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Widmann L, Keranov S, Jafari L, Liebetrau C, Keller T, Troidl C, Kriechbaum S, Voss S, Arsalan M, Richter MJ, Tello K, Gall H, Ghofrani HA, Guth S, Seeger W, Hamm CW, Dörr O, Nef H. Fibroblast growth factor 23 as a biomarker of right ventricular dysfunction in pulmonary hypertension. Clin Res Cardiol 2023; 112:1382-1393. [PMID: 36790465 PMCID: PMC10562503 DOI: 10.1007/s00392-023-02162-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 01/19/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Fibroblast growth factor 23 (FGF-23) has been associated with left ventricular hypertrophy (LVH) and heart failure. However, its role in right ventricular (RV) remodeling and RV failure is unknown. This study analyzed the utility of FGF-23 as a biomarker of RV function in patients with pulmonary hypertension (PH). METHODS In this observational study, FGF-23 was measured in the plasma of patients with PH (n = 627), dilated cardiomyopathy (DCM, n = 59), or LVH with severe aortic stenosis (n = 35). Participants without LV or RV abnormalities served as controls (n = 36). RESULTS Median FGF-23 plasma levels were higher in PH patients than in healthy controls (p < 0.001). There were no significant differences between PH, DCM, and LVH patients. Analysis across tertiles of FGF-23 levels in PH patients revealed an association between higher FGF-23 levels and higher levels of NT-proBNP and worse renal function. Furthermore, patients in the high-FGF-23 tertile had a higher pulmonary vascular resistance (PVR), mean pulmonary artery pressure, and right atrial pressure and a lower cardiac index (CI) than patients in the low tertile (p < 0.001 for all comparisons). Higher FGF-23 levels were associated with higher RV end-diastolic diameter and lower tricuspid annular plane systolic excursions (TAPSE) and TAPSE/PASP. Receiver operating characteristic analysis revealed FGF-23 as a good predictor of RV maladaptation, defined as TAPSE < 17 mm and CI < 2.5 L/min/m2. Association of FGF-23 with parameters of RV function was independent of the glomerular filtration rate in regression analysis. CONCLUSION FGF-23 may serve as a biomarker for maladaptive RV remodeling in patients with PH.
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Affiliation(s)
- Laila Widmann
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Stanislav Keranov
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany.
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany.
| | - Leili Jafari
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | | - Till Keller
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Christian Troidl
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Steffen Kriechbaum
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Sandra Voss
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Mani Arsalan
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Christian W Hamm
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Oliver Dörr
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
| | - Holger Nef
- Department of Cardiology and Angiology, University of Giessen, Klinikstr. 33, 35392, Giessen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site RheinMain, Bad Nauheim, Germany
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Dimov AV, Li J, Nguyen TD, Roberts AG, Spincemaille P, Straub S, Zun Z, Prince MR, Wang Y. QSM Throughout the Body. J Magn Reson Imaging 2023; 57:1621-1640. [PMID: 36748806 PMCID: PMC10192074 DOI: 10.1002/jmri.28624] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/08/2023] Open
Abstract
Magnetic materials in tissue, such as iron, calcium, or collagen, can be studied using quantitative susceptibility mapping (QSM). To date, QSM has been overwhelmingly applied in the brain, but is increasingly utilized outside the brain. QSM relies on the effect of tissue magnetic susceptibility sources on the MR signal phase obtained with gradient echo sequence. However, in the body, the chemical shift of fat present within the region of interest contributes to the MR signal phase as well. Therefore, correcting for the chemical shift effect by means of water-fat separation is essential for body QSM. By employing techniques to compensate for cardiac and respiratory motion artifacts, body QSM has been applied to study liver iron and fibrosis, heart chamber blood and placenta oxygenation, myocardial hemorrhage, atherosclerotic plaque, cartilage, bone, prostate, breast calcification, and kidney stone.
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Affiliation(s)
- Alexey V. Dimov
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Jiahao Li
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Thanh D. Nguyen
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | | | - Pascal Spincemaille
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Sina Straub
- Department of Radiology, Mayo Clinic, Jacksonville, FL, United States
| | - Zungho Zun
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Yi Wang
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
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3
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Carroll AM, Farr M, Russell SD, Schlendorf KH, Truby LK, Gilotra NA, Vader JM, Patel CB, DeVore AD. Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence. J Card Fail 2023; 29:818-831. [PMID: 36958390 DOI: 10.1016/j.cardfail.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/25/2023]
Abstract
Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.
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Affiliation(s)
- Aubrie M Carroll
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stuart D Russell
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren K Truby
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nisha A Gilotra
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University, St Louis, MO, USA
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.
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4
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Aimo A, Huang L, Tyler A, Barison A, Martini N, Saccaro LF, Roujol S, Masci PG. Quantitative susceptibility mapping (QSM) of the cardiovascular system: challenges and perspectives. J Cardiovasc Magn Reson 2022; 24:48. [PMID: 35978351 PMCID: PMC9387036 DOI: 10.1186/s12968-022-00883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
Quantitative susceptibility mapping (QSM) is a powerful, non-invasive, magnetic resonance imaging (MRI) technique that relies on measurement of magnetic susceptibility. So far, QSM has been employed mostly to study neurological disorders characterized by iron accumulation, such as Parkinson's and Alzheimer's diseases. Nonetheless, QSM allows mapping key indicators of cardiac disease such as blood oxygenation and myocardial iron content. For this reason, the application of QSM offers an unprecedented opportunity to gain a better understanding of the pathophysiological changes associated with cardiovascular disease and to monitor their evolution and response to treatment. Recent studies on cardiovascular QSM have shown the feasibility of a non-invasive assessment of blood oxygenation, myocardial iron content and myocardial fibre orientation, as well as carotid plaque composition. Significant technical challenges remain, the most evident of which are related to cardiac and respiratory motion, blood flow, chemical shift effects and susceptibility artefacts. Significant work is ongoing to overcome these challenges and integrate the QSM technique into clinical practice in the cardiovascular field.
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Affiliation(s)
- Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Li Huang
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Andrew Tyler
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Andrea Barison
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
- Department of Biomedical Engineering, School of Imaging Sciences & Biomedical Engineering, King's College London, St Thomas' Hospital, 4th Floor Lambeth Wing, London, SE1 7EH, UK.
| | - Pier-Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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5
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Emrich T, Bordonaro V, Schoepf UJ, Petrescu A, Young G, Halfmann M, Schoeler T, Decker J, Abidoye I, Emrich AL, Kreitner KF, Schmidt KH, Varga-Szemes A, Secinaro A. Right/Left Ventricular Blood Pool T2 Ratio as an Innovative Cardiac MRI Screening Tool for the Identification of Left-to-Right Shunts in Patients With Right Ventricular Disease. J Magn Reson Imaging 2021; 55:1452-1458. [PMID: 34374157 DOI: 10.1002/jmri.27881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Left-to-right (L-R) shunts are characterized by a pathological connection between high- and low-pressure systems, leading to a mixing of oxygen-rich blood with low oxygenated blood. They are typically diagnosed by phase-contrast cardiac magnetic resonance imaging (MRI) which requires extensive planning. T2 is sensitive to blood oxygenation and may be able to detect oxygenation differences between the left (LV) and right ventricles (RV) caused by L-R shunts. PURPOSE To test the feasibility of routine T2 mapping to detect L-R shunts. STUDY TYPE Retrospective. POPULATION Patients with known L-R shunts (N = 27), patients with RV disease without L-R shunts (N = 21), and healthy volunteers (HV; N = 52). FIELD STRENGTH/SEQUENCE 1.5 and 3 T/balanced steady-state free-precession (bSSFP) sequence (cine imaging), T2-prepared bSSFP sequence (T2 mapping), and velocity sensitized gradient echo sequence (phase-contrast MRI). ASSESSMENT Aortic (Qs) and pulmonary (Qp) flow was measured by phase-contrast imaging, and the Qp/Qs ratio was calculated as a measure of shunt severity. T2 maps were used to measure T2 in the RV and LV and the RV/LV T2 ratio was calculated. Cine imaging was used to calculate RV end-diastolic volume index (RV-EDVi). STATISTICAL TESTS Wilcoxon test, paired t-tests, Spearmen correlation coefficient, receiver operating curve (ROC) analysis. Significance level P < 0.05. RESULTS The Qp/Qs and T2 ratios in L-R shunt patients (1.84 ± 0.84 and 0.89 ± 0.07) were significantly higher compared to those in patients with RV disease (1.01 ± 0.03 and 0.72 ± 0.10) and in HV (1.04 ± 0.04 and 0.71 ± 0.09). A T2 ratio of >0.78 showed a sensitivity, specificity, and negative predictive value of 100%, 73.9%, and 100%, respectively, for the detection of L-R shunts. The T2 ratio was strongly correlated with the severity of the shunt (r = 0.83). DATA CONCLUSION RV/LV T2 ratio is an imaging biomarker that may be able to detect or rule-out L-R shunts. Such a diagnostic tool may prevent unnecessary phase-contrast acquisitions in cases with RV dilatation of unknown etiology. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Tilman Emrich
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina.,Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Veronica Bordonaro
- Department of Imaging, Advanced Cardiovascular Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Aniela Petrescu
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Gabrielle Young
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Moritz Halfmann
- Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Theresia Schoeler
- Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Josua Decker
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina.,Department of Diagnostic and Interventional Radiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ibukun Abidoye
- Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Radiology, Afe Babalola University Multisystem Hospital, Ado-Ekiti, Nigeria
| | - Anna Lena Emrich
- Department of Cardiothoracic and Vascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Karl-Friedrich Kreitner
- Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Kai Helge Schmidt
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Aurelio Secinaro
- Department of Imaging, Advanced Cardiovascular Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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6
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Ibe T, Wada H, Sakakura K, Ugata Y, Maki H, Yamamoto K, Seguchi M, Taniguchi Y, Jinnouchi H, Fujita H. Cardiac index predicts long-term outcomes in patients with heart failure. PLoS One 2021; 16:e0252833. [PMID: 34086818 PMCID: PMC8177638 DOI: 10.1371/journal.pone.0252833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/24/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The role of cardiac index (CI) and right atrial pressure (RAP) for predicting long-term outcomes of heart failure has not been well established. The aim of this study was to investigate long-term cardiac outcomes in patients with heart failure having various combinations of CI and RAP. METHODS A total of 787 heart failure patients who underwent right-heart catheterization were retrospectively categorized into the following four groups: Preserved CI (≥2.5 L/min/m2) and Low RAP (<8 mmHg) (PRE-CI/L-RAP; n = 285); Preserved CI (≥2.5 L/min/m2) and High RAP (≥8 mmHg) (PRE-CI/H-RAP; n = 242); Reduced CI (<2.5 L/min/m2) and Low RAP (<8 mmHg) (RED-CI/L-RAP; n = 123); and Reduced CI (<2.5 L/min/m2) and High RAP (≥8 mmHg) (RED-CI/H-RAP; n = 137). Survival analysis was applied to investigate which groups were associated with major adverse cardiovascular events (MACE). RESULTS The RED-CI/L-RAP and RED-CI/H-RAP groups were significantly associated with MACE as compared with the PRE-CI/L-RAP and PRE-CI/H-RAP groups after adjustment for confounding factors (RED-CI/L-RAP vs. PRE-CI/L-RAP: HR 2.11 [95% CI 1.33-3.37], p = 0.002; RED-CI/H-RAP vs. PRE-CI/L-RAP: HR 2.18 [95% CI 1.37-3.49], p = 0.001; RED-CI/L-RAP vs. PRE-CI/H-RAP: HR 1.86 [95% CI 1.16-3.00], p = 0.01; RED-CI/H-RAP vs. PRE-CI/H-RAP: HR 1.92 [95% CI 1.26-2.92], p = 0.002), whereas the difference between the RED-CI/H-RAP and RED-CI/L-RAP groups was not significant (HR 1.03 [95% CI 0.64-1.66], p = 0.89). CONCLUSIONS The hemodynamic severity categorized by CI and RAP levels provided clear risk stratification in patients with symptomatic heart failure. Low CI was an independent predictor of long-term cardiac outcomes.
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Affiliation(s)
- Tatsuro Ibe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yusuke Ugata
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hisataka Maki
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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7
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Abstract
Identifying patients with heart failure at high risk for poor outcomes is important for patient care, resource allocation, and process improvement. Although numerous risk models exist to predict mortality, hospitalization, and patient-reported health status, they are infrequently used for several reasons, including modest performance, lack of evidence to support routine clinical use, and barriers to implementation. Artificial intelligence has the potential to enhance the performance of risk prediction models, but has its own limitations and remains unproved.
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Affiliation(s)
- Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA. https://twitter.com/ramseywehbemd
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA. https://twitter.com/HeartDocSadiya
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA. https://twitter.com/HFpEF
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan Avenue, 15th Floor, Chicago, IL 60611, USA.
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8
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Wen Y, Weinsaft JW, Nguyen TD, Liu Z, Horn EM, Singh H, Kochav J, Eskreis-Winkler S, Deh K, Kim J, Prince MR, Wang Y, Spincemaille P. Free breathing three-dimensional cardiac quantitative susceptibility mapping for differential cardiac chamber blood oxygenation - initial validation in patients with cardiovascular disease inclusive of direct comparison to invasive catheterization. J Cardiovasc Magn Reson 2019; 21:70. [PMID: 31735165 PMCID: PMC6859622 DOI: 10.1186/s12968-019-0579-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 10/04/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Differential blood oxygenation between left (LV) and right ventricles (RV; ΔSaO2) is a key index of cardiac performance; LV dysfunction yields increased RV blood pool deoxygenation. Deoxyhemoglobin increases blood magnetic susceptibility, which can be measured using an emerging cardiovascular magnetic resonance (CMR) technique, Quantitative Susceptibility Mapping (QSM) - a concept previously demonstrated in healthy subjects using a breath-hold 2D imaging approach (2DBHQSM). This study tested utility of a novel 3D free-breathing QSM approach (3DNAVQSM) in normative controls, and validated 3DNAVQSM for non-invasive ΔSaO2 quantification in patients undergoing invasive cardiac catheterization (cath). METHODS Initial control (n = 10) testing compared 2DBHQSM (ECG-triggered 2D gradient echo acquired at end-expiration) and 3DNAVQSM (ECG-triggered navigator gated gradient echo acquired in free breathing using a phase-ordered automatic window selection algorithm to partition data based on diaphragm position). Clinical testing was subsequently performed in patients being considered for cath, including 3DNAVQSM comparison to cine-CMR quantified LV function (n = 39), and invasive-cath quantified ΔSaO2 (n = 15). QSM was acquired using 3 T scanners; analysis was blinded to comparator tests (cine-CMR, cath). RESULTS 3DNAVQSM generated interpretable QSM in all controls; 2DBHQSM was successful in 6/10. Among controls in whom both pulse sequences were successful, RV/LV susceptibility difference (and ΔSaO2) were not significantly different between 3DNAVQSM and 2DBHQSM (252 ± 39 ppb [17.5 ± 3.1%] vs. 211 ± 29 ppb [14.7 ± 2.0%]; p = 0.39). Acquisition times were 30% lower with 3DNAVQSM (4.7 ± 0.9 vs. 6.7 ± 0.5 min, p = 0.002), paralleling a trend towards lower LV mis-registration on 3DNAVQSM (p = 0.14). Among cardiac patients (63 ± 10y, 56% CAD) 3DNAVQSM was successful in 87% (34/39) and yielded higher ΔSaO2 (24.9 ± 6.1%) than in controls (p < 0.001). QSM-calculated ΔSaO2 was higher among patients with LV dysfunction as measured on cine-CMR based on left ventricular ejection fraction (29.4 ± 5.9% vs. 20.9 ± 5.7%, p < 0.001) or stroke volume (27.9 ± 7.5% vs. 22.4 ± 5.5%, p = 0.013). Cath measurements (n = 15) obtained within a mean interval of 4 ± 3 days from CMR demonstrated 3DNAVQSM to yield high correlation (r = 0.87, p < 0.001), small bias (- 0.1%), and good limits of agreement (±8.6%) with invasively measured ΔSaO2. CONCLUSION 3DNAVQSM provides a novel means of assessing cardiac performance. Differential susceptibility between the LV and RV is increased in patients with cine-CMR evidence of LV systolic dysfunction; QSM-quantified ΔSaO2 yields high correlation and good agreement with the reference of invasively-quantified ΔSaO2.
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Affiliation(s)
- Yan Wen
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY USA
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | | | - Thanh D. Nguyen
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | - Zhe Liu
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY USA
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | - Evelyn M. Horn
- Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | - Harsimran Singh
- Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | - Jonathan Kochav
- Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | | | - Kofi Deh
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | - Jiwon Kim
- Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | - Yi Wang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY USA
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
| | - Pascal Spincemaille
- Department of Radiology, Weill Cornell Medicine, New York, NY USA
- Weill Cornell Medical College, 515 East 71th Street, S101, New York, NY 10021 USA
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9
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Aalders M, Kok W. Comparison of Hemodynamic Factors Predicting Prognosis in Heart Failure: A Systematic Review. J Clin Med 2019; 8:jcm8101757. [PMID: 31652650 PMCID: PMC6832156 DOI: 10.3390/jcm8101757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/12/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023] Open
Abstract
Objectives: We systematically reviewed the literature to address the question of which of the three hemodynamic factors predicts prognosis best in heart failure patients when directly compared to each other: cardiac output, preload or afterload. Methods: Prognostic studies in heart failure (HF) were searched that included at least two of the three hemodynamic variables: (1) cardiac output or cardiac index (CI), (2) preload represented by pulmonary capillary wedge pressure (PCWP) and (3) afterload simplified to systolic blood pressure (SBP). Critical appraisal was done according to the QUIPS format for prognostic studies. The main endpoint was all-cause mortality, which could be combined with other endpoints. We report the number of studies in which CI, PCWP and SBP remained significant prognostic predictors in multivariate analysis. We also assessed whether hemodynamic predictors of prognosis varied in four different HF-populations. Results: Included were 18 studies containing a multivariate analysis. PCWP was an independent predictor of prognosis in 10 of 18 studies, SBP in 3 of 14 studies and CI in none of 18 studies. Results were not specific for any of the HF-populations. Conclusions: A higher PCWP and lower SBP are independent predictors of poor prognosis in HF. In spite of the frequently used concept behind HF, this review demonstrates that CI is not an independent predictor of prognosis in HF.
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Affiliation(s)
- Margot Aalders
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands.
| | - Wouter Kok
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands.
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10
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Bobenko A, Schoenrath F, Knierim JH, Friede T, Verheyen N, Mehra MR, Haykowsky M, Herrmann-Lingen C, Duvinage A, Pieske-Kraigher E, Halle M, Falk V, Pieske B, Edelmann F. Exercise training in patients with a left ventricular assist device (Ex-VAD): rationale and design of a multicentre, prospective, assessor-blinded, randomized, controlled trial. Eur J Heart Fail 2019; 21:1152-1159. [PMID: 30924265 DOI: 10.1002/ejhf.1431] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/04/2019] [Accepted: 01/05/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Left ventricular assist device (LVAD) therapy is a promising option for patients with advanced heart failure (HF), refractory to guideline-mandated medical treatment either as a bridge to heart transplantation or as lifelong therapy. Functional capacity improves after LVAD implantation but remains reduced in patients with long-term LVAD therapy. Exercise training (ET) improves functional capacity and quality of life (QoL) in HF and may provide incremental benefits in patients supported with LVAD therapy. METHODS The primary objective of Ex-VAD is to investigate whether a 12-week supervised ET can improve peak oxygen uptake (peakVO2 ) measured by cardiopulmonary exercise testing (CPET) on an ergometer. The study is powered to demonstrate a group difference of 3 mL/min/kg in peakVO2 at week 12, with a power of 0.9 and a standard deviation of 5 mL/min/kg. After baseline assessments to determine whether ET is safe, 66 patients at six trial sites with advanced HF and LVAD therapy will be randomized 2:1 to supervised ET or to the control arm of usual care alone. Patients randomized to ET will perform supervised aerobic endurance and resistance ET (three times/week) for 12 weeks. At baseline and during follow-up, anthropometry, CPET, echocardiography (at rest and exercise), and QoL evaluation will be performed. Blood samples will be collected to examine cardiac-specific relevant biomarkers. Overall physical activity, training sessions, and adherence will be monitored and documented throughout the study using accelerometers and patient diaries. CONCLUSIONS The Ex-VAD trial will assess the effects of a supervised ET programme on peakVO2 and QoL in patients with LVAD. As LVAD therapy moves from crisis support to ambulatory functional enhancement, this trial will provide a rationale to improve functional capacity and, in perspective, cardiovascular outcomes in LVAD-supported patients with advanced HF.
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Affiliation(s)
- Anna Bobenko
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Jan H Knierim
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Christoph Herrmann-Lingen
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - André Duvinage
- Department of Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Martin Halle
- Department of Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Volkmar Falk
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
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11
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Jensen J, Omar M, Kistorp C, Poulsen MK, Tuxen C, Gustafsson I, Køber L, Gustafsson F, Fosbøl E, Bruun NE, Videbæk L, Frederiksen PH, Møller JE, Schou M. Empagliflozin in heart failure patients with reduced ejection fraction: a randomized clinical trial (Empire HF). Trials 2019; 20:374. [PMID: 31227014 PMCID: PMC6588901 DOI: 10.1186/s13063-019-3474-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/27/2019] [Indexed: 12/11/2022] Open
Abstract
Background Data from recent cardiovascular outcome trials in patients with type 2 diabetes (T2D) suggest that sodium-glucose cotransporter 2 (SGLT2) inhibitors can prevent development of heart failure (HF) and prolong life in patients without HF. Ongoing event-driven trials are investigating whether the same effect is present in patients with well-defined HF. The mechanism behind the effect of SGLT2 inhibitors in patients with T2D and the potential effect in patients with overt HF is presently unknown. Methods This is a randomized, double-blinded, placebo-controlled, parallel group, clinical trial including HF patients with reduced left ventricular ejection fraction (HFrEF) with an ejection fraction ≤ 40% on optimal therapy recruited from specialized HF clinics in Denmark. The primary aim is to investigate the effect of the SGLT2 inhibitor empagliflozin on N-terminal pro-brain natriuretic peptide (NT-proBNP). Secondary endpoints include cardiac biomarkers, function and hemodynamics, metabolic and renal parameters, daily activity level, and quality of life. Patients are assigned 1:1 to 90 days treatment with empagliflozin 10 mg daily or placebo. Patients with T2D are required to be on recommended doses of anti-glycemic therapy with a hemoglobin A1c (HbA1c) of 6.5–10.0% (48–86 mmol/mol). To show a between-group difference in the change of NT-proBNP of 30%, a total of 189 patients will be included. Discussion The Empire HF trial will elucidate the effects and modes of action of empagliflozin in HFrEF patients with and without T2D and provide important mechanistic data which will complement ongoing event-driven trials. Trial registration Clinicaltrialsregister.eu, EudraCT Number 2017-001341-27. Registered on 29 May 2017. ClinicalTrials.gov, NCT03198585. Registered on 26 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3474-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesper Jensen
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, DK, Denmark. .,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark.
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, DK, Denmark.,Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, 5000, Odense C, DK, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100, København Ø, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark
| | - Mikael Kjær Poulsen
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, DK, Denmark
| | - Christian Tuxen
- Department of Cardiology, Bispebjerg-Frederiksberg Hospital, Nordre Fasanvej 57, 2000, Frederiksberg, DK, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg-Frederiksberg Hospital, Nordre Fasanvej 57, 2000, Frederiksberg, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, København Ø, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, København Ø, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark
| | - Emil Fosbøl
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, København Ø, DK, Denmark
| | - Niels Eske Bruun
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark.,Clinical Institute, Aalborg University, Søndre Skovvej 15, 9000, Aalborg, DK, Denmark
| | - Lars Videbæk
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, DK, Denmark
| | | | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, DK, Denmark.,Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, 5000, Odense C, DK, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, DK, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, 2200, København N, DK, Denmark
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12
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Christopoulos G, Bois J, Allison TG, Rodriguez-Porcel M, Chareonthaitawee P. The impact of combined cardiopulmonary exercise testing and SPECT myocardial perfusion imaging on downstream evaluation and management. J Nucl Cardiol 2019; 26:92-106. [PMID: 28508270 DOI: 10.1007/s12350-017-0910-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/11/2017] [Accepted: 04/17/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The diagnostic yield of combined cardiopulmonary exercise testing (CPET) and myocardial perfusion imaging (MPI) in patients referred for stress testing has received limited study. METHODS We evaluated consecutive patients who underwent combined CPET-MPI at a single tertiary referral center between 2011 and 2015. An abnormal CPET was defined as any of the following: reduced oxygen consumption, cardiac output impairment, or pulmonary impairment. Normal MPI was defined as the absence of resting or stress perfusion defect. The primary study outcome was change in clinical decision-making after CPET-MPI including management of pulmonary disease, management of deconditioning, heart failure management, and referral for cardiac catheterization. Outcomes of patients with normal and abnormal MPI were presented based on the specific CPET abnormality. RESULTS 415 patients were included in the study. Of the 269 patients that had normal MPI, 206 (77%) had abnormal CPET. Patients with abnormal CPET and normal MPI, compared with patients that had normal CPET and normal MPI, were more frequently diagnosed with pulmonary disease (11.7% vs 3.2%, P = .04) and deconditioning (33.5% vs 17.4%, P = .01). Of the 146 patients that had abnormal MPI, 128 (88%) had abnormal CPET. Patients with abnormal CPET and abnormal MPI, compared with patients that had normal CPET and abnormal MPI, did not statistically differ with regard to the study outcome. CONCLUSION An abnormal CPET, if the MPI was normal, prompted further evaluation and led to management of pulmonary disease and deconditioning.
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Affiliation(s)
| | - John Bois
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Thomas G Allison
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Martin Rodriguez-Porcel
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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13
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IL’GIOVINE ZACHARYJ, SOLOMON NICOLE, DEVORE ADAMD, WOJDYLA DANIEL, PATEL CHETANB, ROGERS JOSEPHG. Blood Pressure Response during Cardiopulmonary Exercise Testing in Heart Failure. Med Sci Sports Exerc 2018; 50:1345-1349. [DOI: 10.1249/mss.0000000000001587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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14
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Cooper LB, Mentz RJ, Stevens SR, Felker GM, Lombardi C, Metra M, Stevenson LW, O'Connor CM, Milano CA, Patel CB, Rogers JG. Hemodynamic Predictors of Heart Failure Morbidity and Mortality: Fluid or Flow? J Card Fail 2016; 22:182-9. [PMID: 26703245 PMCID: PMC4779722 DOI: 10.1016/j.cardfail.2015.11.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/17/2015] [Accepted: 11/20/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with advanced heart failure may continue for prolonged times with persistent hemodynamic abnormalities; intermediate- and long-term outcomes of these patients are unknown. METHODS AND RESULTS We used ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial data to examine characteristics and outcomes of patients with invasive hemodynamic monitoring during an acute heart failure hospitalization. Patients were stratified by final measurement of cardiac index (CI; L/min/m2) and pulmonary capillary wedge pressure (PCWP; mmHg) before catheter removal. The study groups were CI ≥ 2/PCWP < 20 (n = 74), CI ≥ 2/PCWP ≥ 20 (n = 37), CI < 2/PCWP < 20 (n = 23), and CI < 2/PCWP ≥ 20 (n = 17). Final CI was not associated with the combined risk of death, cardiovascular hospitalization, and transplantation (hazard ratio [HR]1.03, 95% confidence interval 0.96-1.11 per 0.2 L/min/m2 decrease, P = .39), but final PCWP ≥ 20 mmHg was associated with increased risk of these events (HR 2.03, 95% confidence interval 1.31-3.15, P < .01), as was higher final right atrial pressure (HR 1.09, 95% confidence interval 1.06-1.12 per mmHg increase, P < .01). CONCLUSION Final PCWP and final right atrial pressure were stronger predictors of postdischarge outcomes than CI in patients with advanced heart failure. The ability to lower filling pressures appears to be more prognostically important than improving CI in the management of patients with advanced heart failure. ClinicalTrials.govIdentifier: NCT00000619.
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Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Lynne W Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carmelo A Milano
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chetan B Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joseph G Rogers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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15
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Intravenous Diuretic Therapy for the Management of Heart Failure and Volume Overload in a Multidisciplinary Outpatient Unit. JACC-HEART FAILURE 2015; 4:1-8. [PMID: 26656139 DOI: 10.1016/j.jchf.2015.06.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study sought to evaluate the effectiveness of intravenous (IV) diuretic treatment for volume management in heart failure (HF). BACKGROUND Limited data exist regarding IV diuretics for the outpatient treatment of volume overload in HF patients. METHODS We analyzed 60 consecutive patients with chronic HF and clinical evidence of worsening congestion who received a bolus and 3-h IV infusion of furosemide at an outpatient HF clinic. Diuretic dosing was derived from the maintenance oral loop diuretic dose with a standardized conversion algorithm. Outcomes included urine output during the visit, weight loss at 24 h, and hospitalization and mortality at 30 days. Safety outcomes included hypokalemia and worsening of renal function. Outcomes were analyzed across subgroups defined by maintenance diuretic dose and ejection fraction (EF). RESULTS The median age of the cohort was 70 years (interquartile range [IQR]: 58 to 80 years), and the median daily loop diuretic dose was 240 mg (IQR: 80 to 800 mg) oral furosemide or equivalent. Twenty-six patients (43.3%) were women, and 36 (60%) had an EF ≤45%. For the entire cohort, the median urine output and 24-h weight loss were 1.1 l (IQR: 0.6 to 1.4 l) and 1.1 kg (IQR: 0.2 to 1.9 kg), respectively. Outcomes were similar across patients with varying maintenance diuretic doses (<40 mg, 40 to 160 mg, 160 to 300 mg, or >300 mg of furosemide or equivalent) and in patients with reduced or preserved EF. Transient worsening of renal function and hypokalemia occurred in 10 patients (8.9%) and 4 patients (3.5%). Although hospitalization was reported as imminent for 28 patients (52.8%), the observed rate of all-cause hospitalization was 31.7% at 30 days with no deaths. CONCLUSIONS Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.
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