Systolic and Diastolic Heart Failure: Differences and Similarities

Cardiac Myosin Activator Omecamtiv Mecarbil: Novel Treatment for Systolic Heart Failure

Systolic Heart failure is a complex clinical syndrome characterized by a decrease in cardiac contractility and a reduction in organ perfusion. Current pharmacologic inotropes attempt to improve contractility via indirect mechanisms but are limited in terms of safety and effectiveness. Omecamtiv mecarbil is a novel agent in a new class of drugs known as cardiac myosin activators; their unique mechanism of action involves directly activating the enzymatic pathway in the cardiac myocyte as a way to improve ventricular contraction. Preclinical and clinical trials have found that omecamtiv mecarbil improves cardiac contractility without increasing the risk of any of the harmful effects that are associated with the currently available inotropic agents. Omecamtiv mecarbil is a worthwhile advance and patients with systolic heart failure would benefit from pharmacological use of this drug.

Retrofitting the Heart: Explaining the Enigmatic Septal Thickening in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is the most common genetic cardiac disease and is characterized by left ventricular hypertrophy. Although this hypertrophy often associates with sarcomeric gene mutations, nongenetic factors also contribute to the disease, leading to diastolic dysfunction. Notably, this dysfunction manifests before hypertrophy and is linked to hypercontractility, as well as nonuniform contraction and relaxation (myofibril asynchrony) of the myocardium. Although the distribution of hypertrophy in hypertrophic cardiomyopathy can vary both between and within individuals, in most cases, it is primarily confined to the interventricular septum. The reasons for septal thickening remain largely unknown. In this article, we propose that alterations in muscle fiber geometry, present from birth, dictate the septal shape. When combined with hypercontractility and exacerbated by left ventricular outflow tract obstruction, these factors predispose the septum to an isometric type of contraction during systole, consequently constraining its mobility. This contraction, or more accurately, this focal increase in biomechanical stress, prompts the septum to adapt and undergo remodeling. Drawing a parallel, this is reminiscent of how earthquake-resistant buildings are retrofitted with vibration dampers to absorb the majority of the shock motion and load. Similarly, the heart adapts by synthesizing viscoelastic elements such as microtubules, titin, desmin, collagen, and intercalated disc components. This pronounced remodeling in the cytoskeletal structure leads to noticeable septal hypertrophy. This structural adaptation acts as a protective measure against damage by attenuating myofibril shortening while reducing cavity tension according to Laplace Law. By examining these events, we provide a coherent explanation for the septum's predisposition toward hypertrophy.

Myofilament dysfunction in diastolic heart failure

Diastolic heart failure (DHF), in which impaired ventricular filling leads to typical heart failure symptoms, represents over 50% of all heart failure cases and is linked with risk factors, including metabolic syndrome, hypertension, diabetes, and aging. A substantial proportion of patients with this disorder maintain normal left ventricular systolic function, as assessed by ejection fraction. Despite the high prevalence of DHF, no effective therapeutic agents are available to treat this condition, partially because the molecular mechanisms of diastolic dysfunction remain poorly understood. As such, by focusing on the underlying molecular and cellular processes contributing to DHF can yield new insights that can represent an exciting new avenue and propose a novel therapeutic approach for DHF treatment. This review discusses new developments from basic and clinical/translational research to highlight current knowledge gaps, help define molecular determinants of diastolic dysfunction, and clarify new targets for treatment.

Non-invasive technologies for heart failure, systolic and diastolic dysfunction modeling: a scoping review

The growing global prevalence of heart failure (HF) necessitates innovative methods for early diagnosis and classification of myocardial dysfunction. In recent decades, non-invasive sensor-based technologies have significantly advanced cardiac care. These technologies ease research, aid in early detection, confirm hemodynamic parameters, and support clinical decision-making for assessing myocardial performance. This discussion explores validated enhancements, challenges, and future trends in heart failure and dysfunction modeling, all grounded in the use of non-invasive sensing technologies. This synthesis of methodologies addresses real-world complexities and predicts transformative shifts in cardiac assessment. A comprehensive search was performed across five databases, including PubMed, Web of Science, Scopus, IEEE Xplore, and Google Scholar, to find articles published between 2009 and March 2023. The aim was to identify research projects displaying excellence in quality assessment of their proposed methodologies, achieved through a comparative criteria-based rating approach. The intention was to pinpoint distinctive features that differentiate these projects from others with comparable objectives. The techniques identified for the diagnosis, classification, and characterization of heart failure, systolic and diastolic dysfunction encompass two primary categories. The first involves indirect interaction with the patient, such as ballistocardiogram (BCG), impedance cardiography (ICG), photoplethysmography (PPG), and electrocardiogram (ECG). These methods translate or convey the effects of myocardial activity. The second category comprises non-contact sensing setups like cardiac simulators based on imaging tools, where the manifestations of myocardial performance propagate through a medium. Contemporary non-invasive sensor-based methodologies are primarily tailored for home, remote, and continuous monitoring of myocardial performance. These techniques leverage machine learning approaches, proving encouraging outcomes. Evaluation of algorithms is centered on how clinical endpoints are selected, showing promising progress in assessing these approaches' efficacy.

Dietary quality and risk of heart failure in men

BACKGROUND

Due to the increasing disease burden, strategies to predict and prevent heart failure (HF) are urgently needed.

OBJECTIVE

We aimed to investigate whether the Alternative Healthy Eating Index (AHEI) and the clinically abbreviated Prime Diet Quality Score (PDQS) are associated with the risk of overall HF, HF with preserved ejection fraction (HFpEF), and HF with reduced ejection fraction (HFrEF).

METHODS

Our study included 44,525 men from the Health Professionals Follow-up Study (HPFS) who were free from cardiovascular disease and cancer at baseline. The AHEI and PDQS were computed based on dietary data repeatedly measured using semiquantitative FFQs. HF, HFpEF, and HFrEF were adjudicated based on review of medical records through 2008. Associations of diet quality with incident HF were estimated with multivariate-adjusted Cox proportional hazards models.

RESULTS

During 929,911 person-years of follow-up, 803 HF cases were documented, including 184 with HFpEF and 181 with HFrEF among those with ejection fraction (EF) data. Adjusting for potential confounders, we did not observe a significant association between the AHEI and overall HF (HR per SD: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.57) or between the PDQS and overall HF (HR per SD: 0.98; 95% CI: 0.91, 1.06; P-trend = 0.82). Both dietary indices were not significantly associated with HFpEF. However, a higher AHEI was associated with lower risk of HFrEF upon comparison of the extreme quintiles (HR per SD: 0.81; 95% CI: 0.69, 0.96; P-trend = 0.02). Every SD increment in the PDQS was associated with 20% lower risk of HFrEF (HR per SD: 0.80; 95% CI: 0.68, 0.95; P-quadratic = 0.03).

CONCLUSIONS

A healthy overall diet was associated with lower risk of HFrEF, and associations were similar with the AHEI and PDQS. We did not observe a significant association between dietary indices and either overall HF or HFpEF.

Understanding and recognition of the right ventricular function and dysfunction via a numerical study

The role played by the right ventricular (RV) dysfunction has long been underestimated in clinical practice. Recent findings are progressively confirming that when the RV efficiency deteriorates both the right and the left circulation is (significantly) affected, but studies dedicated to a detailed description of RV hemodynamic role still lack. In response to such a gap in knowledge, this work proposes a numerical model that for the first time evaluates the effect of isolated RV dysfunction on the whole circulation. Lumped parameter modelling was applied to represent the physio-pathological hemodynamics. Different grades of impairment were simulated for three dysfunctions i.e., systolic, diastolic, and combined systolic and diastolic. Hemodynamic alterations (i.e., of blood pressure, flow, global hemodynamic parameters), arising from the dysfunctions, are calculated and analysed. Results well accord with clinical observations, showing that RV dysfunction significantly affects both the pulmonary and systemic hemodynamics. Successful verification against in vivo data proved the clinical potentiality of the model i.e., the capability of identifying the degree of RV impairment for given hemodynamic conditions. This study aims at contributing to the improvement of RV dysfunction recognition and treatment, and to the development of tools for the clinical management of pathologies involving the right heart.

Phenotyping of hypertensive heart disease and hypertrophic cardiomyopathy using personalized 3D modelling and cardiac cine MRI

Differential diagnosis of hypertensive heart disease (HHD) and hypertrophic cardiomyopathy (HCM) is clinically challenging but important for treatment management. This study aims to phenotype HHD and HCM in 3D + time domain by using a multiparametric motion-corrected personalized modeling algorithm and cardiac magnetic resonance (CMR). 44 CMR data, including 12 healthy, 16 HHD and 16 HCM cases, were examined. Multiple CMR phenotype data consisting of geometric and dynamic variables were extracted globally and regionally from the models over a full cardiac cycle for comparison against healthy models and clinical reports. Statistical classifications were used to identify the distinctive characteristics and disease subtypes with overlapping functional data, providing insights into the challenges for differential diagnosis of both types of disease. While HCM is characterized by localized extreme hypertrophy of the LV, wall thickening/contraction/strain was found to be normal and in sync, though it was occasionally exaggerated at normotrophic/less severely hypertrophic regions during systole to preserve the overall ejection fraction (EF) and systolic functionality. Additionally, we observed that hypertrophy in HHD could also be localized, although at less extreme conditions (i.e. more concentric). While fibrosis occurs mostly in those HCM cases with aortic obstruction, only minority of HHD patients were found affected by fibrosis. We demonstrate that subgroups of HHD (i.e. preserved and reduced EF: HHDpEF & HHDrEF) have different 3D + time CMR characteristics. While HHDpEF has cardiac functions in normal range, dilation and heart failure are indicated in HHDrEF as reflected by low LV wall thickening/contraction/strain and synchrony, as well as much reduced EF.

[The method for prediction of high-grade premature ventricular contractions in patients with heart failure and preserved ejection fraction]

Aim To develop a method for prediction of high-grade ventricular extrasystole (VE) in patients with chronic heart failure with preserved ejection fraction (CHF-PEF) based on results of an echocardiography (EchoCG) study.Material and methods At the first step, the study included 121 patients of the Cardiology Department, Municipal Clinical Hospital #31, St. Petersburg (calculation group) with symptoms and clinical signs of CHF-PEF (median age, 62 years). For testing accuracy of the developed formula, a control group was formed, which consisted of 42 patients with CHF-PEF (median age, 59 years). EchoCG at rest and ECG Holter monitoring were performed for all patient. The VE classification according to B. Lown and M. Wolf (1971) in the M. Ryan (1975) modification was used. Results of the evaluation were determined by the most significant recorded grade. Grade III or higher VE were considered as high-grade VE.Results Using logistic regression analysis of data for patients of the calculation group, a statistical model was constructed and a respective formula was developed to predict a probability of high-grade VE in CHF-PEF patients depending on the presence of risk factors (EchoCG criteria). According to the obtained data the following factors primarily contributed to the model: interventricular septal (IVS) thickness (p=0.007; Wald=7.44), end-diastolic volume index (EDVI) (p=0.044; Wald=4.13), and the degree of diastolic dysfunction (DD) (p<0.0001; Wald=19.90). For testing the formula accuracy, the analysis was performed in the control group. Based on data of both stages, the following values were obtained: for the calculation group, the method sensitivity was 77.8 %, the specificity was 82.4 %, the accuracy was 81.0 %; for the control group, 81.8 %, 70 %, and 76.2 %, respectively; for both groups together, 79.3 %, 80.0 %, and 79.8 %, respectively. In ROC-analysis of this prognostic model, the area under the ROC-curve (AUC) was 0.852 (95 % CI: 0.776-0.910; p<0.0001) for the calculation group; 0.818 (95 % CI: 0.669-0.920; p<0.0001) for the control group; and 0.855 (95 % CI: 0.792-0.905; p<0.0001) for both groups together, which indicated a good quality of the prognostic model.Conclusion The EchoCG predictors of high-grade VE in patients with CHF-PEF included degree of DD, EDVI, and IVS thickness. The developed method with the constructed formula for prediction of high-grade VE in CHF-PEF patients showed high sensitivity, specificity and accuracy.

An overview of hypertension and cardiac involvement in Asia: Focus on heart failure

Cardiovascular Disease (CVD) is the leading cause of deaths worldwide, contributing to about 30% of all deaths. Half of the cases of CVD are estimated in Asia, the world's most populous continent. Hypertension, a major modifiable risk factor for CVD, results in more deaths than any other CV risk factors in the Asian regions. The total number of patients with hypertension is likely to grow as the population ages. The proportion of the elderly population aged 65 years or more in Asia is expected to increase from 7.4% in 2015 to 10.9% in 2030. It is important to note that more than half (54%) of the world's population live in Asia. Aside of being the biggest single risk factor for global deaths, hypertension is also an important precursor and most common risk factor of heart failure (HF). An increase in HF prevalence is clearly related to the rapid epidemiological transition caused by changes in lifestyle in Asian countries. However, the availability of data on HF burden and health care delivery is limited in Asia compared with Europe and North America. This reality has driven the working group of Asian experts for example the HOPE Asia Network to concentrate on hypertension as risk factors for CVD, with the mission to improve the management of hypertension resulting in organ protection toward a goal of achieving "ZERO" CV event in Asia. This paper aims to give an overview regarding the heart problems caused by hypertension in Asia, focus on HF.

Lumped-Parameter Circuit Platform for Simulating Typical Cases of Pulmonary Hypertensions from Point of Hemodynamics

Pulmonary hypertension (PH) presents unusual hemodynamic states characterized by abnormal high blood pressure in pulmonary artery. The objective of this study is to simulate how the hemodynamics develops in typical PH cases without treatment. A lumped-parameter circuit platform of human circulation system is set up to simulate hemodynamic abnormalities of PH in different etiologies and pathogenesis. Four typical cases are considered, which are distal pulmonary artery stenosis, left ventricular diastolic dysfunction, ventricular septal defect, and mitral stenosis. The authors propose regulation laws for chambers and vessels to adapt the abnormal hemodynamic conditions for each PH case. The occurrence and development of each PH case are simulated over time using the lumped-parameter circuit platform. The blood pressure, blood flow, pressure-volume relations for chambers and vessels are numerically calculated for each case of PH progression. The model results could be a quite helpful to understand the hemodynamic mechanism of typical PHs. Graphical Abstract.

Brachial pulse pressure in acute heart failure. Results of the Heart Failure Registry

Aims

To investigate the still uncertain independent prognostic impact of pulse pressure (PP) in acute heart failure (HF), in particular across the left ventricular ejection fraction (EF) phenotypes, and the potential contribution of PP in outlining the individual phenotypes.

Methods and results

We prospectively evaluated 1‐year death and rehospitalization in 4314 patients admitted for acute HF grouped by EF and stratified by their PP level on admission. In HF with reduced (< 40%) EF (HFrEF), the highest quartiles of PP had the lowest unadjusted [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.61–0.98] and adjusted (HR 0.64 0.50–0.82) risk of 1 year all cause death compared to the lowest quartile. Its prognostic impact was partially mediated by systolic blood pressure (SBP). In HF with preserved (≥ 50%) EF (HFpEF), the intermediate quartile of PP showed the lowest 1 year all cause mortality in unadjusted (HR 0.598, CI 0.416–0.858) and adjusted (HR 0.55, 95% CI 0.388‐0.801) models with no relationship with SBP. In a receiver operating characteristic analysis, a combination of PP > 60 mmHg and SBP > 140 mmHg was associated to a preserved EF with a high performance value. No prognostic significance of PP was found in the HF with mid‐range EF subgroup.

Conclusions

In acute HFrEF, there is an almost linear inverse relation between mortality and PP, partly mediated by SBP. In HFpEF, a J‐shaped relationship between mortality and PP was present with a better prognosis at the nadir. A combination of PP > 60 mmHg with SBP > 140 mmHg may be clinically helpful as marker of a preserved left ventricular EF.

Arrhythmogenic mechanisms of obstructive sleep apnea in heart failure patients

Heart failure (HF) affects 23 million people worldwide and results in 300000 annual deaths. It is associated with many comorbidities, such as obstructive sleep apnea (OSA), and risk factors for both conditions overlap. Eleven percent of HF patients have OSA and 7.7% of OSA patients have left ventricular ejection fraction <50% with arrhythmias being a significant comorbidity in HF and OSA patients. Forty percent of HF patients develop atrial fibrillation (AF) and 30%-50% of deaths from cardiac causes in HF patients are from sudden cardiac death. OSA is prevalent in 32%-49% of patients with AF and there is a dose-dependent relationship between OSA severity and resistance to anti-arrhythmic therapies. HF and OSA lead to various downstream arrhythmogenic mechanisms, including metabolic derangement, remodeling, inflammation, and autonomic imbalance. (1) Metabolic derangement and production of reactive oxidative species increase late Na+ currents, decrease outward K+ currents and downregulate connexin-43 and cell-cell coupling. (2) remodeling also features downregulated K+ currents in addition to decreased Na+/K+ ATPase currents, altered Ca2+ homeostasis, and increased density of If current. (3) Chronic inflammation leads to downregulation of both Nav1.5 channels and K+ channels, altered Ca2+ homeostasis and reduced cellular coupling from alterations of connexin expression. (4) Autonomic imbalance causes arrhythmias by evoking triggered activity through increased Ca2+ transients and reduction of excitation wavefront wavelength. Thus, consideration of these multiple pathophysiological pathways (1-4) will enable the development of novel therapeutic strategies that can be targeted against arrhythmias in the context of complex disease, such as the comorbidities of HF and OSA.

An Approximation of Heart Failure Using Cardiovascular Simulation Toolbox

In this paper, we present the simulation of 5 different heart failures with the help of the Cardiovascular Simulation Toolbox (CVST) proposed by O. Barnea et al. at Tel-Aviv University. This is a modified version of the CVST, proposed by G.Ortiz; here, we show that the pathological failures can be covered by this tool. We varied the value of the tool blocks, included the results of the hemodynamic parameters and the P-V loop curves for each disease and compared them to the medical data to prove the effectiveness of the simulation. Based on these changes, we achieved an effective simulation of the following heart failures in the CVST: Diastolic Heart Failure (DHF), Systolic Heart Failure (SHF), Right Ventricle Heart Failure (RVHF), Low Output Heart Failure (LOHF) and High Output Heart Failure (HOHF).

The effects of golimumab treatment on systolic and diastolic left ventricular function in ankylosing spondylitis

Background

Diastolic left ventricular (LV) dysfunction appears more prevalent in ankylosing spondylitis (AS). The effects of tumor necrosis factor alpha (TNF-α) blocking therapy, a strong and effective anti-inflammatory drug, on diastolic LV function in AS are unknown. The objective of the study was to find the effects of 1-year treatment with golimumab 50 mg subcutaneously once per month on systolic and diastolic LV dysfunction in AS patients.

Methods

Forty consecutive AS patients were treated with TNF-α blocking therapy for 1 year. Transthoracic echocardiography was performed in all patients at baseline and after 1 year of treatment.

Results

Diastolic LV function improved after treatment in four out of six (67%) AS patients who completed follow-up (P=0.125), and did not develop or worsen in any of the other patients. Treatment with TNF-α blocking therapy had no effect on systolic LV function.

Conclusion

These findings give support to the hypothesis that diastolic LV dysfunction improves during treatment with TNF-α blocking therapy.

Usefulness of Left Ventricular Vortex Flow Analysis for Predicting Clinical Outcomes in Patients with Chronic Heart Failure: A Quantitative Vorticity Imaging Study Using Contrast Echocardiography

The goal of the study described here was to evaluate whether left ventricular vortex flow parameters, as assessed by contrast echocardiography, enhance prediction of major adverse cardiac events (MACE) in patients with chronic heart failure and systolic dysfunction. A total of 75 patients with contrast echocardiography and systolic dysfunction (ejection fraction ≤45%) were prospectively enrolled and underwent vortex flow analysis with particle image velocimetry using contrast echocardiography. Vortex flow parameters, including kinetic energy fluctuation (KEF), were evaluated. Patients were followed up for a primary endpoint of MACE that comprised hospital admission for cardiovascular causes and cardiac deaths. Across a median 277-d follow-up, 29 patients (38.7%) experienced MACE. Among these, the incidence of diabetes and the E/e' ratio were significantly higher in patients with MACE than in those without, whereas the hemoglobin level and ejection fraction were significantly lower. KEF was significantly lower in patients with MACE. In the multivariate analysis, higher KEF was associated with a lower risk of MACE (hazard ratio = 0.18, 95% confidence interval: 0.04-0.97, p = 0.046). The addition of KEF to a model with conventional parameters (e.g., age, diabetes, ejection fraction and the E/e' ratio) significantly improved the model's discrimination. Elevations in the quantitative left ventricular vortex flow parameter, KEF, as determined by contrast echocardiography, are associated with a lower risk of MACE and improved functional status among patients with chronic heart failure.

Autonomic regulation therapy to enhance myocardial function in heart failure patients: the ANTHEM-HFpEF study

Background

Approximately half of the patients presenting with new‐onset heart failure (HF) have HF with preserved left ventricular ejection fraction (HFpEF) and HF with mid‐range left ventricular ejection fraction (HFmrEF). These patients have neurohormonal activation like that of HF with reduced ejection fraction; however, beta‐blockers and angiotensin‐converting enzyme inhibitors have not been shown to improve their outcomes, and current treatment for these patients is symptom based and empiric. Sympathoinhibition using parasympathetic stimulation has been shown to improve central and peripheral aspects of the cardiac nervous system, reflex control, induce myocyte cardioprotection, and can lead to regression of left ventricular hypertrophy. Beneficial effects of autonomic regulation therapy (ART) using vagus nerve stimulation (VNS) have also been observed in several animal models of HFpEF, suggesting a potential role for ART in patients with this disease.

Methods

The Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Patients with Heart Failure and Preserved Ejection Fraction (ANTHEM‐HFpEF) study is designed to evaluate the feasibility, tolerability, and safety of ART using right cervical VNS in patients with chronic, stable HFpEF and HFmrEF. Patients with symptomatic HF and HFpEF or HFmrEF fulfilling the enrolment criteria will receive chronic ART with a subcutaneous VNS system attached to the right cervical vagus nerve. Safety parameters will be continuously monitored, and cardiac function and HF symptoms will be assessed every 3 months during a post‐titration follow‐up period of at least 12 months.

Conclusions

The ANTHEM‐HFpEF study is likely to provide valuable information intended to expand our understanding of the potential role of ART in patients with chronic symptomatic HFpEF and HFmrEF.

Thrombospondins: A Role in Cardiovascular Disease

Thrombospondins (TSPs) represent extracellular matrix (ECM) proteins belonging to the TSP family that comprises five members. All TSPs have a complex multidomain structure that permits the interaction with various partners including other ECM proteins, cytokines, receptors, growth factors, etc. Among TSPs, TSP1, TSP2, and TSP4 are the most studied and functionally tested. TSP1 possesses anti-angiogenic activity and is able to activate transforming growth factor (TGF)-β, a potent profibrotic and anti-inflammatory factor. Both TSP2 and TSP4 are implicated in the control of ECM composition in hypertrophic hearts. TSP1, TSP2, and TSP4 also influence cardiac remodeling by affecting collagen production, activity of matrix metalloproteinases and TGF-β signaling, myofibroblast differentiation, cardiomyocyte apoptosis, and stretch-mediated enhancement of myocardial contraction. The development and evaluation of TSP-deficient animal models provided an option to assess the contribution of TSPs to cardiovascular pathology such as (myocardial infarction) MI, cardiac hypertrophy, heart failure, atherosclerosis, and aortic valve stenosis. Targeting of TSPs has a significant therapeutic value for treatment of cardiovascular disease. The activation of cardiac TSP signaling in stress and pressure overload may be therefore beneficial.

Alterations in echocardiographic left ventricular function after percutaneous coronary stenting in diabetic patients with isolated severe proximal left anterior descending artery stenosis

Background

There are conflicting theories regarding the use of percutaneous coronary intervention (PCI) of isolated severe proximal left anterior descending (LAD) artery stenosis in place of left internal mammary artery grafting in diabetic patients. The aim of this study was to investigate the effect of PCI on left ventricular function and determine difference between diabetics and non-diabetics.

Methods

A prospective study was conducted on 50 patients with isolated severe proximal LAD stenosis: 23 diabetic and 27 non-diabetic patients. Successful PCI with everolimus-eluting stents was performed for all of the patients. These patients underwent transthoracic echocardiography within 24 h before and 1 month after PCI, and alterations in the left ventricular parameters were compared between the two groups.

Results

There was a significant 12% increment in the mitral annular peak systolic velocity (s′) (p = 0.02), 21% decrement in the trans mitral early filling deceleration time (DT) (p < 0.001), 10% decrement in the systolic left ventricular internal dimension (LVIDs) (p = 0.002), significant increment in the left ventricular ejection fraction (LVEF) (p = 0.004), and significant decrement in the left atrial diameter (p = 0.006) in the diabetic patients after performing PCI. Conversely, the non-diabetic patients showed a statistically significant 14% increase in the DT, 6.3% decrease in the s′ velocity, 8% increase in the LVIDs, significant increment in the left atrial diameter and no change in LVEF after PCI.

Conclusion

Our study demonstrated that everolimus-eluting stents favorably improved the markers of left ventricular systolic and diastolic function in diabetic patients with isolated severe proximal LAD stenosis compared with those of non-diabetic patients with the same condition.

The senescence accelerated mouse prone 8 (SAMP8): A novel murine model for cardiac aging

Because cardiovascular disease remains the major cause of mortality and morbidity world-wide, there remains a compelling need for new insights and novel therapeutic avenues. In this regard, the senescence-accelerated mouse prone 8 (SAMP8) line is a particularly good model for studying the effects of aging on cardiovascular health. Accumulating evidence suggests that this model may shed light on age-associated cardiac and vascular dysfunction and disease. These animals manifest evidence of inflammation, oxidative stress and adverse cardiac remodeling that may recapitulate processes involved in human disease. Early alterations in oxidative damage promote endoplasmic reticulum stress to trigger apoptosis and cytokine production in this genetically susceptible mouse strain. Conversely, pharmacological treatments that reduce inflammation and oxidative stress improve cardiac function in these animals. Therefore, the SAMP8 mouse model provides an exciting opportunity to expand our knowledge of aging in cardiovascular disease and the potential identification of novel targets of treatment. Herein, we review the previous studies performed in SAMP8 mice that provide insight into age-related cardiovascular alterations.

Prevalence of heart failure in the elderly and future projections: the AGES-Reykjavík study

OBJECTIVES

To assess the prevalence of heart failure (HF) in a randomly selected study population of elderly individuals representing the general population of Iceland. Furthermore, to project the number of individuals likely to have HF in the future.

DESIGN

Baseline characteristics and clinical data from 5706 individuals who participated in the population based AGES-Reykjavik Study and gave their informed consent were used. Their age range was 66-98 years (mean age 77.0 ± 5.9 years), 57.6% were females. HF-diagnoses were established by review of hospital records and adjudicated according to prespecified criteria. Data from the 'Statistics Iceland' institution on the current size, age and sex distribution of the population and its prediction into the sixth decade were also used.

RESULTS

The prevalence of HF was 3.6% in the sexes combined, but higher in men (5.1%) than women (2.7%) (p < .001). The prevalence of HF per age groups ≤69, 70-74, 75-79, 80-84 and ≥85 years was 1.7%, 1.5%, 3.7%, 5.2% and 7.2%, respectively. The number of individuals ≥70 years with HF will increase considerably in the future. Thus, a calculation based on the projected age distribution and increase in the number of elderly ≥70 years in the coming decades, demonstrated that the number of patients with HF will have increased 2.3-fold by the year 2040 and tripled by the year 2060.

CONCLUSIONS

This study, in a cohort of elderly participants representative of the general population in a Nordic country, predicts that HF will be a major and increasing health problem in the coming decades.

A Reassessment of the Pathophysiology of Progressive Cardiorenal Disorders

Heart failure and chronic renal diseases are usually progressive and only partially amenable to therapy. These disorders can be the sequelae of hypertension or worsened by hypertension. They are associated with the tissue up-regulation of multiple peptides, many of which are capable of acting within the cell interior. This article proposes that these peptides, intracrines, can form self-sustaining regulatory loops that can spread through heart or kidney, producing progressive disease. Moreover, mineralocorticoid activation seems capable of amplifying some of these peptide networks. This view suggests an expanded explanation of the pathogenesis of progressive cardiorenal disease and suggests new approaches to treatment.

Scoring System Based on Electrocardiogram Features to Predict the Type of Heart Failure in Patients With Chronic Heart Failure

Background

Heart failure (HF) is divided into heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Mortality from HF is inversely related to left ventricular function. Additional studies are required to distinguish between these two types of HF. A previous study showed that HFrEF is less likely when electrocardiogram (ECG) findings are normal. This study aims to create a scoring system based on ECG findings that will predict the type of HF.

Methods

We performed a cross-sectional study analyzing ECG and echocardiographic data from 110 subjects with chronic HF. HFrEF was defined as an ejection fraction ≤ 40%.

Results

Fifty people were diagnosed with HFpEF and 60 people suffered from HFrEF. Multiple logistic regression analysis revealed certain ECG variables that were independent predictors of HFrEF, i.e., left atrial hypertrophy (LAH), QRS duration > 100 ms, right bundle branch block (RBBB), ST-T segment changes and prolongation of the QT interval. Based on receiver operating characteristic (ROC) curve analysis, we obtained a score for HFpEF of -1 to +3, while HFrEF had a score of +4 to +6 with 76% sensitivity, 96% specificity, a 95% positive predictive value, an 80% negative predictive value and an accuracy of 86%.

Conclusions

The scoring system derived from this study, including the presence or absence of LAH, QRS duration > 100 ms, RBBB, ST-T segment changes and prolongation of the QT interval can be used to predict the type of HF with satisfactory sensitivity and specificity.

Clinical factors associated with early readmission among acutely decompensated heart failure patients

INTRODUCTION

Congestive heart failure (CHF) is a common cause of hospital readmission.

MATERIAL AND METHODS

A retrospective study was conducted at Harlem Hospital in New York City. Data were collected for 685 consecutive adult patients admitted for decompensated CHF from March, 2009 to December, 2012. Variables including patient demographics, comorbidities, laboratory studies, and medical therapy were compared between CHF patient admissions resulting in early CHF readmission and not resulting in early CHF readmission.

RESULTS

Clinical factors found to be independently significant for early CHF readmission included chronic obstructive pulmonary disease (odds ratio (OR) = 6.4), HIV infection (OR = 3.4), African-American ethnicity (OR = 2.2), systolic heart failure (OR = 1.9), atrial fibrillation (OR = 2.3), renal disease with glomerular filtration rate < 30 ml/min (OR = 2.7), evidence of substance abuse (OR = 1.7), and absence of angiotensin-converting enzyme inhibitors or angiotensin receptor blocker therapy after discharge (OR = 1.8). The ORs were used to develop a scoring system regarding the risk for early readmission.

CONCLUSIONS

Identifying patients with clinical factors associated with early CHF readmission after an index hospitalization for CHF using the proposed scoring system would allow for an early CHF readmission risk stratification protocol to target particularly high-risk patients.

Cardiac Senescence, Heart Failure, and Frailty: A Triangle in Elderly People

Cardiovascular disease (CVD) is a common problem in the elderly. In particular, the morbidity and mortality of patients with heart failure (HF) increase with age. The poor outcomes of elderly patients with HF can be explained partly by cardiac aging at the cellular and organ levels. Moreover, recent evidence has demonstrated that functional evaluation, which may reflect the status of individual aging, predicts mortality in patients with HF. Age-related changes occur throughout the body and in virtually all organ systems. Thus, we should pay more attention to geriatric conditions when treating patients with HF. Frailty represents a complex clinical syndrome that results from multiple impairments across different organs and is characterized by decreased physiological reserves and increased vulnerability to stressors. Frail patients with CVD have a worse prognosis than non-frail patients. Evidence demonstrates that frailty is an independent risk factor for incident HF among older people. The ways in which cellular senescence promotes age-related CVD and frailty remain an important issue in the biology of aging and clinical geriatrics. Senescent cells that have acquired a senescence-associated secretory phenotype (SASP) can cause local and potentially systemic inflammation. SASP might be a key phenomenon in the association between cellular senescence and the development of age-related CVD and frailty. Frailty is a dynamic and potentially reversible state; therefore, translational research efforts are focused on obtaining mechanistic insights into the pathobiology of frailty, the development of novel therapeutics, and the identification of biomarkers for frailty. This is particularly important in developed countries that are confronted with an aging society.

Numerical simulation of electrocardiograms for full cardiac cycles in healthy and pathological conditions

This work is dedicated to the simulation of full cycles of the electrical activity of the heart and the corresponding body surface potential. The model is based on a realistic torso and heart anatomy, including ventricles and atria. One of the specificities of our approach is to model the atria as a surface, which is the kind of data typically provided by medical imaging for thin volumes. The bidomain equations are considered in their usual formulation in the ventricles, and in a surface formulation on the atria. Two ionic models are used: the Courtemanche-Ramirez-Nattel model on the atria and the 'minimal model for human ventricular action potentials' by Bueno-Orovio, Cherry, and Fenton in the ventricles. The heart is weakly coupled to the torso by a Robin boundary condition based on a resistor-capacitor transmission condition. Various electrocardiograms (ECGs) are simulated in healthy and pathological conditions (left and right bundle branch blocks, Bachmann's bundle block, and Wolff-Parkinson-White syndrome). To assess the numerical ECGs, we use several qualitative and quantitative criteria found in the medical literature. Our simulator can also be used to generate the signals measured by a vest of electrodes. This capability is illustrated at the end of the article. Copyright © 2015 John Wiley & Sons, Ltd.

Cardiac and Hemodynamic Benefits: Mode of Action of Ivabradine in Heart Failure

Heart failure has seen a number of therapeutic advances in recent years. Despite this, heart failure is still related to increasing rates of morbidity, repeated hospitalizations, and mortality. Ivabradine is a recent treatment option for heart failure. It has a mode of action that includes reduction in heart rate, and leads to improvement in outcomes related to heart failure mortality and morbidity, as demonstrated by the results of the SHIFT trial in patients with systolic heart failure, functional classes II and III on the New York Heart Association classification, and left ventricular ejection fraction ≤ 35%. These results are intriguing since many heart failure drugs reduce heart rate without such benefits, or with quite different effects, making it more difficult to understand the novelty of ivabradine in this setting. Many of the drugs used in heart failure modify heart rate, but most have other pathophysiological effects beyond their chronotropic action, which affect their efficacy in preventing morbidity and mortality outcomes. For instance, heart rate reduction at rest or exercise with ivabradine prolongs diastolic perfusion time, improves coronary blood flow, and increases exercise capacity. Another major difference is the increase in stroke volume observed with ivabradine, which may underlie its beneficial cardiac effects. Finally, there is mounting evidence from both preclinical and clinical studies that ivabradine has an anti-remodeling effect, improving left ventricular structures and functions. All together, these mechanisms have a positive impact on the prognosis of ivabradine-treated patients with heart failure, making a compelling argument for use of ivabradine in combination with other treatments.

Comparison of Left Ventricular Myocardial Structure and Function in Patients with Aortic Stenosis and Those with Pure Aortic Regurgitation

OBJECTIVE

We aimed to support the structural and functional distinction between aortic stenosis (AS) and aortic regurgitation (AR).

METHODS

Biopsy specimens taken from 70 selected patients (35 with AS and 35 with AR) undergoing aortic valve replacement (AVR) were analyzed for their cardiomyocyte dimensions and structure, interstitial fibrosis and contractile function. To determine normal values of contractile function, 10 donor hearts were analyzed.

RESULTS

Cardiomyocyte diameter was higher in AS than in AR (22.7 ± 2.2 vs. 13.2 ± 0.7 µm, p < 0.001). Length was higher in AR (121.2 ± 9.4 vs. 95.6 ± 3.7 µm, p < 0.001). Collagen volume fraction was increased in both AS and AR, but was lower in the AS specimens (7.7 ± 2.3 vs. 8.9 ± 2.3, p = 0.01). Myofibril density was reduced in AR (38 ± 4 vs. 48 ± 5%, p < 0.001). Cardiomyocyte diameter and length were closely linked to the relative left ventricular (LV) wall thickness (R² = 0.85, p < 0.001 and R² = 0.68, p = 0.003). The cardiomyocytes of AS patients had higher F_passive (6.6 ± 0.3 vs. 4.6 ± 0.2 kN/m², p < 0.001), but their total force was comparable. F_passive was also significantly higher in AS patients with restrictive rather than pseudo-normal LV filling (7.3 ± 0.5 vs. 6.7 ± 0.6, p = 0.004). In AS patients, but not in AR patients, F_passive showed a significant association with the cardiomyocyte diameter (R² = 0.88, p < 0.001 vs. R² = 0.31, p = 0.6).

CONCLUSIONS

LV myocardial structure and function differ in AS and AR, allowing for compensative adjustment of the diastolic/systolic properties of the myocardium. © 2015 S. Karger AG, Basel.

Molecular effects of the myosin activator omecamtiv mecarbil on contractile properties of skinned myocardium lacking cardiac myosin binding protein-C

Decreased expression of cardiac myosin binding protein-C (cMyBP-C) in the myocardium is thought to be a contributing factor to hypertrophic cardiomyopathy in humans, and the initial molecular defect is likely abnormal cross-bridge (XB) function which leads to impaired force generation, decreased contractile performance, and hypertrophy in vivo. The myosin activator omecamtiv mecarbil (OM) is a pharmacological drug that specifically targets the myosin XB and recent evidence suggests that OM induces a significant decrease in the in vivo motility velocity and an increase in the XB duty cycle. Thus, the molecular effects of OM maybe beneficial in improving contractile function in skinned myocardium lacking cMyBP-C because absence of cMyBP-C in the sarcomere accelerates XB kinetics and enhances XB turnover rate, which presumably reduces contractile efficiency. Therefore, parameters of XB function were measured in skinned myocardium lacking cMyBP-C prior to and following OM incubation. We measured ktr, the rate of force redevelopment as an index of XB transition from both the weakly- to strongly-bound state and from the strongly- to weakly-bound states and performed stretch activation experiments to measure the rates of XB detachment (krel) and XB recruitment (kdf) in detergent-skinned ventricular preparations isolated from hearts of wild-type (WT) and cMyBP-C knockout (KO) mice. Samples from donor human hearts were also used to assess the effects of OM in cardiac muscle expressing a slow β-myosin heavy chain (β-MHC). Incubation of skinned myocardium with OM produced large enhancements in steady-state force generation which were most pronounced at low levels of [Ca(2+)] activations, suggesting that OM cooperatively recruits additional XB's into force generating states. Despite a large increase in steady-state force generation following OM incubation, parallel accelerations in XB kinetics as measured by ktr were not observed, and there was a significant OM-induced decrease in krel which was more pronounced in the KO skinned myocardium compared to WT skinned myocardium (58% in WT vs. 76% in KO at pCa 6.1), such that baseline differences in krel between KO and WT skinned myocardium were no longer apparent following OM-incubation. A significant decrease in the kdf was also observed following OM incubation in all groups, which may be related to the increase in the number of cooperatively recruited XB's at low Ca(2+)-activations which slows the overall rate of force generation. Our results indicate that OM may be a useful pharmacological approach to normalize hypercontractile XB kinetics in myocardium with decreased cMyBP-C expression due to its molecular effects on XB behavior.

Modeling Pathologies of Diastolic and Systolic Heart Failure

Chronic heart failure is a medical condition that involves structural and functional changes of the heart and a progressive reduction in cardiac output. Heart failure is classified into two categories: diastolic heart failure, a thickening of the ventricular wall associated with impaired filling; and systolic heart failure, a dilation of the ventricles associated with reduced pump function. In theory, the pathophysiology of heart failure is well understood. In practice, however, heart failure is highly sensitive to cardiac microstructure, geometry, and loading. This makes it virtually impossible to predict the time line of heart failure for a diseased individual. Here we show that computational modeling allows us to integrate knowledge from different scales to create an individualized model for cardiac growth and remodeling during chronic heart failure. Our model naturally connects molecular events of parallel and serial sarcomere deposition with cellular phenomena of myofibrillogenesis and sarcomerogenesis to whole organ function. Our simulations predict chronic alterations in wall thickness, chamber size, and cardiac geometry, which agree favorably with the clinical observations in patients with diastolic and systolic heart failure. In contrast to existing single- or bi-ventricular models, our new four-chamber model can also predict characteristic secondary effects including papillary muscle dislocation, annular dilation, regurgitant flow, and outflow obstruction. Our prototype study suggests that computational modeling provides a patient-specific window into the progression of heart failure with a view towards personalized treatment planning.

Short-Term Caloric Restriction Suppresses Cardiac Oxidative Stress and Hypertrophy Caused by Chronic Pressure Overload

BACKGROUND

Caloric restriction (CR) prevents senescent changes, in which reactive oxygen species (ROS) have a critical role. Left ventricular (LV) hypertrophy is a risk factor for cardiovascular diseases. We examined whether CR alters cardiac redox state and hypertrophy from chronic pressure overload.

METHODS AND RESULTS

Male c57BL6 mice were subjected to ascending aortic constriction (AAC) with ad libitum caloric intake (AL + AAC group) or 40% restricted caloric intake (CR + AAC group). CR was initiated 2 weeks before AAC and was continued for 4 weeks. Two weeks after constriction, AAC increased LV wall thickness, impaired transmitral flow velocity, and augmented myocyte hypertrophy and fibrosis, in association with enhancement of BNP and collagen III expressions in the AL + AAC group. In the AL + AAC group, oxidative stress in cardiac tissue and mitochondria were enhanced, and NADPH oxidase activity and mitochondrial ROS production were elevated. These changes were significantly attenuated in the CR + AAC group. Additionally, in antioxidant systems, myocardial glutathione peroxidase and superoxide dismutase activities were enhanced in the CR + AAC group.

CONCLUSIONS

Chronic pressure overload increased cardiac oxidative damage, in association with cardiac hypertrophy and fibrosis. Short-term CR suppressed oxidative stress and improved cardiac function, suggesting that short-term CR could be a useful strategy to prevent pressure overload-induced cardiac injury.

Physiologically inspired cardiac scaffolds for tailored in vivo function and heart regeneration

Tissue engineering is well suited for the treatment of cardiac disease due to the limited regenerative capacity of native cardiac tissue and the loss of function associated with endemic cardiac pathologies, such as myocardial infarction and congenital heart defects. However, the physiological complexity of the myocardium imposes extensive requirements on tissue therapies intended for these applications. In recent years, the field of cardiac tissue engineering has been characterized by great innovation and diversity in the fabrication of engineered tissue scaffolds for cardiac repair and regeneration to address these problems. From early approaches that attempted only to deliver cardiac cells in a hydrogel vessel, significant progress has been made in understanding the role of each major component of cardiac living tissue constructs (namely cells, scaffolds, and signaling mechanisms) as they relate to mechanical, biological, and electrical in vivo performance. This improved insight, accompanied by modern material science techniques, allows for the informed development of complex scaffold materials that are optimally designed for cardiac applications. This review provides a background on cardiac physiology as it relates to critical cardiac scaffold characteristics, the degree to which common cardiac scaffold materials fulfill these criteria, and finally an overview of recent in vivo studies that have employed this type of approach.

ROSE-AHF and lessons learned

Nesiritide and dopamine have been recognized for some time as potential renal adjunct therapies in the management of patients with acute heart failure (AHF). Several studies have yielded conflicting evidence of the efficacy of both medications in enhancing the renal function of patients with AHF. The Renal Optimization Strategies Evaluation (ROSE) study was a multicenter double-blind placebo controlled trial designed to assess the potential renoprotective effects of low-dose nesiritide and dopamine in AHF patients with renal dysfunction. This article will focus on previous research, summary of results, and lessons learned from the ROSE-AHF trial as well as future directions for clinical research and applications.

Physical activity in patients with heart failure: barriers and motivations with special focus on sex differences

BACKGROUND

Adherence to recommendations for physical activity is low in both male and female patients with heart failure (HF). Men are more physically active than women. In order to successfully promote physical activity, it is therefore essential to explore how much and why HF patients are physically active and if this is related to sex. The aim of this study was therefore to evaluate physical activity in HF patients, to describe the factors related to physical activity, and to examine potential barriers and motivations to physical activity with special focus on sex differences.

METHODS

The study had a cross-sectional survey design. HF patients living at home received a questionnaire during May-July 2014, with questions on physical activity (from the Short Form-International Physical Activity Questionnaire), and potential barriers and motivations to physical activity.

RESULTS

A total of 154 HF patients, 27% women, with a mean age of 70±10 were included. In total, 23% of the patients reported a high level of physical activity, 46% a moderate level, and 34% a low level. Higher education, self-efficacy, and motivation were significantly associated with a higher amount of physical activity. Symptoms or severity of the disease were not related to physical activity. All the potential barriers to exercise were reported to be of importance. Psychological motivations were most frequently rated as being the most important motivation (41%) to be physically active. Physical motivations (33%) and social motivations were rated as the least important ones (22%). Women had significantly higher total motivation to be physically active. These differences were found in social, physical, and psychological motivations.

DISCUSSION

One-third of the HF patients had a low level of physical activity in their daily life. Severity of the disease or symptoms were not related, whereas level of education, exercise self-efficacy, and motivation were important factors to take into account when advising a HF patient about physical activity. Women reported higher motivation to be physically active than men, but there was no difference in the reported level of physical activity.

β-Arrestins regulate human cardiac fibroblast transformation and collagen synthesis in adverse ventricular remodeling

Cardiac fibroblasts (CFs) produce and degrade the myocardial extracellular matrix and are critical in maladaptive ventricular remodeling that can result in heart failure (HF). β-Arrestins are important signaling molecules involved in β-adrenergic receptor (β-AR) desensitization and can also mediate signaling in a G protein-independent fashion. We hypothesize that β-arrestins play an important role in the regulation of adult human CF biology with regard to myofibroblast transformation, increased collagen synthesis, and myocardial fibrosis which are important in the development of HF. β-Arrestin1 & 2 expression is significantly upregulated in adult human CF isolated from failing left ventricles and β-AR signaling is uncoupled with loss of β-agonist-mediated inhibition of collagen synthesis versus normal control CF. Knockdown of either β-arrestin1 or 2 restored β-AR signaling and β-agonist mediated inhibition of collagen synthesis. Overexpression of β-arrestins in normal CF led to a failing phenotype with increased baseline collagen synthesis, impaired β-AR signaling, and loss of β-agonist-mediated inhibition of collagen synthesis. β-Arrestin knockdown in failing CF diminished TGF-β stimulated collagen synthesis and also inhibited ERK phosphorylation. Overexpression of β-arrestins in normal CF increased basal ERK1/2 and Smad2/3 phosphorylation and enhanced TGF-β-stimulated collagen synthesis. This was prevented by pre-treatment with a MEK1/2 inhibitor. Enhanced β-arrestin signaling appears to be deleterious in CF by promoting a pro-fibrotic phenotype via uncoupling of β-AR signaling as well as potentiating ERK and Smad signaling. Targeted inhibition of β-arrestins in CF may represent a therapeutic strategy to prevent maladaptive myocardial fibrosis.

Diastolic function assessed by cardiac MRI using longitudinal left ventricular fractional shortening

INTRODUCTION

Diastolic dysfunction contributes significantly to diastolic heart failure. We examined the use of cardiac magnetic resonance imaging (CMR) using midwall longitudinal fractional shortening (MLFS) in the evaluation of transthoracic echocardiogram (TTE)-evidenced diastolic dysfunction.

METHODS

A total of 80 patients with CMR within 6 months of TTE and normal ejection fraction were identified. MLFS was calculated as percentage change in distance from the anterior mitral leaflet base to the apical endocardium in systole and diastole.

RESULTS

MLFS of grade II/III [0.14 (0.12-0.16)] was significantly lower than that of grade 0/I [0.20 (0.19-0.21)], P=.001. MLFS detected age-related changes with grade 0 [0.22 (0.21-0.23)] significantly lower than grade I [0.18 (0.16-0.20)], P=.001.

CONCLUSION

TTE-evidenced diastolic dysfunction can be reliably identified by CMR using MLFS.

Alterations in mitochondrial function in cardiac hypertrophy and heart failure

Normal cardiac function requires high and continuous supply with ATP. As mitochondria are the major source of ATP production, it is apparent that mitochondrial function and cardiac function need to be closely related to each other. When subjected to overload, the heart hypertrophies. Initially, the development of hypertrophy is a compensatory mechanism, and contractile function is maintained. However, when the heart is excessively and/or persistently stressed, cardiac function may deteriorate, leading to the onset of heart failure. There is considerable evidence that alterations in mitochondrial function are involved in the decompensation of cardiac hypertrophy. Here, we review metabolic changes occurring at the mitochondrial level during the development of cardiac hypertrophy and the transition to heart failure. We will focus on changes in mitochondrial substrate metabolism, the electron transport chain and the role of oxidative stress. We will demonstrate that, with respect to mitochondrial adaptations, a clear distinction between hypertrophy and heart failure cannot be made because most of the findings present in overt heart failure can already be found in the various stages of hypertrophy.

Beta-blockers in older patients with heart failure and preserved ejection fraction: class, dosage, and outcomes

BACKGROUND

We examined the clinical effectiveness of beta-blockers considered evidenced-based to heart failure and reduced ejection fraction (HFrEF) and their recommended target doses in older adults with HF and preserved ejection fraction (HFpEF).

METHODS

In OPTIMIZE-HF (2003-2004) linked to Medicare (2003-2008), of the 10,570 older (age ≥ 65 years, mean, 81 years) adults with HFpEF (EF ≥ 40%, mean 55%), 8373 had no contraindications to beta-blocker therapy. After excluding 4614 patients receiving pre-admission beta-blockers, the remaining 3759 patients were potentially eligible for new discharge prescriptions for beta-blockers and 1454 received them. We assembled a propensity-matched cohort of 1099 pairs of patients receiving beta-blockers and no beta-blockers, balanced on 115 baseline characteristics. Evidence-based beta-blockers for HFrEF, namely, carvedilol, metoprolol succinate, and bisoprolol and their respective guideline-recommended target doses were 50, 200, and 10mg/day.

RESULTS

During 6 years of follow-up, new discharge prescriptions for beta-blockers had no association with the primary composite endpoint of all-cause mortality or HF rehospitalization (hazard ratio, 1.03; 95% confidence interval {CI}, 0.94-1.13; p=0.569). This association did not vary by beta-blocker evidence class or daily dose. Hazard ratios for all-cause mortality and HF rehospitalization were 0.99 (95% CI, 0.90-1.10; p=0.897) and 1.17 (95% CI, 1.03-1.34; p=0.014), respectively. The latter association lost significance when higher EF cutoffs of ≥45%, ≥50% and ≥55% were used.

CONCLUSIONS

Initiation of therapy with beta-blockers considered evidence-based for HFrEF and in target doses recommended for HFrEF had no association with the composite or individual endpoints of all-cause mortality or HF rehospitalization in HFpEF.