Gender differences in variables related to B-natriuretic peptide, left ventricular ejection fraction and mass, and peak oxygen consumption, in patients with heart failure

Utility of bioelectrical phase angle for cardiovascular risk assessment among individuals with and without diabetes mellitus

PURPOSE

Low values of bioimpedance-derived phase angle (PA) have been associated with various adverse outcomes. We investigated the association of PA with cardiovascular markers in individuals with and without diabetes mellitus (DM).

METHODS

PA was measured in 452 adults (without DM n = 153, T1DM n = 67, T2DM n = 232). Carotid intima-media thickness (IMT), renal resistive index (RRI), ankle-brachial index (ABI) and carotid-femoral Pulse Wave Velocity (cfPWV) were estimated. Furthermore, the levels of high-sensitive Troponin-T [hsTnT], N-terminal brain natriuretic peptide [NT-pro-BNP]) were measured.

RESULTS

PA values were lower in DM independently of age, gender, and BMI (estimated marginal means 6.21, 5.83, 5.95 for controls, T1DM, T2DM p < .05), a finding which persisted after propensity score matching. PA correlated negatively with IMT (r = -0.181), RRI (r = -0.374), cfPWV (r = -0.358), hsTnT (r = -0.238) and NT-pro-BNP (r = -0.318) (all p < .001). In multivariable analysis, the associations with RRI, cfPWV, hsTnT and NT-pro-BNP remained unchanged. PA values 6.0-6.5° for males and 5.2-5.8° for females were predictive of commonly used cutoffs. The combination of ΑCC/AHA ASCVD Score with PA outperformed either factor in predicting cfPWV, RRI for males and hsTnT, BNP for both genders.

CONCLUSIONS

PA exhibits independent correlations with various parameters pertinent to cardiovascular risk and may be useful for cardiovascular assessment.

Cyclic GMP and PKG Signaling in Heart Failure

Cyclic guanosine monophosphate (cGMP), produced by guanylate cyclase (GC), activates protein kinase G (PKG) and regulates cardiac remodeling. cGMP/PKG signal is activated by two intrinsic pathways: nitric oxide (NO)-soluble GC and natriuretic peptide (NP)-particulate GC (pGC) pathways. Activation of these pathways has emerged as a potent therapeutic strategy to treat patients with heart failure, given cGMP-PKG signaling is impaired in heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Large scale clinical trials in patients with HFrEF have shown positive results with agents that activate cGMP-PKG pathways. In patients with HFpEF, however, benefits were observed only in a subgroup of patients. Further investigation for cGMP-PKG pathway is needed to develop better targeting strategies for HFpEF. This review outlines cGMP-PKG pathway and its modulation in heart failure.

An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure

Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.

Propensity Score-Matched Comparison of Right Ventricular Strain in Women and Men Before and After Left Ventricular Assist Device Implantation

Objective: Adverse events following left ventricular assist device (LVAD) implantation are more common in women than in men, but the impact of gender differences on right ventricular (RV) failure is not well defined. Therefore, we calculated RV strain before and after LVAD implantation in matched groups of men and women to determine if gender differences in RV failure after LVAD might account for the gender differences in overall outcomes. Methods: RV free wall longitudinal strain (FWS) and fractional area change were calculated preoperatively and 3 months postoperatively using speckle-tracking echocardiography analysis. A total of 172 patients (86 women, 86 men) were then propensity score matched (1:1) for comparison. Results: Although women had higher preoperative CHA₂DS₂-VASc scores and more frequent moderate mitral regurgitation than men (P = 0.018), the preoperative hemodynamic parameters were similar. Preoperative RV-FWS was -6.7% in women and -6.0% in men (P = 0.65). Postoperatively, women had more progression to severe tricuspid regurgitation (TR) than men (15% vs 7%, P = 0.06). At 3 months the RV-FWS was -7.7% in women and -7.0% in men (P = 0.59). Postoperative TR was moderate-severe in 20% of women and in 9% of men (P = 0.001). Women had a higher incidence of venous thromboembolism, cardiac arrhythmias, and bleeding compared with men. Women also had higher mortality rates at discharge and 30 days after surgery, but the survival rates at 5 years were similar. Conclusions: RV strain measurements track standard hemodynamic and echocardiographic parameters and confirm that gender differences in outcomes following LVAD implantation are not related to gender differences in RV failure rates.

Sex differences in presentation, management, and outcomes among patients hospitalized with acute pulmonary embolism

While the presence of gender disparities in cardiovascular disease have been described, there is a paucity of data regarding the impact of sex in acute pulmonary embolism (PE). We identified all patients admitted to a tertiary care hospital with acute PE between August 1, 2012 through July 1, 2018. We stratified the presenting characteristics, management, and outcomes between women and men. Of the 2031 patients admitted with acute PE, 1081 (53.2%) were women. Women were more likely to present with dyspnea (59.8% vs 52.0%, p < 0.001) and less likely to present with hemoptysis (1.9% vs 4.0%, p = 0.01). Women were older (63.8 ± 17.4 years vs 62.3 ± 15.0 years, p = 0.04), but had lower rates of myocardial infarction, liver disease, smoking history, and prior DVT. PE severity was similar between women and men (massive: 4.9% vs 3.6%; submassive: 43.9% vs 41.8%; p = 0.19), yet women were more likely to present with normal right ventricular size on a surface echocardiogram (63.2% vs 54.8%, p = 0.01). In unadjusted analyses, women were less likely to survive to discharge (92.4% vs 94.7%, p = 0.04), but after adjustment, there was no sex-based survival difference. There were no sex differences in the PE-related diagnostic studies performed, use of advanced therapies, or short-term outcomes, before and after adjustment (p > 0.05 for all). In this large PE cohort from a tertiary care institution, women had different comorbidity profiles and PE presentations compared with men. Despite these differences, there were no sex disparities in PE management or outcomes.

A Multibiomarker Latent Class Analysis in Moderate to Advanced Heart Failure: Differentiating Factors

BACKGROUND

Biomarker science in heart failure (HF) is advancing quickly in our ability to diagnosis and treat patients with this complex syndrome. Researchers are urged to not use single-marker strategies, but instead evaluate biomarkers in patterns to better understand their relationship to one another, as well as disease progression. Latent class mixture modeling allows researchers to determine novel associations between biomarkers.

OBJECTIVE

The objectives of this study were to identify and compare latent classes of cardiovascular biomarkers among patients with moderate to advanced HF.

METHODS

This was a cross-sectional study of 96 participants with moderate to advanced HF. Latent class mixture modeling was used to identify unique classes of biomarkers and their associations to sociodemographic and clinical variables.

RESULTS

The average age of the sample was 54 years, with most of the sample being men (77%) and having an average ejection fraction of 23%. Two unique classes of biomarkers were identified. Latent class 1 had higher levels of all biomarkers, whereas latent class 2 had lower levels. The higher biomarker class had, on average, more neurohormonal activation and fluid retention; however, the higher levels of biomarker class were not more likely to be diagnosed with advanced HF or have more comorbidities.

CONCLUSION

By identifying classes of biomarkers, providers may be better able to identify patients who are at risk of progressing into advanced HF quicker or those who are more likely to have more severe complications, such as fluid overload or renal disease.

Heart Failure Phenotypes Require Sex-Specific Criteria Which Are Based on Ventricular Dimensions

Ejection fraction (EF) is often used as a criterion to establish diagnostic phenotypes of heart failure (HF). Because EF is a derived metric based on end-systolic volume (ESV) and end-diastolic volume (EDV), it is more logical to consider ESV or EDV as cut-off marker. We concentrate on the impact of ESV, which has the advantage of being linearly related to EDV and nonlinearly with EF, both with highly significant correlations. In particular we also analyze if HF classification should distinguish between females and males.ESV and EDV were determined by biplane angiography in 197 HF patients (67 women). As body surface indexed (i) ESVi values for adult healthy females are smaller than for males, we employ classes of ESVi (bins of 10 mL/m²) to group preserved and reduced EF's (cut-off at 50%) for HF. Reference values regarding mean and standard deviation for ESVi are based on a control group (N=155, 65 women) without HF. For interpretation of the findings we use the documented universal relationship connecting EF to ESV: EF = 1 + c₁ {ESV / (c₂ - ESV)}, where c₁ and c₂ are population-based sex-independent constants. In the reference group ESVi (mL/m²) in women (27.4 ± 27.6) is smaller (P=0.0026) than in their male counterparts (43.6 ± 37.5). Similarly, for HF the ESVi in women (45.7 ± 41.4) is smaller (P=0.0033) than in men (64.2 ± 41.4). This signifies (see formula above) that women have higher values for EF, primarily resulting from smaller ventricular size related to their sex, and not exclusively reflecting disease state. Current phenotype classification based on pooled data for males and females may be inappropriate for either sex.The significantly smaller ESVi observed in women has direct consequences for the traditional classification based on EF cutoff values for HF. Sex-specific criteria (regarding ESVi or EF) for HF phenotypes are warranted, and expectedly have substantial consequences for identification, classification, and management of HF patients.

Sex- and Age-Related Reference Values in Cardiology, with Annotations and Guidelines for Interpretation

The definition of "abnormal" in clinical sciences is often based on so-called reference values which point to a range that experts by some sort of consensus consider as normal when looking at biological variables. Such a level is commonly calculated by taking (twice) the standard deviation from the mean, or considering certain percentiles. The suspicion or even confirmation of a disease is then established by demonstrating that the value measured exceeds the upper or lower reference value. As is often the case, the measurement accuracy may depend on the conditions and specific method employed to collect and analyze data. This implies that, for example, data assessed by 2D echocardiography possibly differ from those obtained by MRI and therefore require modality-specific reference values. In this review we summarize reference values for the electrocardiogram, cardiac compartmental volumes, and arterial vessel size in males and females for various age groups. These values may further depend on other variables such as body size, physical training status, and ethnicity. Additional variables relevant for cardiology such as those referring to the microcirculation and biomarkers are only mentioned with reference to the pertinent literature. In general, the sex- and age-specific differences observed are often remarkable and warrant consideration in clinical practice and basic biomedical sciences.

Sex Differences in Heart Failure

Heart failure (HF) represents a global pandemic health problem with a high impact on health-care costs, affecting about 26 million adults worldwide. The overall HF prevalence and incidence are ~2% and ~0.2% per year, respectively, in Western countries, with half of the HF population with reduced ejection fraction (HFpEF) and half with preserved (HFpEF) or mid-range ejection fraction (HFmrEF). Sex differences may exist in HF. More males have HFrEF or HFmrEF and an ischemic etiology, whereas more females have HFpEF and hypertension, diastolic dysfunction, and valvular pathologies as HF etiologies. Females are generally older, have a higher EF, higher frequency of HF-related symptoms, and lower NYHA functional status. Generally, it is observed that female HF patients tend to have more comorbidities such as atrial fibrillation, diabetes, hypertension, anemia, iron deficiency, renal disease, arthritis, frailty, depression, and thyroid abnormalities. However, overall, females have better prognosis in terms of mortality and hospitalization risk compared with men, regardless of EF. Potential sex differences in HF characteristics may be underestimated because of the underrepresentation of females in cardiovascular research and, in particular, the sex imbalance in clinical trial enrollment may avoid to identify sex-specific differences in treatments' benefit.

Sex differences in leptin modulate ventilation in heart failure

BACKGROUND

Leptin modulates ventilation and circulating levels are higher in normal women than men.

OBJECTIVES

The aim of this study was to compare exercise ventilation and gas exchange in men and women with heart failure (HF) and their relation to circulating leptin concentration.

METHODS

Consecutive HF patients were studied by cardiopulmonary exercise testing and assay of circulating leptin concentration.

RESULTS

Fifty-seven men and 20 women were similar with respect to age, BMI, NYHA class, left ventricular ejection fraction, and peak oxygen consumption (all p > 0.05). Leptin concentration was lower (10.3 ± 10 vs. 25.3 ± 16 ng/mL; p < 0.01) and peak exercise ventilatory efficiency (V_E/VCO₂) was higher (43 ± 10 vs. 36 ± 5; p < 0.01) in men. Leptin concentration was associated with peak exercise V_E/VCO₂ (b = -0.35; F = 5.6; p = 0.02).

CONCLUSION

Men have significantly lower circulating leptin concentration and increased ventilatory drive during exercise than women with comparable HF. In men with HF, lower leptin concentration may account for an increased ventilatory drive.

Interrelationship between the Myocardial Mass, Fibrosis, BNP, and Clinical Outcomes in Hypertrophic Cardiomyopathy

Objective Increased left ventricular mass (LVM) and LV fibrosis mass (LVFM) are characteristics of hypertrophic cardiomyopathy (HCM). Additionally, a substantial increase in the plasma B-type natriuretic peptide (BNP) level is observed. Therefore, we investigated the interrelationship and clinical significances of these parameters in a HCM cohort that underwent cardiac MRI (CMR). Methods Patients with HCM (n=109) receiving regular outpatient treatment underwent CMR and follow-up through 2015 from CMR examinations. The clinical outcome measures were all-cause mortality, admission for worsening heart failure, and ventricular tachycardia/fibrillation. Results The baseline body mass index (BMI), LV outflow tract (LVOT) obstruction, New York Heart Association (NYHA) class, and increased left atrial dimension (LAD) index were associated with the plasma BNP level. In the CMR analysis, LVM and LVFM indices significantly correlated with the BNP level (r=0.422 and 0.368, respectively), which were independent determinants according to a multivariate analysis (p=0.009 and 0.023, respectively). A Kaplan-Meier analysis during a median follow-up of 19.4 months showed that the baseline LVM or LVFM index was not associated with the clinical outcomes. However, the baseline BNP level was significantly associated with them (p<0.001). In addition, a multivariate Cox proportional hazard analysis showed that plasma BNP was an independent predictor for the clinical outcomes after adjusting for age, sex, LVM, and LVFM. Conclusion The LVM and LVFM are determinants of the BNP level independent of the BMI, LVOT obstruction, LAD, and NYHA class in patients with HCM. However, plasma BNP may be a more sensitive integrated-marker for the clinical outcomes than LVM or LVFM.

Relationship between sex, ejection fraction, and B-type natriuretic peptide levels in patients hospitalized with heart failure and associations with inhospital outcomes: findings from the Get With The Guideline-Heart Failure Registry

BACKGROUND

In heart failure (HF), there are known differences in plasma B-type natriuretic peptide (BNP) levels between reduced and preserved ejection fraction (EF), but few HF studies have explored sex differences. We sought to evaluate the relationship between sex, EF, and BNP in HF patients and determine prognostic significance of BNP as it relates to sex and EF.

METHODS

We included hospitals in Get With The Guidelines-Heart Failure that admitted 99,930 HF patients with reduced (EF <40%), borderline (EF 40%-49%), or preserved (EF ≥50%) EF. The primary end point was inhospital mortality. Multivariate models were used to compute odds ratios while accounting for hospital clustering.

RESULTS

There were 47,025 patients with reduced (37% female), 13,950 with borderline (48% female), and 38,955 with preserved (65% female) EF. Women compared with men had higher admission median BNP levels with the greatest difference among reduced EF and smallest difference among preserved EF (median BNP in women vs men: EF reduced 1,259 vs 1,113 pg/mL, borderline 821 vs 732 pg/mL, and preserved 559 vs 540 pg/mL; P < .001 all comparisons). Ejection fraction and sex were independently associated with BNP. Inhospital mortality was 2.7%, and patients above the median BNP level had higher mortality than those below. After adjusting for over 20 clinical variables, the ability of BNP to predict inhospital mortality was similar among all subgroups (P for heterogeneity = .47).

CONCLUSIONS

In a large registry, we found that despite sex/EF differences in BNP values, there was no significant difference in the ability of BNP to predict inhospital mortality among these subgroups.