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Di Fiore V, Cappelli F, Del Punta L, De Biase N, Armenia S, Maremmani D, Lomonaco T, Biagini D, Lenzi A, Mazzola M, Tricò D, Masi S, Mengozzi A, Pugliese NR. Novel Techniques, Biomarkers and Molecular Targets to Address Cardiometabolic Diseases. J Clin Med 2024; 13:2883. [PMID: 38792427 PMCID: PMC11122330 DOI: 10.3390/jcm13102883] [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: 04/06/2024] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Cardiometabolic diseases (CMDs) are interrelated and multifactorial conditions, including arterial hypertension, type 2 diabetes, heart failure, coronary artery disease, and stroke. Due to the burden of cardiovascular morbidity and mortality associated with CMDs' increasing prevalence, there is a critical need for novel diagnostic and therapeutic strategies in their management. In clinical practice, innovative methods such as epicardial adipose tissue evaluation, ventricular-arterial coupling, and exercise tolerance studies could help to elucidate the multifaceted mechanisms associated with CMDs. Similarly, epigenetic changes involving noncoding RNAs, chromatin modulation, and cellular senescence could represent both novel biomarkers and targets for CMDs. Despite the promising data available, significant challenges remain in translating basic research findings into clinical practice, highlighting the need for further investigation into the complex pathophysiology underlying CMDs.
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Affiliation(s)
- Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Davide Maremmani
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Alessio Lenzi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Matteo Mazzola
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
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2
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Del Punta L, De Biase N, Pugliese NR. Replay to 'Combined extracardiac ultrasound in heart failure: a step forward in congestion assessment' Letter regarding the article 'The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure'. Eur Heart J Cardiovasc Imaging 2023; 24:e279-e280. [PMID: 37392476 DOI: 10.1093/ehjci/jead152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/03/2023] Open
Affiliation(s)
- Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy
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3
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Biagini D, Pugliese NR, Vivaldi FM, Ghimenti S, Lenzi A, De Angelis F, Ripszam M, Bruderer T, Armenia S, Cappeli F, Taddei S, Masi S, Francesco FD, Lomonaco T. Breath analysis combined with cardiopulmonary exercise testing and echocardiography for monitoring heart failure patients: the AEOLUS protocol. J Breath Res 2023; 17:046006. [PMID: 37524075 DOI: 10.1088/1752-7163/acec08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/31/2023] [Indexed: 08/02/2023]
Abstract
This paper describes the AEOLUS pilot study which combines breath analysis with cardiopulmonary exercise testing (CPET) and an echocardiographic examination for monitoring heart failure (HF) patients. Ten consecutive patients with a prior clinical diagnosis of HF with reduced left ventricular ejection fraction were prospectively enrolled together with 15 control patients with cardiovascular risk factors, including hypertension, type II diabetes or chronic ischemic heart disease. Breath samples were collected at rest and during CPET coupled with exercise stress echocardiography (CPET-ESE) protocol by means of needle trap micro-extraction and were analyzed through gas-chromatography coupled with mass spectrometry. The protocol also involved using of a selected ion flow tube mass spectrometer for a breath-by-breath isoprene and acetone analysis during exercise. At rest, HF patients showed increased breath levels of acetone and pentane, which are related to altered oxidation of fatty acids and oxidative stress, respectively. A significant positive correlation was observed between acetone and the gold standard biomarker NT-proBNP in plasma (r= 0.646,p< 0.001), both measured at rest. During exercise, some exhaled volatiles (e.g., isoprene) mirrored ventilatory and/or hemodynamic adaptation, whereas others (e.g., sulfide compounds and 3-hydroxy-2-butanone) depended on their origin. At peak effort, acetone levels in HF patients differed significantly from those of the control group, suggesting an altered myocardial and systemic metabolic adaptation to exercise for HF patients. These preliminary data suggest that concomitant acquisition of CPET-ESE and breath analysis is feasible and might provide additional clinical information on the metabolic maladaptation of HF patients to exercise. Such information may refine the identification of patients at higher risk of disease worsening.
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Affiliation(s)
- Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico M Vivaldi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Silvia Ghimenti
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Alessio Lenzi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Francesca De Angelis
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Matyas Ripszam
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Tobias Bruderer
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federica Cappeli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Di Francesco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
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4
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Pugliese NR, Masi S, Taddei S. Rethinking albuminuria as a marker to drive treatment in congestive heart failure. Eur Heart J 2023; 44:381-382. [PMID: 36369982 DOI: 10.1093/eurheartj/ehac612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
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5
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Gentile F, Fabiani I, Emdin M. Exercise Oscillatory Ventilation in Heart Failure and Brain-Lung-Heart-Muscle Crosstalk. Eur J Prev Cardiol 2022; 29:1689-1691. [PMID: 35881494 DOI: 10.1093/eurjpc/zwac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Francesco Gentile
- Cardiology Division, Pisa University Hospital, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
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Dini FL, Ballo P, Pugliese NR, Bytyçi I, D'Agostino A, Bajraktari G, Pedrinelli R, Henein MY. Improved diastolic dysfunction is associated with higher forward flow and better prognosis in chronic heart failure. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:727-737. [PMID: 34727251 DOI: 10.1007/s10554-021-02457-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/25/2021] [Indexed: 02/05/2023]
Abstract
The benefit of repeat assessment of left ventricular (LV) systolic and diastolic function in heart failure (HF) remains uncertain. We assessed the prognostic value of repeat echocardiographic assessment of LV filling pressure (LVFP) and its interaction with cardiac index (CI) in ambulatory patients with chronic HF and reduced ejection fraction (HFrEF). We enrolled 357 patients (age 68 ± 11 years; 22% female) with chronic HFrEF. Patients underwent a clinical and echocardiographic examination at baseline. LVFP as assessed by the 2016 Guidelines and Doppler-derived CI were estimated. After the second echocardiographic examination, patients were followed for a median time of 30 months. The study endpoint included all-cause death and hospitalization for worsening HF. Patients who normalized LVFP or showed persistently normal LVFP at the follow-up examination had a significantly lower mortality rate than those with worsening or persistently raised LVFP (p < 0.0001). After stratification by CI, patients with elevated LVFP and CI < 2.0 l/min/m2 had a further worse outcome than those with elevated LVFP and CI ≥ 2.0 l/min/m2 (p < 0.0001). Multivariate survival analysis confirmed an independent prognostic impact of changes in LVFP, incremental to that of established clinical, laboratory and echocardiographic predictors. Repeat assessment of LVFP and CI significantly improved risk stratification of chronic HFrEF outpatients compared to baseline evaluation.
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Affiliation(s)
- Frank Lloyd Dini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Piercarlo Ballo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy.
| | - Ibadete Bytyçi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Andreina D'Agostino
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Gani Bajraktari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Roberto Pedrinelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Michael Y Henein
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
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Pugliese NR, Mazzola M, Madonna R, Gargani L, De Biase N, Dini FL, Taddei S, De Caterina R, Masi S. Exercise-induced pulmonary hypertension in HFpEF and HFrEF: Different pathophysiologic mechanism behind similar functional impairment. Vascul Pharmacol 2022; 144:106978. [PMID: 35301117 DOI: 10.1016/j.vph.2022.106978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 12/27/2022]
Abstract
AIMS Pathophysiological mechanisms behind cardio-pulmonary impairment in heart failure (HF) with reduced (HFrEF) and preserved (HFpEF) ejection fraction are likely different. We analysed them using combined cardiopulmonary-exercise stress echocardiography (CPET-ESE). METHODS We matched 1:1 subjects with HFrEF (n = 90) and HFpEF (n = 90) for age, sex, body mass index (BMI), peak oxygen consumption, and minute ventilation/carbon dioxide production slope. All patients underwent a symptom-limited graded ramp bicycle CPET-ESE compared with 40 age-, sex- and BMI-matched healthy controls. RESULTS During a median follow-up of 25 months, we observed 22 deaths and 80 HF hospitalisations, with similar distribution between HFpEF and HFrEF. Compared with HFrEF, HFpEF had a higher prevalence of metabolic syndrome (p = 0.02) with higher levels of high-sensitivity C-reactive protein and uric acid (p < 0.01). The multipoint mean pulmonary artery pressure/cardiac output (mPAP/CO) slope showed equally increased values in HFrEF and HFpEF (3.5 ± 1.8 and 3.7 ± 1.5 mmHg/L/min) compared with controls (1.8 ± 1.1 mmHg/L/min; p < 0.0001). During exercise, HFpEF displayed more adverse interaction of right ventricle-pulmonary artery (RV-PA; tricuspid annular plane systolic excursion/systolic pulmonary artery pressure: 0.40 ± 0.2 vs 0.47 ± 0.2 mm/mmHg in HFrEF; p < 0.01) and left atrium-left ventricle (LA-LV; LA reservoir strain/LV global longitudinal strain: 1.5 ± 0.8 vs 2.2 ± 1.1 in HFrEF; p < 0.01). The latter were independent predictors of mPAP/CO slope, along with hs-CRP (adjusted R2: 0.21; p < 0.0001). CONCLUSION Despite similar disease severity, HFpEF and HFrEF show different pathophysiological mechanisms. HFpEF is characterised by a worse LA-LV and RV-PA interaction than HFrEF, with more prevalent low-grade systemic inflammation. In HFpEF, these features may have a role in exercise-induced pulmonary hypertension.
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Affiliation(s)
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Raffale De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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8
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Arterial Hypertension and Cardiopulmonary Function: The Value of a Combined Cardiopulmonary and Echocardiography Stress Test. High Blood Press Cardiovasc Prev 2022; 29:145-154. [PMID: 35107808 PMCID: PMC8942964 DOI: 10.1007/s40292-021-00494-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022] Open
Abstract
Arterial hypertension (AH) is a global burden and the leading risk factor for mortality worldwide. Haemodynamic abnormalities, longstanding neurohormonal and inflammatory activation, which are commonly observed in patients with AH, promote cardiac structural remodeling ultimately leading to heart failure (HF) if blood pressure values remain uncontrolled. While several epidemiological studies have confirmed the strong link between AH and HF, the pathophysiological processes underlying this transition remain largely unclear. The combined cardiopulmonary-echocardiography stress test (CPET-ESE) represents a precious non-invasive aid to detect alterations in patients at the earliest stages of HF. The opportunity to study the response of the cardiovascular system to exercise, and to differentiate central from peripheral cardiovascular maladaptations, makes the CPET-ESE an ideal technique to gain insights into the mechanisms involved in the transition from AH to HF, by recognizing alterations that might be silent at rest but influence the response to exercise. Identifications of these subclinical alterations might allow for a better risk stratification in hypertensive patients, facilitating the recognition of those at higher risk of evolution towards established HF. This may also lead to the development of novel preventive strategies and help tailor medical treatment. The purpose of this review is to summarise the potential advantages of using CPET-ESE in the characterisation of hypertensive patients in the cardiovascular continuum.
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9
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Impact of diabetes on cardiopulmonary function: the added value of a combined cardiopulmonary and echocardiography stress test. Heart Fail Rev 2021; 28:645-655. [PMID: 34820732 DOI: 10.1007/s10741-021-10194-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 12/25/2022]
Abstract
Type 2 diabetes mellitus (T2DM) represents a major health issue worldwide, as patients with T2DM show an excess risk of death for cardiovascular causes, twice as high as the general population. Among the many complications of T2DM, heart failure (HF) deserves special consideration as one of the leading causes of morbidity and reduced life expectancy. T2DM has been associated with different phenotypes of HF, including HF with reduced and preserved ejection fraction. Cardiopulmonary exercise testing (CPET) can evaluate the metabolic and ventilatory alterations related to myocardial dysfunction and/or peripheral impairment, representing a unique tool for the clinician to study the whole HF spectrum. While CPET allows for a thorough evaluation of functional capacity, it cannot directly differentiate central and peripheral determinants of effort intolerance. Combining CPET with imaging techniques could provide even higher accuracy and further insights into the progression of the disease since signs of left ventricular systolic and diastolic dysfunction can be detected during exercise, even in asymptomatic diabetic individuals. This review aims to dissect the alterations in cardiopulmonary function characterising patients with T2DM and HF to improve patient risk stratification.
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Simonovic D, Coiro S, Deljanin-Ilic M, Kobayashi M, Carluccio E, Girerd N, Ambrosio G. Exercise-induced B-lines in heart failure with preserved ejection fraction occur along with diastolic function worsening. ESC Heart Fail 2021; 8:5068-5080. [PMID: 34655174 PMCID: PMC8712838 DOI: 10.1002/ehf2.13575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/19/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Aims Pulmonary congestion during exercise assessed by lung ultrasound predicts negative outcome in patients with heart failure with preserved ejection fraction (HFpEF). We aimed at assessing predictors of exercise‐induced pulmonary B‐lines in HFpEF patients. Methods and results Eighty‐one I–II NYHA class HFpEF patients (65.0 ± 8.2 y/o, 56.8% females) underwent standard and strain echocardiography, lung ultrasound, and natriuretic peptide assessment during supine exercise echocardiography (baseline and peak exercise). Peak values and their changes were compared in subgroups according to exercise lung congestion grading (peak B‐lines >10 or ≤10). Exercise elicited significant changes for all echocardiographic parameters in both subgroups [39/81 (48.1%) with peak B‐lines >10; 42/81 (51.9%) with B‐lines ≤10]. Peak values and changes of E‐wave (and its derived indices) were significantly higher in patients with >10 peak B‐lines compared with those with ≤10 B‐line (all P‐values <0.03), showing significant correlation with peak B‐lines for all parameters; concomitantly, global longitudinal strain (GLS) and global strain rate (GSR) during systole (GSRs), early (GSRe) and late (GSRa) diastole, and isovolumic relaxation (GSRivr) were reduced in patients with B‐lines >10 (all P‐values <0.05), showing a negative correlation with peak B‐lines. By adjusted linear regression analysis, peak and change diastolic parameters (E‐wave, E/e′, GSRivr, and E/GSRivr) and peak GLS were individually significantly associated with peak B‐lines. By covariate‐adjusted multivariable model, E/e′ and GSRa at peak exercise were retained as independent predictors of peak B‐lines, with substantial goodness of fit of model (adjusted R2 0.776). Conclusions In HFpEF, development of pulmonary congestion upon exercise is mostly concomitant with exercise‐induced worsening of diastolic function.
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Affiliation(s)
- Dejan Simonovic
- Institute for Treatment and Rehabilitation 'Niška Banja', Clinic of Cardiology, University of Niš School of Medicine, Niš, Serbia
| | - Stefano Coiro
- Cardiology Department, Santa Maria della Misericordia Hospital, Perugia, Italy.,Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
| | - Marina Deljanin-Ilic
- Institute for Treatment and Rehabilitation 'Niška Banja', Clinic of Cardiology, University of Niš School of Medicine, Niš, Serbia
| | - Masatake Kobayashi
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Erberto Carluccio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy.,CERICLET-Centro Ricerca Clinica e Traslazionale, University of Perugia School of Medicine, Perugia, Italy
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11
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Mazzola M, Pugliese NR, Zavagli M, De Biase N, Bandini G, Barbarisi G, D'Angelo G, Sollazzo M, Piazzai C, David S, Masi S, Moggi-Pignone A, Gargani L. Diagnostic and Prognostic Value of Lung Ultrasound B-Lines in Acute Heart Failure With Concomitant Pneumonia. Front Cardiovasc Med 2021; 8:693912. [PMID: 34490365 PMCID: PMC8416771 DOI: 10.3389/fcvm.2021.693912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/20/2021] [Indexed: 01/16/2023] Open
Abstract
Purpose: To evaluate the potential confounding effect of concomitant pneumonia (PNM) on lung ultrasound (LUS) B-lines in acute heart failure (AHF). Methods: We enrolled 86 AHF patients with (31 pts, AHF/PNM) and without (55 pts, AHF) concomitant PNM. LUS B-lines were evaluated using a combined antero-lateral (AL) and posterior (POST) approach at admission (T0), after 24 h from T0 (T1), after 48 h from T0 (T2) and before discharge (T3). B-lines score was calculated at each time point on AL and POST chest, dividing the number of B-lines by the number of explorable scanning sites. The decongestion rate (DR) was calculated as the difference between the absolute B-lines number at discharge and admission, divided by the number of days of hospitalization. Patients were followed-up and hospital readmission for AHF was considered as adverse outcome. Results: At admission, AHF/PNM patients showed no difference in AL B-lines score compared with AHF patients [AHF/PNM: 2.00 (IQR: 1.44–2.94) vs. AHF: 1.65 (IQR: 0.50–2.66), p = 0.072], whereas POST B-lines score was higher [AHF/PNM: 3.76 (IQR: 2.70–4.77) vs. AHF = 2.44 (IQR: 1.20–3.60), p < 0.0001]. At discharge, AL B-lines score [HR: 1.907 (1.097–3.313), p = 0.022] and not POST B-lines score was found to predict adverse events (AHF rehospitalization) after a median follow-up of 96 days (IQR: 30–265) in the overall population. Conclusions: Assessing AL B-lines alone is adequate for diagnosis, pulmonary congestion (PC) monitoring and prognostic stratification in AHF patients, despite concomitant PNM.
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Affiliation(s)
- Matteo Mazzola
- Institute of Clinical Physiology, National Research Council, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Martina Zavagli
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Bandini
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Giorgia Barbarisi
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Gennaro D'Angelo
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Michela Sollazzo
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Chiara Piazzai
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | | | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alberto Moggi-Pignone
- Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
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12
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Pugliese NR, DE Biase N, Balletti A, Filidei F, Pieroni A, D'Angelo G, Armenia S, Mazzola M, Gargani L, Del Punta L, Asomov M, Cerri E, Franzoni F, Nesti L, Mengozzi A, Paneni F, Masi S. Characterisation of haemodynamic and metabolic abnormalities in the heart failure spectrum: the role of combined cardiopulmonary and exercise echocardiography stress test. Minerva Cardiol Angiol 2021; 70:370-384. [PMID: 34137244 DOI: 10.23736/s2724-5683.21.05743-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heart failure (HF) is a complex clinical syndrome characterised by different etiologies and a broad spectrum of cardiac structural and functional abnormalities. Current guidelines suggest a classification based on left ventricular ejection fraction (LVEF), distinguishing HF with reduced (HFrEF) from preserved (HFpEF) LVEF. HF should also be thought of as a continuous range of conditions, from asymptomatic stages to clinically manifest syndrome. The transition from one stage to the next is associated with a worse prognosis. While the rate of HF-related hospitalisation is similar in HFrEF and HFpEF once clinical manifestations occur, accurate knowledge of the steps and risk factors leading to HF progression is still lacking, especially in HFpEF. Precise hemodynamic and metabolic characterisation of patients with or at risk of HF may help identify different disease trajectories and risk factors, with the potential to identify specific treatment targets that might offset the slippery slope towards overt clinical manifestations. Exercise can unravel early metabolic and haemodynamic alterations that might be silent at rest, potentially leading to improved risk stratification and more effective treatment strategies. Cardiopulmonary exercise testing (CPET) offers valuable aid to investigate functional alterations in subjects with or at risk of HF, while echocardiography can assess cardiac structure and function objectively, both at rest and during exercise (exercise stress echocardiography, ESE). The purpose of this narrative review is to summarise the potential advantages of using an integrated CPET-ESE evaluation in the characterisation of both subjects at risk of developing HF and patients with stable HF.
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Affiliation(s)
- Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy -
| | - Nicolò DE Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessio Balletti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Pieroni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Muzaffar Asomov
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eugenio Cerri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ferdinando Franzoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Nesti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Paneni
- Center for Molecular Cardiology, University of Zürich, Zürich, Switzerland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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13
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Passino C, Fabiani I. Multiparametric ultrasound approach for early detection of cardiac dysfunction: ready for the clinical arena? Eur J Prev Cardiol 2021; 28:1926-1927. [PMID: 34089584 DOI: 10.1093/eurjpc/zwab092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Claudio Passino
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana G. Monasterio, via Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, P. Martiri della Liberta', 56127 Pisa, Italy
| | - Iacopo Fabiani
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana G. Monasterio, via Moruzzi 1, 56124 Pisa, Italy
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14
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Gargani L, Pugliese NR, Frassi F, Frumento P, Poggianti E, Mazzola M, De Biase N, Landi P, Masi S, Taddei S, Pang PS, Sicari R. Prognostic value of lung ultrasound in patients hospitalized for heart disease irrespective of symptoms and ejection fraction. ESC Heart Fail 2021; 8:2660-2669. [PMID: 33932105 PMCID: PMC8318481 DOI: 10.1002/ehf2.13206] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/14/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
Aims Lung ultrasound B‐lines are the sonographic sign of pulmonary congestion and can be used in the differential diagnosis of dyspnoea to rule in or rule out acute heart failure (AHF). Our aim was to assess the prognostic value of B‐lines, integrated with echocardiography, in patients admitted to a cardiology department, independently of the initial clinical presentation, thus in patients with and without AHF, and in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF). Methods and results We enrolled consecutive patients admitted for various cardiac conditions. Patients were classified into three groups: (i) acute HFrEF; (ii) acute HFpEF; and (iii) non‐AHF. All patients underwent an echocardiogram coupled with lung ultrasound at admission, according to standardized protocols. We followed up 1021 consecutive inpatients (69 ± 12 years) for a median of 14.4 months (interquartile range 4.6–24.3) for death and rehospitalization for AHF. During the follow‐up, 126 events occurred. Admission B‐lines > 30, ejection fraction < 50%, tricuspid regurgitation velocity > 2.8 m/s, and tricuspid annular plane systolic excursion < 17 mm were independent predictors at multivariable analysis. B‐lines > 30 had a strong predictive value in HFpEF and non‐AHF, but not in HFrEF. Conclusions Ultrasound B‐lines can detect subclinical pulmonary interstitial oedema in patients thought to be free of congestion and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is more robust in patients with HFpEF compared with HFrEF.
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Affiliation(s)
- Luna Gargani
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | | | - Francesca Frassi
- Emergency Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | | | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - Rosa Sicari
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
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15
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Pugliese NR, Fabiani I, Conte L, Nesti L, Masi S, Natali A, Colombo PC, Pedrinelli R, Dini FL. Persistent congestion, renal dysfunction and inflammatory cytokines in acute heart failure: a prognosis study. J Cardiovasc Med (Hagerstown) 2021; 21:494-502. [PMID: 32487865 DOI: 10.2459/jcm.0000000000000974] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Chronic kidney dysfunction (CKD) and persistent congestion influence heart failure prognosis, but little is known about the role of inflammation in this association. We assessed the relationship between inflammatory biomarkers, persistent congestion and CKD and their prognostic implications in patients with acute heart failure. METHODS We enrolled 97 hospitalised patients (mean age: 66 ± 12 years, ejection fraction: 30 ± 8%) with acute heart failure. Before discharge, congestion was assessed using a heart failure scoring system on the basis of Framingham criteria. Circulating levels of high-sensitivity C-reactive protein, TGF-β-1, IL-1, IL-6, IL-10, TNF-α, soluble tumour necrosis factor receptor type 1 and 2 were measured. Patients were divided into four groups according to the presence of CKD (estimated glomerular filtration rate <60 ml/min/1.73 m) and congestion (Framingham heart failure score ≥2). The primary end point was the combination of death and rehospitalisation for acute heart failure. RESULTS During a median follow-up of 32 months, 37 patients died and 14 were rehospitalised for acute heart failure. Patients with CKD and congestion had significantly higher TNF-α (P = 0.037), soluble tumour necrosis factor receptor type 1 (P = 0.0042) and soluble tumour necrosis factor receptor type 2 (P = 0.001), lower TGF-β-1 (P = 0.02) levels, and the worst outcome (P < 0.0001). Congestion (P = 0.01) and CKD (P = 0.02) were independent predictors of the end-point together with N-terminal prohormone of brain natriuretic peptide (P = 0.002) and TNF-α (P = 0.004). TNF-α attenuated the direct relation between CKD, congestion and outcome, explaining 40% of the difference in the outcome. CONCLUSION In patients hospitalised with acute heart failure, the prognostic impact of persistent congestion and CKD is associated with increased cytokine levels, which may also interfere with the outcome.
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Affiliation(s)
- Nicola R Pugliese
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Iacopo Fabiani
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa.,Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa.,Laboratory of Metabolism, Nutrition and Atherosclerosis, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Conte
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa
| | - Lorenzo Nesti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa.,Laboratory of Metabolism, Nutrition and Atherosclerosis, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Andrea Natali
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa.,Laboratory of Metabolism, Nutrition and Atherosclerosis, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | | | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa
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16
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Pugliese NR, De Biase N, Gargani L, Mazzola M, Conte L, Fabiani I, Natali A, Dini FL, Frumento P, Rosada J, Taddei S, Borlaug BA, Masi S. Predicting the transition to and progression of heart failure with preserved ejection fraction: a weighted risk score using bio-humoural, cardiopulmonary, and echocardiographic stress testing. Eur J Prev Cardiol 2020; 28:1650-1661. [PMID: 33624088 DOI: 10.1093/eurjpc/zwaa129] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/25/2020] [Accepted: 11/10/2020] [Indexed: 12/19/2022]
Abstract
AIMS Risk stratification of heart failure (HF) patients with preserved ejection fraction (HFpEF) can promote a more personalized treatment. We tested the prognostic value of a multi-parametric evaluation, including biomarkers, cardiopulmonary exercise testing-exercise stress echocardiography (CPET-ESE), and lung ultrasound, in HFpEF patients and subjects at risk of developing HF (HF Stages A and B). BACKGROUND Risk stratification of heart failure (HF) patients with preserved ejection fraction (HFpEF) can promote a more personalized treatment. DESIGN We tested the prognostic value of a multi-parametric evaluation, including biomarkers, cardiopulmonary exercise testing-exercise stress echocardiography (CPET-ESE), and lung ultrasound, in HFpEF patients and subjects at risk of developing HF (HF Stages A and B). METHODS AND RESULTS We performed a resting clinical/bio-humoural evaluation and a symptom-limited CPET-ESE in 274 patients (45 Stage A, 68 Stage B, and 161 Stage C-HFpEF) and 30 age- and sex-matched healthy controls. During a median follow-up of 18.5 months, we reported 71 HF hospitalizations and 10 cardiovascular deaths. Cox proportional-hazards regression identified five independent predictors and each was assigned a number of points proportional to its regression coefficient: stress-rest ΔB-lines >10 (3 points), peak oxygen consumption <16 mL/kg/min (2 points), minute ventilation/carbon dioxide production slope ≥36 (2 points), peak systolic pulmonary artery pressure ≥50 mmHg (1 point) and resting N-terminal pro-brain natriuretic peptide (NT-proBNP) >900 pg/mL (1 point). The event-free survival probability for low risk (<3 points), intermediate risk (3-6 points), and high risk (>6 points) were 93%, 52%, and 20%, respectively. The area under the curve (AUC) for the scoring system to predict events was 0.92 (95% CI 0.88-0.96), with an accuracy significantly higher than the individual components of the score (all P < 0.01 vs. individual AUCs). CONCLUSION A weighted risk score including NT-proBNP, markers of cardiopulmonary dysfunction and indices of exercise-induced pulmonary congestion identifies HFpEF patients at increased risk for adverse events and Stage A and B subjects more likely to progress towards more advanced HF stages.
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Affiliation(s)
- Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy.,Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | - Lorenzo Conte
- Cardiology Unit, Ospedale Castelnuovo Garfagnana, Italy
| | | | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy
| | - Frank L Dini
- Area Cardiologica, Casa di Cura Villa Esperia, Salice Terme, Pavia, Italy
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Javier Rosada
- Fourth Unit of Internal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, Pisa 56126, Italy
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17
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Pugliese NR, De Biase N, Conte L, Gargani L, Mazzola M, Fabiani I, Natali A, Dini FL, Frumento P, Rosada J, Taddei S, Borlaug BA, Masi S. Cardiac Reserve and Exercise Capacity: Insights from Combined Cardiopulmonary and Exercise Echocardiography Stress Testing. J Am Soc Echocardiogr 2020; 34:38-50. [PMID: 33036818 DOI: 10.1016/j.echo.2020.08.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/13/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) represents the gold standard to estimate peak oxygen consumption (VO2) noninvasively. To improve the analysis of the mechanisms behind effort intolerance, we examined whether exercise stress echocardiography measurements relate to directly measured peak VO2 during exercise in a large cohort of patients within the heart failure (HF) spectrum. METHODS We performed a symptom-limited graded ramp bicycle CPET exercise stress echocardiography in 30 healthy controls and 357 patients: 113 at risk of developing HF (American College of Cardiology/American Heart Association stage A-B) and 244 in HF stage C with preserved (HFpEF, n = 101) or reduced ejection fraction (HFrEF, n = 143). RESULTS Peak VO2 significantly decreased from controls (23, 21.7-29.7 mL/kg/minute; median, interquartile range) to stage A-B (18, 15.4-20.7 mL/kg/minute) and stage C (HFpEF: 13.6, 11.8-16.8 mL/kg/minute; HFrEF: 14.2, 10.7-17.5 mL/kg/minute). A regression model to predict peak VO2 revealed that peak left ventricular (LV) systolic annulus tissue velocity (S'), peak tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (right ventricle-pulmonary artery coupling), and low-load left atrial (LA) reservoir strain/E/e' (LA compliance) were independent predictors, in addition to peak heart rate, stroke volume, and workload (adjusted R2 = 0.76, P < .0001). The model was successfully tested in subjects with atrial fibrillation (n = 49) and with (n = 224) and without (n = 163) beta-blockers (all P < .01). Peak S' showed the highest accuracy in predicting peak VO2 < 10 mL/kg/minute (cut point ≤ 7.5 cm/sec, area under the curve = 0.92, P < .0001) and peak VO2 > 20 mL/kg/minute (cut point > 12.5 cm/sec, area under the curve = 0.84, P < .0001) in comparison with the other cardiac variables of the model (P < .05). CONCLUSIONS Peak VO2 is directly related to measures of LV systolic function, LA compliance, and right ventricle-pulmonary artery coupling, in addition to heart rate and stroke volume and independently of workload, age, and sex. The evaluation of cardiac mechanics may provide more insights into the causes of effort intolerance in subjects from HF stages A-C.
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Affiliation(s)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Conte
- Cardiology Unit, Ospedale Castelnuovo Garfagnana, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frank L Dini
- Area Cardiologica, Casa di Cura Villa Esperia, Salice Terme, Pavia, Italy
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Javier Rosada
- Fourth Unit of Internal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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18
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Coiro S, Simonovic D, Deljanin-Ilic M, Duarte K, Carluccio E, Cattadori G, Girerd N, Ambrosio G. Prognostic Value of Dynamic Changes in Pulmonary Congestion During Exercise Stress Echocardiography in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2020; 13:e006769. [PMID: 32543975 DOI: 10.1161/circheartfailure.119.006769] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with heart failure (HF) with preserved ejection fraction (HFpEF) typically develop dyspnea and pulmonary congestion upon exercise. Lung ultrasound is a simple diagnostic tool, providing semiquantitative assessment of extravascular lung water through B-lines. It has been shown that patients with HFpEF develop B-lines upon submaximal exercise stress echocardiography; however, whether exercise-induced pulmonary congestion carries prognostic implications is unknown. This study aimed at evaluating the prognostic value of B-line assessment during exercise in patients with HFpEF. METHODS Sixty-one New York Heart Association class I to II patients with HFpEF underwent standard echocardiography, lung ultrasound (28-scanning point method), and BNP (B-type natriuretic peptide) assessment during supine exercise echocardiography (baseline and peak exercise). The primary end point was a composite of cardiovascular death or HF hospitalization at 1 year. RESULTS B-lines, E/e', and BNP significantly increased during exercise (P<0.001 for all). By multivariable analysis, both peak (hazard ratio, 1.50 [95% CI, 1.21-1.85], P<0.001), and change (hazard ratio 1.34 [95% CI, 1.12-1.62], P=0.002) B-lines were retained as independent predictors of outcome (hazard ratios per 1 B-line increment), along with BNP and E/e' ratio. Importantly, adding peak B-line on top of a clinical model significantly improved prognostic accuracy (C-index increase, 0.157 [0.056-0.258], P=0.002) and net reclassification (continuous net reclassification improvement, 0.51 [0.09-0.74], P=0.016), with similar results for B-line change. CONCLUSIONS Detection of exercise-induced pulmonary congestion by lung ultrasound is an independent predictor of outcome in patients with HFpEF; its use may help refining the routine risk stratification of these patients on top of well-established clinical variables.
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Affiliation(s)
- Stefano Coiro
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, France (S.C., K.D., N.G.)
| | - Dejan Simonovic
- Institute for treatment and rehabilitation "Niska Banja", Clinic of Cardiology, University of Nis School of Medicine, Serbia (D.S., M.D.-I.)
| | - Marina Deljanin-Ilic
- Institute for treatment and rehabilitation "Niska Banja", Clinic of Cardiology, University of Nis School of Medicine, Serbia (D.S., M.D.-I.)
| | - Kevin Duarte
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, France (S.C., K.D., N.G.)
| | - Erberto Carluccio
- Division of Cardiology, University of Perugia School of Medicine, Italy (E.C., G.A.)
| | | | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, France (S.C., K.D., N.G.).,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France (N.G.)
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Italy (E.C., G.A.)
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19
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Mele D, Pestelli G, Dini FL, Dal Molin D, Smarrazzo V, Trevisan F, Luisi GA, Ferrari R. Novel Echocardiographic Approach to Hemodynamic Phenotypes Predicts Outcome of Patients Hospitalized With Heart Failure. Circ Cardiovasc Imaging 2020; 13:e009939. [PMID: 32312116 DOI: 10.1161/circimaging.119.009939] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although in clinical practice heart failure (HF) patients are classified using left ventricular ejection fraction (LVEF), this categorization is insufficient for prognosis, especially when LVEF is preserved or there is a concomitant right ventricular (RV) dysfunction. We hypothesized that a combined noninvasive evaluation of LV forward flow, filling pressure, and RV function would be better than LVEF in predicting all-cause mortality of hospitalized patients with HF. METHODS Transthoracic echocardiographic examinations of 603 patients hospitalized with HF were analyzed. In a subsample of 200 patients with HF, LV stroke volume index, LV filling pressure estimation, tricuspid annular plane systolic excursion, and systolic pulmonary artery pressure were combined to determine 4 hemodynamic profiles: normal flow-normal pressure, normal flow-high pressure, low flow without RV dysfunction, and low flow with RV dysfunction profile. This model was then applied in a validation cohort (n=403). RESULTS Prognosis worsened from the normal flow-normal pressure profile to the low flow with right ventricular dysfunction profile. At the multivariate survival analysis, the model showed independent high risk-stratification capability (P<0.001), even in subgroups of patients with LVEF < or ≥50% (P=0.011 and P<0.001, respectively) and < or ≥40% (P=0.044 and P<0.001, respectively). LVEF and HF classification based on LVEF did not predict outcome. CONCLUSIONS Echocardiographic-derived profiling of LV forward flow, filling pressure, and RV function allowed categorization of patients hospitalized with HF and predicted all-cause mortality independently of LVEF. This model is based on conventional echocardiography, is easy to apply, and is, therefore, suggested for clinical practice.
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Affiliation(s)
- Donato Mele
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Gabriele Pestelli
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Frank Lloyd Dini
- Cardiovascular Diseases Unit 1, Cardiovascular and Thoracic Department, University of Pisa, Italy (F.L.D.)
| | - Davide Dal Molin
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Vittorio Smarrazzo
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Filippo Trevisan
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Giovanni Andrea Luisi
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Roberto Ferrari
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.).,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola (RA), Italy (R.F.)
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20
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Platz E, Solomon SD. Assessing pulmonary congestion in HFpEF. Eur Heart J 2019; 40:3731-3733. [DOI: 10.1093/eurheartj/ehz805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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