Prevalence and prognosis of asymptomatic left ventricular diastolic dysfunction in ambulatory patients with coronary heart disease

Influence of Left Ventricular Diastolic Dysfunction on the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve

OBJECTIVES

Our study aimed to demonstrate the influence of left ventricular (LV) diastolic dysfunction on the diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR).

METHODS

One hundred vessels from 90 patients were retrospectively analyzed. All patients underwent echocardiography, coronary computed tomography angiography (CCTA), CT-FFR, invasive coronary angiography (ICA), and fractional flow reserve (FFR). The study population was divided into normal and dysfunction groups according to the LV diastolic function, and the diagnostic performance in both groups was assessed.

RESULTS

There was a good correlation between CT-FFR and FFR (R = 0.768 p < 0.001) on a per-vessel basis. The sensitivity, specificity, and accuracy were 82.3%, 81.8%, and 82%, respectively. The sensitivity, specificity, and accuracy were 84.6%, 88.5%, and 87.2% in the normal group and 81%, 77.5%, and 78.7% in the dysfunction group, respectively. CT-FFR showed no statistically significant difference in the AUC in the normal group vs. the dysfunction group (AUC: 0.920 [95% CI 0.787-0.983] vs. 0.871 [95% CI 0.761-0.943], Z = 0.772 p = 0.440). However, there was still a good correlation between CT-FFR and FFR in the normal group (R = 0.767, p < 0.001) and dysfunction group (R = 0.767 p < 0.001).

CONCLUSIONS

LV diastolic dysfunction had no effect on the diagnostic accuracy of CT-FFR. CT-FFR has good diagnostic performance in both LV diastolic dysfunction and the normal group and can be used as an effective tool for finding lesion-specific ischemia while screening for arterial disease in patients.

Diastolic dysfunction and sex-specific progression to HFpEF: current gaps in knowledge and future directions

Diastolic dysfunction of the left ventricle (LVDD) is equally common in elderly women and men. LVDD is a condition that can remain latent for a long time but is also held responsible for elevated left ventricular filling pressures and high pulmonary pressures that may result in (exercise-induced) shortness of breath. This symptom is the hallmark of heart failure with preserved ejection fraction (HFpEF) which is predominantly found in women as compared to men within the HF spectrum. Given the mechanistic role of LVDD in the development of HFpEF, we review risk factors and mechanisms that may be responsible for this sex-specific progression of LVDD towards HFpEF from an epidemiological point-of-view and propose future research directions.

Kinetic energy of left ventricular blood flow across heart failure phenotypes and in subclinical diastolic dysfunction

BACKGROUND

Kinetic energy (KE) of intracardiac blood flow reflects myocardial work spent on accelerating blood and provides a mechanistic window into diastolic filling dynamics. Diastolic dysfunction may represent an early stage in the development of heart failure (HF). Here we evaluated the hemodynamic effects of impaired diastolic function in subjects with and without HF, testing the hypothesis that left ventricular KE differs between controls, subjects with subclinical diastolic dysfunction (SDD), and HF patients.

METHODS

We studied 77 subjects (16 controls, 20 subjects with SDD, 16 HFpEF, 9 HFmrEF, and 16 HFrEF patients, age- and sex-matched at the group level). Cardiac magnetic resonance at 1.5T included intracardiac 4D flow and cine imaging. Left ventricular KE was calculated as 0.5*m*v².

RESULTS

Systolic KE was similar between groups (p>0.4), also after indexing to stroke volume (p=0.25), and was primarily driven by ventricular emptying rate (p<0.0001, R²=0.52). Diastolic KE was higher in heart failure patients than controls (p<0.05) but similar between SDD and HFpEF (p>0.18), correlating with inflow conditions (E-wave velocity, p<0.0001, R²=0.24) and end-diastolic volume (p=0.0003, R²=0.17) but not with average e' (p=0.07).

CONCLUSIONS

Diastolic KE differs between controls and heart failure, suggesting more work is spent filling the failing ventricle, while systolic KE does not differentiate between well-matched groups with normal ejection fraction even in the presence of relaxation abnormalities and heart failure. Mechanistically, KE reflects the acceleration imparted on the blood and is driven by variations in ventricular emptying and filling rates, volumes, and heart rate, regardless of underlying pathology.

The constricting effect of reduced coronary artery compliance on the left ventricle is an important cause of reduced diastolic function in patients with coronary heart disease

Background

Previous studies of left ventricular diastolic function (LVDF) have focused on the decrease in active and passive diastolic function due to ischemic factors but have not investigated if the decrease in compliance of the coronary arteries that bypass the surface of the heart and travel between the myocardium could cause a constricting effect on the ventricular wall like that caused by myocardial fibrosis.

Methods and Results

581 patients diagnosed with coronary heart disease (CHD) were divided into A group (patients are the control group), B group (patients with less than 50% coronary artery stenosis), C group (patients with coronary artery stenosis between 50 and 75%), D group (patients with coronary artery stenosis greater than 75%) according to the degree of coronary stenosis. The diastolic function of the ventricle is reflected by applying the relaxation time constant T value, which refers to the time between peak dp/dt and end-diastolic pressure in the left ventricle. It was concluded that there was a statistical difference in Gensini scores between patients in groups B, C and D (P < 0.001). And multiple linear regression analysis showed that T was correlated with Gensini score and C-dp/dtmax (R = 0.711, P < 0.001). Grouping according to the site of stent implantation and the number of stents implanted, it was found out that the changes in T values before and after left anterior descending artery (LAD) stent implantation were greater than left circumflex artery (LCX) and right coronary artery (RCA) (P < 0.001). And multiple linear regression revealed a correlation between T values and stent length, ventricular stiffness, and C-dp/dtmax (P = 0.001).

Conclusions

The decrease in compliance of the coronary arteries bypassing the surface of the heart and travelling between the myocardium would cause a constricting effect on the ventricular wall like that caused by myocardial fibrosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02809-0.

Genetic Determinants of Body Mass Index and Fasting Glucose Are Mediators of Grade 1 Diastolic Dysfunction

Background Early (grade 1) cardiac left ventricular diastolic dysfunction (G1DD) increases the risk for heart failure with preserved ejection fraction and may improve with aggressive risk factor modification. Type 2 diabetes, obesity, hypertension, and coronary heart disease are associated with increased incidence of diastolic dysfunction. The genetic drivers of G1DD are not defined. Methods and Results We curated genotyped European ancestry G1DD cases (n=668) and controls with normal diastolic function (n=1772) from Vanderbilt's biobank. G1DD status was explored through (1) an additive model genome-wide association study, (2) shared polygenic risk through logistic regression, and (3) instrumental variable analysis using 2-sample Mendelian randomization (the inverse-variance weighted method, Mendelian randomization-Egger, and median) to determine potential modifiable risk factors. There were no common single nucleotide polymorphisms significantly associated with G1DD status. A polygenic risk score for BMI was significantly associated with increased G1DD risk (odds ratio [OR], 1.20 for 1-SD increase in BMI [95% CI, 1.08-1.32]; P=0.0003). The association was confirmed by the inverse-variance weighted method (OR, 1.89 [95% CI, 1.37-2.61]). Among the candidate mediators for BMI, only fasting glucose was significantly associated with G1DD status by the inverse-variance weighted method (OR, 4.14 for 1-SD increase in fasting glucose [95% CI, 1.55-11.02]; P=0.005). Multivariable Mendelian randomization showed a modest attenuation of the BMI association (OR, 1.84 [95% CI, 1.35-2.52]) when adjusting for fasting glucose. Conclusions These data suggest that a genetic predisposition to elevated BMI increases the risk for G1DD. Part of this effect may be mediated through altered glucose homeostasis.

Effect of Percutaneous Coronary Intervention on Diastolic Function in Coronary Artery Disease

Background:

Left ventricle (LV) diastolic dysfunction is often present in patients with significant coronary artery disease (CAD), even in the absence of regional or global LV systolic dysfunction. It has been suggested that abnormalities in LV diastolic function may actually precede LV systolic dysfunction, and therefore, serve as an early and sensitive marker of ischemia. This study aims to find improvement of diastolic function after percutaneous coronary intervention (PCI) in patients with stable or unstable angina.

Methods:

In this single-center hospital-based study, we enrolled 309 patients with either stable or unstable CAD and with normal systolic function who underwent successful PCI. Two-dimensional transthoracic echocardiography was performed at baseline (before PCI) and repeated 48 h after PCI. LV diastolic parameters were compared before and after PCI using paired samples t-test results.

Results:

Mean age of study population was 56.65 ± 9.65 years. Majority of patients were male (63%). There was significant increase in mitral E-wave velocity (68.39 ± 17.52 cm/s vs. 71.64 ± 18.23 cm/s), E/A ratio (0.85 ± 0.29 vs. 0.89 ± 0.32), and early diastolic mitral annular motion (e') (7.02 ± 0.89 cm/s vs. 8.45 ± 0.86 cm/s) following PCI (P < 0.0001). Left atrial volume index (22.53 ± 4.43 vs. 20.81 ± 4.14), tricuspid jet velocity (0.91 ± 0.57 m/s vs. 0.76 ± 0.67 m/s), and E/e' ratio (10.03 ± 3.5 vs. 8.62 ± 2.61) decreased significantly following PCI (P < 0.001).

Conclusion:

This study suggests that LV diastolic filling pattern is modified significantly as early as 48 h after successful PCI. Improvement in impaired relaxation appears to be most likely explanation for these changes. PCI may be potential therapeutic target to improve diastolic function in patients with CAD.

Prognostic Value of Diastolic Dysfunction Derived From D-SPECT in Coronary Artery Disease Patients With Normal Ejection Fraction

Diastolic dysfunction (DD) with normal systolic function has been elucidated to be associated with heart failure and worse prognosis. The recently introduced single photon emission computed tomography (SPECT) with dedicated cardiac cadmium-zinc-telluride (CZT) cameras (D-SPECT) is a novel method to quantitate left ventricular functional parameters. We aimed to evaluate the prognostic value of DD derived from D-SPECT in coronary artery disease (CAD) patients with normal ejection fraction. All CAD patients who underwent D-SPECT and invasive coronary angiography within 3 months were considered. DD was defined as peak filling rate (PFR) <2.1 end diastolic volume (EDV, ml)/s according to the D-SPECT results. Patients were divided into three groups: group 1 (n = 226)-normal PFR; group 2 (n = 67)-ischemia-related DD (abnormal stress PFR and normal rest PFR); and group 3 (n = 106)-rest DD (abnormal rest PFR). The primary clinical endpoint of the present study was a composite of heart failure events (HFE). A total of 399 consecutive CAD patients with normal systolic function undergoing stress D-SPECT were analyzed. The incidence rates of HFE among the three groups were 4.0, 7.5, and 11.3%, respectively. Cox regression analysis showed that the multivariate predictors of HFE were rest PFR, diabetes mellitus, obesity, and old age. DD derived from D-SPECT in CAD patients with normal ejection fraction is predictive of HFE.

Progression of Preclinical Heart Failure: A Description of Stage A and B Heart Failure in a Community Population

BACKGROUND

The aims of this study are to evaluate the rate of progression of preclinical (Stage A and B) heart failure, identify associated characteristics, and evaluate long-term outcomes.

METHODS

Retrospective review of the Olmsted County Heart Function Study. Individuals categorized as Stage A or B heart failure at initial visit that returned for a second visit 4 years later were included. Logistic regression analyses evaluated group differences with adjustment for age and sex.

RESULTS

At visit 1, 413 (32%) individuals were classified as Stage A and 413 (32%) as Stage B. By visit 2, 146 (35%) individuals from Stage A progressed with the vast majority (n=142) progressing to Stage B. In comparison, a total of 23 (6%) individuals progressed from Stage B. A greater rate of progression was seen for Stage A compared with Stage B (8.7 per 100 person-years [95% CI, 7.4-10.2] versus 1.4 per 100 person-years [95% CI, 0.9-2.1]; P<0.001). NT-proBNP correlated with progression for Stage B (P=0.01), but not for Stage A (P=0.39). A multivariate model found female sex (odds ratio, 1.65 [95% CI, 1.05-2.58]; P=0.03), increased E/e' (odds ratio, 1.13 [95% CI, 1.02-1.26], P=0.02), and beta blocker use (odds ratio, 2.19 [95% CI, 1.25-3.82], P=0.006) were associated with progression for Stage A. There was a signal that cardiovascular mortality was higher in individuals who progressed, although not statistically significant (P=0.06 for Stage A and P=0.05 for Stage B).

CONCLUSIONS

There is significant progression of preclinical heart failure in a community population, with progression rates higher for Stage A. NT-proBNP correlated with progression for Stage B, but not for Stage A. No statistically significant differences in long-term outcomes were seen. Study results have clinical implications important to help guide future heart failure screening and prevention strategies.

Ionomic profiling of pericardial fluid in ischemic heart disease

Metals are essential cofactors that play a crucial role in heart function at the cell and tissue level. Information regarding the role of metals in the pericardial fluid and its ionome in ischemic heart disease (IHD) is limited. We aimed to determine the association of elements in pericardial fluid and serum samples of IHD patients and their correlation with systolic and diastolic function. IHD patients have been studied with systolic and diastolic dysfunction categorized on the basis of echocardiographic parameters. We measured concentrations of sixteen elements in the pericardial fluid and serum of 46 patients obtained during open heart surgery with IHD by ICP-MS. The levels of chromium and nickel in pericardial fluid were significantly higher as compared with serum samples of IHD patients (p < 0.05). The chromium, nickel and manganese levels in pericardial fluid were lower in patients with ejection fraction (EF) < 45% as compared to EF > 45% (p < 0.05). There was no significant difference in pericardial concentrations of elements in diastolic dysfunction grade 0-1 with 2 in IHD patients. We also found that decreased concentration of these elements in pericardial fluid is associated with decreased systolic function. These results suggest that pericardial fluid concentrations of these metals may reflect the extent of ischemic heart disease. These findings are hypothesis generating with regards to a role in the pathogenesis of the disorder.

Outcome assessment using estimation of left ventricular filling pressure in asymptomatic patients at risk for heart failure with preserved ejection fraction

AIMS

High prevalence and lack of pharmacological treatment are making heart failure with preserved ejection fraction (HFpEF) a growing public health problem. No algorithm for the screening of asymptomatic patients with risk for HFpEF exists to date. We assessed whether HFA/ESC 2007 diagnostic criteria for HFpEF are helpful to investigate the cardiovascular outcome in asymptomatic patients.

METHODS AND RESULTS

We performed an analysis of the Diagnostic Trial on Prevalence and Clinical Course of Diastolic Dysfunction and Heart Failure (DIAST-CHF) that recruited patients with cardiovascular risk factors. All patients underwent a comprehensive diagnostic workup at baseline. Asymptomatic patients with preserved LVEF (>50%) were selected and classified according to HFA/ESC surrogate criteria for left ventricular elevated filling pressure (mean E/e' >15 or E/e' >8 and presence of either NT-proBNP > 220 ng/l, BNP > 200 ng/l or atrial fibrillation) into elevated filling pressure (FPe) or controls. Cardiovascular hospitalizations and all-cause death were assessed for both groups over a 10-year-follow-up.851 asymptomatic patients (age 65.5 ± 7.6 years, 44% female) were included in the analysis. FPe-patients were significantly older (p < 0.001), more often female (p = 0.003) and more often had a history of coronary artery disease, atrial fibrillation and renal dysfunction (p < 0.001, respectively) compared to controls. Incidence of death was significantly higher in the FPe group after a 10-year follow-up (p < 0.001), whereas cardiovascular hospitalization did not differ between groups.

CONCLUSION

Asymptomatic patients that fulfill HFA/ESC diagnostic criteria for HFpEF are at higher risk of symptomatic HFpEF and have a worse 10-year-outcome than those who do not fulfill criteria.

Risk of de-novo heart failure and competing risk in asymptomatic patients with structural heart diseases

AIMS

Asymptomatic patients with structural heart diseases are classified as a population at high risk for heart failure (HF) in Stage B. However, limited data are available regarding incidence and related factors of de-novo HF (DNHF) considering competing risk in this population.

METHODS AND RESULTS

In 3362 Stage B patients (mean age 68 yrs, male 76%) from the CHART-2 Study (N = 10,219), we examined incidence of death and DNHF, defined as the first episode of either HF hospitalization or HF death, and factors related to DNHF.

RESULTS

During the median 6.0-year follow-up, 627 deaths (31/1000 person-years) and 293 DNHF (15/1000 person-years) occurred. Among the 627 deaths, 212 (34%) and 325 (52%) were specified as cardiovascular and non-cardiovascular deaths, respectively. During the follow-up of 271 DNHF hospitalizations, we observed 124 deaths, including 65 (52%) cardiovascular and 47 (40%) non-cardiovascular deaths. The competing risk model showed that age, diabetes mellitus, stroke, atrial fibrillation, diastolic blood pressure, hemoglobin levels, estimated glomerular filtration ratio and left ventricular ejection fraction was significantly associated with DNHF. Bayesian structural equation modeling showed that many of these cardiac and non-cardiac variables contribute to DNHF by affecting each other, while diabetes mellitus was independently associated with DNHF.

CONCLUSIONS

Stage B patients had a high incidence of DNHF as well as that of death due to both cardiovascular and non-cardiovascular causes. Thus, management of Stage B patients should include multidisciplinary approaches considering both cardiac and non-cardiac factors, in order to prevent DNHF as well as non-HF death as a competing risk.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00418041.

Integrating natriuretic peptides and diastolic dysfunction to predict adverse events in high-risk asymptomatic subjects

Background

Natriuretic peptides and diastolic dysfunction have prognostic value in asymptomatic subjects at risk for heart failure. Their integration might further refine the risk stratification process in this setting. Aim of this paper was to explore the possibility to predict heart failure and death combining diastolic dysfunction and natriuretic peptides in an asymptomatic population at risk for heart failure.

Methods

Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for heart failure. Baseline evaluation included electrocardiogram, echocardiogram, and natriuretic peptides collection. Based on diastolic dysfunction and natriuretic peptides, subjects were classified in four groups: control group (no diastolic dysfunction/normal natriuretic peptides, 57%), no diastolic dysfunction/high natriuretic peptides (9%), diastolic dysfunction/normal natriuretic peptides (24%), and diastolic dysfunction/high natriuretic peptides (11%). We applied Cox multivariable and Classification and Regression Tree analyses.

Results

The mean age of the population was 69 ± 7 years, 44% were women, mean left ventricular ejection fraction was 61%, and 35% had diastolic dysfunction. During a median follow-up of 5.7 years, 95 heart failure/death events occurred. Overall, diastolic dysfunction and natriuretic peptides were predictive of adverse events (respectively, hazard ratio 1.91, confidence interval 1.19–3.05, padjusted = 0.007, and hazard ratio 2.25, confidence interval 1.35–3.74, padjusted = 0.002) with Cox analysis. However, considering the four study subgroups, only the group with diastolic dysfunction/high natriuretic peptides had a significantly worse prognosis compared to the control group (hazard ratio 4.48, confidence interval 2.31–8.70, padjusted &lt; 0.001). At Classification and Regression Tree analysis, diastolic dysfunction/high natriuretic peptides was the strongest prognostic factor (risk range 24–58%).

Conclusions

The DAVID-Berg data suggest that we look for the quite common combination of diastolic dysfunction/high natriuretic peptides to correctly identify asymptomatic subjects at greater risk for incident heart failure/death, thus more suitable for preventive interventions.

Association of Machine Learning-Derived Phenogroupings of Echocardiographic Variables with Heart Failure in Stable Coronary Artery Disease: The Heart and Soul Study

BACKGROUND

Many individual echocardiographic variables have been associated with heart failure (HF) in patients with stable coronary artery disease (CAD), but their combined utility for prediction has not been well studied.

METHODS

Unsupervised model-based cluster analysis was performed by researchers blinded to the study outcome in 1,000 patients with stable CAD on 15 transthoracic echocardiographic variables. We evaluated associations of cluster membership with HF hospitalization using Cox proportional hazards regression analysis.

RESULTS

The echo-derived clusters partitioned subjects into four phenogroupings: phenogroup 1 (n = 85) had the highest levels, phenogroups 2 (n = 314) and 3 (n = 205) displayed intermediate levels, and phenogroup 4 (n = 396) had the lowest levels of cardiopulmonary structural and functional abnormalities. Over 7.1 ± 3.2 years of follow-up, there were 198 HF hospitalizations. After multivariable adjustment for traditional cardiovascular risk factors, phenogroup 1 was associated with a nearly fivefold increased risk (hazard ratio [HR] = 4.8; 95% CI, 2.4-9.5), phenogroup 2 was associated with a nearly threefold increased risk (HR = 2.7; 95% CI, 1.4-5.0), and phenogroup 3 was associated with a nearly twofold increased risk (HR = 1.9; 95% CI, 1.0-3.8) of HF hospitalization, relative to phenogroup 4.

CONCLUSIONS

Transthoracic echocardiographic variables can be used to classify stable CAD patients into separate phenogroupings that differentiate cardiopulmonary structural and functional abnormalities and can predict HF hospitalization, independent of traditional cardiovascular risk factors.

Prognostic Implications of Diastolic Dysfunction Change in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

BACKGROUND

The association between a change in diastolic function (DF) and long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) is unknown. The aim of this study was to investigate the prognostic effect of changes in diastolic dysfunction in patients undergoing PCI.Methods and Results:Consecutive patients who underwent PCI and echocardiography before and after revascularization were prospectively included. Major adverse cardiac event (MACE) was defined as a composite of cardiac death, myocardial infarction, and repeat revascularization. A total of 1,235 patients were identified. Baseline diastolic dysfunction was present in 1,033 patients (83.6%). At follow-up echocardiography, DF had worsened in 219 (17.8%) patients and was unchanged in 623 patients (50.4%). The risk of MACE was significantly higher in the worsened DF group compared with the unchanged DF group (adjusted hazard ratio [aHR]: 2.15; 95% confidence interval [CI]: 1.59 to 2.90; P<0.001) and the improved or normal DF group (aHR: 2.20; 95% CI, 1.49 to 3.27; P<0.001). Patients with worsened DF consistently had a higher risk of MACE in various subgroups, especially irrespective of left ventricular systolic function.

CONCLUSIONS

Aggravation of DF was independently associated with an increased risk of MACE in patients undergoing PCI. Evaluating changes in DF after PCI is a simple but useful method for predicting long-term clinical outcomes.

Untargeted metabolomic analysis of coronary artery disease patients with diastolic dysfunction show disturbed oxidative pathway

INTRODUCTION

Left ventricular diastolic dysfunction (LVDD) is common in patients with coronary artery disease (CAD) with prevalence estimates of 34% and constitutes a predictor of all-cause mortality. Although diastolic dysfunction is induced by myocardial ischemia and has been shown to alter the clinical course, the role of coronary artery disease in the diastolic dysfunction and its progression into heart failure has not been completely elucidated.

OBJECTIVE

The present study was conducted to identify possible metabolites in coronary artery disease patients that are differentially regulated in patients with diastolic dysfunction.

METHODS

The serum of CAD (n = 75) patients and young healthy volunteers (n = 43) were analysed by using gas chromatography mass spectrometry (GC-MS) technique. Pre-processing of data results in 1547 features; among them 1064 features were annotated using NIST library.

RESULTS AND CONCLUSION

Fifteen metabolites were found to be statistically different between cases and control. Variation in metabolites were identified and correlated with several clinically important echocardiography parameters i.e. LVDD grades, ejection fraction (EF) and E/e' values. The results suggested that metabolic products of fatty acid oxidation and glucose oxidation pathways such as oleic acid, stearic acid, palmitic acid, linoleic acid, galactose, pyruvic and lactic acids are predominantly up regulated in patients with coronary artery disease and severity of diastolic dysfunction appears to be linked to increase in fatty acid oxidation and inflammation. The metabolic fingerprints of these patients give us an insight into the pathophysiological mechanism of diastolic dysfunction in coronary artery disease patients although it did not identify validated novel markers.

Plasma NT-proBNP levels associated with cardiac structural abnormalities in asymptomatic health examinees with preserved ejection fraction: a retrospective cross-sectional study

OBJECTIVES

Stage B heart failure (HF) is defined as an asymptomatic abnormality of the heart structure or function. The circulating level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in symptomatic patients with left ventricular (LV) dysfunction caused by a structural or functional abnormality. This study investigated the association of the NT-proBNP level with echocardiography-detected cardiac structural or diastolic abnormalities in asymptomatic subjects with preserved LV systolic function (ejection fraction >50%).

METHODS

We retrospectively studied 652 health examinees who underwent echocardiography and an NT-proBNP test at a health-promotion centre in Seoul, between January 2016 and September 2018. The left ventricular mass index (LVMI) and the left atrial dimension (LAD) were used as markers for structural abnormalities, and the mean e' velocity and mitral early flow velocity/early diastolic tissue velocity (E/e') ratio were used as markers for diastolic dysfunction. The plasma NT-proBNP level was measured using electrochemiluminescence immunoassay (DPC Immulite 2000 XPi, Siemens Healthcare Diagnostics, Tarrytown, New York, USA).

RESULTS

Subjects with preclinical structural abnormalities were older and had a higher body mass index (BMI), higher blood pressure, lower high-density lipoprotein cholesterol level, higher NT-proBNP level, and higher E/e' (p<0.05). Multivariate regression analysis indicated that the factors associated with a higher NT-proBNP level were older age, female sex, lower BMI, higher creatinine level, higher LVMI and higher LAD (p<0.01).

CONCLUSION

Diastolic dysfunction is not associated with higher NT-proBNP levels, whereas preclinical cardiac structural abnormalities, as well as older age, female sex, lower BMI, and higher creatinine level, are associated with higher NT-proBNP levels.

Asymptomatic Left Ventricular Diastolic Dysfunction: Predicting Progression to Symptomatic Heart Failure

Asymptomatic left ventricular diastolic dysfunction (ALVDD) (diastolic abnormalities and normal ejection fraction in the absence of symptoms) is associated with incident heart failure (HF) and decreased survival. Abnormalities of diastolic function might therefore be included in the definition of stage B HF, which denotes individuals at risk for the development of HF. Imaging techniques, especially echocardiography, are necessary for the recognition of preclinical left ventricular (LV) diastolic disturbances, as well as further tracking of pathological changes and responses to treatment. The transition of ALVDD to symptomatic HF is underlain by multiple factors, including both cardiovascular and noncardiovascular determinants. The initiation of management strategies targeting cardiovascular and systemic comorbidities in patients identified as having ALVDD may delay symptomatic progression and improve prognosis.

Noninvasive Cardiac Imaging and the Prediction of Heart Failure Progression in Preclinical Stage A/B Subjects

Heart failure (HF) continues to grow as a cause of morbidity and mortality in our community and presents a significant public health problem, predominantly in individuals ≥65 years of age. Early intervention in asymptomatic HF subjects (Stage A/B) at risk of progression to symptomatic HF (Stage C/D) may provide an opportunity to halt this epidemic. The ability of cardiac imaging to assess cardiac structure and function permits early identification of those at increased risk of developing symptomatic HF. Systolic, diastolic, and structural left ventricular parameters each predict symptomatic HF, but no single parameter has sufficient sensitivity for screening to identify individuals with Stage A/B HF who are at increased risk of disease progression. Transthoracic echocardiography (TTE) has the advantage over other imaging modalities in being able to measure systolic, diastolic, and structural left ventricular parameters, and it identified at least 1 abnormal parameter in >50% of individuals with Stage A/B HF ≥65 years of age. Moreover, identification of at least 1 abnormality according to TTE in individuals with Stage A/B HF ≥65 years of age had 72% to 82% sensitivity for detection of those who subsequently developed symptomatic HF. Therefore, a case can be made for cardiac imaging by using TTE for community-dwelling populations with Stage A/B HF ≥65 years of age to identify those with increased risk of symptomatic HF who can be offered preventative therapies. Further studies are required to determine the best strategy for identifying the risk of symptomatic HF in younger individuals.

Clinical Features Associated With Nascent Left Ventricular Diastolic Dysfunction in a Population Aged 40 to 55 Years

Diastolic dysfunction (DD), an abnormality in cardiac left ventricular (LV) chamber compliance, is associated with increased morbidity and mortality. Although DD has been extensively studied in older populations, co-morbidity patterns are less well characterized in middle-aged subjects. We screened 156,434 subjects with transthoracic echocardiogram reports available through Vanderbilt's electronic heath record and identified 6,612 subjects 40 to 55 years old with an LV ejection fraction ≥50% and diastolic function staging. We tested 452 incident and prevalent clinical diagnoses for associations with early-stage DD (n = 1,676) versus normal function. There were 44 co-morbid diagnoses associated with grade 1 DD including hypertension (odds ratio [OR] = 2.02, 95% confidence interval [CI] 1.78 to 2.28, p <5.3 × 10-29), type 2 diabetes (OR 1.96, 95% CI 1.68 to 2.29, p = 2.1 × 10-17), tachycardia (OR 1.38, 95% CI 0.53 to 2.19, p = 2.9 × 10-6), obesity (OR 1.76, 95% CI 1.51 to 2.06, p = 1.7 × 10-12), and clinical end points, including end-stage renal disease (OR 3.29, 95% CI 2.19 to 4.96, p = 1.2 × 10-8) and stroke (OR 1.5, 95% CI 1.12 to 2.02, p = 6.9 × 10-3). Among the 60 incident diagnoses associated with DD, heart failure with preserved ejection fraction (OR 4.63, 95% CI 3.39 to 6.32, p = 6.3 × 10-22) had the most significant association. Among subjects with normal diastolic function and blood pressure at baseline, a blood pressure measurement in the hypertensive range at the time of the second echocardiogram was associated with progression to stage 1 DD (p = 0.04). In conclusion, DD was common among subjects 40 to 55 years old and was associated with a heavy burden of co-morbid disease.

Direction of Association Between Depressive Symptoms and Lifestyle Behaviors in Patients with Coronary Heart Disease: the Heart and Soul Study

BACKGROUND

Emerging evidence indicates that the association between depression and subsequent cardiovascular events is largely mediated by health behaviors. However, it is unclear whether depression is the cause or the consequence of poor health behaviors.

PURPOSE

The purpose of the present study is to examine prospective, bidirectional relationships of depressive symptoms with behavioral and lifestyle factors among patients with coronary heart disease.

METHODS

Depressive symptoms and lifestyle behaviors (physical activity, medication adherence, body mass index, waist to hip ratio, sleep quality, and smoking status) were assessed at baseline and 5 years later among a prospective cohort of 667 patients with stable coronary heart disease.

RESULTS

Greater depressive symptoms at baseline predicted poorer lifestyle behaviors 5 years later (less physical activity, lower medication adherence, higher body mass index, higher waist to hip ratio, worse sleep quality, and smoking). After adjustment for demographics, cardiac disease severity, comorbidity, and baseline lifestyle behaviors, depressive symptom severity remained predictive of subsequent worsening of physical activity (beta = -0.08; 95 % confidence interval (CI) = -0.16, -0.01; p = 0.03), medication adherence (beta = -0.16; 95 % CI = -0.24, -0.08; p < 0.001), and sleep quality (beta = -0.19; 95 % CI = -0.27, -0.11; p < 0.001). Baseline lifestyle behaviors also predicted 5-year change in depressive symptoms, although the associations were attenuated after adjustment for baseline depressive symptoms and covariates.

CONCLUSIONS

Among patients with coronary heart disease, depressive symptoms were linked to a range of lifestyle risk factors and predicted further declines in physical activity, medication adherence, and sleep quality.

Acute hyperglycemia suppresses left ventricular diastolic function and inhibits autophagic flux in mice under prohypertrophic stimulation

BACKGROUND

Left ventricular (LV) dysfunction is closely associated with LV hypertrophy or diabetes, as well as insufficient autophagic flux. Acute or chronic hyperglycemia is a prognostic factor for patients with myocardial infarction. However, the effect of acute hyperglycemia on LV dysfunction of the hypertrophic heart and the mechanisms involved are still unclear. This study aimed to confirm our hypothesis that either acute or chronic hyperglycemia suppresses LV diastolic function and autophagic flux.

METHODS

The transverse aortic constriction (TAC) model and streptozocin-induced type 1 diabetic mellitus mice were used. LV function was evaluated with a Millar catheter. Autophagic levels and autophagic flux in the whole heart and cultured neonatal rat cardiomyocytes in response to hyperglycemia were examined by using western blotting of LC3B-II and P62. We also examined the effect of an autophagic inhibitor on LC3B-II and P62 protein expression and LC3 puncta.

RESULTS

In mice with TAC, we detected diastolic dysfunction as early as 30 min after TAC. This dysfunction was indicated by a greater LV end-diastolic pressure and the exponential time constant of LV relaxation, as well as a smaller maximum descending rate of LV pressure in comparison with sham group. Similar results were also obtained in mice with TAC for 2 weeks, in addition to increased insulin resistance. Acute hyperglycemic stress suppressed diastolic function in mice with myocardial hypertrophy, as evaluated by invasive LV hemodynamic monitoring. Mice with chronic hyperglycemia induced by streptozocin showed myocardial fibrosis and diastolic dysfunction. In high glucose-treated cardiomyocytes and streptozocin-treated mice, peroxisome proliferator-activated receptor-γ coactivator 1α was downregulated, while P62 was upregulated. Autophagic flux was also significantly inhibited in response to high glucose exposure in angiotensin-II treated cardiomyocytes.

CONCLUSIONS

Acute hyperglycemia suppresses diastolic function, damages mitochondrial energy signaling, and inhibits autophagic flux in prohypertrophic factor-stimulated cardiomyocytes.

Heart Failure in Patients with Preserved Ejection Fraction: Questions Concerning Clinical Progression

Over the last two decades, important advances have been made in explaining some pathophysiological aspects of heart failure with preserved ejection fraction (HFpEF) with repercussions for the successful clinical management of the syndrome. Despite these gains, our knowledge for the natural history of clinical progression from the pre-clinical diastolic dysfunction (PDD) until the final clinical stages is significantly limited. The subclinical progression of PDD to the clinical phenotype of HFpEF and the further clinical progression to some more complex clinical models with multi-organ involvement, similar to heart failure with reduced ejection fraction (HFrEF), continue to be poorly understood. Prospective studies are needed to elucidate the natural history of clinical progression in patients with HFpEF and to identify the exact left ventricular remodeling mechanism that underlies this progression.

Predictors and Clinical Impacts of Aggravated Left Ventricular Diastolic Dysfunction After Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

To determine the predictors of aggravated left ventricular diastolic dysfunction (LVDD) in patients undergoing off-pump coronary artery bypass grafting (OPCAB) and to compare late outcomes according to the aggravated LVDD.

METHODS AND RESULTS

OPCAB was performed in 1,101 patients (2001-2013). LVDD was classified as normal, mild, moderate or severe. Patients were divided into 2 groups: non-aggravated LVDD (group I) and aggravated LVDD (group II). The primary endpoint was aggravation of LVDD. The secondary endpoint was late mortality and morbidity such as major adverse cardiac and cerebrovascular events (MACCE) related to LVDD aggravation postoperatively. There were 894 patients in group I and 207 in group II. Multivariate analysis revealed that preoperative peripheral artery obstructive disease (PAOD) (P=0.04), renal failure (P<0.01), and A' velocity (P<0.01) anticipated aggravated LVDD. The Cox hazards model revealed that aggravated LVDD was a poor prognostic factor for MACCE (P<0.01) and overall survival (P<0.01). The Kaplan-Meier survival curve showed that aggravated LVDD was related to poor late outcomes (freedom from MACCE, P=0.01; overall survival, P<0.01).

CONCLUSIONS

Aggravated LVDD significantly affects late clinical outcomes after OPCAB and preoperative PAOD, renal failure, and A' velocity might be predictors. (Circ J 2016; 80: 1937-1945).

Does left ventricular diastolic dysfunction progress through stages? Insights from a community heart failure study

We performed a retrospective pilot study on a group of symptomatic patients attending our community heart failure clinic with left ventricular diastolic dysfunction (LVDD), rising or elevated LV end diastolic pressure, elevated brain natriuretic peptide (BNP), but with no clinical or radiographic evidence of heart failure; a group we hypothesised may be in the pre-HFPEF stage.

METHODS

Those with LVEF >45% and LV diastolic dysfunction were included and divided into two groups: E/e' <15 and E/e' ≥15 corresponding with rising and raised LVEDP, respectively. Clinical events (deaths and hospital admissions) were compared at 1year and were grouped into all-cause events or cardiovascular events. The total numbers of all-cause and cardiovascular events of the individual groups and the entire cohort were assessed at 1year.

RESULTS

Out of 584 screened, 80 patients were included. Thirty five patients had E/e' <15 and 45 had E/e' ≥15. At 1year follow-up the 1year all-cause events in the E/e' ≥15 group was higher compared to the E/e' <15 group (p=0.03). At 12months, in the entire cohort there were a total of 45 clinical events (39 hospital admissions and 6 deaths) out of which 20 events were cardiovascular.

CONCLUSION

Patients in the pre-HFPEF stage had many events and those with elevated E/e' ≥15 had a poor 1year outcome. As this was strongly influenced by comorbidities we suggest close monitoring of these patients in dedicated HFPEF clinics along with vigorous management of comorbidities.

The Impact of Race on the Prognosis of Preclinical Diastolic Dysfunction: A Large Multiracial Urban Population Study

BACKGROUND

This study was performed to assess the impact of race on the incidence of heart failure and survival in patients with preclinical diastolic dysfunction.

METHODS

All adults during a 5-year period with grade 1 diastolic dysfunction on echocardiogram, left ventricular ejection fraction ≥ 50%, and no diagnosis of heart failure were included in this study. Clinical endpoints were new diagnosis of heart failure (International Classification of Diseases-Ninth Revision code 428.0) and all-cause mortality. A total of 7878 patients: 20.8% non-Hispanic White, 35.8% non-Hispanic Black, and 31.0% Hispanic individuals (mean age was 68 ± 12 years, 37% men) were included in the study. Non-Hispanic Whites were older, more frequently male, and had a higher mean socioeconomic status and more antecedent myocardial infarction.

RESULTS

Non-Hispanic Blacks and Hispanics had more hypertension, diabetes, renal disease, and cerebrovascular disease. After a median follow-up time of 6 years, 1356 patients developed heart failure and 2078 patients died. The 10-year cumulative probabilities of heart failure and all-cause mortality were 23.9% and 32.6%, respectively. Time to incident heart failure was similar among the 3 racial groups. However, non-Hispanic Blacks (hazard ratio 0.80, P = .002) and Hispanics (hazard ratio 0.67, P < .001) experienced lower mortality compared with non-Hispanic Whites, which was confirmed on a propensity-scored sensitivity analysis.

CONCLUSIONS

Time to heart failure was similar among the 3 racial groups, however, non-Hispanic Whites experienced worse survival compared with non-Hispanic Blacks and Hispanics, despite their higher burden of risk factors. The reasons for worse survival in the non-Hispanic white population need to be further explored.

Assessing the Risk of Progression From Asymptomatic Left Ventricular Dysfunction to Overt Heart Failure: A Systematic Overview and Meta-Analysis

OBJECTIVES

This study sought to provide estimates of the risk of progression to overt heart failure (HF) from systolic or diastolic asymptomatic left ventricular dysfunction through a systematic review and meta-analysis.

BACKGROUND

Precise population-based estimates on the progression from asymptomatic left ventricular dysfunction (or stage B HF) to clinical HF (stage C HF) remain limited, despite its prognostic and clinical implications. Pre-emptive intervention with neurohormonal modulation may attenuate disease progression.

METHODS

MEDLINE and EMBASE were systematically searched (until March 2015). Cohort studies reporting on the progression from asymptomatic left ventricular systolic dysfunction (ALVSD) or asymptomatic left ventricular diastolic dysfunction (ALVDD) to overt HF were included. Effect estimates (prevalence, incidence, and relative risk) were pooled using a random-effects model meta-analysis, separately for systolic and diastolic dysfunction, with heterogeneity assessed with the I(2) statistic.

RESULTS

Thirteen reports based on 11 distinct studies of progression of ALVSD were included in the meta-analysis assessing a total of 25,369 participants followed for 7.9 years on average. The absolute risks of progression to HF were 8.4 per 100 person-years (95% confidence interval [CI]: 4.0 to 12.8 per 100 person-years) for those with ALVSD, 2.8 per 100 person-years (95% CI: 1.9 to 3.7 per 100 person-years) for those with ALVDD, and 1.04 per 100 person-years (95% CI: 0.0 to 2.2 per 100 person-years) without any ventricular dysfunction evident. The combined maximally adjusted relative risk of HF for ALVSD was 4.6 (95% CI: 2.2 to 9.8), and that of ALVDD was 1.7 (95% CI: 1.3 to 2.2).

CONCLUSIONS

ALVSD and ALVDD are each associated with a substantial risk for incident HF indicating an imperative to develop effective intervention at these stages.

Positive Affect and Health Behaviors Across 5 Years in Patients With Coronary Heart Disease: The Heart and Soul Study

OBJECTIVES

Positive psychological states are linked to superior health and longevity, possibly due to behavioral factors. We evaluated cross-sectional and 5-year associations between positive affect and health behaviors in patients with coronary heart disease (CHD).

METHODS

Outpatients with CHD reported positive affect, physical activity, sleep quality, medication adherence, cigarette smoking, and alcohol use at baseline (n = 1022) and 5 years later (n = 662). Covariates in regression analyses included demographics, cardiac disease severity, and depressive symptoms.

RESULTS

At baseline, higher positive affect (per 1 standard deviation) was associated with better health behaviors: physical activity (odds ratio [OR] = 1.52, 95% 95% confidence interval [CI] = 1.30-1.77, p < .001), sleep quality (OR = 1.24, 95% CI = 1.04-1.48, p = .015), medication adherence (OR = 1.46, 95% CI = 1.12-1.90, p = .005), and nonsmoking (OR = 1.29, 95% CI = 1.06-1.57, p = .012), but was unrelated to alcohol use. Baseline positive affect did not predict health behaviors at follow-up, accounting for baseline behaviors. However, increases in positive affect across 5 years co-occurred with improvements in physical activity (B = 0.023, standard error [SE] = 0.008, p = .002), sleep quality (B = 0.011, SE = 0.005, p = .039), and medication adherence (B = 0.014, SE = 0.004, p < .001), but not smoking status (OR = 1.07, 95% CI = 0.73-1.55, p = .74).

CONCLUSIONS

Positive affect was associated with health behaviors among patients with CHD. Efforts to sustain or enhance positive affect may be promising for promoting better health behaviors.

Association between left ventricular end-diastolic pressure and coronary artery disease as well as its extent and severity

Patients with myocardial ischemia exhibit increased left ventricular end-diastolic pressure (LVEDP). The study was to evaluate the relationship between LVEDP measured by left cardiac catheterization and coronary artery disease (CAD) as well as its extent and severity evaluated by coronary angiography (CAG). 912 patients who underwent CAG and left cardiac catheterization were enrolled. There were 313 patients without CAD and 599 with CAD according to CAG. The extent and severity of coronary artery was evaluated by number of vessels and Gensini score. Analyze the correlation of LVEDP and CAD as well as its extent and severity. LVEDP was significantly higher in CAD patients than non-CAD (9.58±5.78 mmHg vs 10.9±5.46 mmHg, P<0.001), and was correlated independently with the presence of CAD (OR = 0.11, per 5 mmHg increase, 95% CI 1.02-1.29, P = 0.02). LVEDP was increased with an increase of number of vessels. By linear regression analysis, LVEDP was significantly associated with Gensini score (standardized β = 0.034, P = 0.001). In non-CAD group, LVEDP was only correlated with age (r = 0.123, P = 0.030). In conclusion, our findings suggest that elevated LVEDP was significantly associated with CAD as well as its extent and severity. LVEDP was only correlated with age in non-CAD patients. LVEDP measurement provides incremental clinical value for CAD and non-CAD patients.

The Prognostic Utility of Echo-Estimated Left Ventricular End-Diastolic Pressure-Volume Relationship in Stable Coronary Artery Disease: The Heart and Soul Study

BACKGROUND

While changes in the left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) can be estimated using echocardiography, their prognostic utility in stable coronary artery disease (CAD) is unknown.

METHODS

Using echo-estimated LV end-diastolic volume index and diastolic function category, the relative position of the LV-EDPVR was defined in 901 participants with stable CAD as: (1) left-shifted, (2) right-shifted, or (3) intermediate. We then evaluated the association of LV-EDPVR position relative to the intermediate category with time to hospitalization for heart failure (HF) or cardiovascular (CV) death using Cox proportional hazards models.

RESULTS

During 7.0 ± 3.1 years of follow-up, there were 207 admissions for HF or CV deaths. Both leftward and rightward shifts of LV-EDPVR were associated with a significantly higher risk of HF or CV death (HR 1.73, 95% CI 1.15-2.62 and HR 6.75, 95% CI 4.02-11.31, respectively). In multivariable-adjusted models, these associations were attenuated but remained significant (HR 1.66, 95% CI 1.08-2.55 for left-shifted and HR 4.19, 95% CI 2.32-7.55 for right-shifted). The association of LV-EDPVR with HF or CV death was no longer significant after inclusion of N-terminal pro-brain natriuretic peptide level as a covariate.

CONCLUSIONS

In stable CAD, echo-estimated leftward and rightward shifts in the LV-EDPVR are associated with HF and CV death. The loss of these associations after adjustment for N-terminal pro-brain natriuretic peptide level suggests that echo-estimated LV-EDPVR captures changes in LV filling pressure at any given LV end-diastolic volume.

Long-term outcome in men and women after CABG; results from the IMAGINE trial

BACKGROUND

The aim of this study is to determine sex differences in long-term outcome after coronary artery bypass grafting (CABG).

METHODS

The international randomized controlled IMAGINE study included 2553 consecutive patients with a left ventricular ejection fraction of >40% who underwent isolated CABG. Median follow-up was 32 months (IQR 17-42 months). The composite endpoint comprised of death, myocardial infarction (MI), cerebrovascular event, angina, revascularization and congestive heart failure. Cox regression analysis was used to examine sex differences in outcome post-CABG.

RESULTS

Of the 2553 patients, 2229 were men and 324 (13%) were women. Women were older and more often reported diabetes and hypertension. Smoking and impaired renal function were more prevalent in men. Women experienced a higher event rate during follow-up (composite endpoint 18% vs 12%; P = 0.007). Cox regression showed an increased risk of the composite endpoint in women after adjustment for age (HR 1.48 (95% CI: 1.11-1.97)) which was non-significant after additional adjustment for other confounders (HR 1.26 (95% CI: 0.92-1.72)).

CONCLUSION

Women have a worse long-term outcome after CABG than men in univariate analysis. However, after adjusting for potential confounders female sex became a non-significant predictor for prognosis, possibly due to the small sample size of women. Definite answers regarding sex-differences in long-term outcome after CABG should come from future pooling of studies comprising a larger number of women.

Association of CHADS2, CHA2DS2-VASc, and R2CHADS2 scores with left atrial dysfunction in patients with coronary heart disease (from the Heart and Soul study)

The predictive ability of the CHADS2 index to stratify stroke risk may be mechanistically linked to severity of left atrial (LA) dysfunction. This study investigated the association between the CHADS2 score and LA function. We performed resting transthoracic echocardiography in 970 patients with stable coronary heart disease and normal ejection fraction and calculated baseline LA functional index (LAFI) using a validated formula: (LA emptying fraction×left ventricular outflow tract velocity time integral)/LA end-systolic volume indexed to body surface area. We performed regression analyses to evaluate the association between risk scores and LAFI. Among 970 subjects, mean CHADS2 was 1.7±1.2. Mean LAFI decreased across tertiles of CHADS2 (42.8±18.1, 37.8±19.1, 36.7±19.4, p<0.001). After adjustment for age, sex, race, systolic blood pressure, hyperlipidemia, myocardial infarction, revascularization, body mass index, smoking, and alcohol use, high CHADS2 remained associated with the lowest quartile of LAFI (odds ratio 2.34, p=0.001). In multivariable analysis of component co-morbidities, heart failure, age, and creatinine clearance<60 ml/min were strongly associated with LA dysfunction. For every point increase in CHADS2, the LAFI decreased by 4.0%. Secondary analyses using CHA2DS2-VASc and R2CHADS2 scores replicated these results. Findings were consistent when excluding patients with baseline atrial fibrillation. In conclusion, CHADS2, CHA2DS2-VASc, and R2CHADS2 scores are associated with LA dysfunction, even in patients without baseline atrial fibrillation. These findings merit further study to determine the role of LA dysfunction in cardioembolic stroke and the value of LAFI for risk stratification.

Pre-clinical diastolic dysfunction

Pre-clinical diastolic dysfunction (PDD) has been broadly defined as left ventricular diastolic dysfunction without the diagnosis of congestive heart failure (HF) and with normal systolic function. PDD is an entity that remains poorly understood, yet has definite clinical significance. Although few original studies have focused on PDD, it has been shown that PDD is prevalent, and that there is a clear progression from PDD to symptomatic HF including dyspnea, edema, and fatigue. In diabetic patients and in patients with coronary artery disease or hypertension, it has been shown that patients with PDD have a significantly higher risk of progression to heart failure and death compared with patients without PDD. Because of these findings and the increasing prevalence of the heart failure epidemic, it is clear that an understanding of PDD is essential to decreasing patients' morbidity and mortality. This review will focus on what is known concerning pre-clinical diastolic dysfunction, including definitions, staging, epidemiology, pathophysiology, and the natural history of the disease. In addition, given the paucity of trials focused on PDD treatment, studies targeting risk factors associated with the development of PDD and therapeutic trials for heart failure with preserved ejection fraction will be reviewed.

Peripheral artery disease and risk of cardiovascular events in patients with coronary artery disease: insights from the Heart and Soul Study

Among patients with coronary artery disease (CAD), those with peripheral artery disease (PAD) have a greater vulnerability to cardiovascular (CV) events than those with CAD alone. In a prospective cohort study of patients with CAD, we evaluated potential mechanisms that might explain the adverse CV outcomes associated with PAD. We performed a prospective cohort study of 1018 patients with stable CAD who were recruited from 2000 to 2002. Incident symptomatic PAD events were adjudicated during a follow-up period of 7.2 ± 2.6 years. We used Cox proportional hazards models to evaluate the association between incident symptomatic PAD events and subsequent risk of CV events or death. Models were adjusted for demographics, traditional risk factors, inflammation, insulin resistance and health behaviors. Among the 1018 patients, 50 patients who did not report a history of PAD at baseline suffered incident symptomatic PAD events during the follow-up period. Those patients had a higher risk of subsequent CV events and death compared to those who did not develop PAD. After adjustment for traditional risk factors, symptomatic PAD events remained associated with a 70% increased risk of subsequent CV events (adjusted HR 1.7; 95% CI 1.0, 2.9; p = 0.04) and an 80% increased risk of death (adjusted HR 1.8; 95% CI 1.2, 2.7; p = 0.006). Inflammatory biomarkers were the strongest risk factor contributing to the excess risk. In a contemporary cohort of patients with CAD, incident symptomatic PAD events were associated with an increased risk for subsequent CV events. The increased vulnerability to CV events was partially explained by shared CV risk factors and inflammation.

Depressive symptoms and white blood cell count in coronary heart disease patients: prospective findings from the Heart and Soul Study

BACKGROUND

Depression has been associated with elevated white blood cell (WBC) count - indicative of systemic inflammation - in cross-sectional studies, but no longitudinal study has evaluated whether depressive symptoms predict subsequent WBC count or vice versa. We sought to evaluate the bidirectional association between depressive symptoms and WBC count in patients with coronary heart disease (CHD).

METHODS

Depressive symptoms were assessed at baseline and annually during 5 consecutive years of follow-up in 667 outpatients with stable CHD from the Heart and Soul Study. The presence of significant depressive symptoms was defined as a score of ≥10 on the Patient Health Questionnaire (PHQ-9) at one or more assessments. WBC count was measured in blood samples collected at baseline and after 5 years of follow-up.

RESULTS

Of the 667 participants, 443 (66%) had no depressive symptoms (PHQ-9<10), 86 (13%) had depressive symptoms (PHQ-9≥10) at 1 assessment, and 138 (21%) had depressive symptoms at 2 or more annual assessments. Across the three groups, participants with recurrent depressive symptoms had higher WBC levels after 5 years of follow-up (p<.001). This relationship was essentially unchanged after adjustment for demographics, traditional cardiovascular risk factors, cardiac disease severity, inflammatory cytokine levels, and health behaviors (p=.009). Baseline WBC count was not associated with subsequent depressive symptoms (p=.18).

CONCLUSIONS

Depressive symptoms independently predicted higher subsequent WBC count in patients with stable CHD, but baseline WBC count did not predict subsequent depressive symptoms. These findings support a unidirectional relationship in which depression is a risk-factor for inflammation.

Arterial stiffness, carotid atherosclerosis and left ventricular diastolic dysfunction in postmenopausal women

BACKGROUND

Postmenopausal women have an increased cardiovascular morbidity that may be due to the increase in classical cardiovascular risk factors and also to the arterial structure and function alterations. The aim of our study was to evaluate the association of aortic pulse wave velocity (PWV), and carotid intima-media thickness (IMT), with left ventricular diastolic dysfunction (LVDD) in postmenopausal women.

PATIENTS AND METHODS

In 96 women without overt cardiovascular disease (age 62±7.7 years), and with normal left ventricular systolic function, aortic PWV was assessed by using an oscillometric device, intima-media thickness was measured by B-mode ultrasonography and the parameters of left ventricular diastolic function were evaluated by a transthoracic echocardiographic study.

RESULTS

LVDD, defined as an E/A ratio≤1 was found in 50 patients (52%). All of them had mild LVDD. In these patients we found significant increase in age (p<0.001), aortic PWV (p<0.001), carotid IMT (p=0.002) and plaque score (p=0.004) when compared with patients without LVDD. In a logistic regression analyzed, after adjusting for age, only aortic PWV was a significant predictor of LVDD (2.15, 95% CI 1.39-3.31, p=0.0006).

CONCLUSIONS

This study among postmenopausal women provides evidence that increased arterial stiffness as measured by aortic PWV and not carotid IMT may be a marker or a risk factor for LVDD, independent of other classical risk factors.

Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

Incremental prognostic significance of peripheral endothelial dysfunction in patients with heart failure with normal left ventricular ejection fraction

OBJECTIVES

The purpose of this study was to investigate whether peripheral endothelial dysfunction could predict the occurrence of cardiovascular events in patients with heart failure (HF) with normal left ventricular ejection fraction (HFNEF).

BACKGROUND

Endothelial dysfunction plays an important role in HF, but the relation between peripheral endothelial dysfunction and prognosis in HFNEF remains unknown.

METHODS

We conducted a prospective cohort study of 321 patients with HFNEF. We evaluated cardiac function by echocardiography measuring the ratio of early transmitral flow velocity to tissue Doppler early diastolic mitral annular velocity (E/e'), noninvasively assessed peripheral endothelial function by reactive hyperemia-peripheral arterial tonometry (RH-PAT) as the RH-PAT index (RHI), and followed cardiovascular events.

RESULTS

A total of 59 patients had a cardiovascular event. Kaplan-Meier analysis demonstrated a significantly higher probability of cardiovascular events in the low RHI group than in the high RHI group (mean follow-up: 20 months; log-rank test: p < 0.001). Multivariate Cox hazard analysis identified RHI (per 0.1) (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.67 to 0.94; p = 0.007), E/e' (Ln[E/e'] [per 0.1]) (HR: 1.15; 95% CI: 1.04 to 1.26; p = 0.006), and B-type natriuretic peptide (BNP) (Ln[BNP] [per picogram/milliliter]) (HR: 1.81; 95% CI: 1.44 to 2.28; p < 0.001) as independent predictors of cardiovascular events. The C-statistics for cardiovascular events substantially increased when the RHI was added to the HFNEF prognostic 5 factors (PF5)-age, diabetes, New York Heart Association classification, HF hospitalization history, and left ventricular ejection fraction-which were identified in the I-PRESERVE (Irbesartan in Heart Failure with Preserved Ejection Fraction Study) (PF5 alone: 0.671; PF5 + RHI: 0.712). The net reclassification index was significant after addition of the RHI (19.0%, p = 0.01).

CONCLUSIONS

Peripheral endothelial dysfunction independently correlated with future cardiovascular events, adding incremental clinical significance for risk stratification in patients with HFNEF. (Endothelial Dysfunction Assessed by Reactive Hyperemia Peripheral Arterial Tonometry and Heart Failure with Preserved Left Ventricular Ejection Fraction; UMIN000002640).

The Dutch Childhood Oncology Group guideline for follow-up of asymptomatic cardiac dysfunction in childhood cancer survivors

BACKGROUND

The Late Effects of Childhood Cancer task force of the Dutch Childhood Oncology Group (DCOG LATER) developed a guideline for follow-up of asymptomatic cardiac dysfunction in childhood cancer survivors (CCS). In this paper, we present the methods, available evidence and final recommendations of our guideline.

MATERIALS AND METHODS

A multidisciplinary working group specified clinical questions that should be answered to get to recommendations for the guideline. We carried out short or extensive evidence summaries and determined methodological quality of studies and levels of evidence in order to answer all clinical questions. When evidence was lacking for CCS, we carefully extrapolated evidence from other populations. Final recommendations were based on evidence and consensus.

RESULTS

There was high-level evidence for the increased risk of cardiac dysfunction in CCS and its main risk factors. Evidence was lacking regarding the prognosis, diagnosis and treatment of cardiac dysfunction in CCS. We recommended echocardiographic screening for asymptomatic cardiac dysfunction in CCS treated with cardiotoxic treatments and counseling about potential advantages and disadvantages of our screening recommendations.

CONCLUSION

The DCOG LATER guideline recommends risk-based screening for asymptomatic cardiac dysfunction in CCS, but it should be noted that recommendations are not completely supported by evidence in CCS.

Heart failure, diastolic dysfunction and atrial fibrillation; mechanistic insight of a complex inter-relationship

Atrial fibrillation (AF) and heart failure (HF) commonly coexist, and their co-presence is associated with adverse outcomes relating to thromboembolic events, HF progression, hospitalisation and death. Diastolic dysfunction (DD) is also frequently present in patients with HF and is an independent predictor of hospitalisation and mortality. The presence of DD is a strong predictor of incident AF in patients with HF. In this review, we provide mechanistic insight into pathophysiological processes that frequently promote the occurrence of AF, HF and DD and outline the yin-yang relationship between AF, DD and HF. More recently, invasive studies have also shown that asymptomatic paroxysmal atrial fibrillation (PAF) is a common phenomenon in HF patients. We examine complex inter-relationships between PAF, HF and DD and speculate upon the possible clinical influence of undiagnosed PAF in HF patients.

Mitral annular calcium, inducible myocardial ischemia, and cardiovascular events in outpatients with coronary heart disease (from the Heart and Soul Study)

We sought to determine whether mitral annular calcium (MAC) is associated with inducible myocardial ischemia and adverse cardiovascular outcomes in ambulatory patients with coronary artery disease (CAD). MAC is associated with cardiovascular disease (CVD) in the general population, but its association with CVD outcomes in patients with CAD has not been evaluated. We examined the association of MAC with inducible ischemia and subsequent cardiovascular events in 1,020 ambulatory patients with CAD who were enrolled in the Heart and Soul Study. We used logistic regression to determine the association of MAC with inducible ischemia and Cox proportional hazards models to determine the association with CVD events (myocardial infarction, heart failure, stroke, transient ischemic attack or death). Models were adjusted for age, gender, race, smoking, history of heart failure, blood pressure, high-density lipoprotein, and estimated glomerular filtration rate. Of the 1,020 participants 192 (19%) had MAC. Participants with MAC were more likely than those without MAC to have inducible ischemia (adjusted odds ratio 2.06, 95% confidence interval 1.41 to 3.01, p = 0.0002). During an average of 6.26 ± 2.11 years of follow-up, there were 310 deaths, 161 hospitalizations for heart failure, 118 myocardial infarctions, and 55 cerebrovascular events. MAC was associated with an increased rate of cardiovascular events (adjusted hazard ratio 1.39, 95% confidence interval 1.08 to 1.79, p = 0.01). In conclusion, we found that MAC was associated with inducible ischemia and subsequent CVD events in ambulatory patients with CAD. MAC may indicate a high atherosclerotic burden and identify patients at increased risk for adverse cardiovascular outcomes.

Left atrial function predicts heart failure hospitalization in subjects with preserved ejection fraction and coronary heart disease: longitudinal data from the Heart and Soul Study

OBJECTIVES

This study sought to determine whether left atrial (LA) dysfunction predicts heart failure (HF) hospitalization in subjects with preserved baseline ejection fraction (EF).

BACKGROUND

Among patients with preserved EF, factors leading to HF are not fully understood. Cross-sectional studies have demonstrated LA dysfunction at the time of HF, but longitudinal data on antecedent atrial function are lacking.

METHODS

We performed resting transthoracic echocardiography in 855 subjects with coronary heart disease and EF ≥50%. Left atrial functional index (LAFI) was calculated as ([LA emptying fraction × left ventricular outflow tract-velocity time integral] / [indexed LA end-systolic volume]), where LA emptying fraction was defined as (LA end-systolic volume--LA end-diastolic volume) / LA end-systolic volume. We used Cox models to evaluate the association between LAFI and HF hospitalization.

RESULTS

Over a median follow-up of 7.9 years, 106 participants (12.4%) were hospitalized for HF. Rates of HF hospitalization were inversely proportional to quartile (Q) of LAFI: Q1, 47 per 1,000 person-years; Q2, 18.3; Q3, 9.6; and Q4, 5.3 (p < 0.001). Each standard deviation decrease in LAFI was associated with a 2.6-fold increased hazard of adverse cardiovascular outcomes (unadjusted hazard ratio: 2.6, 95% confidence interval: 2.1 to 3.3, p < 0.001), and the association persisted even after adjustment for clinical risk factors, N-terminal pro-B-type natriuretic peptide, and a wide range of echocardiographic parameters (adjusted hazard ratio: 1.5, 95% confidence interval: 1.0 to 2.1, p = 0.05).

CONCLUSIONS

Left atrial dysfunction independently predicts HF hospitalization in subjects with coronary heart disease and preserved baseline EF. The LAFI may be useful for HF risk stratification, and LA dysfunction may be a potential therapeutic target.