could accurately evaluate the left ventricular remodeling in patients with myocardial infarction after revascularization.

Skin blood flow and its oscillatory components in patients with acute myocardial infarction

BACKGROUND/AIMS

Laser Doppler flowmetry (LDF) was used to determine the influence of acute myocardial infarction (AMI) and of successful reperfusion treatment on basal skin blood flow and its oscillatory components.

METHODS

Skin LDF was performed on all extremities in 58 patients 4-9 days after AMI (Killip class I), and in 71 healthy age- and sex-matched controls. Wavelet analysis was applied to evaluate oscillatory components within the interval 0.005-2 Hz.

RESULTS

AMI patients had reduced mean flow (p < 0.01) and oscillatory components (p < 0.04) in all extremities. Reperfused (n = 40), compared to nonreperfused (n = 18), patients had higher mean flow and total spectral amplitude at all recording points. The difference was statistically significant only in legs (group median LDF in the left leg was 9.68 AU for reperfused and 5.71 AU for nonreperfused patients, p < 0.04, and 11.47 and 4.24 AU in the right leg, p < 0.01). Reperfused patients had significantly higher total spectral amplitude in both legs (p < 0.04).

CONCLUSIONS

In AMI patients, reduced skin blood flow and its oscillatory components may reflect ongoing neurohumoral activation despite absence of clinically apparent heart failure. The reduction of blood flow and its oscillatory components was larger in nonreperfused AMI patients, although they had a comparable left ventricular function.

Acute myocardial infarction attributable to adrenergic crises in a patient with pheochromocytoma and neurofibromatosis 1

OBJECTIVE

To describe a rare case of acute myocardial infarction in a patient with neurofibromatosis 1 and pheochromocytoma and to review the literature on the coexistence of these 2 diseases, the causes of myocardial injury in patients with pheochromocytoma, and the utility of genetic testing and pheochromocytoma screening for those patients and their families.

METHODS

We present a case report, including the detailed clinical, laboratory, and radiographic data, results of adrenal mass pathology, and results of coronary angiography. We also survey other relevant reports available in the literature.

RESULTS

A 43-year-old woman with a history of long-standing hypertension, neurofibromatosis 1, headaches, sweating, and palpitations presented to the hospital with chest pain and shortness of breath. She was found to have an acute myocardial infarction and pulmonary edema, as well as a right adrenal mass. A pheochromocytoma was suspected, and phenoxybenzamine was added to her treatment regimen. Cardiac catheterization showed nonobstructive coronary disease. The levels of plasma catecholamine metabolites were extremely high. The patient underwent uncomplicated laparoscopic right adrenalectomy 2 weeks after this admission. Surgical pathology confirmed the diagnosis of pheochromocytoma.

CONCLUSION

Adrenergic crisis attributable to pheochromocytoma can result in acute myocardial infarction even in the absence of obstructive coronary disease. Inclusion of pheochromocytoma in the differential diagnosis of hypertension in patients with neurofibromatosis is very important and helps avoid mistakes in the management of such patients.

Randomized active-controlled study comparing effects of treatment with carvedilol versus metoprolol in patients with left ventricular dysfunction after acute myocardial infarction

BACKGROUND

Carvedilol has previously been demonstrated to be beneficial in patients with acute myocardial infarction (AMI) and left ventricular (LV) dysfunction. However, metoprolol has not to date been randomly evaluated in the same patient population. The objective of this study was to compare the effects of treatment with carvedilol versus metoprolol in patients with LV dysfunction after AMI.

METHODS

The study enrolled 313 high-risk patients with anterior AMI and LV ejection fraction of <45%, randomly assigned to treatment with carvedilol or metoprolol. Patients were followed-up for a mean period of 13.4 months. The primary end point was time to composite adverse events (t-CAE). The secondary end points were time to composite hard events (t-CHE) and health-related quality of life.

RESULTS

No differences were found either in the primary end point of t-CAE or in the secondary end point of t-CHE. A significant benefit was observed in 4 of 8 health-related quality of life domains in the carvedilol group, with fewer carvedilol group patients being withdrawn from therapy in the hospital.

CONCLUSIONS

Treatment with carvedilol, in comparison to that with metoprolol in patients with AMI and LV dysfunction, did not differ significantly in regard to the primary end point of t-CAE or to the secondary end point of t-CHE but resulted in better long-term quality of life and favorable early safety profile.

Effects of aldosterone receptor blockade in patients with mild-moderate heart failure taking a beta-blocker

AIMS

Spironolactone improves prognosis in severe heart failure (HF). We investigated its effects in patients with mild-moderate HF treated with an ACE inhibitor and beta-blocker.

METHODS AND RESULTS

Randomised, double-blind, parallel-group, 3-month comparison of placebo and spironolactone (25 mg daily) in 40 patients in New York Heart Association (NYHA) class I (20%), II (70%) or III (10%), with a left ventricular ejection fraction of <40%. The mean (standard error) changes from baseline in the spironolactone and placebo groups were, respectively: i) B-type natriuretic peptide (BNP) -53.4(22.2) pg/mL and +3.3(12.1) pg/mL, P=0.04, ii) pro-collagen type III N-terminal amino peptide (PIIINP) -0.6(0.2) micromol/L and +0.02(0.2) micromol/L, P=0.02 and iii) creatinine +10.7(3.2) micromol/L and -0.3(2.6) micromol/L, P=0.01. Compared with placebo, spironolactone therapy was associated with a reduction in self-reported health-related quality of life: change in visual analog score: -6 (3) vs. +6 (4); P=0.01. No differences were observed on other biochemical, neurohumoral, exercise and autonomic function assessments.

CONCLUSION

In patients with mild-moderate HF, spironolactone reduced neurohumoral activation (BNP) and a marker of collagen turnover (PIIINP) but impaired renal function and quality of life. The benefit-risk ratio of aldosterone blockade in mild HF is uncertain and requires clarification in a large randomised trial.

Screening for ventricular remodeling

Current guidelines emphasize the importance of preventing heart failure (HF) by targeting people with preclinical forms of the disease. Accordingly, there is considerable interest in identifying left ventricular (LV) remodeling, the fundamental substrate for HF, in asymptomatic individuals in the community. Increased LV mass and asymptomatic LV systolic and LV diastolic dysfunction are the remodeling phenotypes that could be potentially considered for population-wide screening. Plasma levels of natriuretic peptides (NP) have been extensively investigated for such screening purposes. However, a majority of investigations suggest that their performance characteristics are suboptimal for identifying LV remodeling phenotypes unless high-risk individuals (eg, older men with hypertension) are targeted. In general, the prevalence of LV systolic dysfunction in women is too low to justify screening. In recent reports, sequential screening strategies combining urine and plasma NP or plasma NP and hand-held portable echocardiography have been advocated as potential approaches to identify asymptomatic LV systolic dysfunction in a cost-effective manner. Additional studies are warranted to confirm these findings.

Overview of vasopressin receptor antagonists in heart failure resulting in hospitalization

Patients with worsening heart failure (HF) requiring hospitalization commonly have a history of progressive fluid retention, decreased renal function, and hyponatremia. For these patients, diuretics have traditionally been the mainstay of treatment, but they are associated with electrolyte abnormalities and impaired renal function. Previous studies have shown that levels of the endogenous arginine vasopressin (AVP) hormone are elevated in patients with HF and may be the contributing factor to fluid retention and hyponatremia, and probably progression of HF. Vasopressin antagonists represent a unique class of therapeutic agents because of their potential role in both the short- and long-term treatment of patients hospitalized with worsening HF. As "aquaretics," AVP antagonists offer the possibility of added efficacy in relieving congestion and improving symptoms with minimal adverse effects in combination with standard medical therapy. Some AVP receptor antagonists have shown promising results in animal studies and small-scale clinical trials. The purpose of this review was to update the current status of studies with the available AVP antagonists.

Heart Failure Following Anterior Myocardial Infarction: An Indication for Ventricular Restoration, a Surgical Method to Reverse Post-Infarction Remodeling

Anterior myocardial infarction produces abrupt left ventricular (LV) dysynergy and global systolic dysfunction. Rapid intense neurohumoral activation, infarct expansion, and early ventricular chamber dilatation all contribute to restoring a normal stroke volume despite a persistently depressed ejection fraction. Continued neurohumoral activation provokes late remodeling of the remote non-infarcted myocardium, characterized by an abnormal progressively increasing LV volume/mass ratio that leads to further LV remodeling. Heart failure is a progressive disorder of LV remodeling. Heart failure from post-infarction remodeling is unique because of the persistent non-functioning scar that self- perpetuates abnormal loading conditions and neurohumoral activation. Medical therapy attenuates remodeling and improves survival but does not change the size of the scar. Surgical ventricular restoration to exclude the non-functioning infarct from the ventricular cavity decreases ventricular volumes, increases global ejection fraction, attenuates neurohumoral activation and yields an excellent 5-year survival. Combined medical and surgical therapy is recommended in this patient population.

Pharmacologic effects on cardiac remodeling

Clinical research during the past several decades has shown the importance of cardiac remodeling as a basic mechanism in the progression of heart failure. Changes in cardiac remodeling have high concordance with long-term clinical outcomes. Cardiac remodeling should be regarded as a primary target for treatment and also can serve as a reliable surrogate for clinical outcomes. Neurohormonal blockade with combination treatments that inhibit the renin-angiotensin-aldosterone and sympathetic systems has proven effective in improving cardiac remodeling and clinical outcomes. Such treatment should be standard therapy for patients with left ventricular dysfunction after myocardial infarction and patients with chronic heart failure.

Predictors of mortality in patients with acute myocardial infarction and cardiogenic shock

BACKGROUND

Although cardiogenic shock (CS) is the leading cause of death for acute myocardial infarction (AMI) patients, reliable predictive factors in the acute stage, such as cardiovascular peptides, have not yet been identified.

METHODS AND RESULTS

In 42 consecutive AMI patients with CS on admission, successfully treated by primary percutaneous coronary intervention (PCI) within 12 h of onset, related factors including brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), renin, aldosterone, catecholamines, and adrenomedullin, were investigated 24 h from onset, as well as the 1-year mortality rates. During the 12-month follow-up period, 15 patients died from cardiovascular causes (group D). There were no significant differences in patient characteristics, angiographic findings, and left ventricular systolic function between group D subjects and the survivors (group S: n=27). Multivariate analysis identified high levels of adrenomedullin as an independent predictor of 1-year mortality (risk ratio: 6.42, 95% confidence interval, 1.49-43.31, p<0.05).

CONCLUSIONS

The acute-phase plasma concentration of adrenomedullin may be a reliable predictor of mortality in patients with AMI complicated by CS and successfully treated by direct PCI, as may be BNP concentration, peak-creatine kinase value, and ventricular fibrillation.

Evaluation of neurohumoral activation (adrenomedullin, BNP, catecholamines, etc.) in patients with acute myocardial infarction

OBJECTIVE

The object of our study was to identify the most useful predictor of patient prognosis in acute myocardial infarction (AMI), from 7 acute-phase cardiovascular peptides which take part in neurohumoral activation [brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), renin, aldosterone, adrenomedullin, epinephrine and norepinephrine].

METHODS

In 141 consecutive AMI patients, 24 hours from onset, we evaluated plasma concentration levels of the 7 types of cardiovascular peptides and the relationships between the values of these peptides and short-term clinical prognosis, including mortality.

RESULTS

Plasma levels of all cardiovascular peptides were significantly higher in patients who suffered mortality than in surviving patients (BNP: 1,267+/-997 pg/ml vs. 293+/-327 pg/ml, p<0.0001; ANP: 164+/-186 pg/ml vs. 64+/-76 pg/ml, p<0.001; adrenomedullin: 13.61+/-3.29 Fmol/l vs. 3.45+/-1.52 Fmol/I, p<0.0001; renin: 8.79+/-7.15 ng/ml/h vs. 4.34+/-5.10 ng/ml/h, p<0.01; aldosterone: 249+/-210 pg/ml vs. 68+/-74 pg/ml, p<0.0001; epinephrine: 3,191+/-8,360 pg/ml vs. 68+/-74 pg/ml, p<0.0001; norepinephrine: 21.8+/-46.2 ng/ml vs. 0.9+/-0.8, ng/ml p<0.0001). Multivariate analysis identified only high levels of adrenomedullin as an independent related factor of cardiogenic shock (risk ratio: 5.84, 95% C.I.: 1.80-18.95, p=0.003), and as an independent predictor of short-term mortality (risk ratio: 16.16, 95% C.I.: 1.38-189.71, p=0.03).

CONCLUSIONS

Acute-phase neurohumoral activation, involving renin, aldosterone, epinephrine, norepinephrine, BNP, ANP, and adrenomedullin may be closely related to poor patient outcomes, including mortality. Our results suggest that acute-phase plasma adrenomedullin concentrations may be the most useful predictor of patient prognosis in the setting of AMI, out of the 7 types of cardiovascular peptides involved in neurohumoral activation.