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Butts B, Brown JA, Denney TS, Ballinger S, Lloyd SG, Oparil S, Sanders P, Merriman TR, Gaffo A, Singh J, Kelley EE, Calhoun DA, Dell'Italia LJ. Racial Differences in XO (Xanthine Oxidase) and Mitochondrial DNA Damage-Associated Molecular Patterns in Resistant Hypertension. Hypertension 2022; 79:775-784. [PMID: 35164526 PMCID: PMC10652275 DOI: 10.1161/hypertensionaha.121.18298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We previously reported increased plasma XO (xanthine oxidase) activity in patients with resistant hypertension. Increased XO can cause mitochondrial DNA damage and promote release of fragments called mitochondrial DNA damage-associated molecular patterns (mtDNA DAMPs). Here, we report racial differences in XO activity and mtDNA DAMPs in Black and White adults with resistant hypertension. METHODS This retrospective study includes 91 resistant hypertension patients (44% Black, 47% female) with blood pressure >140/90 mm Hg on ≥4 medications and 37 normotensive controls (30% Black, 54% female) with plasma XO activity, mtDNA DAMPs, and magnetic resonance imaging of left ventricular morphology and function. RESULTS Black-resistant hypertension patients were younger (mean age 52±10 versus 59±10 years; P=0.001), with higher XO activity and left ventricular wall thickness, and worse diastolic dysfunction than White resistant hypertension patients. Urinary sodium excretion (mg/24 hour per kg) was positively related to left ventricular end-diastolic volume (r=0.527, P=0.001) and left ventricular mass (r=0.394, P=0.02) among Black but not White resistant hypertension patients. Patients with resistant hypertension had increased mtDNA DAMPs versus controls (P<0.001), with Black mtDNA DAMPS greater than Whites (P<0.001). Transmission electron microscopy of skeletal muscle biopsies in resistant hypertension patients demonstrates mitochondria cristae lysis, myofibrillar loss, large lipid droplets, and glycogen accumulation. CONCLUSIONS These data warrant a large study to examine the role of XO and mitochondrial mtDNA DAMPs in cardiac remodeling and heart failure in Black adults with resistant hypertension.
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Affiliation(s)
- Brittany Butts
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Jamelle A Brown
- Center for Free Radical Biology and Department of Pathology, UAB SOM (J.A.B., S.B.)
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University (T.S.D.)
| | - Scott Ballinger
- Center for Free Radical Biology and Department of Pathology, UAB SOM (J.A.B., S.B.)
| | - Steven G Lloyd
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Paul Sanders
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Nephrology Research and Training Center and Division of Nephrology UAB SOM (P.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Tony R Merriman
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
| | - Angelo Gaffo
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Jasvinder Singh
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Eric E Kelley
- Department of Physiology and Pharmacology, West Virginia University (E.E.K.)
| | - David A Calhoun
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Louis J Dell'Italia
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
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Abstract
PURPOSE OF REVIEW The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF). RECENT FINDINGS Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies. SUMMARY Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.
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Sharma K, Mok Y, Kwak L, Agarwal SK, Chang PP, Deswal A, Shah AM, Kitzman DW, Wruck LM, Loehr LR, Heiss G, Coresh J, Rosamond WD, Solomon SD, Matsushita K, Russell SD. Predictors of Mortality by Sex and Race in Heart Failure With Preserved Ejection Fraction: ARIC Community Surveillance Study. J Am Heart Assoc 2020; 9:e014669. [PMID: 32924735 PMCID: PMC7792380 DOI: 10.1161/jaha.119.014669] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) accounts for half of heart failure hospitalizations, with limited data on predictors of mortality by sex and race. We evaluated for differences in predictors of all‐cause mortality by sex and race among hospitalized patients with HFpEF in the ARIC (Atherosclerosis Risk in Communities) Community Surveillance Study. Methods and Results Adjudicated HFpEF hospitalization events from 2005 to 2013 were analyzed from the ARIC Community Surveillance Study, comprising 4 US communities. Comparisons between clinical characteristics and mortality at 1 year were made by sex and race. Of 4335 adjudicated acute decompensated heart failure cases, 1892 cases (weighted n=8987) were categorized as HFpEF. Men had an increased risk of 1‐year mortality compared with women in adjusted analysis (hazard ratio [HR], 1.27; 95% CI, 1.06–1.52 [P=0.01]). Black participants had lower mortality compared with White participants in unadjusted and adjusted analyses (HR, 0.79; 95% CI, 0.64–0.97 [P=0.02]). Age, heart rate, worsening renal function, and low hemoglobin were associated with increased mortality in all subgroups. Higher body mass index was associated with improved survival in men, with borderline interaction by sex. Higher blood pressure was associated with improved survival among all groups, with significant interaction by race. Conclusions In a diverse HFpEF population, men had worse survival compared with women, and Black participants had improved survival compared with White participants. Age, heart rate, and worsening renal function were associated with increased mortality across all subgroups; high blood pressure was associated with decreased mortality with interaction by race. These insights into sex‐ and race‐based differences in predictors of mortality may help strategize targeted management of HFpEF.
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Affiliation(s)
- Kavita Sharma
- Division of Cardiology The Johns Hopkins Hospital Baltimore MD
| | - Yejin Mok
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Lucia Kwak
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Patricia P Chang
- Department of Medicine University of North Carolina Chapel Hill NC
| | - Anita Deswal
- Section of Cardiology Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston TX
| | - Amil M Shah
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Dalane W Kitzman
- Cardiology and Geriatrics Sections Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Lisa M Wruck
- Duke Clinical Research InstituteCenter for Predictive Medicine Durham NC
| | - Laura R Loehr
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Gerardo Heiss
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Josef Coresh
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Wayne D Rosamond
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Scott D Solomon
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Kunihiro Matsushita
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
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4
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Scrutinio D, Guida P, Passantino A, Ammirati E, Oliva F, Lagioia R, Raimondo R, Venezia M, Frigerio M. Acutely decompensated heart failure with chronic obstructive pulmonary disease: Clinical characteristics and long-term survival. Eur J Intern Med 2019; 60:31-38. [PMID: 30446355 DOI: 10.1016/j.ejim.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common comorbidities in patients hospitalized with heart failure and is generally associated with poor outcomes. However, the results of previous studies with regard to increased mortality and risk trajectories were not univocal. We sought to assess the prognostic impact of COPD in patients admitted for acutely decompensated heart failure (ADHF) and investigate the association between use of β-blockers at discharge and mortality in patients with COPD. METHODS We studied 1530 patients. The association of COPD with mortality was examined in adjusted Fine-Gray proportional hazard models where heart transplantation and ventricular assist device implantation were treated as competing risks. The primary outcome was 5-year all-cause mortality. RESULTS After adjusting for establisked risk markers, the subdistribution hazard ratios (SHR) of 5-year mortality for COPD patients compared with non-COPD patients was 1.25 (95% confidence intervals [CIs] 1.06-1.47; p = .007). The relative risk of death for COPD patients increased steeply from 30 to 180 days, and remained noticeably high throughout the entire follow-up. Among patients with comorbid COPD, the use of β-blockers at discharge was associated with a significantly reduced risk of 1-year post-discharge mortality (SHR 0.66, 95%CIs 0.53-0.83; p ≤.001). CONCLUSIONS Our data indicate that ADHF patients with comorbid COPD have a worse long-term survival than those without comorbid COPD. Most of the excess mortality occurred in the first few months following hospitalization. Our data also suggest that the use of β-blockers at discharge is independently associated with improved survival in ADHF patients with COPD.
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Affiliation(s)
| | - Pietro Guida
- Istituti Clinici Scientifici Maugeri, I.R.C.C.S., Italy
| | | | | | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Rocco Lagioia
- Istituti Clinici Scientifici Maugeri, I.R.C.C.S., Italy
| | - Rosa Raimondo
- Istituti Clinici Scientifici Maugeri, I.R.C.C.S., Italy
| | - Mario Venezia
- Istituti Clinici Scientifici Maugeri, I.R.C.C.S., Italy
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
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5
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Yang BQ, Assad TR, O'Leary JM, Xu M, Halliday SJ, D'Amico RW, Farber-Eger EH, Wells QS, Hemnes AR, Brittain EL. Racial differences in patients referred for right heart catheterization and risk of pulmonary hypertension. Pulm Circ 2018; 8:2045894018764273. [PMID: 29480090 PMCID: PMC5858628 DOI: 10.1177/2045894018764273] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
African Americans (AA) have a higher incidence of pulmonary hypertension (PH) risk factors. Few studies have examined the racial differences in the prevalence and etiology of PH and direct comparison of invasive hemodynamics between AAs and Caucasians has rarely been reported. In this study, we examined whether racial differences exist in patients referred for right heart catheterization (RHC) and hypothesized that AA race is an independent risk factor for PH and is associated with increased adjusted mortality. We extracted data for AA and Caucasian patients who underwent RHC at Vanderbilt between 1998 and 2014. Clinical information was obtained from Vanderbilt's Synthetic Derivative, a de-identified mirror of our Electronic Medical Record. A total of 4576 patients were analyzed, including 586 (13%) AAs and 3990 (87%) Caucasians. AAs were younger than Caucasians by an average of eight years, but had more prevalent heart failure, features of metabolic syndrome, and higher creatinine. AAs also had higher mean pulmonary artery pressure and pulmonary vascular resistance. After adjusting for relevant co-morbidities, the AA race is associated with 41% increased risk of PH (odds ratio [OR] = 1.41, 95% confidence interval [CI] = 1.12–1.79). Among patients with PH, AA race is associated with 24% increased adjusted mortality (hazard ratio [HR] = 1.24, 95% CI = 1.09–1.45). AAs were younger but had more prevalent cardiometabolic and renal disease and worse pulmonary hemodynamics. The AA race is an independent risk factor for PH. Among patients with PH, the AA race is associated with increased adjusted mortality. Future studies should focus on delineating whether genetic or environmental factors contribute to PH risk in AAs.
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Affiliation(s)
- Bin Q Yang
- 1 12328 Vanderbilt University Medical Center, Department of Medicine, Nashville, TN, USA
| | - Tufik R Assad
- 2 12328 Vanderbilt University Medical Center, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, USA
| | - Jared M O'Leary
- 3 12328 Vanderbilt University Medical Center, Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Meng Xu
- 4 12328 Vanderbilt University Department of Biostatistics, Nashville, TN, USA
| | - Stephen J Halliday
- 2 12328 Vanderbilt University Medical Center, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, USA
| | - Reid W D'Amico
- 5 12328 Vanderbilt University Department of Biomedical Engineering, Nashville, TN, USA
| | - Eric H Farber-Eger
- 3 12328 Vanderbilt University Medical Center, Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Quinn S Wells
- 3 12328 Vanderbilt University Medical Center, Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Anna R Hemnes
- 2 12328 Vanderbilt University Medical Center, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, USA
| | - Evan L Brittain
- 3 12328 Vanderbilt University Medical Center, Division of Cardiovascular Medicine, Nashville, TN, USA
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6
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Goyal P, Paul T, Almarzooq ZI, Peterson JC, Krishnan U, Swaminathan RV, Feldman DN, Wells MT, Karas MG, Sobol I, Maurer MS, Horn EM, Kim LK. Sex- and Race-Related Differences in Characteristics and Outcomes of Hospitalizations for Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2017; 6:JAHA.116.003330. [PMID: 28356281 PMCID: PMC5532983 DOI: 10.1161/jaha.116.003330] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Sex and race have emerged as important contributors to the phenotypic heterogeneity of heart failure with preserved ejection fraction (HFpEF). However, there remains a need to identify important sex‐ and race‐related differences in characteristics and outcomes using a nationally representative cohort. Methods and Results Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project—Nationwide Inpatient Sample files between 2008 and 2012. Hospitalizations with a diagnosis of HFpEF were included for analysis. Demographics, hospital characteristics, and age‐adjusted comorbidity prevalence rates were compared between men and women and whites and blacks. In‐hospital mortality was determined and compared for each subgroup. Multivariable regression analyses were used to identify and compare correlates of in‐hospital mortality for each subgroup. A sample of 1 889 608 hospitalizations was analyzed. Men with HFpEF were slightly younger than women with HFpEF and had a higher Elixhauser comorbidity score. Men experienced higher in‐hospital mortality compared with women, a finding that was attenuated after adjusting for comorbidity. Blacks with HFpEF were younger than whites with HFpEF, with lower rates of most comorbidities. Hypertension, diabetes, anemia, and chronic renal failure were more common among blacks. Blacks experienced lower in‐hospital mortality compared with whites, even after adjusting for age and comorbidity. Important correlates of mortality among all 4 subgroups included pulmonary circulation disorders, liver disease, and chronic renal failure. Atrial fibrillation was an important correlate of mortality only among women and blacks. Conclusions Differences in patient characteristics and outcomes reinforce the notion that sex and race contribute to the phenotypic heterogeneity of HFpEF.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY .,Division of Clinical Epidemiology and Evaluative Sciences Research, Weill Cornell Medical College, New York, NY
| | - Tracy Paul
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Zaid I Almarzooq
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Janey C Peterson
- Division of Clinical Epidemiology and Evaluative Sciences Research, Weill Cornell Medical College, New York, NY
| | - Udhay Krishnan
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Dmitriy N Feldman
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Martin T Wells
- Departments of Statistical Science and Social Statistics, Cornell University, Ithaca, NY
| | - Maria G Karas
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Irina Sobol
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mathew S Maurer
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY
| | - Evelyn M Horn
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Luke K Kim
- Division of Cardiology/Department of Medicine, Weill Cornell Medical College, New York, NY
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7
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Chung ES, Casey DE, Snow R. Redefining Hospital Readmissions to Better Reflect Clinical Course of Care for Heart Failure Patients. Am J Med Qual 2016; 22:98-102. [PMID: 17395965 DOI: 10.1177/1062860606298245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The prevailing definition of a hospital readmission is a hospital admission that occurs within a specified time frame after discharge from the first or index admission. This definition may be questionable for studies with long or indefinite time frames during which the effect of interventions in the index admission will likely wane, making it less appropriate to classify a later hospitalization as a readmission. The current study proposes an alternative definition of readmission and compares the new definition to the traditional one. The comparison shows that the new method is more conceptually correct because it takes into account the waning effect of the index admission. It can identify readmissions regardless of when they occur. It increases a readmission sample size and thus statistical power.
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8
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Salabei JK, Lorkiewicz PK, Mehra P, Gibb AA, Haberzettl P, Hong KU, Wei X, Zhang X, Li Q, Wysoczynski M, Bolli R, Bhatnagar A, Hill BG. Type 2 Diabetes Dysregulates Glucose Metabolism in Cardiac Progenitor Cells. J Biol Chem 2016; 291:13634-48. [PMID: 27151219 DOI: 10.1074/jbc.m116.722496] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Indexed: 12/22/2022] Open
Abstract
Type 2 diabetes is associated with increased mortality and progression to heart failure. Recent studies suggest that diabetes also impairs reparative responses after cell therapy. In this study, we examined potential mechanisms by which diabetes affects cardiac progenitor cells (CPCs). CPCs isolated from the diabetic heart showed diminished proliferation, a propensity for cell death, and a pro-adipogenic phenotype. The diabetic CPCs were insulin-resistant, and they showed higher energetic reliance on glycolysis, which was associated with up-regulation of the pro-glycolytic enzyme 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3 (PFKFB3). In WT CPCs, expression of a mutant form of PFKFB, which mimics PFKFB3 activity and increases glycolytic rate, was sufficient to phenocopy the mitochondrial and proliferative deficiencies found in diabetic cells. Consistent with activation of phosphofructokinase in diabetic cells, stable isotope carbon tracing in diabetic CPCs showed dysregulation of the pentose phosphate and glycero(phospho)lipid synthesis pathways. We describe diabetes-induced dysregulation of carbon partitioning using stable isotope metabolomics-based coupling quotients, which relate relative flux values between metabolic pathways. These findings suggest that diabetes causes an imbalance in glucose carbon allocation by uncoupling biosynthetic pathway activity, which could diminish the efficacy of CPCs for myocardial repair.
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Affiliation(s)
- Joshua K Salabei
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center
| | | | - Parul Mehra
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center
| | - Andrew A Gibb
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center, Physiology
| | - Petra Haberzettl
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center
| | - Kyung U Hong
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center
| | - Xiaoli Wei
- Chemistry, the Center for Regulatory and Environmental Analytical Metabolomics, University of Louisville, Louisville, Kentucky 40202
| | - Xiang Zhang
- Chemistry, the Center for Regulatory and Environmental Analytical Metabolomics, University of Louisville, Louisville, Kentucky 40202 Pharmacology and Toxicology, and
| | | | | | - Roberto Bolli
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center, Physiology
| | - Aruni Bhatnagar
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center, Physiology, the Departments of Biochemistry and Molecular Genetics
| | - Bradford G Hill
- From the Institute of Molecular Cardiology, Diabetes and Obesity Center, Physiology, the Departments of Biochemistry and Molecular Genetics,
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9
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A Critical Evaluation of the Representation of Black Patients With Heart Failure and Preserved Ejection Fraction in Clinical Trials. J Cardiovasc Nurs 2016; 31:202-8. [DOI: 10.1097/jcn.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Kelly JP, Mentz RJ, Mebazaa A, Voors AA, Butler J, Roessig L, Fiuzat M, Zannad F, Pitt B, O'Connor CM, Lam CSP. Patient selection in heart failure with preserved ejection fraction clinical trials. J Am Coll Cardiol 2015; 65:1668-1682. [PMID: 25908073 DOI: 10.1016/j.jacc.2015.03.043] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/08/2015] [Indexed: 12/11/2022]
Abstract
Recent clinical trials in patients with heart failure with preserved ejection fraction (HFpEF) have provided important insights into participant selection strategies. Historically, HFpEF trials have included patients with relatively preserved left ventricular ejection fraction ranging from 40% to 55% and a clinical history of heart failure. Contemporary HFpEF trials have also incorporated inclusion criteria such as hospitalization for HFpEF, altered functional capacity, cardiac structural and functional abnormalities, and abnormalities in neurohormonal status (e.g., elevated natriuretic peptide levels). Careful analyses of the effect of these patient selection criteria on outcomes in prior trials provide valuable lessons for future trial design. We review recent and ongoing HFpEF clinical trials from a patient selection perspective and appraise trial patient selection methodologies in relation to outcomes. This review reflects discussions between clinicians, scientists, trialists, regulators, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum in Paris, France, on December 6, 2013.
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Affiliation(s)
- Jacob P Kelly
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques, Université de Lorraine and CHU de Nancy, Nancy, France
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Christopher M O'Connor
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore
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11
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Salabei JK, Lorkiewicz PK, Holden CR, Li Q, Hong KU, Bolli R, Bhatnagar A, Hill BG. Glutamine Regulates Cardiac Progenitor Cell Metabolism and Proliferation. Stem Cells 2015; 33:2613-27. [PMID: 25917428 DOI: 10.1002/stem.2047] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/08/2015] [Accepted: 03/29/2015] [Indexed: 12/27/2022]
Abstract
Autologous transplantation of cardiac progenitor cells (CPCs) alleviates myocardial dysfunction in the damaged heart; however, the mechanisms that contribute to their reparative qualities remain poorly understood. In this study, we examined CPC metabolism to elucidate the metabolic pathways that regulate their proliferative capacity. In complete growth medium, undifferentiated CPCs isolated from adult mouse heart proliferated rapidly (Td = 13.8 hours). CPCs expressed the Glut1 transporter and their glycolytic rate was increased by high extracellular glucose (Glc) concentration, in the absence of insulin. Although high Glc concentrations did not stimulate proliferation, glutamine (Gln) increased CPC doubling time and promoted survival under conditions of oxidative stress. In comparison with Glc, pyruvate (Pyr) or BSA-palmitate, Gln, when provided as the sole metabolic substrate, increased ATP-linked and uncoupled respiration. Although fatty acids were not used as respiratory substrates when present as a sole carbon source, Gln-induced respiration was doubled in the presence of BSA-palmitate, suggesting that Gln stimulates fatty acid oxidation. Additionally, Gln promoted rapid phosphorylation of the mTORC1 substrate, p70S6k, as well as retinoblastoma protein, followed by induction of cyclin D1 and cdk4. Inhibition of either mTORC1 or glutaminolysis was sufficient to diminish CPC proliferation, and provision of cell permeable α-ketoglutarate in the absence of Gln increased both respiration and cell proliferation, indicating a key role of Gln anaplerosis in cell growth. These findings suggest that Gln, by enhancing mitochondrial function and stimulating mTORC1, increases CPC proliferation, and that interventions to increase Gln uptake or oxidation may improve CPC therapy.
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Affiliation(s)
- Joshua K Salabei
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA
| | - Pawel K Lorkiewicz
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA
| | - Candice R Holden
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA.,Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA
| | - Qianhong Li
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA
| | - Kyung U Hong
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA
| | - Roberto Bolli
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA.,Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA
| | - Aruni Bhatnagar
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA.,Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA.,Department of Biochemistry and Molecular Biology, University of Louisville, Louisville, Kentucky, USA
| | - Bradford G Hill
- Department of Medicine, Institute of Molecular Cardiology, University of Louisville, Louisville, Kentucky, USA.,Department of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, Kentucky, USA.,Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA.,Department of Biochemistry and Molecular Biology, University of Louisville, Louisville, Kentucky, USA
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12
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Ogah OS, Stewart S, Falase AO, Akinyemi JO, Adegbite GD, Alabi AA, Ajani AA, Adesina JO, Durodola A, Sliwa K. Predictors of rehospitalization in patients admitted with heart failure in Abeokuta, Nigeria: data from the Abeokuta heart failure registry. J Card Fail 2014; 20:833-40. [PMID: 25175695 DOI: 10.1016/j.cardfail.2014.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We sought, for the first time, to examine the rate and predictors of hospital readmission in patients discharged after an episode of heart failure (HF) in Nigeria. METHODS This was a hospital-based, prospective, observational study that used the data from the Abeokuta HF Registry. RESULTS Overall, 1.53% (95% confidence interval [CI] 0.58-4.02) and 12.2% (95% CI 8.88-16.8) of patients were re-hospitalized at least once within 30 days and 6 months, respectively (5.3% had multiple readmissions); the latter comprised 21/138 men (15.2%) and 11/124 (8.9%) women. A total of 11 (4.2%) died (all of whom had been rehospitalized). Worsening HF (24 cases, 75%) was the commonest reason for readmission. Among others, factors associated with rehospitalization included presence of mitral regurgitation (odds ratio [OR] 2.37, 95% CI 1.26-4.46), age ≥ 60 years (OR 2.04, 95% CI 0.96-3.29), presence of tricuspid regurgitation (OR 1.77, 95% CI 0.86-3.61), and presence of atrial fibrillation (OR 1.34, 95% CI 0.59-3.03). However, on an adjusted basis, only female sex (adjusted OR 0.33, 95% CI 0.14-0.79; P = .014 vs male) and body mass index <19 kg/m² (adjusted OR 3.74, 95% CI 1.15-12.16; P = .028 vs ≥ 19 kg/m²) were independent correlates of readmission during 6 months' follow-up. CONCLUSIONS HF rehospitalization within 6 months' follow-up occurred in ∼12% of our cohort living an environment where HF etiology is predominately nonischemic and the HF population is relatively younger. Higher rates of readmission were noted in those with older age, lower body mass index, low literacy, lower serum sodium level, and presence of atrial fibrillation, renal dysfunction, and valvular dysfunction.
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Affiliation(s)
- Okechukwu S Ogah
- Division of Cardiology, Department of Medicine, University College Hospital, Ibadan, Nigeria; Soweto Cardiovascular Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa.
| | - Simon Stewart
- Soweto Cardiovascular Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa; NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Ayodele O Falase
- Division of Cardiology, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Joshua O Akinyemi
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | - Gail D Adegbite
- Department of Medicine, Sacred Heart Hospital, Lantoro, Abeokuta, Nigeria
| | - Albert A Alabi
- Department of Medicine, Sacred Heart Hospital, Lantoro, Abeokuta, Nigeria
| | - Akinlolu A Ajani
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Julius O Adesina
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Amina Durodola
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Karen Sliwa
- Soweto Cardiovascular Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa; Department of Medicine, Hatter Institute for Cardiovascular Research in Africa and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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13
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Gupta DK, Shah AM, Castagno D, Takeuchi M, Loehr LR, Fox ER, Butler KR, Mosley TH, Kitzman DW, Solomon SD. Heart failure with preserved ejection fraction in African Americans: The ARIC (Atherosclerosis Risk In Communities) study. JACC. HEART FAILURE 2013; 1:156-63. [PMID: 23671819 PMCID: PMC3650857 DOI: 10.1016/j.jchf.2013.01.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES In an entirely African-American cohort, we compared clinical characteristics, cardiac structure and function, and all-cause mortality in patients with heart failure (HF) with preserved ejection fraction (HFpEF) in relation to patients with heart failure with reduced ejection fraction (HFrEF) and those without HF. BACKGROUND African Americans are at increased risk for HF. Nevertheless, there are limited phenotypic and prognostic data in African Americans with HFpEF compared with those with HFrEF and those without HF. METHODS Middle-aged African Americans from the Jackson, Mississippi, cohort of the ARIC (Atherosclerosis Risk In Communities) study (n = 2,445) underwent echocardiography between 1993 and 1995. HF prevalence was available in 1,962 patients for whom left ventricular ejection fraction (LVEF) could be quantified. Participants with HF were categorized as having HFpEF (LVEF ≥50%), HFrEF (LVEF <50%), or no HF, with comparisons made between groups. RESULTS HF was identified in 116 (5.9%) participants (HFpEF n = 85 [73%]; HFrEF n = 31 [27%]). Compared with those without HF, those with HFpEF were older, were more likely to be female, and had more frequent comorbidities and concentric hypertrophy. In relation to HFrEF, those with HFpEF were more likely to be female but less likely to have coronary heart disease, diabetes mellitus, chronic kidney disease, left atrial enlargement, and eccentric hypertrophy. Over a median 13.7 years of follow-up, risk of death differed between groups, with age- and sex-adjusted hazard ratios of 1.51 (95% confidence interval: 1.01 to 2.25) for HFpEF versus those without HF and 2.50 (95% confidence interval: 1.37 to 4.58) for HFrEF versus HFpEF. CONCLUSIONS In this cohort of middle-aged African Americans, HFpEF was the most common form of HF and was associated with a substantially better prognosis than HFrEF but worse than those without HF.
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14
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Giamouzis G, Kalogeropoulos A, Georgiopoulou V, Laskar S, Smith AL, Dunbar S, Triposkiadis F, Butler J. Hospitalization Epidemic in Patients With Heart Failure: Risk Factors, Risk Prediction, Knowledge Gaps, and Future Directions. J Card Fail 2011; 17:54-75. [DOI: 10.1016/j.cardfail.2010.08.010] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Revised: 08/03/2010] [Accepted: 08/16/2010] [Indexed: 01/17/2023]
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15
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Gordon HS, Nowlin PR, Maynard D, Berbaum ML, Deswal A. Mortality after hospitalization for heart failure in blacks compared to whites. Am J Cardiol 2010; 105:694-700. [PMID: 20185019 DOI: 10.1016/j.amjcard.2009.10.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 10/19/2022]
Abstract
Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.
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16
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Albert NM, Trochelman K, Meyer KH, Nutter B. Characteristics associated with racial disparities in illness beliefs of patients with heart failure. Behav Med 2010; 35:112-25. [PMID: 19933058 DOI: 10.1080/08964280903334519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
African Americans have greater misperceptions about heart failure (HF) than Caucasians. We examined socioeconomic and medical history factors to determine if they explain differences in accuracy of HF illness beliefs by race. 519 patients completed an illness beliefs and socioeconomic status survey. After establishing univariate associations by race, linear regression with backward selection was used to identify factors associated with HF illness beliefs accuracy. HF illness beliefs were less accurate among African Americans (p < .01). In multivariate models, race remained a predictor of HF illness beliefs accuracy, as did education level and living status (all ps < or = .01). Illness beliefs of African Americans were inaccurate and independently associated with social support and education level. Health care providers must consider patient education processes as a possible cause of differences and focus on what and how they teach, literacy level, materials used, and family engagement and education.
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Affiliation(s)
- Nancy M Albert
- Nursing Institute and the Kaufman Center for Heart Failure, Cleveland Clinic, 9500 Euclid Avenue, Mail code J3-4, Cleveland, OH 44195, USA.
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Adebayo AK, Adebiyi AA, Oladapo OO, Ogah OS, Aje A, Ojji DB, Falase AO. Characterisation of heart failure with normal ejection fraction in a tertiary hospital in Nigeria. BMC Cardiovasc Disord 2009; 9:52. [PMID: 19922629 PMCID: PMC2785749 DOI: 10.1186/1471-2261-9-52] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 11/18/2009] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The study aimed to determine the frequency and characteristics of heart failure with normal EF in a native African population with heart failure. METHODS It was a hospital cohort study. Subjects were 177 consecutive individuals with heart failure and ninety apparently normal control subjects. All the subjects underwent transthoracic echocardiography. The group with heart failure was further subdivided into heart failure with normal EF (EF > or = 50) (HFNEF) and heart failure with low EF(EF <50)(HFLEF). RESULTS The subjects with heart failure have a mean age of 52.3 +/- 16.64 years vs 52.1 +/- 11.84 years in the control subjects; p = 0.914. Other baseline characteristics except blood pressure parameters and height were comparable between the group with heart failure and the control subjects. The frequency of HFNEF was 39.5%. Compared with the HFLEF group, the HFNEF group have a smaller left ventricular diameter (in diastole and systole): (5.2 +/- 1.22 cm vs 6.2 +/- 1.39 cm; p < 0.0001 and 3.6 +/- 1.24 cm vs 5.4 +/- 1.35 cm;p < 0.0001) respectively, a higher relative wall thickness and deceleration time of the early mitral inflow velocity: (0.4 +/- 0.12 vs 0.3 +/- 0.14 p < 0.0001 and 149.6 +/- 72.35 vs 110.9 +/- 63.40 p = 0.001) respectively. The two groups with heart failure differed significantly from the control subjects in virtually all echocardiographic measurements except aortic root diameter, LV posterior wall thickness(HFLEF), and late mitral inflow velocity(HFNEF). HFNEF accounted for 70(39.5%) of cases of heart failure in this study. Hypertension is the underlying cardiovascular disease in 134(75.7%) of the combined heart failure population, 58 (82.9%) of the subjects with HFNEF group and 76(71%) of the HFLEF group. Females accounted for 44 (62.9%) of the subjects with HFNEF against 42(39.3%) in the HFLEF group (p = 0.002). CONCLUSION The frequency of heart failure with normal EF in this native African cohort with heart failure is comparable with the frequency in other populations. These groups of patients are more likely female, hypertensive with concentric pattern of left ventricular hypertrophy.
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Affiliation(s)
- Adedeji K Adebayo
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Adewole A Adebiyi
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Olulola O Oladapo
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Akinyemi Aje
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Dike B Ojji
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Ayodele O Falase
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
- College of Medicine University of Ibadan, Ibadan, Nigeria
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18
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Left ventricular geometry, risk factors, and outcomes of hospitalized patients with diastolic heart failure in Japan. J Cardiol 2009; 54:101-7. [DOI: 10.1016/j.jjcc.2009.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/07/2009] [Accepted: 04/28/2009] [Indexed: 11/19/2022]
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Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJV. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. Eur J Heart Fail 2009; 11:130-9. [PMID: 19168510 PMCID: PMC2639415 DOI: 10.1093/eurjhf/hfn013] [Citation(s) in RCA: 364] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 08/31/2008] [Accepted: 11/03/2008] [Indexed: 11/12/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are global epidemics incurring significant morbidity and mortality. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. Evaluation of cardiac and pulmonary function is often problematic and occasionally misleading. Echocardiography and pulmonary function tests should be performed in every patient. Careful interpretation is required to avoid misdiagnosis and inappropriate treatment. Airflow obstruction, in particular, must be demonstrated when clinically euvolaemic. Very high and very low concentrations of natriuretic peptides have high positive and negative predictive values for diagnosing HF in those with both conditions. Intermediate values are less informative. Both conditions are systemic disorders with overlapping pathophysiological processes. In patients with HF, COPD is consistently an independent predictor of death and hospitalization. However, the impact on ischaemic and arrhythmic events is unknown. Greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. The resulting symptomatic and prognostic benefits outweigh those attainable by treating either condition alone.
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Affiliation(s)
- Nathaniel Mark Hawkins
- Aintree Cardiac Centre, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
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20
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Abstract
PURPOSE OF REVIEW A substantial proportion of patients with heart failure have preserved ejection fraction. Though patients with preserved ejection fraction experience a substantial burden of morbidity and mortality, the understanding of heart failure pathophysiology in this group remains incomplete and evidence-based therapeutic options are limited. RECENT FINDINGS The prevalence of heart failure in patients with preserved ejection fraction is increasing and prognosis in this population remains poor despite modern medical therapy. Though diastolic dysfunction is typically present, increasing evidence suggests that extracardiac factors such as renal dysfunction and enhanced central aortic stiffness may play an important role in the development and progression of heart failure symptoms. Results of the first randomized, controlled clinical trials in this population suggest a possible therapeutic role for renin-angiotensin system blockade in reducing heart failure-associated morbidity, but there is still no evidence-supported strategy for reducing mortality in this population. SUMMARY Though the epidemiology and impact of heart failure with preserved ejection fraction are increasingly clear, consensus regarding pathophysiology and the optimal therapeutic approach is still lacking. Pending completion of additional therapeutic trials in this population, treatment remains largely empiric and focused on optimizing myocardial performance in diastole by control of blood pressure, restoration or maintenance of sinus rhythm, and relief of volume overload.
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Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular health disparities: a systematic review of health care interventions. Med Care Res Rev 2007; 64:29S-100S. [PMID: 17881625 PMCID: PMC2367222 DOI: 10.1177/1077558707305416] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.
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Pirracchio R, Cholley B, De Hert S, Solal AC, Mebazaa A. Diastolic heart failure in anaesthesia and critical care. Br J Anaesth 2007; 98:707-21. [PMID: 17468492 DOI: 10.1093/bja/aem098] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Diastolic heart failure is an underestimated pathology with a high risk of acute decompensation during the perioperative period. This article reviews the epidemiology, risk factors, pathophysiology, and treatment of diastolic heart failure. Although frequently underestimated, diastolic heart failure is a common pathology. Diastolic heart failure involves heart failure with preserved left ventricular (LV) function, and LV diastolic dysfunction may account for acute heart failure occurring in critical care situations. Hypertensive crisis, sepsis, and myocardial ischaemia are frequently associated with acute diastolic heart failure. Symptomatic treatment focuses on the reduction in pulmonary congestion and the improvement in LV filling. Specific treatment is actually lacking, but encouraging data are emerging concerning the use of renin-angiotensin-aldosterone axis blockers, nitric oxide donors, or, very recently, new agents specifically targeting actin-myosin cross-bridges.
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Affiliation(s)
- R Pirracchio
- Department of Anaesthesiology, Lariboisière University Hospital, Paris, France
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Abraham WT, Massie BM, Lukas MA, Lottes SR, Nelson JJ, Fowler MB, Greenberg B, Gilbert EM, Franciosa JA. Tolerability, safety, and efficacy of beta-blockade in black patients with heart failure in the community setting: insights from a large prospective beta-blocker registry. ACTA ACUST UNITED AC 2007; 13:16-21. [PMID: 17268206 DOI: 10.1111/j.1527-5299.2007.888111.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Heart failure (HF) clinical trials suggest different responses of blacks and whites to beta-blockers. Differences between clinical trial and community settings may also have an impact. The Carvedilol Heart Failure Registry (COHERE) observed experience with carvedilol in 4280 patients with HF in a community setting. This analysis compares characteristics, outcomes, and carvedilol dosing of blacks and whites in COHERE. Compared with whites (n=3433), blacks (n=523) had more severe HF symptoms despite similar systolic function. At similar carvedilol maintenance doses, symptoms improved in 33% of blacks vs 28% of whites, while worsening in 10% and 11%, respectively (both nonsignificant), and HF hospitalization rates were reduced comparably in both groups (-58% vs -56%, respectively; both P<.001). Incidence and hazard ratios of death were similar in blacks and whites (6.9% vs 7.5%, hazard ratio 1.2 vs 1.0, P=.276). Thus carvedilol was similarly effective in blacks and whites with HF in the community setting, consistent with carvedilol clinical trials.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University School of Medicine, Columbus, OH, USA
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24
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Gary R. Self-care practices in women with diastolic heart failure. Heart Lung 2007; 35:9-19. [PMID: 16426931 DOI: 10.1016/j.hrtlng.2005.04.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Accepted: 04/12/2005] [Indexed: 01/14/2023]
Abstract
BACKGROUND For many patients with heart failure (HF), performing self-care is complicated by the complex medication regimen, symptom monitoring, and required decision-making. Women with HF are typically older and more physically debilitated, have more comorbidities, and may be at higher risk for poor self-care practices. Previous studies have largely excluded patients with diastolic heart failure (DHF), however, so little is known about their self-care practices. OBJECTIVES The purposes of the study were to describe the (a) performance of self-care behaviors and (b) demographic and clinical characteristics that affected self-care practices in women with DHF. METHODS Thirty-two women who were 50 years of age or older and diagnosed with DHF were recruited through cardiologist referral from an outpatient HF clinic in an academic health care setting. Data were collected using a semistructured interview guide. Descriptive statistics were used to analyze participant demographic and clinical characteristics. The responses were tabulated in order of frequency and then coded into categories. RESULTS The mean age of the women was 68 +/- 11 years; 81% had annual incomes at or below the poverty level, 41% lived alone, and the majority had three or more comorbidities. Although most perceived their HF knowledge to be fair to good, and 62% had received HF educational information, only six (19%) weighed daily, few followed the recommended sodium restrictions, and 91% were sedentary at the time of the interview. The only self-care behavior that was consistently practiced (72%) was taking prescribed medications. Exertional intolerance often interfered with household chores and was cited most often as the reason for poorer quality of life. Decision-making about self-care activities such as taking diuretics was typically based on daily plans and social outings. Medical attention was sought only when acute or life-threatening symptoms occurred. Few women actively participated in ongoing symptom monitoring, and confusion over symptom recognition was a recurrent problem. CONCLUSIONS Lower socioeconomic status and advancing age increase vulnerability for poor self-care and negative clinical outcomes in women with DHF. Recommendations to improve self-care practices among economically disadvantaged women with HF such as prescribing routine activities as exercise, screening for depression, and home visits to increase socialization are discussed along with areas for future research.
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Affiliation(s)
- Rebecca Gary
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia 30322, USA
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25
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Ilksoy N, Hoffman M, Moore RH, Easley K, Jacobson TA. Comparison of African-American patients with systolic heart failure versus preserved ejection fraction. Am J Cardiol 2006; 98:806-8. [PMID: 16950190 DOI: 10.1016/j.amjcard.2006.03.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Revised: 03/30/2006] [Accepted: 03/30/2006] [Indexed: 11/17/2022]
Abstract
Evidence exists for race-specific differences in the cause and natural history of heart failure (HF). These differences may have important treatment implications, but relatively limited data on African-Americans exist. A cohort of 89 African-American patients admitted to an urban teaching hospital with diagnoses of HF was examined. Most patients had systolic HF (71%), and the remainder had HF with preserved ejection fractions (EFs). Patients with HF with preserved EFs tended to be generally older (67 vs 57 years, p = 0.01) and were more likely to be women (69% vs 42%, p = 0.02). There were no significant differences between patients with systolic HF and those with HF with preserved EFs in the prevalence of coronary artery disease (23%), diabetes mellitus (44%), or chronic obstructive pulmonary disease (38%). Gastrointestinal bleeding and anemia were significant contributors to admission in patients with preserved EFs, with baseline hematocrits being significantly lower (34.9 vs 38.3, p = 0.01). On discharge, patients with HF with preserved EFs were less likely to be prescribed angiotensin-converting enzyme inhibitors than patients with systolic HF (65% vs 83%, p = 0.08) or diuretics (58% vs 82.%, p = 0.03). In conclusion, differences exist in African-American patients who present with HF; optimal therapeutic approaches will require a better understanding of their underlying pathophysiology.
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Affiliation(s)
- Nurcan Ilksoy
- Emory University School of Medicine, Department of Medicine, Atlanta, Georgia, USA.
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26
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Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355:251-9. [PMID: 16855265 DOI: 10.1056/nejmoa052256] [Citation(s) in RCA: 3000] [Impact Index Per Article: 166.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prevalence of heart failure with preserved ejection fraction may be changing as a result of changes in population demographics and in the prevalence and treatment of risk factors for heart failure. Changes in the prevalence of heart failure with preserved ejection fraction may contribute to changes in the natural history of heart failure. We performed a study to define secular trends in the prevalence of heart failure with preserved ejection fraction among patients at a single institution over a 15-year period. METHODS We studied all consecutive patients hospitalized with decompensated heart failure at Mayo Clinic Hospitals in Olmsted County, Minnesota, from 1987 through 2001. We classified patients as having either preserved or reduced ejection fraction. The patients were also classified as community patients (Olmsted County residents) or referral patients. Secular trends in the type of heart failure, associated cardiovascular disease, and survival were defined. RESULTS A total of 6076 patients with heart failure were discharged over the 15-year period; data on ejection fraction were available for 4596 of these patients (76 percent). Of these, 53 percent had a reduced ejection fraction and 47 percent had a preserved ejection fraction. The proportion of patients with the diagnosis of heart failure with preserved ejection fraction increased over time and was significantly higher among community patients than among referral patients (55 percent vs. 45 percent). The prevalence rates of hypertension, atrial fibrillation, and diabetes among patients with heart failure increased significantly over time. Survival was slightly better among patients with preserved ejection fraction (adjusted hazard ratio for death, 0.96; P=0.01). Survival improved over time for those with reduced ejection fraction but not for those with preserved ejection fraction. CONCLUSIONS The prevalence of heart failure with preserved ejection fraction increased over a 15-year period, while the rate of death from this disorder remained unchanged. These trends underscore the importance of this growing public health problem.
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Affiliation(s)
- Theophilus E Owan
- Cardiorenal Research Laboratory, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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